CROHN’S
DISEASE
Marlee Griggs & Narjess Yazback,
INTRODUCTION: WHAT IS
CROHN'S DISEASE?

Crohn disease (CD) is a chronic regional enteritis
that can affect any part of the gastrointestinal tract
(GI) from mouth to anus but it is most commonly
seen in the terminal ileum (Rendi, 2013).

This inflammatory bowel disease (IBD) was initially
described in 1932 by Crohn, Ginzburg, and
Oppenheimer, but it was not distinguished from
Ulcerative colitis (UC) until 1959. The difference is
that UC typically affects lower parts of the GI: colon
and rectum (Rendi, 2013)
 Prevalence
& Incidence

Approximately 7 per 100,000 people in the US are affected
with CD.

Members of European Jewish heritage have a 3-5 times higher
prevalence than the general population.

Two peaks of incidence are seen: Early adulthood (teens-20’s)
& elderly (60-70’s)

CD is mainly seen in urban areas and northern climates, but it
is increasingly growing in regions such as Africa, South
America, and Asia (Rendi, 2013).

Smokers are more likely to develop CD than nonsmokers
(National Digestive Diseases Information Clearinghouse
(NDDIC), 2013).
PATHOPHYSIOLOGY


Crohn’s disease is an
inflammatory bowel disease (IBD)
meaning it causes irritation,
inflammation and swelling that
can manifest in different parts
along the GI tract. Due to the
chronic inflammation, strictures
(narrowed intestinal passageways)
are formed resulting in the most
common symptom: abdominal
cramps & pain.
Although the cause of Crohn’s
disease is unknown, there is an
evident genetic predisposition. It
is often seen in Px with biological
relatives who suffer from some
form of IBD, and there is a 13-18%
increase in incidence in first
degree relatives (Rendi, 2013).
PATHOPHYSIOLOGY


Risk factors
Genetic  NOD2 (nucleotide binding domain 2)
 Chromosomes 3,7,12, 16 (However less than
10% of people with mutations of these chromosomes
or NOD2 develop the disease) (Rendi, 2013).
Environmental  Tobacco (smoking)
 Infective agents  although bacteria trigger
excessive inflammation, they are not the
single causative agent.
 “The search for an infectious cause of inflammatory bowel

disease continues, but it seems more likely that the ultimate
cause is polyfactorial” (Rendi, 2013)
PATHOPHYSIOLOGY

Signs and Symptoms

Abdominal pain/ cramping LRQ (Most
common)

Diarrhea

Nausea & Vomiting
Weight loss
Fever
Rectal bleeding
Anemia (General fatigue)
Dermal manifestation





PATHOPHYSIOLOGY
Complications of Crohn’s disease






Intestinal blockage caused by the thickening of the
intestinal wall due to swelling and scar tissue.
Ulcers
Fistulas (Tunnels in the affected area)– These can
often become infected.
Fissures
Impaired nutrient absorption which results in
protein, calories and vitamin deficiency.
Risk factor for colon cancer.
(National Digestive Diseases Information Clearinghouse
(NDDIC), 2013)
PATIENT CASE SCENARIO

Primary Medical Diagnosis


Crohn’s Disease
HPI
A forty-one year old woman presents to the ED with c/o
abdominal pain and n/v since colonoscopy performed on
2/3/14
 Reports pain as constant and 10/10
 Patient reports taking oxycodone every 6 hours for pain relief
at home
 Admitted to the ICU and scheduled for an exploratory
laparotomy with possible drainage of an abdominal abscess
and possible ileostomy


Past Medical History


Diagnosed with Crohn’s disease and Diverticulitis in 2012
History of ileostomy and ostomy reversal that has possibly
reopened
PATIENT CASE SCENARIO

Assessment





Febrile
Severe abdominal pain-10/10
Watery stool in ileostomy bag
Malnourished, weight of 78 lbs
Complaints of n/v
DIAGNOSIS
(MDGuidelines, 2009)
Colonoscopy:
Provides view of the entire colon
Tissue for biopsy and laboratory analysis
The presence of granulomas
(clusters of inflammatory cells)
confirm the diagnosis because they
only occur with Crohn’s disease
CT Scan:
Provides image of the whole bowel
Allows the doctor to see the location and
extent of the disease
Also checks for complications like partial
blockages, abscesses or fistulas
MRI:
Creates detailed images of organs and
tissues
Very useful in the diagnosis and
management of the disease
Capsule Endoscopy:
Swallow a capsule that has a camera in it
Takes pictures as it moves through the
digestive tract
The images are downloaded which can be
checked for signs of Crohn’s disease
(Mayo Clinic, 2011)
TREATMENT OVERVIEW

Medication Management (Mayo Clinic, 2011)



Surgery (Chandra & Moore, 2011)




Reduce inflammatory process that leads to exacerbation
Long-term remission through limiting complications
Symptom relief
Correction of disease complications
Restore individual’s health and function
Nutrition (Richman & Rhodes, 2013)




Diet low in animal fat30% of energy requirements
Avoid foods that are high in insoluble fiber
Avoid processed foods high in fat
Include supplemental Vitamin D and dairy products if
tolerated
TREATMENT (MAYBERRY, LOBO, FORD, &
THOMAS, 2013); (MAYO CLINIC, 2011)

Using monotherapy to encourage remission:

Corticosteroids


Budesonide


Useful in patients with a first presentation of the disease or a
single inflammatory exacerbation in a 12-month period
Less effective than traditional corticosteroids, but have fewer
adverse effects
5-aminosalicylate (5-ASA)

Less effective than the above drugs, but also with fewer
adverse effects
Not recommended for long-term use
 Effective for short-term treatment and to induce
remission

TREATMENT (MAYBERRY, LOBO, FORD, &
THOMAS, 2013); (MAYO CLINIC, 2011)

Immunosuppressant Drugs:

azathioprine or mercaptopurine
Suppress the immune system response which reduces the
inflammatory process
 Most commonly used immunosuppressant's for the treatment
of Crohn’s disease


Combined with corticosteroid or budesonide
therapy in patients that:
Have two or more inflammatory exacerbations in a 12month period
 Cannot be tapered off the corticosteroid therapy

TREATMENT (MAYBERRY, LOBO, FORD, &
THOMAS, 2013); (MAYO CLINIC, 2011)

Anti-Tumor Necrosis Factor-Alpha Therapy:

Infliximab and adalimumab


Neutralizes tumor necrosis factor-alpha in the bloodstream
and prevents inflammation
Treatment option for patients with severe Crohn’s
disease

Unresponsive to conventional therapy
TREATMENT (CHANDRA & MOORE, 2011)

Surgery may be indicated if:

The disease is not responsive to medication therapy

Treatment requires excessive steroid use

Complications from medications arise

Patients have difficulty with medication adherence
SURGERY OPTIONS (CHANDRA & MOORE, 2011)

Bowel Resection




Preferred surgery
Involves removing part of the diseased bowel
Healthy ends may be reconnected, or a stoma may be
created
Strictureplasty

Heineke-Mikulicz strictureplasty most commonly used


For stricture sites <5 cm
A longitudinal cut is made along the bowel which is then
sewn together transversely

Allows for the narrowed area of the bowel to be enlarged and
prevents bowel obstruction
PATIENT TREATMENT
Not currently taking any maintenance medications
 Patient was admitted into the ICU and was prepped
for an exploratory laparotomy

Drainage of pelvic abscess
 Resection of terminal ileum
 Ileostomy with Hartman’s pouch
 Dissection of fistula


Dietician reviewed patients chart and provided
information for nutritional supplements
NURSING DIAGNOSIS (NANDA)
 Alteration
in nutrition: Less than body
requirements R/T abdominal pain,
nausea &vomiting, diarrhea, and
decreased absorption of the intestines
AEB patient’s weight of 78 Ibs.
NCLEX QUESTION

1. The nurse is reviewing the record of a female
client with Crohn’s disease. Which stool
characteristics should the nurse expect to see
documented in the client’s record?
a. Diarrhea
b. Chronic constipation
c. Constipation alternating with diarrhea
d. Stools constantly oozing form the rectum
NCLEX ANSWER
NCLEX QUESTION

A)
B)
C)
D)
E)
Which area of the alimentary canal is the most
common location for Crohn’s disease?
Ascending colon
descending colon
sigmoid colon,
terminal ileum
rectum
REFERENCES
Chandra, R., & Moore, J. W. E., (2011). The surgical options and management of intestinal
Crohn’s disease. Indian Journal of Surgery, 73, 432-438.
Mayberry, J. F., Lobo, A., Ford, A.C., & Thomas, A. (2012). NICE clinical guidelines (CG152):
The management of Crohn’s disease in adults, children, and young people. Alimentary
Pharmacology & Therapeutics, 37, 195-203.
Mayo Clinic (2011, August 9). Diseases and conditions: Crohn’s disease. Retrieved from
http://www.mayoclinic.org/diseases-conditions/crohns-disease/basics/definition/CON20032061
MDGuidelines (2009, April). Crohn’s disease. Retrieved from
http://www.mdguidelines.com/crohns-disease
National Digestive Diseases Information Clearinghouse (NDDIC) (2013, July). Retrieved 2014,
from NIDDK: National Institute of Diabetes and Digestive and Kidney Diseases:
http://digestive.niddk.nih.gov/ddISeases/pubs/crohns/#causes
Rendi, M. M. (2013, July). Crohn disease pathology. Retrieved from Medscape:
http://emedicine.medscape.com/article/1986158-overview
Richman, E., & Rhodes, J. M. (2013). Review article: Evidence-based dietary advice for patients
with inflammatory bowel disease. Alimentary Pharmacology & Therapeutics, 38, 11561171.