CROHN’S DISEASE – Etiology, Types, Pathophysiology, Signs and Symptoms, Diagnostic Evaluation and Management
Crohn’s disease is a chronic idiopathic inflammatory disease that can affect any part of GI tract, usually the small intestine and large intestine that characterized by ulceration, swelling and scarring of the part of intestine. It is also known as regional enteritis
ETIOLOGY
IBD is most commonly begins during adolescence and early adulthood (usually between the ages of 15 and 35). There is a small second peak of newly diagnosed cases after age 50. Although the reason for this is not completely understood
- The exact cause of Crohn’s disease is unknown
- Family history of inflammatory bowel disease
- Immune system problems: for some reason, people with Crohn’s disease have an immune system that reacts inappropriately
- Genetics: brothers, sisters, children and parents of person with IBD, including Crohn’s disease, are slightly more likely to develop the disease themselves
- Environmental factors: environmental factors may help trigger Crohn’s disease. Associated environmental factors may include any of the following:
Substances from something you have seen
Microbes such as bacteria or viruses
Cigarette smoke
Other substances that are yet unknown
TYPES
- Crohn’s colitis
- Crohn’s enteritis
- Crohn’s terminal ileitis
- Crohn’s enterocolitis and ileocolitis
Crohn’s colitis is inflammation that is confined to the colon. Abdominal pain and bloody diarrhea are the common symptoms. Anal fistulae and perirectal abscesses can also occur.
Crohn’s enteritis refers to inflammation confined to the small intestine (the first part, called the jejunum or the second part, called the ileum). Involvement of the ileum alone is referred to as Crohn’s ileitis. Abdominal pain and diarrhea are the common symptoms. Obstruction of the small intestine can also occur.
Crohn’s terminal ileitis is inflammation that affects only the very end of the small intestine (terminal ileum), the part of the small intestine closest to the colon. Abdominal pain and diarrhea are the common symptoms. Small intestinal obstruction can also occur.
Crohn’s enterocolitis and ileocolitis are terms to describe inflammation that involve both the small intestine and the colon. Bloody diarrhea and abdominal pain are the common symptoms. Small intestinal obstruction can also occur.
PATHOPHYSIOLOGY
In the early stages, Crohn’s disease causes small, scattered, shallow, crater-like ulcerations (erosions) on the inner surface of the bowel —- these erosions are called aphthous ulcers. This erosion becomes deeper and larger, ultimately becoming true ulcers (which are deeper than erosions) —- it will cause scarring and stiffness of the bowel —- as the disease progresses, the bowel becomes increasingly narrowed, and ultimately can become obstructed —- deep ulcers can puncture holes in the wall of the bowel, and bacteria from within the bowel can spread to infect adjacent organs and the surrounding abdominal cavity —- narrowing of the small intestine to the point of obstruction —- when the intestine is obstructed, digesting food, fluid and gas from the stomach and the small intestine cannot pass into the colon —- the symptoms of small intestinal obstruction then appear, including severe abdominal cramps, nausea, vomiting and abdominal distension
SIGNS AND SYMPTOMS
Common symptoms of Crohn’s disease include abdominal pain, diarrhea, and weight loss. Less common symptoms include poor appetite, fever, night sweats, rectal pain, and occasionally rectal bleeding. The symptoms of Crohn’s disease are dependent on the location, the extent, and the severity of the inflammation.
- Swelling of the tissue of the anal sphincter, the muscle at the end of the colon that controls defecation
- Development of ulcers and fissures (long ulcers) within the anal sphincter. These ulcers and fissures can cause bleeding and pain with defecation
- Development of anal fistulae (abnormal tunnels between the anus or rectum and the skin surrounding the anus). Mucus and pus may drain from the openings of the fistulae on the skin.
- Development of perirectal abscesses (collections of pus in the anal or rectal area). Perirectal abscesses can cause fever, pain and tenderness around the anus.
DIAGNOSTIC EVALUATION
The diagnosis of Crohn’s disease is suspected in patients with fever, abdominal pain and tenderness, diarrhea with or without bleeding, and anal diseases
- Laboratory blood tests may show elevated white blood cell counts and sedimentation rates, both of which suggest infection or inflammation
- Other blood tests may show low red blood cell counts (anemia), low blood proteins, and low body minerals, reflecting loss of these minerals due to chronic diarrhea
- Colonscopy: it is more accurate than barium X-rays in detecting small ulcers or small areas of inflammation of the colon and terminal ileum. Colonoscopy also allows for small tissue samples to be taken and sent for examination under the microscope to confirm the diagnosis of Crohn’s disease. Colonscopy also is more accurate than barium X-rays in assessing the degree (activity) of inflammation
- Computerized axial tomography (CAT) or (CT): scanning is a computerized X-ray technique that allows imaging of the entire abdomen and pelvis. It can be especially helpful in detecting abscesses
- Video capsule endoscopy (VCE): VCE has also been added to the list of tests for diagnosing Crohn’s disease. For video capsule endoscopy, a capsule containing a miniature video camera is swallowed. As the capsule travels through the small intestine, it sends video images of the lining of the small intestine to a receiver carried on a belt at the waist. The images are downloaded and then reviewed on a computer.
- Stool specimens: mainly composed of mucus, blood, pus and intestinal organisms, especially Entamoeba histolytica (active stage). Fecal leukocytes and RBCs indicate inflammation of GI tract. Stool positive for bacterial pathogens, ova and parasites or clostridium indicates infections. Stool positive for fat indicates malabsorption
- Barium enema: may be performed after visual examination has been done, although rarely done during acute, relapsing stage, because it can exacerbate condition.
- Electrolytes: decreased potassium, magnesium and zinc are common in severe diseases
COMPLICATIONS
- Bowel strictures
- Nutritional deficiencies
- Loss of weight
- Anemia
- Growth retardation
- Delayed puberty
- Formation of fistulas
- Massive intestinal bleeding
MANAGEMENT
The aim of the management is
- To understand the natural history and prognostic factors of Crohn’s disease
- To understand when to use early combination therapy with an anti-TNF agent and immunomodulator in moderate to severe Crohn’s patients.
- To understand the side effects of anti-TNF therapy
- To understand when to administer appropriate vaccinations to inflammatory bowel disease patients both before and during immunosuppressive therapy
MEDICAL MANAGEMENT
- Immunosuppressant – to reduce the inflammation. This drug includes:
- Azathioprine
- Cyclosporine
- Infliximab
- Tacrolimus
- Mycohenoate mofetil
- Aminosalicylates (oral)
- Olsalazine: antibacterial action
- Balsalazine
- Mesalamine
- Corticosteroids (oral)
- Prednisolone
- Prednisone
- Corticosteroids (rectal)
- Hydrocortisone intrarectal form
- Retention enema
- Immune Modifiers
- 9-mercaptourine
- Azathioprine
- Cyclosporine
- Monoclonal antibodies
- Infiximab reduces inflammation
- Antibiotics
- Metronidazole IV
- Ciprofloxacin
These drugs are helpful to reduce harmful intestinal bacteria and suppress the intestine’s immune system
- Iron supplements should also be prescribed to restore the iron level to normal
Surgical Management
Surgery plays important but different roles in management of Crohn’s disease and ulcerative colitis. Surgery is indicated for patients whose disease is refractory to medical therapy and for the management of complications. It plays a curative role in ulcerative colitis
Surgical intervention is avoided whenever possible in Crohn’s disease because of high rates of recurrence of disease process in the same area. Surgical approaches to Crohn’s disease focus on sparing and conserving as much of the bowel as possible, particularly when the small bowel is involved
DIETARY RECOMMENDATIONS
- Eat regularly, do not skip meals. Empty bowels produce gas
- When adding new food to your diet, try a little bit with other foods you know will be easy to digest
- Small, frequent meals are best, always chew thoroughly
- Rice, potatoes, or pasta once daily may reduce bowel frequency and irritation
- High potassium foods will help offset the side effects of diarrhea
- Limit foods containing simple sugars. They aggravate diarrhea
The following are potential anal irritants:
- Coconut
- Dried fruits (raisins, figs)
- Foods with seeds or nuts
- Raw fruits (oranges, apples)
- Raw vegetables (celery, corn, coleslaw)
- Spicy foods
NURSING MANAGEMENT
The goal of nursing management is:
- To control the inflammatory process
- To relieve symptoms
- To correct metabolic and nutritional problems and promote healing
- To achieve the previous health status
Nursing Diagnosis
- Diarrhea related to inflamed intestinal mucosa
- Deficit fluid volume related to diarrhea
- Chronic pain-related inflammatory disease of small intestine
- Imbalanced nutrition less than the body requirement related to pain
- Ineffective coping related to feeing of rejection
- Diarrhea related to inflamed intestinal mucosa
Interventions
- Anti-diarrheal medications are commonly used to treat diarrhea
- Nurse monitors the number and consistency of stools
- Perineal area must be clean with antiseptic solution and then with water
- Perineal area must be clean in every evacuation
- Report reduction in frequency of stools, return to more normal stool consistency
- Identify and avoid contributing factors
- Promote bed rest, provide bedside commode
- Deficit fluid volume related to diarrhea
Interventions
- Monitor intake and output chart
- Provide fluids as prescribed by the doctor to maintain hydration
- Monitor electrolytes and acid base balance because diarrhea can lead to metabolic acidosis
- Watch for cardiac dysrhythmias and muscular weakness due to loss of electrolytes
- Chronic pain-related inflammatory disease of small intestine
Interventions
- Administer medications for control of inflammatory process as prescribed
- Observe and record changes in pain, frequency, location, characteristics, precipitating events and duration
- Monitor for distension, increased temperature, hypotension and rectal bleeding – all signs of obstruction due to inflammation
- Clean the rectal area and apply ointments as necessary to decrease discomfort from skin breakdown
- Prepare the patient for surgery if response to medical and drug therapy is unsatisfactory
- Imbalanced nutrition less than the body requirement related to pain
Interventions
- Encourage a diet that is low in residue fiber and fat and high in calories, protein and carbohydrates with vitamin and mineral supplements
- Monitor weight daily
- Provide small frequent feeding to prevent distension
- Have the patient participate in meal planning to encourage compliance and increased knowledge
- Prepare the patient for elemental diet
- Restart oral fluid intake gradually. Offer clear liquids hourly, avoid cold fluids
- Ineffective coping related to feeling of rejection
Interventions
- Offer understanding concern and encouragement
- Facilitate supportive psychological counseling, if appropriate
- Encourage the patients usual support by people to be involved in management of disease
- Encourage health-promoting behavior
HEALTH EDUCATION
- Provide comprehensive education about anatomy and physiology of GI system, the chronic disease process, drug therapy, potential complications and potential surgery
- Instruct patient about all prescribed medications including the purpose, dosage and adverse effects
- Encourage regular follow-up and report signs of complications
Increasing abdominal distension
Cramping pain
Diarrhea, malaise, fever
- Explain the importance of adequate hydration and nutrition monitoring weight
- Encourage the patient to participate in stress-reducing activities, such as exercise, relaxation techniques, music therapy
- For further information and support
- Information about IBD must be given in a way that promotes positivity and reassurance
- Nutrition and dietary considerations need to be discussed
- If the patient is on medications, instruct regarding the dose, when and how to take the drug, why it is ordered and also about the side effects
- Instructions regarding the daily care provided if patient has an ileostomy or colostomy
- Encourage regular follow-up and to report signs of complications
- Encourage the patient to participate in stress-reducing activities, such as exercise, relaxation techniques, etc
