Crohn's disease
Crohn's disease: Excerpt from Handbook of Diseases
Crohn’s disease is an inflammation of the alimentary tract characterized by exacerbations and remissions. It can affect any portion of the tract from the mouth to the anus. In 50% of cases, the disease involves the colon and small bowel. About 33% of cases involve the terminal ileum, and 10% to 20% of cases involve only the colon. The disease can extend through all layers of the intestinal wall and may also involve regional lymph nodes and the mesentery.
Crohn’s disease is most prevalent in adults ages 20 to 40. It’s two to three times more common in people of Jewish ancestry and least common in blacks.
Causes
Although the exact cause of Crohn’s disease is unknown, possible causes include allergies and other immune disorders and infection. However, no infecting organism has been isolated. A genetic cause has also been implicated in some cases.
As the disease progresses, deep ulcers and fissures extend into muscle layers of the wall. These lesions give rise to characteristic “cobblestone” appearance.
Whatever the cause of Crohn’s disease, lacteal blockage in the intestinal wall leads to edema and, eventually, to mucosal inflammation, ulceration, stricturing, and fistula and abscess formation. Absorption is impaired and small bowel obstruction may result.
Signs and symptoms
Clinical effects vary according to the location and extent of the inflammation.
Acute disease
Acute inflammatory signs and symptoms mimic appendicitis and include steady, colicky, pain in the right lower quadrant; cramping; tenderness; flatulence; nausea; fever; and diarrhea. Bleeding may occur and, although usually mild, may be massive. Bloody stool may also occur.
Chronic disease
Chronic symptoms are more typical of the disease, with complaints of abdominal distention and crampy abdominal pain. Symptoms may include a low-grade fever, weight loss, fatigue, and weakness. Diarrhea is usually nonbloody and intermittent, with right lower quadrant or periumbilical pain.
Fistulizing disease results from sinus tracts that can develop and penetrate through the bowel. Fistulas in the mesentery may be asymptomatic or may result in fever, chills, tender abdomen, and leukocytosis. Fistulas from the colon to small intestine can manifest with symptoms of diarrhea, weight loss, and malnutrition.
Complications
Crohn’s disease may lead to intestinal obstruction, fistula formation between the small bowel and the bladder, perianal and perirectal abscesses and fistulas, intra-abdominal abscesses, and perforation.
Diagnosis
Upper GI series with small-bowel follow-through may demonstrate ulcerations, stricture, and fistulas. A barium enema showing the string sign (segments of stricture separated by normal bowel) supports the diagnosis. Flexible sigmoidoscopy and colonoscopy may show patchy areas of inflammation, ulcers, strictures, and granulomas, thus helping to rule out ulcerative colitis. However, a definitive diagnosis is possible only after a biopsy.
Laboratory findings usually indicate increased white blood cell count and erythrocyte sedimentation rate, hypokalemia, hypocalcemia, hypomagnesemia, and decreased hemoglobin level related to anemia from chronic inflammation, blood loss from the mucosa, and iron deficiency. Leukocytosis can be related to corticosteroid therapies, inflammation, or abscess formation. Sedimentation rate is increased in patients with active inflammation. Hypoglobulinemia may result from intestinal protein loss.
Treatment
No cure for Crohn’s disease exists; treatment is aimed at restoring and maintaining bowel and nutritional status by suppressing inflammation, and minimizing discomfort caused by pain and diarrhea. In debilitated patients, therapy includes I.M. hyperalimentation to maintain nutrition while resting the bowel.
Mild to moderated disease benefits from sulfasalazine, an antibacterial, and other 5-ASA (5-amino salicylic acid) agents. Drug therapy may include an anti-inflammatory, a corticosteroid, an immunosuppressant (such as azathioprine and mercaptopurine), and an antibacterial. An antispasmodic, such as propantheline and dicyclomine, may be used for abdominal cramping. Metronidazole and aperfloxacin have proved to be effective in some patients.
Effective treatment requires important changes in lifestyle: physical rest, low-residue diet, and elimination of dairy products for lactose intolerance.
Surgery may be necessary on poor response to medical therapy to correct bowel perforation, massive hemorrhage, intra-abdominal abscess, stricture, fistulas, or acute intestinal obstruction. Colectomy with ileostomy is necessary in many patients with extensive disease of the large intestine and rectum.
Special considerations
❑ If the patient is receiving sulfasalazine, a folic acid supplement should also be given because this medication impairs folate absorption.
❑ Record fluid intake and output (including the amount of stool), and weigh the patient daily. Watch for dehydration and maintain fluid and electrolyte balance.
❑ Be alert for signs of intestinal bleeding (bloody stool); check stool daily for occult blood.
❑ If the patient is receiving a steroid, watch for adverse reactions, such as GI bleeding. Remember that steroids can mask signs of infection.
❑ Check hemoglobin level and hematocrit regularly. Give iron supplements and blood transfusions as needed.
❑ Give an analgesic as needed.
❑ After each bowel movement, provide skin care. Always keep a clean, covered bedpan within the patient’s reach. Ventilate the room to eliminate odors.
❑ Observe the patient for fever and pain or pneumaturia, which may signal bladder fistula. Abdominal pain and distention and fever may indicate intestinal obstruction. Watch for stool from the vagina and an enterovaginal fistula.
❑ Before ileostomy, arrange for a visit by an enterostomal therapist for preoperative education and stoma marking.
❑ After surgery, frequently check the nasogastric tube for proper functioning. Monitor vital signs and fluid intake and output. Watch for wound infection.
❑ Provide meticulous stoma care, and teach it to the patient and his family.
❑ Realize that ileostomy changes the patient’s body image, so offer reassurance and emotional support.
Clinical tip Educate the patient regarding stress management techniques. Refer the patient to a support group if necessary.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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