Crohns Disease

Also called as Regional Enteritis, Granulomatous Colitis, Ileitis. Is a chronic transmural inflammation of the G.I tract that usually affects the small and large intestines but it can occur in any part of the alimentary canal. Cause is unknown, but is multifactorial with factors including viral or bacterial infection, immune disorder, defect in the intestinal barrier, dysfunctional repair of mucosal injury, genetic predisposition, dietary and environmental factors (chemical additives, milk products, heavy metals, low fiber) and cigarette smoking. Complications include stricture and fistulae formation, dehydration, nutritional deficiencies, hemorrhage, bowel perforation, and intestinal obstruction. Incidence of colorectal cancer is higher in patients with Crohns Disease. Assessment: 1. Signs and symptoms are characterized by exacerbations and remissions; onset may be abrupt or insidious. 2. Crampy intermittent pain.

Inflammatory pattern result in milder abdominal pain, but with malnutrition due to malabsorption and weight loss, and possible anemia (hypochromic or macrocytic). Fibrostenotic pattern may present with partial small bowel obstructions: Diffuse abdominal pain, nausea, vomiting, and bloating. Perforating pattern is characterized by sudden profuse diarrhea, fever, localized tenderness due to abscess, and symptoms of fistulae, such as pneumaturia and recurrent urinary tract infection. 3. Abdominal tenderness occurs, especially in right lower quadrant; right lower quadrant fullness or mass is palpable. 4. Chronic diarrhea caused by irritating discharge; usual consistency is soft or semi-liquid. Bloody stools or steatorrhea (fatty stools) may occur. 5. Low-grade fever occurs if abscesses are present. 6. Arthralgias may also occur. Diagnostic Evaluation: 1. Increased white blood cell count and sedimentation rate; decreased hemoglobin; decreased albumin; and possibly decreased potassium, magnesium, and calcium due to diarrhea. 2. Stool analysis shows leukocytes but no pathogens. 3. Barium enema permits visualization of lesion of large intestine and terminal ileum; needs to be scheduled before upper G.I. to prevent interference by barium passing through colon. 4. Upper G.I. barium studies show classic string sign at terminal ileum that suggests constriction of a segment of intestine. 1.5. Colonoscopy to note cobblestone appearance of ulcerations and fissures, skip lesions, and rectal sparing; biopsy can be taken for definitive diagnosis.

Surgical Interventions: 1. Surgery is indicated only for complications. Roughly 70% of Crohns disease patients eventually require one or more operations for obstructions, fistulae, fissures, abscesses, toxic megacolon, or perforation. 2. Surgical options include: Segmental bowel resection with anastomosis. Subtotal colectomy with ileorectal anastomosis (spares rectum). Total proctocolectomy with end ileostomy for severe disease in colon and rectum.

Nursing Interventions: 1. Monitor frequency and consistency of stools to evaluate volume losses and effectiveness of therapy. 2. Monitor dietary therapy; weigh the patient daily. 3. Monitor electrolytes, especially potassium. Monitor intake and output. Monitor acid-base balance because diarrhea can lead to metabolic acidosis. 4. Monitor for distention, increased temperature, hypotension, and rectal bleeding; all signs of obstruction caused by inflammation. 5. Observe and record changes in pain, especially frequency, location, characteristics, precipitating events, and duration. 6. Offer understanding, concern, and encouragement because patient is often embarrassed about frequent and malodorous stools, and often fearful of eating. 7. Have patient participate in meal planning to encourage compliance and increase knowledge. 8. Encourage patients usual support persons to be involved in management of the disease. 9. Provide small, frequent feedings to prevent distention of the gastric pouch. Diet is low in residue, fiber, and fat; high in calories, protein, vitamins, and minerals. 10.Provide fluids as directed to maintain hydration (1,000 mL/24 hours minimum intake to meet body fluid needs). 11.Clean rectal area and apply ointments as necessary to decrease discomfort from skin breakdown. 12.Facilitate supportive counseling, if appropriate.