CROHN'S DISEASE Crohn's disease is a chronic idiopathic inflammatory disease that can affect any part of the GI tract,

usually the small and large intestines. It is predominantly a transmural disease of the bowel wall. Other names for this disease include regional enteritis, granulomatous colitis, transmural colitis, ileitis, and ileocolitis.

Pathophysiology and Etiology 1. Exact etiology is unknown for this disease. It is thought to be multifactorial with the following theories: a. Genetic predisposition. b. Environmental agents, such as infections (viral or bacterial overload) or dietary factors, may trigger the disease. c. Immunologic imbalance or disturbances. d. Defect in the intestinal barrier that increases the permeability of the bowel. e. Defect in the repair of mucosal injury leading to chronic condition. f. Cigarette smoking is a risk factor in developing disease and increases exacerbations. In contrast, cigarette smoking seems to have a protective effect with ulcerative colitis. 2. Intestinal tissue is thickened and edematous; ulcers enlarge, deepen, and form transverse and longitudinal linear ulcers that intersect, resembling cobblestone appearance. The deep penetration of these ulcers may form fissures, abscesses, and fistulae. The healing and fibrosis of these lesions may lead to stricture. 3. The rectum is typically spared from disease, and skip lesions are discontinuous areas of diseased bowel. 4. Transmural inflammation is a characteristic finding of this disease as well as granulomas. 5. Involvement of the upper GI (mouth, esophagus, stomach, and duodenum) is rare, and, if present, there is usually disease elsewhere. 6. May occur at any age; however, peak incidence is in the third decade, with a smaller peak in the fifth decade. 7. Most common in whites and those of Jewish descent. 8. The clinical presentation can be divided into three patterns: a. Inflammatory b. Fibrostenotic (stricturing) c. Perforating (fistulizing) 9. Recurrences tend to fall into the same pattern for each individual patient and may provide an approach to treatment. Clinical Manifestations These are characterized by exacerbations and remissions may be abrupt or insidious.
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Crampy intermittent pain

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Chronic diarrhea usual consistency is soft or semiliquid. Bloody stools or steatorrhea (due to malabsorption) may occur. Fever may indicate infectious complication such as abscess. Fecal urgency and tenesmus. Other symptoms include anorexia, weight loss, malaise, nausea, arthralgias, and hematochezia. Rectal examination may reveal a perirectal abscess, fistula, fissure, or skin tags (which represent healed perianal lesions). The inflammatory pattern may display malabsorption, weight loss, and less abdominal pain; fibrostenotic pattern may display a partial small bowel obstruction, diffuse abdominal pain, nausea, vomiting, and bloating; perforating pattern may display a sudden profuse diarrhea due to enteroenteric fistula, fever, and localized tenderness due to abscess, or other fistulizing symptoms, such as pneumaturia and recurrent UTIs.

Diagnostic Evaluation
1. 2. 3. 4. 5. 6. 7. 8. 9.

The diagnosis is based on a combination of laboratory, radiologic, endoscopic, and histologic findings. CBC may show mild leukocytosis, thrombocytosis, anemia. Elevated ESR, hypoalbuminemia. Stool analysis may reveal leukocytes but no enteric pathogens; guaiac-positive stool. Upper GI and small-bowel follow-through barium studies may show the classic string sign at the terminal ileum, which suggests a constriction of an intestinal segment. A barium enema may permit visualization of lesions in the large intestine and terminal ileum. CT of the abdomen and pelvis are helpful with diagnosis but more often used to evaluate complications, such as abscess or fistulae. Colonoscopy is the procedure of choice. Typical findings include presence of skip lesions, cobblestoning, ulcerations, and rectal sparing. Biopsy may reveal granulomas, infiltration of lymphocytes, and monocytes.

MANAGEMENT Medical Management

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2. 3. 4. 5. 6.

The goals of medical management include managing symptoms, reducing complications, inducing remissions, improving nutrition, and avoiding surgical interventions when possible. Management is also based on location and severity of disease and extraintestinal complications. Weight loss, water and electrolyte imbalances, and iron, vitamin, mineral, and protein deficiencies occur in 80% of patients. During acute episodes, bowel rest is usually required. Nutritional replacements may include an elemental diet (Vivonex) administered orally or through an NG tube. TPN may be ordered. For milder cases, a low-residue diet may be indicated and avoidance of untolerated foods. Nutritional supplements may be ordered to provide additional nutrients and calories.

Drug Therapy 1. There is no known cure for this disease; it is primarily treated with medications. The disease severity and the area of the GI tract influence drug therapy. TABLE 18-3 Drugs that Treat IBS ADVERSE EFFECTS Headache, diarrhea, abdominal pain, abdominal cramping, malaise, hair loss, rash, orange discoloration of urine, bone marrow suppression, photosensitivity, and decreased sperm motility in men.

CATEGORY 5-ASA drugs

ROUTE Oral

DRUG Sulfasalazine (Azulfidine)

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CONSIDERATIONS Monitor CBC for signs of bone marrow suppression. Recommend daily sunscreen use. Decreased sperm motility is reversible upon drug discontinuation. Urine discoloration is harmless. Use with caution in patients with renal insufficiency.

Oral

Olsalazine (Dipentum)

Oral

Mesalamine (Pentasa, Asacol) and balsalazide (Colazal)

Headache, diarrhea, abdominal pain, abdominal cramping, malaise, rash, joint pain, and nephrotoxicity. Rare cases of hepatitis have been reported to the FDA. Headache, diarrhea, abdominal pain, abdominal cramping, malaise, rash, arthralgias, and nephrotoxicity.

Use mesalamine with caution in patients with renal insufficiency. Researchers have yet to determine the safety of balsalazide in patients with renal impairment. Asacol tablets may be excreted whole in stool. Ask patients to report frequent passage of whole tablets. Effective for distal disease (inflammation in the rectum and sigmoid colon). Most adverse effects are mild and transient. Available in both enema and suppository form for topical

Rectal

Mesalamine (Rowasa)

Abdominal pain, cramping, rectal bleeding, fever, and nephrotoxicity.

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treatment of distal disease. The enema form allows coverage from the rectum to the sigmoid colon; suppositories suppress rectal inflammation. Corticosteroids Prednisone, methylprednisolone (Medrol), and budesonide (Entocort EC) I.V. Hydrocortisone (SoluCortef) and methylprednisolone (SoluMedrol) Rectal Hydrocortisone/pramoxine (ProctoFoam) and hydrocortisone (Cortenema) Oral Cushingoid appearance, hypertension, acne, water retention, weight gain, hair loss, increased appetite, hypokalemia, gastric irritation, ulcer formation, adrenal suppression, decreased resistance to infection. Complications associated with prolonged use include osteoporosis, cataract development, growth retardation, peptic ulceration, hyperglycemia, hypertension, aseptic joint necrosis, and glaucoma.
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May be administered in I.V. form when the gastrointestinal tract isn't able to absorb drugs properly. Budesonide is approved for treating mild to moderately active Crohn's disease of the terminal ileum. Because of budesonide's first-pass metabolism, systemic adverse effects are less common than those that occur with conventional steroids. Corticosteroids aren't indicated for maintenance therapy in treating IBS secondary to associated long-term adverse effects. Monitor for bone marrow suppression. Pregnancy category D. Testing available that evaluates the patient's ability to metabolize the drug, determines therapeutic levels, and monitors for hepatotoxicity. Infusion reactions usually resolve with decreasing the rate of infusion. Perform tuberculosis (TB) skin test prior to first dose, because of the drug's ability to allow latent TB to

Immunemodulating agents

Oral

6-mercaptopurine (Purinethol) and azathioprine (Imuran)

Bone marrow suppression, increased vulnerability to infection, rash, fever, malaise, arthralgias, hepatic dysfunction, nausea, vomiting, diarrhea, pancreatitis, hair loss, and neoplasm development.

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Biologic agents

I.V.

Infliximab (Remicade)

Infusion-related reactions: pruritis, rash, chest pain, hypotension, hypertension, dyspnea, headache, nausea, vomiting, fatigue, and fever. Other potential adverse effects (rare):

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autoantibody development (lupuslike syndrome) and increased susceptibility to infection.

become active, a positive skin test (>5 mm induration) indicates the need for treatment for latent TB, before initiation of infliximab therapy. Do not administer to patients with an active infection.

Rayhorn, N., & Rayhorn, D. (2002). Inflammatory bowel disease: Symptoms in the bowel and beyond. NP Journal, 27(11), 24-25.

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3. 4.

5. 6. 7.

8.

9. 10. 11.

5-Aminosalicylic acid (5-ASA; Asacol, Pentasa, Dipentum) first-line drug to induce and maintain remission. Has anti-inflammatory effect locally without systemic absorption. Asacol releases mesalamine in the terminal ileum and colon. Pentasa releases mesalamine throughout the GI tract. Topical 5-ASA (Rowasa suppositories or enemas) is used for distal colitis. Sulfasalazine (Azulfidine) one-third absorbed systemically; remaining two-thirds splits into 5-ASA (acts locally) and sulfapyridine (absorbed). Is a first-line agent but may have unfavorable adverse effects. Antibiotics (Flagyl, Cipro) may be used in conjunction with 5-ASA or sulfasalazine to induce remission. Corticosteroids to reduce inflammation; given orally, I.V., or by suppository, retention enema, or foam, depending on the severity of disease. Steroids should be tapered off whenever possible. Immunomodulators: 6-mercaptopurine (Imuran), azathioprine, (Purinethol), methotrexate (Rheumatex), cyclosporine (Sandimmune), and tacrolimus (Prograf) are used in patients who are steroid-dependent or steroid-refractory. Assists with fistula improvement or healing. Antidiarrheals, such as loperamide (Imodium), diphenoxylate and atropine (Lomotil), opium tincture (paregoric), and codeine, decrease stool frequency in mild to moderate disease; use with caution. Fish oil may be used in maintaining remission. The adverse effects (diarrhea, flatulence, halitosis, heartburn) may limit patient use. Miscellaneous drugs include antispasmodics (dicyclomine), bulking agents (psyllium), or tricyclic antidepressants (amitriptyline) for treatment of abdominal pain. Infliximab (Remicade) a monoclonal antibody that blocks the activity of the inflammatory agent, tumor necrosis factor. It is indicated for moderate to severe disease not responding to traditional therapies, and for patients with draining fistulae.

Surgery Indicated only for the complications of Crohn's disease. Approximately 70% of Crohn's disease patients will eventually require one or more operations to relieve obstruction, close fistulae, drain abscesses, repair perforations, manage hemorrhage, or widen strictures. Depending on the patient, surgical options include:

Segmental bowel resection with anastomosis Subtotal colectomy with ileorectal anastomosis Total colectomy with ileostomy for severe disease in colon and rectum. Kock pouch and ileal reservoir-anal anastomosis are contraindicated in Crohn's patients. These procedures require the use of the small intestine in which Crohn's disease may develop.

Complications

Abscess (occurs in 20%), and fistulae (occur in 40%) Strictures may result from inflammation, edema, abscess, adhesions, but usually from fibrostenosis Hemorrhage, bowel perforation, intestinal obstruction

Nutritional deficiencies: poor caloric intake due to food avoidance, malabsorption of bile salts and fat, vitamin B12 deficiency with ileal disease, short-gut syndrome after extensive surgical resections Dehydration and electrolyte disturbances Peritonitis and sepsis

Nursing Assessment

Assess frequency and consistency of stools to evaluate volume losses and effectiveness of therapy. Have the patient describe the location, severity, and onset of abdominal cramping or pain. Ask the patient about weight loss and anorexia. Weigh daily to monitor changes. Have the patient describe foods eaten to elicit dietary exacerbations. Determine if the patient smokes, including duration and amount. Ask about family history of GI diseases.

Nursing Diagnoses

Imbalanced Nutrition: Less Than Body Requirements related to pain, nausea Deficient Fluid Volume related to diarrhea Chronic Pain related to the inflammatory disease of the small intestine Ineffective Coping related to feelings of rejection and embarrassment

NURSING INTERVENTIONS Achieving Adequate Nutritional Balance

Encourage 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 feedings to prevent distention. Have patient participate in meal planning to encourage compliance and increase knowledge. Prepare patient for elemental diet or TPN if the patient is debilitated.

Maintaining Fluid and Electrolyte Balance

Monitor intake and output. Provide fluids as prescribed to maintain hydration (1,000 mL/24 hours is minimum intake to meet body fluid needs). Monitor stool frequency and consistency. Monitor electrolytes (especially potassium) and acid-base balance, because diarrhea can lead to metabolic acidosis. Watch for cardiac dysrhythmias and muscle weakness due to loss of electrolytes.

Controlling Pain

Administer medications for control of inflammatory process, as prescribed.

Observe and record changes in pain frequency, location, characteristics, precipitating events, and duration. Monitor for distention, increased temperature, hypotension, and rectal bleeding all signs of obstruction due to the inflammation. Clean rectal area, and apply ointments as necessary to decrease discomfort from skin breakdown. Prepare patient for surgery if response to medical and drug therapy is unsatisfactory. Surgery is determined specifically for each patient. Recurrence of the disease is possible after surgery.

Providing Psychosocial Support

Offer understanding, concern, and encouragement this person is often embarrassed about frequent and malodorous stools and often is fearful of eating. Facilitate supportive psychological counseling, if appropriate. Encourage patient's usual support people to be involved in management of the disease and seek additional support groups as needed. Encourage health-promoting behavior.

Patient Education and Health Maintenance

Provide comprehensive education about anatomy and physiology of the 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, as well as to discuss use of any OTC drugs with health care provider. Encourage regular follow-up and to report signs of complications: increasing abdominal distention, cramping pain, diarrhea, malaise, anorexia, fever, and passing stool through urethra or vagina. Explain the importance of adequate hydration and nutrition (based on individual tolerance) and monitoring weight. Encourage patient to participate in stress-reducing activities such as exercise, relaxation techniques, music therapy.

EVALUATION: EXPECTED OUTCOMES

Improved nutritional intake; weight stable Adequate fluid intake; no evidence of dehydration; electrolyte levels within normal limits Demonstrates relief of pain and symptoms manageable Verbalizes improved attitude toward ways to live with the disease