CHRONIC INFLAMMATORY BOWEL DISEASE Regional Enteritis (Crohn's Disease)
Crohn's Disease is a chronic idiopathic inflammatory disease, that can affect any part of the GI tract, usually the small and large intestines.
Other names: Regional enteritis/granulomatous colitis, transmural colitis, ileitis and ileocolitis.
Causes
Exact cause is unknown. It is thought to be multifactorial.
a. Genetic predisposition
b. Environmental agents may trigger the disease (infectious viral or bacterial overload) or dietary factors.
c. Immunologic imbalance or disturbances.
d. Defect in intestinal barrier - increases permeability of the bowel
e. Defect in the repair of mucosal injury - chronic condition
f. Cigarette smoking- increases exacerbations
Incidence: May occur at any age, mostly between 15 and 35 years of age. Highest incidence with Caucasians of Jewish descent.
Pathophysiology
Inflammation (subacute & chronic) extends through the intestinal mucosa.
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Ulcers enlarge, deepen and form transverse and longitudinal linear ulcers that intersect (cobblestone appearance)
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Formation-fissures, abscesses and fistulae. Healing and fibrosis of these lesions
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Stricture (obstruction)
Clinical Manifestations
May be abrupt or insidious.
1. Crampy pain-right lower quadrant.
2. Chronic diarrhoea-soft or semiliquid. Bloody stools or steatorrhea (due to malabsorption) may occur
3. Fever, faecal urgency and tenesmus
4. Palpable right lower quadrant fullness or mass.
Diagnostic Evaluation
1. CBC may show mild leucocytosis, thrombocytosis, anaemia.
2. Elevated ESR, hypoalbuminemia
3. Stool analysis may reveal leukocytes.
4. Barium study of the upper GI tract reveals the classic "string sign" on the x-ray of the terminal ileum, indicating the constriction of a segment of intestine.
5. Bowel sounds hyperactive over the right lower quadrant.
6. Barium enema may permit visualization of lesions in the large intestine and terminal ileum.
7. CT of the abdomen and pelvis used to evaluate complications abscess or fistula.
8. Colonoscopy procedure of choice
Management
- Well balanced, low residue, high-protein diets with supplemental vitamin therapy and iron replacement helps to meet nutritional needs,
- Intravenous therapy to correct fluid and electrolyte imbalance due to dehydration caused by diarrhoea.
- Cold foods, smoking to be avoided because they increase intestinal motility
- Untolerated foods are avoided and a low residue diet may be indicated
- Sedation and antidiarrheal/anti peristaltic medications reduce the colonic peristalsis to a minimum to rest the inflammed bowel.
- 5- Amino salicylic acid (5-ASA, Asacol, Pentasa, Dipentum) 1" line of drug. Has an anti-inflammatory effects
- Sulfonamides such as sulfasalazine (Azulfidine) or sulfisoxazole (Gautrisin) are effective for mild or moderate inflammation.
- Antibiotics (Flagyl, Cipro) (perforation/peritonitis and abscess). used for secondary infection.
- Corticosteroids reduce inflammation depending on the severity of disease Prednisone, Budesonide (PO), Solu-medrol (IV) Cortenema (retention enema).
- Immunomodulators (6 mercaptopurine, azothioprine, methotrexate) used in patients who are steroid dependent.
- Others antispasmodics (Bentyl), bulking agents (Citrucel, metamucil) tricyclic antidep (Elavil) for treatment of abdominal pain.
- Infliximab (Remicade) new drug, a monoclonal antibody) that blocks the activity of inflammatory agent. Indicated for moderate to severe disease not responding to traditional therapies.
Surgical Management
Indicated only for the complications of Crohn's disease. The surgical operation include:
- 1. Segmental colectomy (removal of a segment of the colon) with colocolonic anastomosis (joining of the remaining portions of the colon).
- 2. Subtotal colectomy (removal of nearly all the colon with ileorectal anastomosis (joining of the ileum and rectum):
- 3. Total colectomy (excision of the entire colon) with ileostomy (surgical excision of an opening into the ileum, usually by means of an ileal stoma on the abdominal wall.
Complications
- Abscess & fistulae.
- Strictures (may result from inflammation, edema, abscess, adhesions, but usually from fibro stenosis
- Haemorrhage, bowel perforation, intestinal obstruction.
- Nutritional deficiencies.
- Dehydration and electrolyte disturbances.
- Peritonitis and sepsis.
- Increased risk of small bowel and colorectal cancer.
Nursing Management
- Encourage a diet that is low in residue, fibre and fat and high in calories, protein and carbohydrates with vitamin and mineral supplements.
- Monitor weight daily.
- Provide small, frequent feedings to prevent distention.
- Monitor intake and output
- Provide fluids as prescribed to maintain hydration.
- Monitor stool frequency and consistency.
- Monitor electrolytes (esp. K) and acid-base balance, because diarrhoea can lead to metabolic acidosis.,
- Watch for cardiac dysrhythmias and muscle weakness due to loss of electrolytes.
- Administer medications for the control of inflammatory process, as prescribed.
- Observe and record changes in pain (frequency, location, characteristics, precipitating events and duration).
- Monitor for distention, increased temperature, hypotension and rectal bleeding)
- Clean rectal area and apply-ointments as necessary to decrease discomfort from skin breakdown.
- Prepare patient for surgery if response to medical and drug therapy is unsatisfactory.
- Offer understanding, concern and encouragement this person is often embarrassed about frequent and malodorous stools and often is fearful of eating.
