Crohn's Disease Complications and Diagnosis

Crohn's Disease/Ulcerative Colitis

• Inflammatory bowel diseases (IBDs) affecting the gastrointestinal tract
• Peak age of onset between teens and mid-30s, and a second peak around age 60
• Equally affects both sexes
• More common in individuals of Jewish and Middle European descent
• Chronic disorder with periods of exacerbations (attacks) and remissions (periods of reduced symptoms)

Crohn's Disease: Pathologic Characteristics

• A non-continuous inflammatory disease
• Can affect any point from the mouth to the anus
• Characterized by "skip lesions" (inflammation occurring in sections of the GI Tract but not uniformly)
• Affects the entire thickness of the bowel wall
• Cobblestone appearance of the colonic mucosa
• Granulomas and small bowel involvement are common features

Crohn's Disease: Etiology and Pathophysiology

• Ulcerations are deep and longitudinal (along the length of the bowel)
• Ulcers penetrate between islands of inflamed edematous mucosa
• This creates a classic cobblestone appearance
• Narrowing of the lumen with stricture development can occur
• Bowel obstruction is possible

Crohn's Disease: Etiology and Pathophysiology

• Microscopic leaks can allow bowel contents to spill into the peritoneal cavity, potentially leading to peritonitis
• Abscesses or fistulas (abnormal passages) that connect with other loops of bowel, skin, bladder, rectum, or vagina can form

Crohn's Disease: Clinical Manifestations

• A chronic disorder with mild to severe exacerbations occurring unpredictably over years
• Diarrhea and cramp-like abdominal pain are common complaints
• Other symptoms can include bloody stool, fever, fatigue, weight loss and rectal bleeding

Crohn's Disease: Complications

• Intestinal: Fistulas, strictures, anal abscesses, perforation, recurrence after surgery, common at anastomoses (connection points in the GI Tract)
• Extra-intestinal: Thromboembolism, arthritis, ankylosing spondylitis, eye inflammation, kidney stones, gallstones, and skin lesions

Crohn's Disease: Complications

• Nutritional problems are common due to small intestine involvement.
• Common problems include fat malabsorption, anemia, electrolyte disturbances, and dehydration

Crohn's Disease: Diagnostic Studies

• History, physical examination, and blood tests (CBC, serum electrolyte levels, serum protein levels)
• Stool cultures, stool tests, colonoscopy, flexible sigmoidoscopy, upper endoscopy, capsule endoscopy
• CT scans and barium studies to visualize inflammation, abscess, strictures, and fistula formation

Crohn's Disease: Collaborative Care - Drug Therapy

• Step-up approach using less-toxic medications initially (aminosalicylates)
• Step-down approach incorporating biologic (immunologic) and targeted therapies
• Corticosteroids, immunosuppressants (azathioprine, 6-MP, MTX), and 5-aminosalicylates/sulfasalazine (e.g., azulfidine)
• Antimicrobials are also used (e.g., metronidazole, ciprofloxacin)
• Methylprednisone and budesonide (Entocort) are also commonly used

Crohn's Disease: Collaborative Care - Immunosuppressants and Biologics

• Immunosuppressants (with regular CBC monitoring) including methotrexate, and sometimes anti-TNF agents
• Regular follow up needed for CBC monitoring in immunosuppressed patients.

Crohn's Disease: Collaborative Care - Surgical Interventions

• Strictureplasty procedures are used to widen areas of narrowed bowel
• Complete bowel resection is required in severe cases
• Other surgeries include procedures to correct complications (fistulas, abscesses, perforations) and anastomoses

Crohn's Disease: Collaborative Care - Nutritional Therapy

• Dietary consultation plays a key role in correcting and preventing malnutrition
• Replacing fluid and electrolytes, preventing weight loss, and correcting high-calorie, high-protein diets are important
• Avoiding low-residue foods is essential for many patients

Crohn's Disease: Nursing Management

• Assessing pain, autoimmune disorders, infection, fluid/electrolyte balance and presence of blood in diarrhea
• Examining weight loss, anxiety, depression, use of prescribed medications, family history, and coping strategies
• Teaching the patient about rest, diet, and perianal care, recognizing symptoms of recurrence, and knowing when to seek medical care

Ulcerative Colitis: Clinical Manifestations

• A chronic inflammatory disease of the large intestine
• Typically involves the rectum and colon, with inflammation spreading into adjacent tissue
• Ulcerations, fistulas, and abscess formation can occur
• Bloody diarrhea with mucous is the primary symptom, frequently associated with abdominal pain, fatigue, and weight loss.

Ulcerative Colitis: Complications

• Intestinal: Strictures, perforations, hemorrhage, toxic megacolon, carcinoma, and Clostridium difficile infection
• Extra-intestinal: Thromboembolism, arthritis, ankylosing spondylitis, eye inflammation, kidney stones, gallstones, skin lesions

Ulcerative Colitis: Collaborative Care - Surgical Interventions

• Total colectomy with rectal mucosal stripping and ileoanal reservoir or pouch are procedures for treatment of ulcerative colitis
• Other procedures might include total protocolectomy with a continent ileostomy

Ulcerative Colitis and Crohn Disease - Nutritional Therapy and Discharge Instructions

• Provide information to patients about dietary modifications to reduce symptoms
• Instructions on stoma care, including changing appliances, monitoring skin, and cleaning techniques.

Student Response Questions

• Includes diet recommendations after colostomy surgery: fruits, vegetables, whole-grain breads, and poached eggs with rice.
• Also includes assessment of patient knowledge regarding disease recurrence.
• Also includes assessment of patient knowledge regarding stoma care.