Presented By: Guio Bien R.

Bautista

Introduction

Crohns Disease is an idiopathic, chronic, transmural

inflammatory process of the bowel that can affect any part of the gastro intestinal tract from the mouth to the anus.
Most cases involve the small bowel, particularly the

terminal ileum

History
1806: First reported case of Crohns by Combe and Sanders to the Royal College of Physicians in

London, England 1913: Surgical evidence of the disease reported in the paper Chronic Intestinal Enteritis written by Dr. Kennedy Dalziel at the Western Infirmary in Glasgow Described in 1932 by Crohn, Ginsburg, and Oppenheimer of Mount Sinai Hospital in New York

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.

Classification

Crohn'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.

Distribution of gastrointestinal Crohn's disease data from American Gastroenterological Association

Classification

Crohn'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 the caliber of the feces.

Stricturing

Classification
Penetrating disease creates abnormal passage ways between the bowel

and other structures such as the skin. Inflammatory disease causes inflammation without causing strictures or fistulae.

Inflammatory

Penetrating

Endoscopy image of colon showing serpiginous ulcer in Crohn's disease

Causes of Crohns Disaese

Genetics
The disease runs in families then 30 times more likely to

develop CD. Mutations in the NOD2 /CARD15 gene are associated with Crohn's disease. Over 30 genes that show genetics play a role in the disease, either directly through causation or indirectly as with a mediator variable. Anomalies in the XBP1 gene have recently been identified as a factor, pointing towards a role for the unfolded protein response pathway of the endoplasmatic reticulum in inflammatory bowel diseases.
NOD2 : nucleotide-binding oligomerization domain containing 2 CARD15 :Cathapse Activation Recruitment Domain

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 a

dramatic 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 may

induce autophagy and hinder the body's ability to attack invasive bacteria.

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

subspecies paratuberculosis plays a role in Crohn's disease and it causes a very similar disease, Johne's disease, in cattle. A study in 2003 put forth the "cold-chain" hypothesis, that psychrotrophic bacteria such as Yersinia spp and Listeria spp contribute to Crohns disease.

Mycobacterium avium subspecies paratuberculosis colonies from stool sample of Crohns disease patient

Prevalence
Males and females are equally affected. Smokers are two times more

likely 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 from 2748 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.

The Digestive System and Anatomy and Physiology of the Small Intestine

Pathophysiology
Crohn's

disease shows a transmural pattern of inflammation, meaning that the inflammation may span the entire depth of the intestinal wall. Ulceration is an outcome seen in highly active disease. Inflammation is characterized by focal infiltration of neutrophils, a type of inflammatory cell, into the epithelium.

Pathophysiology
These neutrophils, along with mononuclear cells, may

infiltrate into the crypts leading to inflammation or abscess

Granulomas known as giant cells, are found in 50% of cases

and are most specific for Crohn's disease.

The granulomas of

Crohn's disease do not show "caseation", a cheese-like appearance on microscopic examination that is characteristic of granulomas associated

Pathophysiology of Inflammatory Bowel Disease/CD

Section of Colectomy Showing Transmural Inflammation

Gastrointestinal Symptoms

Abdominal pain accompanied by diarrhoea(may or

may not be bloody), flatulence, bloating, perianal discomfort . People who have had surgery often end up with short bowel syndrome of the gastrointestinal tract. Ileitis results in large volume watery feces & colitis result in a smaller volume of feces of higher frequency. In severe cases, an individual may have more than 20 bowel movements per day and may need to awaken at night to defecate. The mouth may be affected by non-healing sores (aphthous ulcers). Difficulty in swallowing (dysphagia).

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 have

malabsorption of carbohydrates or lipids, which can further exacerbate weight loss.

Extraintestinal Symptoms
Inflammation of the interior portion of the eye, known as

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

Episcleritis

Uveitis

Extraintestinal Symptoms
Crohn's

disease is associated with seronegative spondyloarthropathy ;inflammation of joints or muscle, osteoporosis,neurological complications like seizures, myopathy, peripheral neuropathy . Ankylosing spondylitis include painful, warm, swollen, stiff joints and loss of joint mobility or function.

Ankylosing spondylitis

Extraintestinal Symptoms
Erythema nodosum, presents as red nodules on the shins is due to
inflammation 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

Pyoderma gangrenosum, is typically a painful ulcerating nodule.

Extraintestinal Symptoms

Pyoderma gangrenosum on the leg of a person with Crohn's Disease

Crohn's disease also increases the risk of blood clots; painful swelling 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 the immune system attacks the red blood cells.

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

result of Crohn's disease.

Complications
Crohn's disease can lead to several mechanical complications within the intestines, including obstruction, fistulae, and abscesses. Obstruction: Occurs from strictures or adhesions which narrow the lumen, blocking the passage of the intestinal contents. Fistulae: Develop between two loops of bowel, between the bowel and bladder, between the bowel and vagina, and between the bowel and skin. Abscesses: Collections of infection, which can occur in the abdomen or in the perianal area in Crohn's disease sufferers.

Endoscopic image of colon cancer identified in the sigmoid colon on screening colonoscopy for Crohn's disease.

Diagnosis

Crohn's disease does not diagnose with complete certainty. A colonoscopy is 70% effective in diagnosing the disease via

direct 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 making the diagnosis.

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

Endoscopic image of Crohn's colitis showing deep ulceration

Radiologic Tests
A barium X-ray where barium sulfate suspension is

ingested and fluoroscopic images of the bowel are taken to check inflammation and narrowing of the small bowel.
Identifying anatomical abnormalities when strictures of

the colon are too small for a colonoscope to pass through, or in the detection of colonic fistulae.

Blood Tests
A complete blood count may reveal anemia caused either

by blood loss or vitamin B12 deficiency. Erythrocyte sedimentation rate(ESR) and C-reactive protein measurements can also be useful to check the degree of inflammation. Testing for anti-Saccharomyces cerevisiae antibodies (ASCA) and anti-neutrophil cytoplasmic antibodies (ANCA) has been evaluated to identify inflammation of the intestine.

Crohn's Disease & Ulcerative Colitis

Ulcerative colitis mimics the symptoms of Crohn's disease,

as both are inflammatory bowel diseases that can affect the colon. Sometimes its not possible to tell the difference, in those case the disease is classified as indeterminate colitis.

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

Crohn's disease Commonly Usually Seldom Common No increase in rate of primary sclerosing cholangitis Patchy areas of inflammation (Skip lesions) Deep geographic and serpiginous (snake-like) ulcers May be transmural, deep into tissues Common Widely regarded as an autoimmune disease Associated with Th17 May have non-necrotizing non-periintestinal crypt granulomas Often returns following removal of affected part Ulcerative colitis Seldom Always Usually Seldom Higher rate Continuous area of inflammation Continuous ulcer Shallow, mucosal Seldom

Terminal ileum involvement Colon involvement Rectum involvement Involvement around the anus Bile duct involvement Distribution of Disease Endoscopy Depth of inflammation Fistulae

Autoimmuue disease Cytokine response Granulomas on biopsy Surgical cure

No consensus Vaguely associated with Th2 Non-peri-intestinal crypt granulomas not seen Usually cured by removal of colon

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

and surgery because there is still no cure for Chrons disease . Adequately controlled Crohn's disease may not significantly restrict daily living. Treatment for Crohn's disease is only when symptoms are active and involve first treating the acute problem, then maintaining remission.

Medication
Antibiotics use to reduce inflammation . Prolonged use of corticosteroids has significant side.

Alternatives include aminosalicylates alone, though only a

minority are able to maintain the treatment, and many require immunosuppressive drugs.

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

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 of that portion of bowel.

Management of Crohn's Disease: Diagnosed by Clinical Evaluation, Radiographic Studies, Endoscopy, Laboratory Tests and Stool Studies

Nursing Interventions
Monitor frequency and consistency of stools to evaluate volume losses

and 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 metabolic acidosis. Monitor for distention, increased temperature, hypotension, and rectal bleeding; 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 is often embarrassed about frequent and malodorous stools, and often fearful of eating.

Nursing Interventions
Have patient participate in meal planning to encourage

compliance and increase knowledge. Encourage patients usual support persons to be involved in management of the disease. Provide small, frequent feedings to prevent distention of the gastric pouch. Diet is low in residue, fiber, and fat; high in calories, protein, vitamins, and minerals. Provide fluids as directed to maintain hydration (1,000 mL/24 hours minimum intake to meet body fluid needs). Clean rectal area and apply ointments as necessary to decrease discomfort from skin breakdown. Facilitate supportive counseling, if appropriate.

Lifestyle Changes
Dietary adjustments, proper hydration and smoking

cessation reduce symptoms. Have a balanced diet with proper portion control & eat small meals frequently instead of big meals. Do regular exercise and take enough sleep. Identifying foods that trigger symptoms.

Diet for Crohn's Disease

Drink lots of fluid to keep body hydrated and prevent

constipation. Take multivitamin-mineral supplement to replace lost nutrients . Eat a high fiber diet when CD is under control. During a flare up, limit high fiber foods and follow a low fiber diet. Avoid lactose-containing foods if one has lactose intolerance or use lactase enzymes and lactase pretreated foods. Try small frequent meals. Eating a high protein diet with lean meats, fish and eggs, may help relieve symptoms of Crohns.

Diet for Crohn's Disease

Take pre-digested nutritional drinks to give bowel a rest and

replenish 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 in managing . The role of prebiotics such as psyllium & probiotics helpful in the healing process.

Dietary Management in Crohns Disease

Complex Carbohydrates Patients should select complex carbohydrates, which are also a good source of fiber. Fresh fruit such as apples, grapefruit, oranges, plums, blueberries, raspberries, and strawberries might be protective 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.

Proteins in Crohns Disease

Proteins are very important for growth in children and for

repair of cells. Diarrhoea can cause protein deficiency so Crohns patients may need more protein. One study reported that a soy protein diet was useful for patients who were intolerant to milk products. Oily fish, such as salmon and tuna, poultry & lean meats may be particularly beneficial in Crohns disease.

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 treatment period 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 6 h 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 the effect 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

Crohn's disease patients are in danger of becoming

malnourished. The following are several reasons to consider these findings: Poor digestion and malabsorption of dietary fats, carbohydrates, water, protein, minerals and vitamins. During disease flare-ups chronic disease patients usually will increase levels of energy and caloric needs for the body. Symptoms of abdominal pain, nausea, or lacking taste sensations will have an ill affect on food intake resulting in loss of appetite.

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 with Crohns showed that they can eat enough food but cant absorb food adequately, especially carbohydrates.

Vitamin and Mineral Deficiencies

Absorption of vitamin and minerals vary depending on type and location

of the disease. Individuals that have Crohns disease where the ileum is affected may have a vitamin B12 deficiency due to that they are unable to absorb enough of the B12 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 of vitamin 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 and ulceration of the colon. Potassium and magnesium deficiency occur due to diarrhoea or vomiting. Trace element deficiencies are normally present in those with poor nutritional intake and have and extensive small intestine disease.

Foods to Avoid
People with Crohn's disease find that there are certain foods that seem to make their symptoms 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 the symptoms 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.

Complementary and Alternative Medicine

Crohn's

disease sufferers have tried complementary or alternative therapy.These include diets, probiotics, fish oil and other herbal and nutritional supplements. Acupuncture is used to treat inflammatory bowel disease in China, and is being used more frequently in Western society. Methotrexate is a folate anti-metabolite drug which is also used for chemotherapy. Metronidazole and ciprofloxacin are antibiotics which are used to 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.