Chron's Disease Report

8/2/2019 Chron's Disease Report

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Presented By:

Guio Bien R. Bautista


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Introduction Crohns Disease is an idiopathic, chronic, transmuralinflammatory process of the bowel that can affect anypart of the gastro intestinal tract from the mouth to

the anus.

Most cases involve the small bowel, particularly theterminal ileum


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History

1806: First reported case of Crohns by Combe andSanders to the Royal College of Physicians inLondon, England

1913: Surgical evidence of the disease reported in the

paper Chronic Intestinal Enteritis written by Dr.Kennedy Dalziel at the Western Infirmary inGlasgow

Described in 1932 by Crohn, Ginsburg, andOppenheimer of Mount Sinai Hospital in New York


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Prevalence Higher number of cases of Crohns disease found in

western industrialized nations.

Males and females are equally affected.

Smokers are three times more likely to develop Crohn's

disease. Crohn's disease affects between 400,000 and 600,000

people in North America.

Prevalence estimates for Northern Europe have ranged

from 2748 per 100,000. Crohn's disease tends to present initially in the teens

and twenties.


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ClassificationCrohn's disease can be categorized by the area of

the gastrointestinal tract which it affects: Ileocolic Crohn's disease: Affects both the

ileum and the large intestine (50%)

Crohn's ileitis: Affects the ileum only (30%)Crohn's colitis: Affects the large intestine,

accounts for the remaining twenty percent of

cases.


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Distribution of gastrointestinal Crohn's disease data from

American Gastroenterological Association


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ClassificationCrohn's disease may also be categorized by the behavior

of disease as it progresses: Stricturing disease causes narrowing of the bowel

which may lead to bowel obstruction or changes in thecaliber of the feces.

Stricturing


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Classification

Penetrating disease creates abnormal passage ways between the bowel

and other structures such as the skin.

Inflammatory disease causes inflammation without causing stricturesor fistulae.

Inflammatory Penetrating


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Endoscopy image of colon showing serpiginous ulcer in

Crohn's disease


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Causes ofCrohns DisaeseGenetics

The disease runs in families then 30 times more likely todevelop CD.

Mutations in the NOD2 /CARD15 gene are associated withCrohn's disease.

Over 30 genes that show genetics play a role in the disease,either directly through causation or indirectly as with amediator variable.

Anomalies in the XBP1 gene have recently been identified

as a factor, pointing towards a role for the unfolded proteinresponse pathway of the endoplasmatic reticulum ininflammatory bowel diseases.

NOD2 : nucleotide-binding oligomerization domain containing 2

CARD15 :Cathapse Activation Recruitment Domain


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Environmental Factors Smoking has been shown to increase the risk of the return of active

disease, or "flares".

Hormonal contraception in the US in the 1960s is linked with adramatic increase in the incidence rate of Crohn's disease.

Immune System Crohn's disease is thought to be an autoimmune disease, with

inflammation stimulated by an over-active Th1 cytokine response.

Recent gene to be implicated in Crohn's disease is ATG16L1, which mayinduce autophagy and hinder the body's ability to attack invasivebacteria.


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Microbes

A.V. Singh et al. have suggested that Mycobacterium avium

subspecies paratuberculosis plays a role in Crohn's disease and itcauses a very similar disease, Johne's disease, in cattle.

A study in 2003 put forth the "cold-chain" hypothesis, thatpsychrotrophic bacteria such as Yersinia spp and Listeria sppcontribute to Crohns disease.

Mycobacterium avium subspecies paratuberculosis coloniesfrom stool sample ofCrohns disease patient


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Prevalence

Males and females are equally affected. Smokers are two times morelikely to develop Crohn's disease than nonsmokers.

Crohn's disease affects between 400,000 and 600,000 people in North

America. Prevalence estimates for Northern Europe have ranged from2748 per 100,000.

Crohn's disease tends to present initially in the teens and twenties,with another peak incidence in the fifties to seventies, although the

disease can occur at any age.


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The Digestive System

and

Anatomy and Physiology of theSmall Intestine
http://../Videos/The%20digestion%20process%20-%20What%20happens%20to%20your%20food%20as%20it%20travels%20through%20your%20body%20until%20it%20exits%20.mp4http://../Downloads/DIGESTION%20ANATOMY%20A&P%20II.ppthttp://../Downloads/small-intestine.pdfhttp://../Downloads/small-intestine.pdfhttp://../Downloads/DIGESTION%20ANATOMY%20A&P%20II.ppthttp://../Videos/The%20digestion%20process%20-%20What%20happens%20to%20your%20food%20as%20it%20travels%20through%20your%20body%20until%20it%20exits%20.mp4http://../Downloads/small-intestine.pdfhttp://../Downloads/DIGESTION%20ANATOMY%20A&P%20II.ppthttp://../Videos/The%20digestion%20process%20-%20What%20happens%20to%20your%20food%20as%20it%20travels%20through%20your%20body%20until%20it%20exits%20.mp4


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Pathophysiology

Crohn's disease shows a transmural pattern ofinflammation, meaning that the inflammation may spanthe entire depth of the intestinal wall.

Ulceration is an outcome seen in highly active disease.

Inflammation is characterized by focal infiltration ofneutrophils, a type of inflammatory cell, into theepithelium.


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Pathophysiology of Inflammatory Bowel Disease/CD


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Section of Colectomy Showing Transmural Inflammation


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Gastrointestinal SymptomsAbdominal pain accompanied by diarrhoea(may or

may not be bloody), flatulence, bloating, perianaldiscomfort .

People who have had surgery often end up with shortbowel syndrome of the gastrointestinal tract.

Ileitis results in large volume watery feces & colitisresult in a smaller volume of feces of higher frequency.

In severe cases, an individual may have more than 20bowel movements per day and may need to awaken atnight to defecate.

The mouth may be affected by non-healing sores(aphthous ulcers).

Difficulty in swallowing (dysphagia).


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Systemic Symptoms Up to 30% of children with Crohn's disease have

retardation of growth. Among older individuals, Crohn's disease may manifest as

weight loss related to decreased food intake

People with extensive small intestine disease also havemalabsorption of carbohydrates or lipids, which canfurther exacerbate weight loss.


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Extraintestinal Symptoms

Inflammation of the interior portion of the eye, known as

uveitis, can cause eye pain & the white part of the eye, acondition called episcleritis.

Episcleritis Uveitis


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Crohn's disease is associated with seronegativespondyloarthropathy ;inflammation of joints or muscle,osteoporosis,neurological complications like seizures, myopathy,peripheral neuropathy .

Ankylosing spondylitis include painful, warm, swollen, stiffjoints and loss of joint mobility or function.

Ankylosing spondylitis


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Erythema nodosum, presents as red nodules on the shins is due toinflammation of the underlying subcutaneous tissue and is

characterized by septal panniculitis.

Erythema nodosum on the back and leg of a person with Crohn's Disease



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Pyoderma gangrenosum, is typically a painful ulcerating nodule.

Crohn's disease also increases the risk of blood clots; painfulswelling of the lower legs can be a sign of deep venous

thrombosis. Difficult breathing may be a result of pulmonary embolism.Autoimmune hemolytic anemia, a condition in which theimmune system attacks the red blood cells.

Pyoderma gangrenosum on the leg of a person with Crohn'sDisease

ExtraintestinalSymptoms


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Clubbing, a deformity of the ends of the fingers, also be a

result of Crohn's disease.


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Complications

Crohn's disease can lead to several mechanicalcomplications within the intestines, includingobstruction, fistulae, and abscesses.

Obstruction: Occurs from strictures or adhesionswhich narrow the lumen, blocking the passage of theintestinal contents.

Fistulae: Develop between two loops of bowel,between the bowel and bladder, between the boweland vagina, and between the bowel and skin.

Abscesses: Collections of infection, which can occurin the abdomen or in the perianal area in Crohn'sdisease sufferers.


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Endoscopic image of colon cancer identified in the

sigmoid colon on screening colonoscopy for Crohn's

disease.


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Diagnosis

Crohn's disease does not diagnose with complete certainty.

A colonoscopy is 70% effective in diagnosing the disease viadirect visualization of the colon and the terminal ileum.

Capsule endoscopy help in endoscopic diagnosis.

30% of Crohn's disease involves only the ileum,

cannulation of the terminal ileum is required in makingthe diagnosis.


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CT scan showing Crohn's disease in the fundus of the stomach

Endoscopic image of Crohn's colitis showing deepulceration


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Radiologic Tests

A barium X-ray where barium sulfate suspension isingested and fluoroscopic images of the bowel are taken tocheck inflammation and narrowing of the small bowel.

Identifying anatomical abnormalities when strictures ofthe colon are too small for a colonoscope to pass through,or in the detection of colonic fistulae.


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Blood Tests

A complete blood count may reveal anemia caused eitherby blood loss or vitamin B12 deficiency.

Erythrocyte sedimentation rate(ESR) and C-reactiveprotein measurements can also be useful to check thedegree of inflammation.

Testing for anti-Saccharomyces cerevisiae antibodies(ASCA) and anti-neutrophil cytoplasmic antibodies(ANCA) has been evaluated to identify inflammation ofthe intestine.


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Crohn's Disease & Ulcerative Colitis

Ulcerative colitis mimics the symptoms of Crohn's disease,as both are inflammatory bowel diseases that can affect thecolon.

Sometimes its not possible to tell the difference, in those

case the disease is classified as indeterminate colitis.


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Comparisons of Various Factors in Crohn's Disease & Ulcerative Colitis

Crohn's disease Ulcerative colitisTerminal ileum involvement Commonly SeldomColon involvement Usually Always

Rectum involvement Seldom Usually

Involvement around the anus Common Seldom

Bile duct involvementNo increase in rate of primary

sclerosing cholangitisHigher rate

Distribution of Disease

Patchy areas of inflammation (Skip

lesions) Continuous area of inflammation

EndoscopyDeep geographic and serpiginous

(snake-like) ulcersContinuous ulcer

Depth of inflammationMay be transmural, deep into

tissuesShallow, mucosal

Fistulae Common Seldom

Autoimmuue diseaseWidely regarded as an autoimmune

diseaseNo consensus

Cytokine response Associated with Th17 Vaguely associated with Th2

Granulomas on biopsyMay have non-necrotizing non-peri-

intestinal crypt granulomas

Non-peri-intestinal crypt

granulomas not seen

Surgical cure Often returns following removal ofaffected part

Usually cured by removal of colon


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Treatment

Remission may be prolonged in Crohns disease. Symptoms controlled with medication, lifestyle changes

and surgery because there is still no cure for Chronsdisease .

Adequately controlled Crohn's disease may notsignificantly restrict daily living.

Treatment for Crohn's disease is only when symptoms areactive and involve first treating the acute problem, thenmaintaining remission.


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Medication

Antibiotics use to reduce inflammation .

Prolonged use of corticosteroids has significant side.

Alternatives include aminosalicylates alone, though only aminority are able to maintain the treatment, and many

require immunosuppressive drugs.


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Medicine Used in Treatment of Crohn's Disease

Anti-inflammatory agents : such as 5-aminosalicylic acid (5-ASA) -Sulfasalazine

(Azulfidine), Asacol

Corticosteroids such as

Prednisone and methylprednisolone

Immunomodulators

such as azathioprine, mercaptopurine, methotrexate,infliximab, adalimumab.

Antibiotics

such as metronidazole (Flagyl) and ciprofloxacin (Cipro)that decrease inflammation by an unknown mechanism


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Surgery

Crohn's cannot be cured by surgery. Surgery required in case of obstructions, fistulas and/or

abscesses, or if the disease does not respond to drugs. After the first surgery, Crohn's usually shows up at the site

of the resection though it can appear in other locations. After a resection, scar tissue builds up which can cause

strictures. A stricture is when the intestines become too small to allow

excrement to pass through easily which can lead to a

blockage. For patients with an obstruction due to a stricture, two

options for treatment are strictureplasty and resection ofthat portion of bowel.


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Management of Crohn's Disease: Diagnosed by Clinical Evaluation,

Radiographic Studies, Endoscopy, Laboratory Tests and Stool Studies


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Nursing Interventions

Monitor frequency and consistency of stools to evaluate volume lossesand effectiveness of therapy.

Monitor dietary therapy; weigh the patient daily.

Monitor electrolytes, especially potassium. Monitor intake and output.Monitor acid-base balance because diarrhea can lead to metabolicacidosis.

Monitor for distention, increased temperature, hypotension, and rectalbleeding; all signs of obstruction caused by inflammation.

Observe and record changes in pain, especially frequency, location,characteristics, precipitating events, and duration.

Offer understanding, concern, and encouragement because patient isoften embarrassed about frequent and malodorous stools, and oftenfearful of eating.


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Nursing Interventions

Have patient participate in meal planning to encouragecompliance and increase knowledge.

Encourage patients usual support persons to be involved inmanagement of the disease.

Provide small, frequent feedings to prevent distention ofthe gastric pouch. Diet is low in residue, fiber, and fat; highin calories, protein, vitamins, and minerals.

Provide fluids as directed to maintain hydration (1,000mL/24 hours minimum intake to meet body fluid needs).

Clean rectal area and apply ointments as necessary todecrease discomfort from skin breakdown.

Facilitate supportive counseling, if appropriate.


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Lifestyle Changes

Dietary adjustments, proper hydration and smokingcessation reduce symptoms.

Have a balanced diet with proper portion control & eatsmall meals frequently instead of big meals.

Do regular exercise and take enough sleep.

Identifying foods that trigger symptoms.


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Diet for Crohn's Disease

Drink lots of fluid to keep body hydrated and preventconstipation.

Take multivitamin-mineral supplement to replace lostnutrients .

Eat a high fiber diet when CD is under control.

During a flare up, limit high fiber foods and follow a lowfiber diet.

Avoid lactose-containing foods if one has lactoseintolerance or use lactase enzymes and lactase pretreatedfoods.

Try small frequent meals.

Eating a high protein diet with lean meats, fish and eggs,may help relieve symptoms ofCrohns.


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Diet for Crohn's Disease

Take pre-digested nutritional drinks to give bowel a rest andreplenish lost nutrients.

Limit caffeine, alcohol and sorbitol . Limit gas-producing foods such as broccoli, cabbage, cauliflower,

brussels sprouts, dried peas ,lentils, onions, and carbonated

drinks. Reduce fat intake if part of the intestines has been surgically

removed. If the ileum has been resected, a Vitamin B12 injection may be

required.

Studies found that fish oil and flax seed oil may be helpful inmanaging . The role of prebiotics such as psyllium & probiotics helpful in

the healing process.


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Dietary Management in Crohns Disease

Complex Carbohydrates

Patients should select complex carbohydrates, whichare also a good source of fiber.

Fresh fruit such as apples, grapefruit, oranges, plums,

blueberries, raspberries, and strawberries might beprotective for Crohns disease.

Simple sugars can increase inflammation.

High-fiber foods can cause gas, bloating, and pain in

Crohns disease patients. Commercial products Beano are available that can

reduce gas.


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Proteins in Crohns Disease Proteins are very important for growth in children and for

repair of cells.

Diarrhoea can cause protein deficiency so Crohns patientsmay need more protein.

One study reported that a soy protein diet was useful forpatients who were intolerant to milk products.

Oily fish, such as salmon and tuna, poultry & lean meatsmay be particularly beneficial in Crohns disease.


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Oils in Crohns Disease Omega-3 fatty acids are important compounds for Crohns disease.

A study showed that the palmitic acid absorption-oxidation observed

for the Crohns patients increased from 4.41.1% before the treatmentperiod to 7.61.1% after treatment.

This compares favourably with Watkins et al. who found that 2.11.5%of the administered dose of palmitic acid was excreted in breath over 6h for patients with mucosal disorders compared to 6.6 2.4% for

normal subjects. A study by Andersson et al. investigated patients with Crohns disease,

most of whom had been subjected to ileal resection, and compared theeffect of a low fat (40 g/day) versus a high fat (100 g/day) diet.

The general condition of the patients improved when consuming the

low fat diet, including diarrhoea, steatorrhea and electrolyte balance. Weight gain was observed even though the fat intake was significantly

reduced from the mean 150 g reported in home use.

Nutrient Importance in a Crohns Disease Diet


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Nutrient Importance in a Crohns Disease Diet

Crohn's disease patients are in danger of becoming

malnourished. The following are several reasons toconsider these findings:

Poor digestion and malabsorption of dietary fats,carbohydrates, water, protein, minerals and vitamins.

During disease flare-ups chronic disease patients usuallywill increase levels of energy and caloric needs for the body.

Symptoms of abdominal pain, nausea, or lacking tastesensations will have an ill affect on food intake resulting in

loss of appetite.


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Food Absorption

Food absorption is a huge issue when it comes to

patients with Crohns Disease. People that have inflammation only in the large

intestine most often absorb food normally.

Over 40 percent of individuals diagnosed withCrohns showed that they can eat enough food butcant absorb food adequately, especiallycarbohydrates.


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Vitamin and Mineral Deficiencies

Absorption of vitamin and minerals vary depending on type and locationof the disease.

Individuals that have Crohns disease where the ileum is affected may havea vitamin B12 deficiency due to that they are unable to absorb enough of theB12 vitamin from oral supplements or food intake.

One of the most common deficiency associated with the common Crohns

Disease Diet and which affects about sixty-eight percent, is the lack ofvitamin D, which supports bone formation and calcium metabolism. Deficiency of the iron in patients with Ulcerative Colitis and Crohns

Disease is also common due to the loss of blood,inflammation andulceration of the colon.

Potassium and magnesium deficiency occur due to diarrhoea orvomiting.

Trace element deficiencies are normally present in those with poornutritional intake and have and extensive small intestine disease.


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Foods to Avoid

People with Crohn's disease find that there are certain foods that seem to make theirsymptoms worse. These include:

Dairy products

Spicy foods

Chocolate

Caffeinated beverages, such as coffee, teas, and some soft drinks

Alcoholic beverages

Certain raw fruits and vegetables If raw fruits and vegetables cause problem then try cooked or find other fruits and

vegetables that don't make the symptoms worse. Some other foods that make thesymptoms worse in some people include:

Popcorn

Fruit juices

Beans

Onions

Artificial sweeteners, such as sorbitol or mannitol

High-fat foods such as butter, red meat, avocados, nuts, and fried foods.


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Complementary and Alternative Medicine

Crohn's disease sufferers have tried complementary or

alternative therapy.These include diets, probiotics, fish oil andother herbal and nutritional supplements.

Acupuncture is used to treat inflammatory bowel disease inChina, and is being used more frequently in Western society.

Methotrexate is a folate anti-metabolite drug which is also usedfor chemotherapy.

Metronidazole and ciprofloxacin are antibiotics which are usedto treat Crohn's disease.

Thalidomide has shown response in reversing endoscopic

evidence of disease. Canabis derived drugs may be used to treat Crohn's disease with

its anti-inflammatory properties.

Probiotics include Sacchromyces boulardii and E. coli.


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Chron's Disease Report