CLINICAL PRESENTATION ON

CROHN’S DISEASE

Presented by;Tintu K Mathew, M. Sc. Nursing 1st yearNINE, PGIMER

BIODATA OF THE PATIENT

Name : Mr. Ram Prakah KailaAge : 6oyrsSex : MaleC.R No. : 1287652Marital Status : MarriedWard/Bed No : A G E/34Address : Shimla,

Himachal Pradesh

BIODATA OF THE PATIENT contd…

Religion : HinduEducation : GraduateOccupation : Retd. Govt. ServantMonthly Family income : Rs.

20,000/monthDate of Admission : 1st September 2010Consultant : Prof.Bhasin Diagnosis : Chron’s Disease

(Small Bowel)

CHIEF COMPLAINTSH/O Abdominal pain x 1 ½

monthsH/O Loose stools x 1

monthH/O Loss of appetite x 15

daysH/O Fever in the evening

on/off 1 monthH/O Weight loss x 2 years

History of Present Illness Pain in abdomen which is sudden in onset,

dull aching, and colicky type radiating to back, feeling of pain started from the epigastrium, towards right side at umbilicus.

Progressive loose stool 3 to 4 times per day, watery with no blood from last 1month. He is having fever on/off especially in the evening.

Progressive weight loss since 2 years.

History of Past illnessSimilar complaints since 2004, and got treated

in Shimla with ATT drugs and got some improvement.

In 2006, he underwent colonoscopy for the same complaints and started again with ATT.

In 2008, when he got the similar complaints they referred him to Jalandhar and after undergoing investigations he got treated for the symptoms.

In 2009, he developed fever, loose motion and he was referred to PGI and diagnosed as having Crohn’s Disease.

Other historyFamily HistoryHealth facility near home.HousingPatient’s sensitivity/allergy/precautionPersonal HistoryEliminationMobility and exercise

GENERAL PHYSICAL EXAMINATIONHEAD TO TOE ASSESSMENT

Height: 172 cmWeight: 58 kg

General Appearance Thin built Sensorium

Conscious and orientedPosture

NormalVital SignsTemp. : 38oc Pulse : 80b/min Respiration : 18breaths/min B.P : 126/86 mm of

Hg

PHYSICAL EXAMINATION contd…

Skin Slight dryness or paleness. Skin is intact,peri-anal excoriation present.

no pigmentations. Hair

Hair is clean. No pediculi or dandruff.Eyes

No discharge, redness, swelling. short sightedness corrected by spectacles.

PHYSICAL EXAMINATION contd…

ENTNo discharge from ear or nose. No DNS.

Oral mucosaDental caries absent no sore.

No Gingivitis and stomatitis

GlandsLymph nodes are not enlarged

PHYSICAL EXAMINATION contd…

ChestNormal shape with symmetrical chest movements. No complaints of dyspnoea, orthopnea or paroxysmal nocturnal dyspnoea.

AbdomenNormal size, no fluids, and is cylindrical in shape. No scar, pigmentation or distension. There is pain in abdomen since 1 ½ months.

PHYSICAL EXAMINATION contd…

LimbsFull range of motion is present in both upper and lower limbs.

BackThere is no tenderness. Shape and curvature of spine is normal. No lordosis, kyphosis, scoliosis.

Genitourinary systemHe is having normal bladder function.no complaints of micturition,dribbling etc

Systemic examinationNervous system

All the cranial nerves are intact.Motor system

Muscle tone and strength is normal.Respiratory system:

Bilateral breath sounds are equal. No adventitious sounds: wheezing, crepitus are absent. Respiratory rate: 18 breaths/min

Circulatory systemS1 & S2 normal. Heart rate: 80 beats/min

 

Systemic examination contd…..

Gastrointestinal systemLower abdominal pain since 1 ½ months (pain gets aggravated with food spicy foods and beverages)Progressive watery white tarry stools without blood tinged.

Musculoskeletal systemFull range of motion present in both upper and lower limbs

Urinary systemNormal bladder function.

Details of the disease condition – CROHN’S DISEASE

CROHN’S DISEASE

DefinitionCrohn's disease is an

inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms.

ANATOMY AND PHYSIOLOGY OF INTESTINE

Incidence Approximately 500,000 to two million people

in the United States are affected with crohn’s disease.

Men and women are equally affected Occur in people of all age groups More often diagnosed in people between the

ages of 20 and 30 and after 50.Common in relatives of patients with Crohn's

disease.

Classification •aff

ects both the ileum and large intestine

Ileocolic

•affects the ileum only

Crohn's ileitis

•affects the large intestine

Crohn's colitis

Vienna classification of Crohn's disease.

• Causes narrowing of the bowel & may lead to bowel obstructionStricturing

disease• Creates fistulae between the bowel

and other structures such as the skinPenetrating disease

• Causes inflammation without causing strictures or fistulae

Inflammatory

disease

Etiology The exact cause is unknown.Possible causes. Infection by certain bacteria, such as strains of

mycobacterium.Activation of the immune system in the

intestineA gene called NOD2 is associated with Crohn's

disease.Environmental factors

PATHOPHYSIOLOGY

Small, shallow erosions on inner surface of bowel (aphthous ulcers)

Erosions become deeper and larger (true ulcer)

Scarring and stiffness of the bowel

Narrowing of the bowel

Bowel obstruction

Clinical manifestations

Book picture• Abdominal pain• Diarrhea• Weight loss• Poor appetite • Fever• Vomiting• Night sweats• Rectal pain, rectal bleeding• Non-healing sores

Patient picture• Present for 1 ½ months• Present for 1 month• Present since 2 years• Present• Present for 1 month• Absent• Absent• Absent• Absent

DIAGNOSTIC EVALUATION

• History and Physical examination • Stool examination• X-rays• Barium enema• Sigmoidoscopic examination• Endoscopy• Abdominal MRI/CT scan, ultrasound

DIAGNOSTIC EVALUATION contd….

CBCESRPrealbumin/albumin/total proteinSerum iron-binding folic acid

capacity/transferrin levelsClotting studiesElectrolytesUrineUrine culture

Investigations

Test HbWBCNeutrophils Eosinophils Basophils Lymphocytes Monocytes ESRPlatelets PTS. sodiumS. PotassiumBUNS. Creatinine

Patient value

12 g%13,200 cells/mm3

75%04%0%19%2%25 mm/hr1.5 x 105 cells/mm3

14 sec131 mEq/L3.6 mEq/L25 mg/dl0.5 mg/dl

Investigations contd….

Stool examinationStool microscopy : 100 fat globules/HPFOccult blood : positive Radiologic studyCT scan: Marked ulceration, inflammatory changes

and narrowing of colon. ColonoscopyMultiple ulcers in terminal ileum, and there were

diffuse small bowl fold thickening.

COMPLICATIONS

Intestinal complicationsObstruction and perforation of the small intestineAbscesses (collections of pus)Fistulae Intestinal bleeding. Massive distention or dilatation of the colon (megacolon)Rupture (perforation) of the intestine.Increased risk of cancer of the small intestine and colon.

COMPLICATIONS contd…..

Nutritional complications• Deficiencies of proteins, calories, and vitamins.Skin complications• Erythema nodosum (painful red raised spots on

the legs)• Pyoderma gangrenosum (an ulcerating skin

condition generally found around the ankles)• Arthritis (sacroiliac joint arthritis)• Ankylosing spondylitis

COMPLICATIONS contd…..

EyesUveitisEpiscleritis

OthersHepatitisRecurrent bacterial

infectionsLiver cirrhosis

Management

Combination of these

options

Drugs

Nutrition

supplements Surge

ry

Medical management

Drug therapy • Anti-Inflammation Drugs.• Immune System Suppressors. • Antibiotics. • Anti-Diarrheal • Fluid and electrolyte

Replacements• Nutrition Supplementation • Total parental nutrition.

Drugs getting for the patientTab.Prednisolone 20 mg OD. Tab Metrogyl 400mg TID. T.Rabeprazole 20mg OD T.Supradyn 1 tab OD T. Crocin 500mg sos.

Surgery in Crohn's disease

• Removal of a diseased segment of the small intestine that is causing obstruction.

• Drainage of pus from abdominal and peri-rectal abscesses.

• Resection of internal fistulae (such as a fistula between the colon and bladder) that are causing infections.

Nursing management

Acute pain (abdomen) related to, prolonged diarrhea, and perirectal excoriation

Diarrhea related to inflammation, irritation and underlying bowel pathology.

Imbalanced nutrition less than body requirements related to altered absorption of nutrients, hypermetabolic state, fear that eating may cause diarrhea.

Risk for fluid volume deficit related to losses through normal routes (severe frequent diarrhea) and restricted intake (nausea/anorexia)

Ineffective coping, related to situational crisis, unpredictable nature of disease process, personal vulnerability, inadequate coping method, lack of support system, severe pain, lack of sleep and rest.

Knowledge, deficient regarding condition, prognosis, treatment, self-care, and discharge needs related to information misinterpretation, lack of recall unfamiliarity with resources

REFERENCESSmeltzer C S, Bare G B, Brunner and Suddarth

Textbook of Medical Surgical Nursing 10th ed. Philadelphia: Mosby; 2004 Pp:781-813

Black M.J, Hawks H.J Medical surgical nursing. 7th ed. St.Louis: Saunders Publications; 2004 Pp:1671-1699

Nettina, Sandra M, Mills, Jacqueline E. Lippincott Manual of Nursing Practice 8th ed. Lippincott Williams & Wilkins; 2006 Pp: 574-610

Lewis S M, Heitkemper M M, Dirksen S R Medical Surgical Nursing. 6th ed. Missouri: Mosby; 2004 Pp: 861-885

THANK YOU