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Crohn's Disease
Description/Etiology
Crohns disease (CD) is an incurable form of inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal (GI) tract from the mouth to the anus. CD impairs intestinal absorption of nutrients, causes growth impairment and delayed puberty in children, and impairs quality of life. The exact etiology is unknown; emerging evidence suggests that CD is a form of immunodeficiency with immune system defects ranging from disrupted mucosal barrier function to abnormal phagocyte biology. CD can affect multiple parts of the GI tract simultaneously, and typically causes disconnected patches of ulceration between healthy mucosal areas, which creates a cobblestone appearance. It most commonly develops in the terminal ileum (also called regional enteritis) and the proximal colon (also called granulomatous colitis), extends through all bowel tissue layers, and can penetrate extraintestinal structures. The three types of disease activity that occur in CD are inflammatory, characterized by diarrhea, abdominal pain, and fever; penetrating, with development of abscesses, fissures, or fistulas that extend into the peritoneum; and stricturing, which leads to bowel obstruction. Assessmentat diagnosis or serially to evaluate disease statusis arduous for CD patients because symptoms are aggravated by invasive examination, and accurate diagnosis necessitates comparison of multiple clinical, radiologic, endoscopic, and histologic features. Disease location, activity, and severity determine the course of treatment, which usually begins with medication and lifestyle changes but ultimately involves surgery for sequelae resolution in most cases. Although the course of CD is often relapsing/remitting and patient response to treatment varies widely, most patients lead normal lives but have a slightly shorter life expectancy.

Facts and Figures

The incidence of CD has increased steadily over the past 50 years, especially in Northern Europe and North America, where it occurs most commonly. The annual incidence of CD is 68/100,000 persons in the U.S. and Western Europe, 0.54.2/100,000 in Asia, 0.32.6/100,000 in South Africa, and 00.03/100,000 in Latin America. The age of onset of CD shows a bimodal age distribution, with a large peak at 1525 years and a smaller peak at 5070 years. Increased incidence is documented in Ashkenazi Jews, Whites, and females. An estimated 30% of patients have small-bowel disease only, 30% have colon disease only, and 40% have disease that affects the colon and small bowel. Extraintestinal disease manifestations occur in up to 35% of patients. The most common complication of CD is small bowel obstruction, which occurs in 3050% of patients. Surgical resection is necessary in 7580% of patients within 20 years of symptom onset. The 15-year survival rate is 94%.

ICD-9
555.9

ICD-10
K50

Risk Factors
Authors
Sara Grose, MSN, RN Cinahl Information Systems, Glendale, CA Tanja Schub, BS Cinahl Information Systems, Glendale, CA

Risk factors for CD include cigarette smoking, appendectomy, Salmonella or Campylobacter gastroenteritis, family history of CD, and certain genetic mutations (e.g., CARD15, SLC22A4/SLC22A5, DLG5 genes). Antibiotic use may be a risk factor for CD in children. Risk factors for postsurgical CD recurrence include smoking, penetrating disease, longer duration of disease, previous resection, family history of inflammatory bowel disease, and disease extent > 100 cm.

Reviewers
Leonard Buckley, BS, MD Cinahl Information Systems, Glendale, CA Rosalyn Robinson, DNP, RN, APNP, FNP-BC Nursing Practice Council Glendale Adventist Medical Center, Glendale, CA

Signs and Symptoms/Clinical Presentation

Depending on the area(s) of GI tract involvement, presentation includes chronic or nocturnal diarrhea, abdominal pain, fever, dehydration, anorexia, nausea, and fatigue. Rectal bleeding, abdominal mass or distention, cramping unrelieved by stool or flatus, and steatorrhea may be present. Extraintestinal manifestations (e.g., skin/oral lesions, iritis, amenorrhea, arthritis, multifocal osteomyelitis, sclerosing cholangitis, gallstones, kidney stones) may be the first indication of CD.

Assessment
Physical Findings of Particular Interest CD onset is insidious; patients typically present with weight loss, malnutrition, and anemia because they limit food intake to avoid postprandial cramping Laboratory Tests That May Be Ordered CBC with differential may indicate anemia and elevated WBC count; serum electrolytes may show imbalance Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may be elevated

Editor
Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems, Glendale, CA

May 3, 2013

Published by Cinahl Information Systems, a division of EBSCO Publishing. Copyright2013, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

 Serum levels of albumin; protein; vitamins A, B12, C, and D; selenium; zinc; and magnesium may be low; BUN and creatinine may be elevated Anti-Saccharomyces cerevisiae antibody (ASCA) test is positive in most CD patients Stool exam results vary by disease site: Terminal ileal disease usually causes watery, bile salt-induced diarrhea; colon involvement generally produces liquid/semi-formed stools containing blood and mucus; and small bowel disease may produce steatorrhea Histologic examination of biopsy tissue usually reveals inflammation, ulceration, mucosal friability with erythema, lymphoid hyperplasia, and granuloma Other Diagnostic Tests/Studies X-ray using barium contrast with fluoroscopy, CT scan, or MRI may show mucosal destruction, bowel wall thickening, deviation from normal bowel contour/function, bowel constriction, abscess cavities, fistulas, or perirectal disease Colonoscopy, sigmoidoscopy, or capsule endoscopy may show CD-related abnormalities, clarify other diagnostic tests, determine the need for surgery, or obtain biopsy

Treatment Goals
Induce/Maintain Remission and Promote Optimum GI Tract Function Assess all physiologic systems for disease manifestations and complications; review laboratory test results to determine CD status and location; monitor pain, vital signs, weight, height in children, skin integrity, oral and perianal hygiene, and intake and urine and stool volume Administer medications as ordered and monitor treatment efficacy and for adverse effects; drugs used to treat CD include corticosteroids (e.g., prednisone), immunomodulators (e.g., azathioprine, 6-mercaptopurine), tumor necrosis factor (TNF) inhibitors (e.g., infliximab), anti-inflammatory drugs (e.g., sulfasalazine, mesalamine), and intestinal flora modulators (e.g., prebiotics, probiotics, antibiotics); antidiarrheal agents (e.g., loperamide) may be given for chronic diarrhea and anticholinergic agents (e.g., propantheline) may be given for abdominal cramps Promote resolution of inflammation, malnutrition, and dehydration with a diet specific to disease severity. Diet may include total parenteral nutrition (TPN), enteral feedings, an elemental diet, or a diet low in residue, fiber, and fat and high in calories, protein, and carbohydrates; B12, folic acid, fat-soluble vitamins, and calcium may be ordered Encourage intake despite anorexia; request referral to a registered dietitian Follow facility pre- and postsurgical protocols if patient becomes a surgical candidate (e.g., for bowel resection, strictureplasty, colectomy with ileostomy, resolution of perianal disease, fistula, perforation, or hemorrhage); reinforce pre- and postsurgical education and verify completion of facility informed consent documents Provide Emotional Support, Educate, and Identify Support Resources Assess patients anxiety level/coping ability and encourage discussion about embarrassment over GI symptoms or using an ostomy bag, treatment risks and benefits, and individualized disease course/prognosis; request referral to a social worker for age-appropriate support groups and to a mental health clinician for counseling

Food for Thought

The two major forms of IBD are CD and ulcerative colitis (UC), which is characterized by disease that is limited to the colon and rectum (for more information, see Quick Lesson AboutUlcerative Colitis ); although smoking is a risk factor for developing CD, it appears to be protective against developing UC CD does not affect fertility. Pregnancy in women with CD is not associated with congenital malformations, but is associated with increased risk of miscarriage, stillbirth, premature birth, low birth weight infant, and labor and delivery complications Growth hormone is somewhat effective in reversing growth impairment in children with CD

Red Flags
CD patients are at increased risk for leukemia and cancers of the small bowel, colon, lung, skin, bladder, pancreas, liver, testes, prostate, and kidney Medications routinely used to treat CD can cause life-threatening complications and other chronic disease conditions; NSAIDs and sugar substitutes are contraindicated in CD Narcotic analgesics and antidiarrheal agents may precipitate toxic megacolon Risk of venous thromboembolism (i.e. deep vein thrombosis and pulmonary embolism) is increased in patients with CD, especially during disease flares Extensive bowel resection may lead to short bowel syndrome, characterized by severe malabsorption of fluids, electrolytes, and nutrients; patients with short bowel syndrome may require antimotility drugs, frequent small meals, and in-home TPN

What Do I Need to Tell the Patient/Patients Family?

Emphasize the importance of lifelong medical surveillance and prompt medical attention for new/worsening symptoms; educate that acute flare-ups, pain, diarrhea, surgery, and malabsorption complications are inevitable even with strict treatment adherence Advise that certain foods (e.g., bulky grains, hot spices, alcohol, milk products) may worsen diarrhea and cramping

References
1. DynaMed. (2012, November 25). Crohn's disease. Ipswich, MA: EBSCO Publishing. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&site=dynamed&id=AN +114217 2. Lichtenstein, G. R., Hanauer, S. B., Sandborn, W. J., & Practice Parameters Committee of American College of Gastroenterology. (2009). Management of Crohns disease in adults. American Journal of Gastroenterology, 104(2), 465-483. 3. Rangasamy, P., Chen, Y., Coash, M. L., Gay, S. B., Haddad, J. L., Lin, E. C., ... Zhou, D. (2011). Crohn disease. Medscape reference. Retrieved from http://emedicine.medscape.com/article/172940-overview

4. Simon, T. G., Shah, S. A., & Feller, E. (2013). Crohn disease. In F. J. Domino (Ed.), The 5-minute clinical consult 2013 (21st ed., pp. 310-318). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 5. The role of growth hormone and insulin-like growth factor-1 in Crohns disease: Implications for therapeutic use of human growth hormone in pediatric patients. (2011). Current Opinion in Pediatrics, 23(5), 545-551.