DIPOLOG MEDICAL CENTER COLLEGE FOUNDATION INC.

College of Nursing

A
CASE STUDY
OF
CROHN’S DISEASE (REGIONAL ENTERITIS)

Submitted by:
Tiffany Luv B. Adrias
BSN III - Orlando

Submitted to:
Maridol Claro
INSTRUCTOR
 CONTENTS

A. Introduction

B. Terminologies

C. Anatomy and Physiology

D. Pathophysiology

E. Nursing Care Plan

F. Discharge Instructions (Methods) Style

G. Drug Study

H. Readings r/t Digestive Cases / Articles Summary and Reaction

I. General Evaluation including Laboratory / Diagnostic Tests

INTRODUCTION

Regional enteritis commonly occurs in adolescents or young adults but can appear at any
time of life. It is more common in women, and it occurs frequently in the older population
(between the ages of 50 and 80). It can occur anywhere along the GI tract, but the most
common areas are the distal ileum and colon. The incidence of Crohn’s disease has risen over
the past 30 years. Crohn’s disease is seen two times more often in patients who smoke than in
nonsmokers.

In regional enteritis, the onset of symptoms is usually insidious, with prominent lower right
quadrant abdominal pain and diarrhea unrelieved by defecation. Scar tissue and the
formation of granulomas interfere with the ability of the intestine to transport products of the
upper intestinal digestion through the constricted lumen, resulting in crampy abdominal pains.
There is abdominal tenderness and spasm. Because eating stimulates intestinal peristalsis, the
crampy pains occur after meals. The result is weight loss, malnutrition, and secondary anemia.
Ulcers in the membranous lining of the intestine and other inflammatory changes result in a
weeping, swollen intestine that continually empties an irritating discharge into the colon.
Disrupted absorption causes chronic diarrhea and nutritional deficits. The result is a person
who is thin and emaciated from inadequate food intake and constant fluid loss. In some
patients, the inflamed intestine may perforate, leading to intra-abdominal and anal
abscesses. Fever and leukocytosis occur. Chronic symptoms include diarrhea, abdominal pain,
steatorrhea, anorexia, weight loss, and nutritional deficiencies. Abscesses, fistulas, and fissures
are common. Symptoms extend beyond the GI tract and commonly include joint involvement
(eg, arthritis), skin lesions (eg, erythema nodosum), ocular disorders (eg, conjunctivitis), and
oral ulcers.

Complications of regional enteritis include intestinal obstruction or stricture formation,

perianal disease, fluid and electrolyte imbalances, malnutrition from malabsorption, and
fistula and abscess formation. A fistula is an abnormal communication between two body
structures, either internal or external. The most common type of small bowel fistula that results
from regional enteritis is the enterocutaneous fistula. Abscesses can be the result of an internal
fistula tract into an area that results in fluid accumulation and infection. Patients with regional
enteritis are also at increased risk for colon cancer.
TERMINOLOGIES

Crohn’s disease - a type of inflammatory bowel disease (IBD). It causes

inflammation of your digestive tract, which can lead to abdominal pain, severe

diarrhea, fatigue, weight loss and malnutrition.

Crypt abscess- a collection of specialized immune cells called neutrophils inside the

colon. It is an example of acute inflammation and is often seen in a condition called

active colitis.

Perinuclear anti-neutrophil cytoplasmic antibody test (pANCA) - test measures the

amount of peripheral antineutrophil cytoplasmic antibodies (p-ANCA) in blood.

Steatorrhea - an increase in fat excretion in the stools. Steatorrhea is one of the

clinical features of fat malabsorption and noted in many conditions such as exocrine

pancreatic insufficiency (EPI), celiac disease, and tropical sprue.

Transmural inflammation - sectional interruption or loss of the five-layer structure.

ANATOMY AND PHYSIOLOGY

LARGE INTESTINE
The large intestine is approximately 1.5m long and comprises the caecum, colon,
rectum, anal canal and anus (Fig 1). The structure of the large intestine is very
similar to that of the small intestine (see part 4), except that its mucosa is
completely devoid of villi.
Caecum and appendix
Chyme that has not been absorbed by the time it leaves the small intestine
passes through the ileocaecal valve and enters the large intestine at the caecum.
On receipt of the contents of the ileum, the caecum continues the absorption of
water and salts. The caecum is about 6cm long and extends downwards into the
appendix, a winding tubular sac containing lymphoid tissue. The appendix is
thought to be the vestige of a redundant organ; its narrow and twisted shape
makes it an attractive site for the accumulation and multiplication of intestinal
bacteria.
Colon
At its other end, the caecum seamlessly joins up with the colon, this is the longest
portion of the large intestine (Fig 1). Food residue starts by travelling upwards through
the ascending colon, located on the right side of the abdomen. The ascending colon
bends near the liver at the right colic flexure (or hepatic flexure) and becomes the
transverse colon, passing across to the left side of the abdomen. Just above the spleen
at the left colic flexure (or splenic flexure), the transverse colon becomes the
descending colon, which runs down the left side of the abdomen. Before the next bend,
the descending colon transforms into the sigmoid colon.

Rectum, anal canal and anus

The large intestine opens into the rectum, which is continued by the anal canal.
The rectum forms the final 20cm of the GI tract. It is continuous with the sigmoid
colon and connects with the anal canal and anus (Fig 2, page 52). The rectum
ends in an expanded section called the rectal ampulla, where faeces are stored
before being released; the rectum is usually empty since faeces are not normally
stored there for long. The anal canal located in the perineum (outside the
abdominopelvic cavity), is 3.8-5cm long and opens to the exterior of the body at
the anus (Fig 2). It has two sphincters:
 Internal anal sphincter, which is controlled by involuntary muscles;
 External anal sphincter, which is made of skeletal muscle and is under
voluntary control.
 Except during defecation, both anal sphincters normally remain closed.
 PATHOPHYSIOLOGY

Triggering Events

Dysregulated inflammatory and immune response in genetically susceptible persons

Amplification of immune response

Release of inflammatory mediators

Mucous breakdown and continuous exposure to lumen dietary or bacterial antigens

Impaired handling of microbial antigens by the immune system

Inflammation

Inflammation + subsequent injury of tissue (cryptitis)

Crypt abscess influx + epithelial necrosis

Focal aphthoid ulceration

Influx and proliferation of inflammatory mediators

Transmural inflammation
Lymphedema and bowel wall thickening

CROHN’S DISEASE
 NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Encourage patient to
Objective: Acute Pain After 8 hours of report pain. After 8 hours of nursing
related to nursing Assess reports of interventions, the goal
cramping hyperperistalsi interventions, the abdominal cramping or was met. The patient
abdominal pain s, prolonged patient will report pain, noting location, reported pain is
abdominal diarrhea, pain is duration, intensity (0–10 relieved/controlled and
guarding skin/tissue relieved/controlle scale). Investigate and the patient appears
irritation,
distraction d and the patient report changes in pain relaxed and was able to
perirectal
behaviors will appear to be characteristics sleep/rest appropriately.
excoriation,
restlessness fissures, relaxed and able Note nonverbal cues
facial mask of fistulas as to sleep/rest (restlessness, reluctance
pain. evidenced by appropriately. to move, abdominal
cramping guarding, withdrawal,
abdominal and depression).
T: 36.9°C pain, Investigate
PR: 80 bpm Guarding/distr discrepancies between
RR: 17cpm action verbal and nonverbal
BP: 120/80mmHg behaviors, cues.
restlessness, Review factors that
and facial aggravate or alleviate
mask of pain pain.
Encourage patient to
assume position of
comfort (knees flexed).
Provide comfort
measures (back rub,
reposition) and
diversional activities.
Cleanse rectal area with
mild soap and water or
wipes after each stool
and provide skin
care (A&D ointment,
Sween ointment, karaya
gel, Desitin, petroleum
jelly).
Provide sitz bath as
appropriate.
Observe for ischiorectal
and perianal fistulas.
DISCHARGE INSTRUCTIONS (METHODS) STYLE

What to Expect at Home

 After a flare-up of your Crohn’s disease, you may be more tired and have less energy
than before. This should get better. Ask your health care provider about any side effects
from your new medicines. You should see your provider regularly. You may also need
frequent blood tests, especially if you are on new medicines.
 If you went home with a feeding tube, you will need to learn how to use and clean the
tube and your skin where the tube enters your body.

 When you first go home, you may be asked to drink only liquids or eat different foods
from what you normally eat. Ask your provider when you can start your regular diet. You
should eat a well-balanced, healthy diet. It is important that you get enough calories,
protein, and important nutrients from a variety of food groups.

 Certain foods and drinks can make your symptoms worse. These foods may cause
problems for you all the time or only during a flare-up. Avoid foods that make your
symptoms worse.
 If your body does not digest dairy foods well, limit dairy products. Try low-lactose
cheeses, such as Swiss and cheddar, or an enzyme product, such as Lactaid, to help break
down lactose. If you must stop eating dairy products, talk with a dietitian about getting
enough calcium. Some experts believe that you should avoid dairy products altogether
until you are tolerating your regular diet.

 Too much fiber may make your symptoms worse. Try baking or stewing fruits and
vegetables if eating them raw bothers you.
 Avoid foods that are known to cause gas, such as beans, spicy food, cabbage, broccoli,
cauliflower, raw fruit juices, and fruit (especially citrus fruits). Avoid or limit alcohol and
caffeine. They may make your diarrhea worse.
 Eat smaller meals, and eat more often. Drink plenty of liquids.
 Ask your provider about extra vitamins and minerals you may need, including:
 Iron supplements (if you are anemic)
 Nutrition supplements
  Calcium and vitamin D supplements to help keep your bones strong
 Vitamin B-12 shots, to prevent anemia
 Talk with a dietitian, especially if you lose weight or your diet becomes very limited.

 You may feel worried about having a bowel accident, embarrassed, or even feel sad or
depressed. Other stressful events in your life, such as moving, job loss, or the loss of a
loved one, can cause problems with your digestion.

 These tips may help you manage your ulcerative colitis:

 Join a support group. Ask your provider about groups in your area.
 Exercise. Talk with your provider about an exercise plan that is right for you.
 Try biofeedback to reduce muscle tension and slow your heart rate, deep breathing
exercises, hypnosis, or other ways to relax. Examples include doing yoga, listening to
music, reading, or soaking in a warm bath.
 See a mental health care provider for help if necessary.

Drug Treatments
 Your provider may give you some medicines to help relieve your symptoms. Based on how
severe your ulcerative colitis is and how you respond to treatment, you may need to take
one or more of these medicines:
 Anti-diarrhea drugs can help when you have very bad diarrhea. You can buy loperamide
(Imodium) without a prescription. Always talk to your provider before using these drugs.
 Fiber supplements may help your symptoms. You can buy psyllium powder (Metamucil) or
methylcellulose (Citrucel) without a prescription.
 Always talk to your provider before using any laxative medicines.
 You may use acetaminophen (Tylenol) for mild pain. Drugs such as aspirin, ibuprofen
(Advil, Motrin), or naproxen (Aleve, Naprosyn) may make your worse. Talk to your
provider before taking these medicines. You may also need a prescription for stronger
pain medicines.
 There are many types of drugs your provider may use to prevent or treat attacks of your
Crohn’s disease.
When to Call the Doctor
Call your provider if you have:
 Persistent or recurring cramps or pain in your lower stomach area

 Bloody diarrhea, often with mucus or pus

 Diarrhea that cannot be controlled with diet changes and drugs

 Weight loss (in everyone) and failure to gain weight (in children)

 Rectal bleeding, drainage, or sores

 Fever that lasts more than 2 or 3 days, or a fever higher than 100.4°F (38°C)
without an explanation

 Nausea and vomiting that lasts more than a day

 Skin sores or lesions that do not heal

 Joint pain that keeps you from doing your everyday activities

 Side effects from any drugs prescribed for your condition

 DRUG STUDY

Mechanism of
Drug Indications Contraindications Side effects Nursing considerations
Action
Generic Name: Inhibits inflammatory Indicated for Hypersensitivity to CNS: Amnesia, Use budesonide cautiously
cells and mediators, the treatment and budesonide or its asthenia, benign if patient has tubercular
Budesonide
possibly by maintenance of mild components, recent intracranial infection; untreated fungal,
Brand Name: decreasing influx to moderate Crohn's septal ulcers or nasal hypertension, bacterial, or systemic viral
into nasal passages disease. surgery or trauma dizziness, fatigue, infection; or ocular herpes
Entocort
or bronchial walls. (nasal spray); status fever, headache EENT: simplex.
Classification: As a result, nasal or asthmaticus or other Bad taste, cataracts, Closely monitor a child’s
airway inflammation acute asthma dry mouth, epistaxis, growth pattern;
Corticosteroids
decreases. Oral episodes (oral glaucoma, nasal budesonide may stunt
inhalation form also inhalation) irritation, oral or growth.
inhibits mucus pharyngeal candidiasis, Administer Respules by jet
secretion in airways, pharyngitis, rhinitis, nebulizer connected to an
decreasing the sinusitis ENDO: air compressor.
amount and Growth suppression in Patient exposed to
viscosity of sputum children chickenpox may receive
GI: Abdominal pain, varicella zoster immune
diarrhea, dyspepsia, globulin or pooled I.V.
flatulence, indigestion, immunoglobulin. If
nausea, vomiting GU: chickenpox develops, give
UTI antiviral as ordered. A
MS: Arthralgia, back patient exposed to
pain measles may need pooled
RESP: Bronchospasm, I.M. immunoglobulin.
increased cough, Assess patient for
respiratory tract effectiveness of
infection budesonide therapy,
SKIN: Contact especially if being weaned
dermatitis, purpura, from a systemic
rash, urticaria corticosteroid. If patient
Other: Anaphylaxis, has increased asthma or
angioedema an immunologic condition
previously suppressed
 Mechanism of Nursing
Drug Indications Contraindications Side effects
Action considerations
Generic Name: As a prodrug of To treat Hypersensitivity to CNS: Ataxia, chills, Monitor CBC, liver
sulfapyridine and 5- inflammatory salicylates, depression, fatigue, fever, function test results, and
Sulfasalazine
aminosalicylic acid bowel sulfasalazine, Guillain-Barré syndrome, BUN and serum
Brand Name: (mesalamine), delivers diseases, sulfonamides, headache, insomnia, creatinine levels before
more sulfapyridine and such as chemically related meningitis, peripheral and periodically during
Azulfidine
mesalamine to the colon ulcerative drugs, or their neuropathy, seizures, prolonged sulfasalazine
Classification: than either metabolite colitis, and to components; intestinal vertigo, weakness therapy.
could provide alone. maintain or or urinary obstruction; CV: Pericarditis, vasculitis Be aware that
Anti-inflammatory
Sulfapyridine provides prolong porphyria EENT: Hearing loss, sulfasalazine doses
drugs antibacterial action remission orange-yellow tears, over 4 g or a blood level
along the intestinal wall; pharyngitis, tinnitus over 50 mcg/ml
mesalamine inhibits GI: Abdominal pain, increases the risk of
cyclooxygenase, anorexia, cirrhosis, adverse and toxic
thereby decreasing the diarrhea, elevated liver reactions.
production of enzymes, hepatitis, Monitor fluid intake and
arachidonic acid hepatotoxicity, indigestion, output and urine color,
metabolites and jaundice, nausea, pH, and consistency.
reducing colonic pancreatitis, ulcerative Acidic urine may require
inflammation. colitis exacerbation, alkalization to prevent
vomiting crystalluria.
GU: Crystalluria, decreased Warning!
ejaculatory volume, male Monitor patient,
infertility, nephritis, especially during the
nephrotic syndrome, first month of
orange-yellow urine, toxic sulfasalazine therapy,
nephrosis for hypersensitivity
HEME: Agranulocytosis, reactions that may
aplastic anemia, Heinz body become life-threatening.
or hemolytic anemia, At first sign of rash,
leukopenia, neutropenia, mucosal lesions or any
thrombocytopenia, unusual other sign of
bleeding or bruising hypersensitivity, stop
MS: Arthralgia, sulfasalazine therapy
rhabdomyolysis and notify prescriber.
RESP: Cyanosis, idiopathic
pulmonary fibrosis,
lymphocytic interstitial
pneumonitis, pleuritis
SKIN: Alopecia, drug rash
with eosino philia and
systemic symptoms
(DRESS), erythema
multiforme, exfoliative
dermatitis, epidermal
necrolysis, photosensitivity,
pruritus, purpura, rash,
Stevens-Johnson
syndrome, toxic epidermal
necrolysis, urticaria
Other: Anaphylaxis,
angioedema, lupus
erythematosus-like
syndrome, serum sickness
syndrome
 Mechanism of Nursing
Drug Indications Contraindications Side effects
Action considerations
Generic Name: May exert Used for people Breastfeeding, CNS: Aphasia, cerebral Follow facility policy for
immunosuppressive with Crohn's hypersensitivity to thrombosis, chills, preparing and handling
Methotrexate
effects by inhibiting disease who don't methotrexate or its dizziness, drowsiness, drug; parenteral form
Brand Name: replication and respond well to components, fatigue, fever, head poses a risk of
function of T and other medications pregnancy ache, hemiparesis, carcinogenicity,
Rheumatrix
possibly B leukoencephalopathy, mutagenicity, and
Classification: lymphocytes. malaise, paresis, teratogenicity. Avoid skin
Methotrexate also seizures contact.
Immunosuppressants
slows rapidly CV: Chest pain, deep Monitor results of CBC,
growing cells, such vein thrombosis, chest Xray, liver and renal
as epithelial skin hypotension, pericardial function tests, and
cells in psoriasis. effusion, pericarditis, urinalysis before and
This action may thromboembolism during treatment.
result from the ENDO: Gynecomastia Administer subcutenaous
drug’s inhibition of EENT: Blurred vision, injection into patient’s
dihydrofolate conjunctivitis, gingivitis, abdomen or thigh.
reductase, the glossitis, pharyngitis, Increase patient’s fluid
enzyme that stomatitis, transient intake to 2 to 3 L daily,
reduces folic acid to blindness, tinnitus unless contraindicated, to
tetrahydrofolic acid. GI: Abdominal pain, reduce the risk of adverse
Inhibition of anorexia, cirrhosis, GU reactions.
tetrahydrofolic acid diarrhea, elevated liver Assess patient for
interferes with DNA function test results, bleeding and infection.
synthesis and cell enteritis, GI bleeding and Be aware that high doses
reproduction in ulceration, hepatitis, of methotrexate can impair
rapidly proliferating hepatotoxicity, nausea, renal elimination by
cells. pancreatitis, vomiting forming crystals that
GU: Cystitis, hematuria, obstruct urine flow. To
infertility, menstrual prevent drug precipitation,
dysfunction, nephropathy, alkalinize patient’s urine
renal failure, tubular with sodium bicarbonate
necrosis, vaginal tablets, as ordered.
discharge Follow standard
HEME: Anemia, aplastic precautions because drug
anemia, leukopenia, can cause
neutropenia, immunosuppression.
pancytopenia, If patient becomes
thrombocytopenia dehydrated from vomiting,
MS: Arthralgia, notify prescriber and
dysarthria, myalgia, expect to withhold drug
stress fracture until patient recovers.
RESP: Dry nonproductive If patient receives high
cough, dyspnea, doses of drug,
interstitial pneumonitis, keep leucovorin readily
pneumonia, pulmonary available as antidote.
fibrosis or failure, Be aware that
pulmonary infiltrates methotrexate resistance
SKIN: Acne, alopecia, may develop with
altered skin pigmentation, prolonged use.
ecchymosis, erythema
multiforme, exfoliative
dermatitis, furunculosis,
necrosis, photosensitivity,
pruritus, psoriatic lesions,
rash, Stevens- Johnson
syndrome, telangiectasia,
toxic epidermal
necrolysis, ulceration,
urticarial
Other: Anaphylaxis,
increased risk of
infection,
lymphadenopathy,
lymphoproliferative
disease
READINGS R/T DIGESTIVE CASES / ARTICLES SUMMARY AND REACTIONS
GENERAL EVALUATION INCLUDING LABORATORY OR DIAGNOSTIC TESTS

Physical Exam and History

 Your doctor will begin by gathering information about your health and your family health
history. They’ll do a physical exam and look for symptoms of Crohn’s

Lab Tests

 Blood tests:

 Antibody tests: These help doctors tell if you have Crohn’s or ulcerative colitis:
o Anti-Saccharomyces cerevisiae antibody test (ASCA): People with this protein are
more likely to have Crohn’s.
o Perinuclear anti-neutrophil cytoplasmic antibody test (pANCA): People with this
protein are more likely to have ulcerative colitis.
 Complete blood count (CBC): It checks for anemia (low numbers of red blood cells) and
infection.
 C-reactive protein: It looks for this protein, which is a sign of inflammation.
 Electrolyte panel: Your body might be low on minerals like potassium if you have Crohn’s-
related diarrhea.
 Erythrocyte sedimentation rate: This gauges the amount of inflammation in your system
by measuring the amount of time it takes for your blood to fall to the bottom of a special
tube.
 Iron and B12 levels: These can be low if your small intestine isn’t absorbing nutrients like it
should.
 Liver function: The disease can affect your liver and bile duct.

Imaging Studies and Endoscopy

 Crohn's disease may appear anywhere along the gastrointestinal tract, from the mouth to the
rectum. X-rays and other images can help identify the severity and location of Crohn's
disease. These studies may include the following:
o Balloon-assisted enteroscopy: There are about 20 feet of small intestines in your
body. They curve around and lie on top of one another. This test makes it easier for
doctors to look at them. The version most often used for Crohn’s is a double-balloon (or
double-balloon assisted) test. There’s also a version with a single balloon. Both types
work like this: The doctor uses a special flexible tube called an endoscope, which has
a tiny camera on one end. It has either one or two balloons attached behind it. They’ll
inflate them and deflate the balloons to move the tube through your intestine. It’s a lot
like pulling a curtain onto a rod.

o Barium X-rays and other X-rays: A barium X-ray can show where and how severe
Crohn's disease is. It is especially helpful for finding any problems in parts of the small
intestine that can't be easily viewed by other techniques.

o Colonoscopy or sigmoidoscopy: Colonoscopy and sigmoidoscopy allow your doctor

to directly view the large intestine, which is the lower part of the digestive tract. These
techniques can often provide the most accurate information about the intestines. They
may be better at finding small ulcers or inflammation than other techniques. They can
be used to judge the severity of any inflammation. Colonoscopy is the most important
tool in diagnosing Crohn's disease.
o Computed tomography (CT) scan: CT scanning uses computer-aided X-ray
techniques to make more detailed images of the abdomen and pelvis than can be
seen in traditional X-rays. CT scans can help find abscesses that might not show up
on other X-rays. Abscesses are small pockets of infection.

o Leukocyte scintigraphy: White blood cells gather at spots in your body where
there’s inflammation. For this test, the doctor will take a little blood from your arm
and add a harmless amount of a radioactive substance. They’ll put it back in your
body and use a special camera to see if the cells travel to spots in your
gastrointestinal tract that could signal Crohn’s. It’s not a commonly used test.

o Magnetic resonance imaging (MRI): Use of MRI to make a Crohn’s

diagnosis is on the rise. This test gives your doctor a clear picture of the
inside of your body, but it doesn’t subject you to radiation. It can help your
doctor see your small intestines and spot an anal abscess (pus-filled sore)
or fistula (tunnel that forms between an abscess and one of your anal