ACTIVITY 1.

CROHN’S DISEASE

Crohn's disease is a type of inflammatory bowel disease (IBD). It causes inflammation
of your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue,
weight loss and malnutrition. Inflammation caused by Crohn's disease can involve
different areas of the digestive tract in different people.

II.CAUSES AND RISK FACTORS

The exact cause of Crohn's disease remains unknown. Previously, diet and stress were
suspected, but now doctors know that these factors may aggravate, but don't cause,
Crohn's disease. Several factors, such as heredity and a malfunctioning immune system,
likely play a role in its development.

 Immune system. It's possible that a virus or bacterium may trigger Crohn's

disease; however, scientists have yet to identify such a trigger. When your
immune system tries to fight off the invading microorganism, an abnormal
immune response causes the immune system to attack the cells in the
digestive tract, too.

 Heredity. Crohn's is more common in people who have family members

with the disease, so genes may play a role in making people more
susceptible. However, most people with Crohn's disease don't have a family
history of the disease.

RISK FACTORS

 Age. Crohn's disease can occur at any age, but you're likely to develop the
condition when you're young. Most people who develop Crohn's disease are
diagnosed before they're around 30 years old.

 Ethnicity. Although Crohn's disease can affect any ethnic group, whites

have the highest risk, especially people of Eastern European (Ashkenazi)
Jewish descent. However, the incidence of Crohn's disease is increasing
among Black people who live in North America and the United Kingdom.

 Family history. You're at higher risk if you have a first-degree relative, such

as a parent, sibling or child, with the disease. As many as 1 in 5 people with
Crohn's disease has a family member with the disease.
  Cigarette smoking. Cigarette smoking is the most important controllable
risk factor for developing Crohn's disease. Smoking also leads to more-
severe disease and a greater risk of having surgery. If you smoke, it's
important to stop.

 Nonsteroidal anti-inflammatory medications. These include ibuprofen

(Advil, Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium and
others. While they do not cause Crohn's disease, they can lead to
inflammation of the bowel that makes Crohn's disease worse.

III.PATHOPHYSIOLOGY
SIGNS AND SYMPTOMS

 Diarrhea

 Fever

 Fatigue

 Abdominal pain and cramping

 Blood in your stool

 Mouth sores

 Reduced appetite and weight loss

 Pain or drainage near or around the anus due to inflammation from a tunnel
into the skin (fistula)

IV.DIAGNOSIS

Lab tests

 Blood tests. Your doctor may suggest blood tests to check for anemia — a
condition in which there aren't enough red blood cells to carry adequate
oxygen to your tissues — or to check for signs of infection.

 Stool studies. You may need to provide a stool sample so that your doctor
can test for hidden (occult) blood or organisms, such as parasites, in your
stool.

Procedures

 Colonoscopy. This test allows your doctor to view your entire colon and the
very end of your ileum (terminal ileum) using a thin, flexible, lighted tube
with a camera at the end. During the procedure, your doctor can also take
small samples of tissue (biopsy) for laboratory analysis, which may help to
make a diagnosis. Clusters of inflammatory cells called granulomas, if
present, help essentially confirm the diagnosis of Crohn's.

 Computerized tomography (CT). You may have a CT scan — a special X-

ray technique that provides more detail than a standard X-ray does. This test
 looks at the entire bowel as well as at tissues outside the
bowel. CT enterography is a special CT scan that provides better images of
the small bowel. This test has replaced barium X-rays in many medical
centers.

 Magnetic resonance imaging (MRI). An MRI scanner uses a magnetic field

and radio waves to create detailed images of organs and tissues. MRI is
particularly useful for evaluating a fistula around the anal area (pelvic MRI)
or the small intestine (MR enterography).

 Capsule endoscopy. For this test, you swallow a capsule that has a camera
in it. The camera takes pictures of your small intestine and transmits them to
a recorder you wear on your belt. The images are then downloaded to a
computer, displayed on a monitor and checked for signs of Crohn's disease.
The camera exits your body painlessly in your stool.

You may still need endoscopy with biopsy to confirm the diagnosis of
Crohn's disease. Capsule endoscopy should not be performed if there is a
bowel obstruction.

 Balloon-assisted enteroscopy. For this test, a scope is used in conjunction

with a device called an overtube. This enables the doctor to look further into
the small bowel where standard endoscopes don't reach. This technique is
useful when capsule endoscopy shows abnormalities but the diagnosis is
still in question.

V.MEDICAL MANAGEMENT
Anti-inflammatory drugs

Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel
disease. They include:

 Corticosteroids. Corticosteroids such as prednisone and budesonide

(Entocort EC) can help reduce inflammation in your body, but they don't
work for everyone with Crohn's disease. Doctors generally use them only if
you don't respond to other treatments.

Corticosteroids may be used for short-term (three to four months) symptom

improvement and to induce remission. Corticosteroids may also be used in
combination with an immune system suppressor.

 Oral 5-aminosalicylates. These drugs include sulfasalazine (Azulfidine),

which contains sulfa, and mesalamine (Asacol HD, Delzicol, others). Oral 5-
aminosalicylates have been widely used in the past but now are generally
considered of very limited benefit.

Immune system suppressors

These drugs also reduce inflammation, but they target your immune system, which
produces the substances that cause inflammation. For some people, a combination of
these drugs works better than one drug alone.

Immune system suppressors include:

 Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol,

Purixan). These are the most widely used immunosuppressants for
treatment of inflammatory bowel disease. Taking them requires that you
follow up closely with your doctor and have your blood checked regularly to
look for side effects, such as a lowered resistance to infection and
inflammation of the liver. They may also cause nausea and vomiting.

 Methotrexate (Trexall). This drug is sometimes used for people with

Crohn's disease who don't respond well to other medications. You will need
to be followed closely for side effects.

Biologics
This class of therapies targets proteins made by the immune system. Types of biologics
used to treat Crohn's disease include:

 Natalizumab (Tysabri) and vedolizumab (Entyvio). These drugs work by

stopping certain immune cell molecules — integrins — from binding to
other cells in your intestinal lining. Because natalizumab is associated with a
rare but serious risk of progressive multifocal leukoencephalopathy — a
brain disease that usually leads to death or severe disability — you must be
enrolled in a special restricted distribution program to use it.

Vedolizumab recently was approved for Crohn's disease. It works like

natalizumab but appears not to carry a risk of brain disease.

 Infliximab (Remicade), adalimumab (Humira) and certolizumab pegol

(Cimzia). Also known as TNF inhibitors, these drugs work by neutralizing an
immune system protein known as tumor necrosis factor (TNF).

 Ustekinumab (Stelara). This was recently approved to treat Crohn's disease

by interfering with the action of an interleukin, which is a protein involved in
inflammation.

Antibiotics

Antibiotics can reduce the amount of drainage from fistulas and abscesses and
sometimes heal them in people with Crohn's disease. Some researchers also think that
antibiotics help reduce harmful intestinal bacteria that may play a role in activating the
intestinal immune system, leading to inflammation. Frequently prescribed antibiotics
include ciprofloxacin (Cipro) and metronidazole (Flagyl).

Other medications

In addition to controlling inflammation, some medications may help relieve your signs
and symptoms, but always talk to your doctor before taking any over-the-counter
medications. Depending on the severity of your Crohn's disease, your doctor may
recommend one or more of the following:

 Anti-diarrheals. A fiber supplement, such as psyllium powder (Metamucil)

or methylcellulose (Citrucel), can help relieve mild to moderate diarrhea by
 adding bulk to your stool. For more severe diarrhea, loperamide (Imodium
A-D) may be effective.

 Pain relievers. For mild pain, your doctor may recommend acetaminophen

(Tylenol, others) — but not other common pain relievers, such as ibuprofen
(Advil, Motrin IB, others) or naproxen sodium (Aleve). These drugs are likely
to make your symptoms worse and can make your disease worse as well.

 Vitamins and supplements. If you're not absorbing enough nutrients, your

doctor may recommend vitamins and nutritional supplements.

 Strictureplasty: Widens narrowed areas of your intestine that could lead to

blockages. The surgeon doesn’t remove any part of your intestine.
 Fistula removal: Closes, opens, removes, or drains a fistula that doesn’t heal
with medication. Most fistulas in people with Crohn’s form either between two
different parts of your intestine; the intestine and another body part like
your bladder; or your intestine and your skin. Which surgery you need depends on
where the fistula is.
 Colectomy: Removes your colon when it's badly diseased, but leaves your rectum.
 Proctolectomy: Removes your colon and rectum (together called the large
intestine) when both are badly damaged.
 End ileostomy: This kind of proctolectomy reroutes the end of your small intestine
through a small hole in your belly, called a stoma. Waste then drains into
an ostomy bag outside this hole.
 Bowel resection: Removes part of your small or large intestine that’s been
damaged by Crohn’s and connects the two healthy ends.
 Abscess drainage: Your surgeon cuts into an infection in your belly, pelvis, or
around your anus and puts in a tube to drain pus.
 Ileostomy: Reroutes stool, either temporarily or permanently, through a hole in the
belly called a stoma. You may get an ileostomy to let your intestine heal after
another operation, to reduce inflammation, or so you can get another surgery on
your rectum or anus. Stool drains into an ostomy bag or a special pouch your
surgeon creates to connect to your anus.

Nutrition therapy
Your doctor may recommend a special diet given by mouth or a feeding tube (enteral
nutrition) or nutrients infused into a vein (parenteral nutrition) to treat your Crohn's
disease. This can improve your overall nutrition and allow the bowel to rest. Bowel rest
can reduce inflammation in the short term.

VI.NURSING INTERVENTION

1. Provide emotional support to the patient and his family.

2. Schedule patient care to include rest periods throughout the day.
3. If the patient is receiving parenteral nutrition, provide meticulous site care.
4. Give iron supplements and blood transfusion as ordered.
5. Administer medications as ordered.
6. Provide good patient hygiene and meticulous oral care if the patient is
restricted to nothing by mouth.
7. Record fluid intake and output, weigh the patient daily.
8. If the patient is receiving TPN, monitor his condition closely.
9. Evaluate the effectiveness of medication administration.
10. Emphasize the importance of adequate rest.
11. Give the patient a list of foods to avoid, including lactose-containing milk
products, spicy or fried high-residue foods.
12. Teach the patient about the prescribed medications, their desires effects
and possible adverse reactions.

VII.COMPLICATIONS

 Bowel obstruction. Crohn's disease can affect the entire thickness of the

intestinal wall. Over time, parts of the bowel can scar and narrow, which may
block the flow of digestive contents. You may require surgery to remove the
diseased portion of your bowel.

 Ulcers. Chronic inflammation can lead to open sores (ulcers) anywhere in

your digestive tract, including your mouth and anus, and in the genital area
(perineum).

 Fistulas. Sometimes ulcers can extend completely through the intestinal

wall, creating a fistula — an abnormal connection between different body
parts. Fistulas can develop between your intestine and your skin, or between
 your intestine and another organ. Fistulas near or around the anal area
(perianal) are the most common kind.

When fistulas develop in the abdomen, food may bypass areas of the bowel
that are necessary for absorption. Fistulas may form between loops of
bowel, in the bladder or vagina, or through the skin, causing continuous
drainage of bowel contents to your skin.

In some cases, a fistula may become infected and form an abscess, which
can be life-threatening if not treated.

 Anal fissure. This is a small tear in the tissue that lines the anus or in the
skin around the anus where infections can occur. It's often associated with
painful bowel movements and may lead to a perianal fistula.

 Malnutrition. Diarrhea, abdominal pain and cramping may make it difficult

for you to eat or for your intestine to absorb enough nutrients to keep you
nourished. It's also common to develop anemia due to low iron or vitamin
B-12 caused by the disease.

 Colon cancer. Having Crohn's disease that affects your colon increases your
risk of colon cancer. General colon cancer screening guidelines for people
without Crohn's disease call for a colonoscopy every 10 years beginning at
age 50. Ask your doctor whether you need to have this test done sooner
and more frequently.

 Other health problems. Crohn's disease can cause problems in other parts

of the body. Among these problems are anemia, skin disorders,
osteoporosis, arthritis, and gallbladder or liver disease.

 Medication risks. Certain Crohn's disease drugs that act by blocking

functions of the immune system are associated with a small risk of
developing cancers such as lymphoma and skin cancers. They also increase
risk of infection.

Corticosteroids can be associated with a risk of osteoporosis, bone fractures,

cataracts, glaucoma, diabetes and high blood pressure, among other
conditions. Work with your doctor to determine risks and benefits of
medications.
 Blood clots. Crohn's disease increases the risk of blood clots in veins and
arteries.