LIceo de Cagayan University R.N. Pelaez Blvd.
Kauswagan, Carmen Cagayan de Oro City
College of Nursing
Medical Surgical Nursing Report
Submitted on: August, 9 2008
CONTENTS I. II. Overview of the report Assessment A. B. C. D. Anatomy and Physiology of the Digestive tract Pathophysiology Signs and Symptoms Diagnostic Tests
III. Nursing Management A. B. C. Nursing Diagnosis Independent Nursing Actions Dependent Nursing Actions Medical Management Surgical Management Pharmacologic Management IV. Expected Outcome A. B. Prognosis Complication
I. Overview of the report Crohn's disease, a type of inflammatory bowel disease (IBD), is a condition in which the lining of your digestive tract becomes inflamed, causing severe diarrhea and abdominal pain. The inflammation often spreads deep into the layers of affected tissue. Like ulcerative colitis, another common IBD, Crohn's disease can be both painful and debilitating and sometimes may lead to life-threatening complication. While there's no known medical cure for Crohn's disease, therapies can greatly reduce the signs and symptoms of Crohn's disease and even bring about a long-term remission. With these therapies, many people afflicted with Crohn's disease are able to function normally in their everyday lives. Crohn’s disease is an ongoing disorder that causes inflammation of the digestive tract, also referred to as the gastrointestinal (GI) tract. Crohn’s disease can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine, called the ileum. The swelling extends deep into the lining of the affected organ. The swelling can cause pain and can make the intestines empty frequently, resulting in diarrhea. Crohn’s disease is an inflammatory bowel disease, the general name for diseases that cause swelling in the intestines. Because the symptoms of Crohn’s disease are similar to other intestinal disorders, such as irritable bowel syndrome and ulcerative colitis, it can be difficult to diagnose. Ulcerative colitis causes inflammation and ulcers in the top layer of the lining of the large intestine. In Crohn’s disease, all layers of the intestine may be involved, and normal healthy bowel can be found between sections of diseased bowel. Crohn’s disease affects men and women equally and seems to run in some families. About 20 percent of people with Crohn’s disease have a blood relative with some form of inflammatory bowel disease, most often a brother or sister and sometimes a parent or child. Crohn’s disease can occur in people of all age groups, but it is more often diagnosed in people between the ages of 20 and 30. People of Jewish heritage have an increased risk of developing Crohn’s disease, and African Americans are at decreased risk for developing Crohn’s disease.
Crohn’s disease Inflammatory Bowel Disease (IBD) - refers to two chronic inflammatory GI disorders: Regional Enteritis (Crohn’s disease) and Ulcerative Colitis Regional Enteritis - first diagnosed in adolescents or young adults but can appear at any time of life - Histopathologic changes consistent with regional entiritis most commonly occur in tract. - is seen more often in smokers than non-smokers. - Sub acute and chronic inflammation of the GI tract wall that extends through all layers. Although it can occur anywhere in the GI tract, it most commonly occurs in the distal ileum and to a lesser degree the ascending colon. distal ileum and colon but can occur anywhere along the GI
II. Assessment A. Anatomy and Physiology of the Gastrointestinal tract
Each cell of the body requires a constant supply of nutrients to use as the basic building blocks of the body and for the hundreds of biochemical process that are continuously going on within the body. The digestive system is the way in which the body transforms food into the energy it needs to build, repair and fuel itself. To be absorbed and used by the body, however, food substances must first be broken down into pieces small enough to cross the cellular membrane. The first step in this process is digestion. Digestion begins in the mouth. Food, once chewed, travels through the throat or pharynx to the esophagus and then on to the stomach. From the stomach, it passes into the small, then large intestines where it is further digested with the aid of bile and enzymes from the pancreas and liver, and finally absorbed. Any waste materials of this process exit the body through the colon and rectum. Mouth The mouth is the oral cavity where foods are received and prepared for digestion. The mouth is responsible for the secretion of salivary amylase, which begins the digestion process by converting starches into sugars. Pharynx The pharynx ,or throat, is a muscular tube that serves as a vehicle for both respiration and digestion. When we swallow, reflex movements of muscles in the pharynx propel food into the esophagus. Esophagus The esophagus is a tube that carries swallowed foods to the stomach. Stomach The stomach is a muscular organ that is located in the central/upper left hand region of the abdominal cavity. The function of the stomach is to break down food items. The stomach secretes digestive juices, such as hydrochloric acid and pepsin, to aid in this process. It's muscular walls churn the food until it is in a semi-liquid form.
Small Intestines The small intestines digest and absorb many of the foods we eat. In addition to secreting a strong mucus membrane to protect it's walls from the strong acid food mixture that passes into it from the stomach, the small intestines (along with the liver and pancreas) secrete enzymes that help to digest proteins and carbohydrates and break them down into their simplest form. Once digested, nutrients are extracted and are absorbed by the body. Large Intestines The large intestine is responsible for the elimination of food materials that cannot be digested and assimilated by the body. It is also responsible for the re-absorption of water used during the digestive process. As food materials pass through the large intestine, friendly bacteria that live in the colon act upon this waste, producing vitamin K and some of the B-vitamins. Liver The liver is the largest gland in our bodies. It is located in the upper right portion of the abdominal cavity, with the lower edge of the liver extending just below the rib cage. The liver is responsible for a multitude of different functions, including:
• • • • • • • • •
The synthesis of lipoproteins such as cholesterol. Synthesis of bile, which is necessary for fat digestion and absorption. Manufactures carnitine for use in cell mediated fat transport. Regulation of the amount of cholesterol circulating in the blood. The storage and releasing of glucose. Converts lactic acid into glycogen. Converts B vitamins into their active co-enzyme form. Coverts ammonia into urea, which is excreted by the kidneys. The production or synthesis of specific proteins such as albumin and blood clotting factors.
The storage of substances such as glucose, fat soluble vitamins, including A, B12, D, E & K, folate, and minerals such as copper and iron. Modification and inactivation of hormones; i.e., the breakdown of hormones that have served their function. Detoxification of chemical elements whether ingested or inhaled. Removal of harmful substances from the blood and converts them into less harmful substances that can be eliminated.
Pancreas The pancreas is a gland that is located in the upper left hand quadrant of the abdominal cavity. The pancreas houses the Isles of Landerhorn, which are responsible for regulating blood sugar levels. It also produces enzymes that digest fats, proteins and carbohydrates. In addition, the pancreas also produces an alkaline fluid, which neutralizes the acidity of foods as they exit the stomach and proceed into the small intestines.
Pathophysiology Edema and thickening of the mucosa Inflamed mucosa ulceration
(these lesions are not in continous contact with one another and are separated by normal tissue. These cluster of ulcers tend to take on a classic “ cobble stone” appearance.) Fistula, fissures, and abscesses forms as the inflammation extend into the peritoneum Bowel walls becomes thickened comes fibrotic Intestinal lumen narrows disease bowel loops sometimes adhere to other loops surrounding them
C. Clinical Manifestation:
Signs and Symptoms
-prominent lower right quadrant abdominal pain -diarrhea unrelieved by medication -scar tissue and formation of granuloma which interferes with the ability of the intestine to transport products of the upper intestinal digestion through the constricted lumen, results in -crampy abdominal pain occurs after meals because eating stimulates intestinal peristalsis -abdominal tenderness and spasm * to avoid this bouts of crampy pain the patient tends to limit food intake, reducing the amount and types of food to such a degree that normal nutritional requirement are often not met, results in - weight loss -malnutrition -secondary anemia *ulcers in the membranous lining of the intestine and other inflammatory changes, results in -weeping -edematous intestine which continually empties an irritating discharge into the colon . Inflamed intestine may perforate leading to -intraabdominal and anal abscesses -fever and leukocytosis Chronic Symptoms: -diarrhea -abdominal pain -steatorrhea ( excessive fat in the feces ) -anorexia
-nutritional deficiency -weight loss Symptoms that may extend beyond GI tract: -Joint disorder ( arthritis) -skin lesions ( erythema nodosum) -occular disorder ( conjunctivitis) -oral ulcers
-Proctosigmoidoscopy is usually performed initially to determine whether the recto sigmoid are is inflamed -Stool examination is the result may be positive for occult blood and steatorrhea. -Barrium study of the upper GI tract that shows -the Classic of intestine -cobblestone appearance, fistulas, and fissures -Endoscopy - An instrument for examining visually the interior of a bodily canal or a hollow organ such as the colon, bladder, or stomach. - is a medical procedure where a long, flexible, tubular instrument called the colonoscope is used to view the entire inner lining of the colon (large intestine) and the rectum. -Intestinal Biopsy - A biopsy is a diagnostic procedure in which tissue or cells are removed from a part of the body and specially prepared for examination under a microscope. When the tissue involved is part of the intestinal, the procedure is called a intestinal biopsy. “String Sign” on an X-ray film of the terminal ileum, indicating the constriction of a segment
-Barium enema may show ulceration ( the cobble stone appearance), fissure, and fistula -CT scan which may show bowel wall thickening and fistula formation -Complete Blood Count (CBC) is performed to assess hematocrit and hemoglobin levels ( usually decreased ) as well as the white Blood Cell Count ( may be elevated )
- Erythrocyte Sedimentation Rate (ESR) is usually elevated -laboratory test that measures the rate of settling of RBCs:elevation is indicative of inflammation also called the “SED rate” -Albumin and Protein level may be decreased, indicating malnutrition III. Nursing Management A. Nursing Diagnosis
-Diarrhea elated to the inflammatory process -Acute pain related to increased peristalsis and GI inflammation -Deficient fluid volume related to anorexia, nausea, and diarrhea -Imbalanced nutrition, less than body requirements, related to dietary restrictions, nausea and malabsorption -Activity intolerance related to fatigue -Anxiety related to impending surgery -Ineffective coping related to repeated episodes of diarrhea -Risk for impaired skin integrity related to malnutrition and diarrhea -Risk for ineffective therapeutic regimen management related to
insufficient knowledge concerning the process and management of the disease
B. Independent Nursing Actions
-Maintaining Normal Elimination Patterns -Determine if there is a relationship between diarrhea and certain foods, activities, or emotional stress -Identify any precipitating factors as well as stool frequency, consistency and amount -Provide ready access to bathroom or bedpan; keep environment clean and odor-free -Administer anti-diarrheal agents as prescribed and record frequency and consistency of stools after therapy has started -Encourage bed rest to decrease peristalsis -Relieving Pain -Describe character of pain (dull, burning or cramp-like) and its onset, pattern and medication relief -Administer anticholinergic medications 30 minutes before a meal to decrease intestinal motility. -Give analgesic agents as prescribe; reduce pain by position changes, local application of heat (as prescribed) diversional acivities, and prevention of fatigue. -Maintaining Fluid Balance -Record intake and output, including wound or fistula drainage. -Monitor weight daily. -Assess for signs of fluid volume deficit: dry skin and mucous membranes, decreased skin turgor, oliguria, exhaustion, decreased temperature, increased hematocrit. -Evaluate urine specific gravity, and note hypotension. -Encourage oral intake: monitor intravenous flow rate.
-Initiate measures to decrease diarrhea; dietary restrictions, stress reduction, and antidiarrheal agents. Promoting Nutritional Measures -Use PN when symptoms are severe. -Record fluid intake and output daily weights during PN therapy; test for glucose daily. -Give feedings high in in protein and low in fat and residue after PN therapy; note intolerance ( eg, vomiting, diarrhea, distention ). -Provide small, frequent, low residue feedings if oral foods are tolerated. -Restrict activities to conserve energy, reduce peristalsis, and reduce calorie requirements. Promoting Rest -Recommend intermittent rest periods during the day; schedule or restrict activities to conserve energy and reduce metabolic rate. -Encourage activity within limits; advise bed rest with active or passive exercises for a patient who is febrile, has frequent stools, or is bleeding. Reducing Anxiety -Establish rapport by being attentive and displaying a calm, confident manner. -Provide time for patient to ask questions and express feelings. -Note nonverbal indicators of anxiety (restlessness, tense facial expressions). -Tailor information about impending surgery to patient’s level of understanding and desire for detail. Promoting Coping Skills -Provide understanding and emotional support to patients who feels isolated, helpless and out of control.
-Recognize that behavior may be affected by a number of factors unrelated to inherent emotional characteristics. - Support patient’s attempts to deal with stresses -Communicate that patients feeling are understood; encouraged patient to discuss any disturbing matters. -Used stress-reduction measures: relaxation techniques, breathing exercises, and biofeedback. -Refer for professional counseling as needed. Preventing Skin Breakdown -Examine skin, especially perianal skin. -Provide perianal care after each bowel movement. -Give immediate care to reddened or irritated areas over bony prominences. -Use pressure-relieving devices to avoid skin breakdown. -Consult with a wound care specialist or enterostomal therapist as indicated. Monitoring and Managing Potential Complications -
Monitor serum electrolyte levels; administer replacements. Report dysrhythmias or change level of consciousness. Monitor rectal bleeding, and give blood and volume expanders. Monitor blood pressure; obtain laboratory blood studies. Monitor for indications of perforation: acute increase in abdominal pain, rigid abdomen, vomiting or hypotension. Monitor for signs of obstruction and toxic megacolon: abdominal distention, decreased or absent bowel sounds, changes in mental status, fever, tachycardia, hypotension, dehydrations and electrolyte imbalances.
Promoting home and community- base care Teaching patient’s self-care
Assess need for additional information about medical management (medications, diet) and surgical interventions. Provide information about nutritional management (blond, lowresidue, high-protein, high-calorie, and high-vitamin diet). Give rationale for using steroids and anti inflammatory, anti bacterial, anti diarrheal, and anti spasmodic agents. Emphasized importance of taking medications as prescribed and not abruptly discontinuing regimen ( especially steroids, because serious medical problems my result.
Explain procedure and preoperative and postoperative care if surgery is required. Review ileostomy care as necessary. Obtain information from the national foundation for ileitis and colitis.
Continuing care -
Refer for homecare nurse if nutritional status is compromise and patient is receiving PN. Explain that disease can be controlled and patient can lead a healthy life between exacerbations. Encouraged patient to rest as needed and modified activities according to energy levels during a flare-up. Advice patient to limit task that impose strain on the lower abdominal muscles and to sleep close to bathroom because of frequent diarrhea. Suggest room deodorizers for odor control.
Instruct about medications and the need to take them on schedule while at home. Recommend used of medication reminders (containers that separate pills according to day and time).
Recommend low-residue, high-protein, and high- calorie diet during an acute phase. Encourage patient to keep a record of foods that
irritate bowel and to eliminate them from diet. Recommend intake of 8 glasses of water per day. Provide support for prolonged nature of disease because it is a strain on family life and financial resources. Arranged for individual and family counseling as indicated. Provide time for patient to express fears and frustrations. E. Dependent Nursing Actions Medical Management Surgical Management Pharmacologic Management Treatment may include drugs, nutrition supplements, surgery, or a combination of these options. The goals of treatment are to control inflammation, correct nutritional deficiencies, and relieve symptoms like abdominal pain, diarrhea, and rectal bleeding. At this time, treatment can help control the disease by lowering the number of times a person experiences a recurrence, but there is no cure. Treatment for Crohn’s disease depends on the location and severity of disease, complications, and the person’s response to previous medical treatments when treated for reoccurring symptoms. Some people have long periods of remission, sometimes years, when they are free of symptoms. However, the disease usually recurs at various times over a person’s lifetime. This changing pattern of the disease means one cannot always tell when a treatment has helped. Predicting when a remission may occur or when symptoms will return is not possible. Someone with Crohn’s disease may need medical care for a long time, with regular doctor visits to monitor the condition. (Pharmacologic Management) Drug Therapy Anti-Inflammation Drugs. Most people are first treated with drugs containing mesalamine, a substance that helps control inflammation. Sulfasalazine is the most
commonly used of these drugs. Patients who do not benefit from it or who cannot tolerate it may be put on other mesalamine-containing drugs, generally known as 5ASA (5-aminosalycylic acid) agents, such as Asacol, Dipentum, or Pentasa. Possible side effects of mesalamine-containing drugs include nausea, vomiting, heartburn, diarrhea, and headache. Olsalazine (Dipentum).
Antispasmodics. Such as Hyoscyamine, Dicyclomine may be useful to patients who do not respond to standard interventions; Psyllium Absorbs water to increase bulk in stools, thereby decreasing diarrhea. Antibiotics. Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or prior surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or metronidazole, ciprofloxacin Anti-infectives. Metrinidazole, Ciprofloxacin treats local suppurative infections, or maybe part of a long term treatment regimen. Antiulcer agent. Antacids, Ranitidine decreases gastric irritation, preventing inflammation and reducing risk of infection in colitis. Anti-Diarrheal and Fluid Replacements. Diarrhea and crampy abdominal pain are often relieved when the inflammation subsides, but additional medication may also be necessary. Several antidiarrheal agents could be used, including diphenoxylate, loperamide, and codeine. Patients who are dehydrated because of diarrhea will be treated with fluids and electrolytes. Bile Acid Sequestrant. Cholestyramine binds bile salts, reducing diarrhea that results from excess bile acid.
Cortisone or Steroids. AdrenoCorticoTropic Hormone (ACTH), Hydrocortisone Cortisone drugs and steroids—called corticosteriods—provide very effective results. Prednisone is a common generic name of one of the drugs in this group of medications. In the beginning, when the disease it at its worst, prednisone is usually prescribed in a large dose. The dosage is then lowered once symptoms have been controlled. These drugs can cause serious side effects, including greater susceptibility to infection. Immune System Suppressors/Immune-modulating Agents . Drugs that suppress the immune system are also used to treat Crohn’s disease. Most commonly prescribed are 6-mercaptopurine or a related drug, azathioprine. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. These drugs may cause side effects like nausea, vomiting, and diarrhea and may lower a person’s resistance to infection. When patients are treated with a combination of corticosteroids and immunosuppressive drugs, the dose of corticosteroids may eventually be lowered. Some studies suggest that immunosuppressive drugs may enhance the effectiveness of corticosteroids. Monoclonal Antibodies. IV infliximab binds to tumor necrosis factor alpha (TNF alpha) an inflammatory agent found in high amounts in crohn’s disease. Drug blocks the inflammatory agents activity, leading to decrease inflammation and promoting intestinal healing. Infliximab (Remicade). This drug is the first of a group of medications that blocks the body’s inflammation response. The U.S. Food and Drug Administration approved the drug for the treatment of moderate to severe Crohn’s disease that does not respond to standard therapies (mesalamine substances, corticosteroids, immunosuppressive agents) and for the treatment of open, draining fistulas. Infliximab, the first treatment approved specifically for Crohn’s disease is a TNF substance. Additional research will need to be done in order to fully understand the range of treatments Remicade may offer to help people with Crohn’s disease.
Nutrition Supplementation The doctor may recommend nutritional supplements, especially for children whose growth has been slowed. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need to be fed intravenously for a brief time through a small tube inserted into the vein of the arm. This procedure can help patients who need extra nutrition temporarily, those whose intestines need to rest, or those whose intestines cannot absorb enough nutrition from food. There are no known foods that cause Crohn’s disease. However, when people are suffering a flare in disease, foods such as bulky grains, hot spices, alcohol, and milk products may increase diarrhea and cramping. Surgery Two-thirds to three-quarters of patients with Crohn’s disease will require surgery at some point in their lives. Surgery becomes necessary when medications can no longer control symptoms. Surgery is used either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, perforation, abscess, or bleeding in the intestine. Surgery to remove part of the intestine can help people with Crohn’s disease, but it is not a cure. Surgery does not eliminate the disease, and it is not uncommon for people with Crohn’s Disease to have more than one operation, as inflammation tends to return to the area next to where the diseased intestine was removed. Some people who have Crohn’s disease in the large intestine need to have their entire colon removed in an operation called a colectomy. A small opening is made in the front of the abdominal wall, and the tip of the ileum, which is located at the end of the small intestine, is brought to the skin’s surface. This opening, called a stoma, is where waste exits the body. The stoma is about the size of a quarter and is usually located in the right lower part of the abdomen near the beltline. A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed. The majority of colectomy patients go on to live normal, active lives.
Sometimes only the diseased section of intestine is removed and no stoma is needed. In this operation, the intestine is cut above and below the diseased area and reconnected. Because Crohn’s disease often recurs after surgery, people considering it should carefully weigh its benefits and risks compared with other treatments. Surgery may not be appropriate for everyone. People faced with this decision should get as much information as possible from doctors, nurses who work with colon surgery patients (enterostomal therapists), and other patients. Patient advocacy organizations can suggest support groups and other information resources. (See For More Information for the names of such organizations.) People with Crohn’s disease may feel well and be free of symptoms for substantial spans of time when their disease is not active. Despite the need to take medication for long periods of time and occasional hospitalizations, most people with Crohn’s disease are able to hold jobs, raise families, and function successfully at home and in society. (Surgical Management) When nonsurgical measures fail to relieve the sever symptoms of inflammatory bowel disease, surgery may be recommended (Segmental, Subtotal, or Total Colectomy).A fecal diversion maybe needed, such as ileostomy, Continent Ileal Reservoir (Koch Pouch), or Ileoanal anastomosis. Strictureplasty or fecal diversions may be needed (e.g., Ileal reservoir, Ileoanal Anastomosis). Proctocolectomy with Ileostomy (Excision of colon, rectum, and anus) may be performed if rectum is severely involved.
IV.Expected Outcome A.Prognosis -Report decrease in frequency of diarrheal stools - complies with dietary restrictions; maintains bedrest - takes medication as prescribed -Experiences less pain -Maintains fluid volume balance -drinks 1-2 L of oral fluids daily -has normal body temperature -displays adequate skin turgor and moist mucus membranes -Attains optimal nutrition; tolerates small, frequent feedings without diarrhea. -Prevents fatigue -rests periodically during the day -adheres to activity restrictions -Experiences less anxiety -Copes successfully with diagnosis -verbalizes feelings freely -uses appropriate stress reduction behaviors -Maintains skin integrity -cleans perianal skin after defecation -uses lotion or ointment a skin barrier -Acquires an understanding of the disease process -modifies diet appropriately to decrease diarrhea -adheres to medication regimen as prescribed -Recovers without complications -electrolytes within normal ranges -normal sinus or base line cardiac rhythm -maintains fluid balance -experiences no perforation or rectal bleeding
B. Complications -Intestinal Obstruction or stricture formation -Perianal disease -Fluid and Electrolyte imbalances -Malnutrition from malabsorption -fistula and abscess formation * the most common type of small bowel fistula caused by regional enteritis is the “ enterocutaneous fistula” ( an abnormal opening between the small bowel and the skin) *abscesses can be the result of an internal fistula that results in fluid accumulation and infection. *patients with regional enteritis are also at increased risk of colon cancer.
Comparison of Regional Enteritis and Ulcerative Colitis Factor Course Pathology Early late Clinical manifestation Location Bleeding Perianal involvement Fistulas Rectal involvement Diarrhea Diagnostic Study Findings Barium Series Regional enteritis Prolonged, Variable Transmural thickening Deep, penetrating granulomas Ileum, ascending colon ( usually ) Usually not, but if it occurs tends to be mild Common Common About 20% Less severe Rectum, descending colon Common - severe Rare - mild Rare Almost 100% Severe Ulcerative Colitis Exacerbation, remission Mucosal ulceration Minute, mucosal ulceration
Regional, discontinuous lesions Narrowing of colon Thickening of bowel wall Mucosal edema Stenosis fistulas May be unremarkable unless accompanied by perianal fistulas Distinct ulcerations separated by relatively normal mucosa in ascending colon Corticosteroids, sulfonamides (sulfasaline [ Azulfidine ] ) Antibiotics Parenteral nutrition
Diffuse involvement No narrowing of colon No mucosal edema Stenosis rare Shortening of colon Abnormal inflamed mucosa
Friable mucosa with pseudopolyps or ulcers in descending colon Corticosteroids, sulfonamides; sulfasalazine useful in preventing recurrence Bulk hydrophilic agents Antibiotics
Partial or complete colectomy, with ileostomy or anastomosis Rectum can be reserved in some patients Recurrence common Small Bowel Obstruction Right-sided hydronephrosis Nephrolithiasis Cholelithiasis Arthritis Retinitis, Iritis Erythema Nodosum
Proctocolectomy, with ileostomy
Rectum can be preserved in only a few patients ”Cured” bicolectomy
Toxic Megecolon Perforation Hemorrhage Malignant Neoplasms Pyelonephritis Nephrolithiasis Cholangiocarcinoma Arthritis Retinitis, Iritis Erythema Nodosum