CROHNS

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-20s)

& elderly (60-70s)

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

Crohns 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 Crohns
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 Crohns 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

Crohns 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 Crohns 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 Crohns 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 Crohns 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 individuals health and function

Nutrition (Richman & Rhodes, 2013)

Diet low in animal fat30% 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 Crohns 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 Crohns

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 Hartmans 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 patients weight of 78 Ibs.

NCLEX QUESTION

1. The nurse is reviewing the record of a female

client with Crohns disease. Which stool
characteristics should the nurse expect to see
documented in the clients 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 Crohns 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
Crohns 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 Crohns disease in adults, children, and young people. Alimentary
Pharmacology & Therapeutics, 37, 195-203.
Mayo Clinic (2011, August 9). Diseases and conditions: Crohns disease. Retrieved from
http://www.mayoclinic.org/diseases-conditions/crohns-disease/basics/definition/CON20032061
MDGuidelines (2009, April). Crohns 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.