Crohn's disease
Crohn's disease: Excerpt from Professional Guide to Diseases (Eighth Edition)
Crohn’s disease, also known as regional enteritis and granulomatous colitis, is an inflammation of any part of the GI tract (usually the proximal portion of the colon or, less commonly, the terminal ileum) that extends through all layers of the intestinal wall. It may also involve regional lymph nodes and the mesentery. Granulomas are usually surrounded by normal mucosa; when these lesions are present in multiples, they’re commonly referred to as skip lesions. The surface of the inflamed GI tract usually has a cobblestone appearance, which is different from alternating areas of inflammation and fissure crevices.
Causes and incidence
In Crohn’s disease, lacteal blockage in the intestinal wall leads to edema and, eventually, inflammation, ulceration, and stenosis. Abscesses and fistulas may also occur.
Although the exact cause of Crohn’s disease is unknown, autoimmune and genetic factors are thought to play a role. Up to 5% of those with the disease have one or more affected relatives; Jewish ancestry is also a risk factor. However, a pattern of Mendelian inheritance hasn’t been identified.
The incidence of Crohn’s disease has risen steadily over the past 50 years; it now affects 7 out of every 100,000 people. Crohn’s disease is most prevalent in adults ages 20 to 40. It’s two to three times more common in those of Jewish ancestry and least common in blacks.
Signs and symptoms
Clinical effects may be mild and nonspecific initially; they vary according to the location and extent of the lesion. 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 stools may also occur.
Chronic symptoms, which are more typical of the disease, are more persistent and less severe; they include diarrhea (four to six stools per day) with pain in the right lower abdominal quadrant, steatorrhea (excess fat in feces), marked weight loss and, rarely, clubbing of fingers. The patient may complain of weakness and fatigue. Complications include intestinal obstruction, fistula formation between the small bowel and the bladder, perianal and perirectal abscesses and fistulas, intra-abdominal abscesses, and perforation.
Diagnosis
Barium enema showing the string sign (segments of stricture separated by normal bowel) supports a diagnosis of Crohn’s disease. (See The “string sign,” page 712.) Sigmoidoscopy and colonoscopy may show patchy areas of inflammation, thus helping to rule out ulcerative colitis. However, biopsy is required for a definitive diagnosis.
Laboratory findings commonly indicate increased white blood cell count and erythrocyte sedimentation rate, hypokalemia, hypocalcemia, hypomagnesemia, and a decreased hemoglobin level.
Treatment
To control the inflammatory process, medications, such as 5-aminosalicylate, may be prescribed. Corticosteroids and immunomodulators may be prescribed if 5-aminosalicylate isn’t effective or in patients with severe Crohn’s disease. In debilitated patients, therapy includes total parenteral nutrition to maintain nutritional status while resting the bowel. If abscesses or fistulas occur, antibiotics may be prescribed. Infliximab (an antibody to tumor necrosis factor-alpha, an immune chemical that promotes inflammation) may also be prescribed.
Effective treatment requires important changes in lifestyle: physical rest, restricted diet (specific foods vary from person to person), and elimination of dairy products for lactose intolerance.
Surgery may be necessary to correct bowel perforation, massive hemorrhage, fistulas, or acute intestinal obstruction. Colectomy with ileostomy is necessary in many patients with extensive disease of the large intestine and rectum.
Special considerations
Although treatment is based largely on symptoms, you should monitor the patient’s status carefully for signs of worsening.
❑ 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 stools); check stools daily for occult blood.
❑ Check hemoglobin level and hematocrit regularly. Give iron supplements and blood transfusions, as ordered.
❑ Provide good patient hygiene and mouth care if the patient is restricted to nothing by mouth. After each bowel movement, give good 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 stools from the vagina and an enterovaginal fistula.
❑ Before ileostomy, arrange for a visit by an enterostomal therapist.
❑ After surgery, frequently check the patient’s I.V. and nasogastric tube for proper functioning. Monitor his 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.
❑ Stress the need for a severely restricted diet and bed rest, which may be trying, particularly for the young patient. Encourage him to try to reduce tension. If stress is clearly an aggravating factor, refer him for counseling.
❑ Refer the patient to a support group such as the Crohn’s and Colitis Foundation of America.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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