CROHN’S DISEASE

Marlee Griggs & Narjess Yazback,

INTRODUCTION: WHAT IS CROHN'S DISEASE? Crohn disease (CD) is a chronic regional

enteritis that can affect any part of the gastrointestinal tract (GI) from mouth to anus but it is most commonly seen in the terminal ileum (Rendi, 2013).

This inflammatory bowel disease (IBD) was initially described in 1932 by Crohn, Ginzburg, and Oppenheimer, but it was not distinguished from Ulcerative colitis (UC) until 1959. The difference is that UC typically affects lower parts of the GI: colon and rectum (Rendi, 2013)

Prevalence & Incidence

Approximately 7 per 100,000 people in the US are affected with CD.

Members of European Jewish heritage have a 3-5 times higher prevalence than the general population.

Two peaks of incidence are seen: Early adulthood (teens-20’s) & elderly (60-70’s)

CD is mainly seen in urban areas and northern climates, but it is increasingly growing in regions such as Africa, South America, and Asia (Rendi, 2013).

Smokers are more likely to develop CD than nonsmokers (National Digestive Diseases Information Clearinghouse (NDDIC), 2013).

PATHOPHYSIOLOGY Crohn’s disease is an

inflammatory bowel disease (IBD) meaning it causes irritation, inflammation and swelling that can manifest in different parts along the GI tract. Due to the chronic inflammation, strictures (narrowed intestinal passageways) are formed resulting in the most common symptom: abdominal cramps & pain.

Although the cause of Crohn’s disease is unknown, there is an evident genetic predisposition. It is often seen in Px with biological relatives who suffer from some form of IBD, and there is a 13-18% increase in incidence in first degree relatives (Rendi, 2013).

PATHOPHYSIOLOGY Risk factors Genetic NOD2 (nucleotide binding domain 2) Chromosomes 3,7,12, 16 (However less

than 10% of people with mutations of these chromosomes or NOD2 develop the disease) (Rendi, 2013).

Environmental Tobacco (smoking) Infective agents although bacteria trigger

excessive inflammation, they are not the single causative agent.

“The search for an infectious cause of inflammatory bowel disease continues, but it seems more likely that the ultimate cause is polyfactorial” (Rendi, 2013)

PATHOPHYSIOLOGY Signs and Symptoms

Abdominal pain/ cramping LRQ (Most common)

Diarrhea Nausea & Vomiting Weight loss Fever Rectal bleeding Anemia (General fatigue) Dermal manifestation

PATHOPHYSIOLOGYComplications of Crohn’s disease

Intestinal blockage caused by the thickening of the intestinal wall due to swelling and scar tissue.

Ulcers Fistulas (Tunnels in the affected area)– These can

often become infected. Fissures Impaired nutrient absorption which results in

protein, calories and vitamin deficiency. Risk factor for colon cancer.

(National Digestive Diseases Information Clearinghouse (NDDIC), 2013)

PATIENT CASE SCENARIO Primary Medical Diagnosis

Crohn’s Disease HPI

A forty-one year old woman presents to the ED with c/o abdominal pain and n/v since colonoscopy performed on 2/3/14

Reports pain as constant and 10/10 Patient reports taking oxycodone every 6 hours for pain

relief at home Admitted to the ICU and scheduled for an exploratory

laparotomy with possible drainage of an abdominal abscess and possible ileostomy

Past Medical History Diagnosed with Crohn’s disease and Diverticulitis in 2012 History of ileostomy and ostomy reversal that has possibly

reopened

PATIENT CASE SCENARIO Assessment

Febrile Severe abdominal pain-10/10 Watery stool in ileostomy bag Malnourished, weight of 78 lbs Complaints of n/v

DIAGNOSISColonoscopy:

Provides view of the entire colonTissue for biopsy and laboratory analysis

The presence of granulomas (clusters of inflammatory cells) confirm the diagnosis because they only occur with Crohn’s disease

CT Scan:Provides image of the whole bowelAllows the doctor to see the location and extent of the diseaseAlso checks for complications like partial blockages, abscesses or fistulas

MRI:Creates detailed images of organs and tissuesVery useful in the diagnosis and management of the disease

Capsule Endoscopy:Swallow a capsule that has a camera in itTakes pictures as it moves through the digestive tractThe images are downloaded which can be checked for signs of Crohn’s disease(MDGuidelines, 2009)

(Mayo Clinic, 2011)

TREATMENT OVERVIEW Medication Management (Mayo Clinic, 2011)

Reduce inflammatory process that leads to exacerbation

Long-term remission through limiting complications Surgery (Chandra & Moore, 2011)

Symptom relief Correction of disease complications Restore individual’s health and function

Nutrition (Richman & Rhodes, 2013) Diet low in animal fat30% of energy requirements Avoid foods that are high in insoluble fiber Avoid processed foods high in fat Include supplemental Vitamin D and dairy products if

tolerated

TREATMENT (MAYBERRY, LOBO, FORD, & THOMAS, 2013); (MAYO CLINIC, 2011)

Using monotherapy to encourage remission: Corticosteroids

Useful in patients with a first presentation of the disease or a single inflammatory exacerbation in a 12-month period

Budesonide Less effective than traditional corticosteroids, but

have fewer adverse effects 5-aminosalicylate (5-ASA)

Less effective than the above drugs, but also with fewer adverse effects

Not recommended for long-term use Effective for short-term treatment and to

induce remission

TREATMENT (MAYBERRY, LOBO, FORD, & THOMAS, 2013); (MAYO CLINIC, 2011)

Immunosuppressant Drugs: azathioprine or mercaptopurine

Suppress the immune system response which reduces the inflammatory process

Most commonly used immunosuppressant's for the treatment of Crohn’s disease

Combined with corticosteroid or budesonide therapy in patients that: Have two or more inflammatory exacerbations

in a 12-month period Cannot be tapered off the corticosteroid therapy

TREATMENT (MAYBERRY, LOBO, FORD, & THOMAS, 2013); (MAYO CLINIC, 2011)

Anti-Tumor Necrosis Factor-Alpha Therapy: Infliximab and adalimumab

Neutralizes tumor necrosis factor-alpha in the bloodstream and prevents inflammation

Treatment option for patients with severe Crohn’s disease Unresponsive to conventional therapy

TREATMENT (CHANDRA & MOORE, 2011)

Surgery may be indicated if:

The disease is not responsive to medication

therapy

Treatment requires excessive steroid use

Complications from medications arise

Patients have difficulty with medication

adherence

SURGERY OPTIONS (CHANDRA & MOORE, 2011)

Bowel Resection Preferred surgery Involves removing part of the diseased bowel Healthy ends may be reconnected, or a stoma may

be created Strictureplasty

Heineke-Mikulicz strictureplasty most commonly used For stricture sites <5 cm

A longitudinal cut is made along the bowel which is then sewn together transversely Allows for the narrowed area of the bowel to be

enlarged and prevents bowel obstruction

PATIENT TREATMENT

Not currently taking any maintenance medications

Patient was admitted into the ICU and was prepped for an exploratory laparotomy Drainage of pelvic abscess Resection of terminal ileum Ileostomy with Hartman’s pouch Dissection of fistula

Dietician reviewed patients chart and provided information for nutritional supplements

NURSING DIAGNOSIS (NANDA)

Alteration in nutrition: Less than body requirements R/T abdominal pain, nausea &vomiting, diarrhea, and decreased absorption of the intestines AEB patient’s weight of 78 Ibs.

NCLEX QUESTION 1. The nurse is reviewing the record of a

female client with Crohn’s disease. Which stool characteristics should the nurse expect to see documented in the client’s record?

a. Diarrheab. Chronic constipationc. Constipation alternating with diarrhead. Stools constantly oozing form the rectum 

NCLEX ANSWER

Diarrhea

NCLEX QUESTION Which area of the alimentary canal is the

most common location for Crohn’s disease?

A) Ascending colonB) descending colon C) sigmoid colon, D) terminal ileumE) rectum

REFERENCESChandra, R., & Moore, J. W. E., (2011). The surgical options and management of intestinal

Crohn’s disease. Indian Journal of Surgery, 73, 432-438.

Mayberry, J. F., Lobo, A., Ford, A.C., & Thomas, A. (2012). NICE clinical guidelines (CG152):

The management of Crohn’s disease in adults, children, and young people. Alimentary

Pharmacology & Therapeutics, 37, 195-203.

Mayo Clinic (2011, August 9). Diseases and conditions: Crohn’s disease. Retrieved from

http://www.mayoclinic.org/diseases-conditions/crohns-disease/basics/definition/CON-20032061

MDGuidelines (2009, April). Crohn’s disease. Retrieved from

http://www.mdguidelines.com/crohns-disease

National Digestive Diseases Information Clearinghouse (NDDIC) (2013, July). Retrieved 2014,

from NIDDK: National Institute of Diabetes and Digestive and Kidney Diseases:

http://digestive.niddk.nih.gov/ddISeases/pubs/crohns/#causes

Rendi, M. M. (2013, July). Crohn disease pathology. Retrieved from Medscape:

http://emedicine.medscape.com/article/1986158-overview

Richman, E., & Rhodes, J. M. (2013). Review article: Evidence-based dietary advice for patients

with inflammatory bowel disease. Alimentary Pharmacology & Therapeutics, 38, 1156-

1171.