A CHRONIC RELAPSING inflammatory disorder, Crohn disease can affect any area of the gastrointestinal (GI) tract from the mouth to the anus; however, it most commonly involves the distal ileum and the proximal colon.1 Half of patients with the disease have ileocolic disease, 30% have ileal disease only, and 20% have colonic disease only.2
Although not curable, Crohn disease is treatable. This article describes the pathophysiology and complications associated with Crohn disease, available treatments, and nursing considerations to help patients manage the disease and prevent exacerbations.For a quick review of normal GI anatomy, see Traveling down the GI tract.
What's behind Crohn disease?
In the United States, the prevalence of Crohn disease is 201 per 100,000 adults.1 It occurs in men and women equally.3 While it can occur at any age, it most commonly starts in adolescence, with the median age of diagnosis 20 to 30 years.1 Though the etiology is unknown, research suggests a familial tendency; 5% to 20% of people with Crohn disease have a close relative with some form of inflammatory bowel disease.3 Researchers are investigating the genetic component. One mutation associated with Crohn disease is the NOD2/CARD15 gene.2
Environmental factors also play a role. Examples of contributing environmental factors include exposure to air pollution, consumption of a western diet containing excessive amounts of sugar and polyunsaturated fats, and exposure to cigarette smoke, both active and passive. The disease is most prevalent in northern, urban areas of developed countries.4
Crohn disease frequently develops after infectious gastroenteritis, and research shows a substantial risk of disease development after appendectomy.4 Use of oral contraceptives and nonselective nonsteroidal anti-inflammatory drugs can exacerbate the disease.1
Aphthoid lesions and other pathology
Crohn disease commonly begins as small inflammatory aphthoid lesions in the mucosa and submucosa of the bowel. Aphthoid lesions are shallow ulcers with a white base and elevated margin. As the lesions multiply, they're interspersed with normal-appearing mucosal tissue. Because of this pattern, they're often called “skip” lesions.
Though all layers of the bowel are involved, the submucosal layer is most affected. Fissures and crevices form in the tissue, surrounded by areas of submucosal edema, giving the inflamed bowel a cobblestone appearance.6 Over time, the bowel wall becomes thick and inflexible. Adjacent mesentery may become inflamed and regional lymph nodes enlarge.5
Flares and remissions
A relapsing disorder, Crohn disease is characterized by episodes of disease flares followed by periods of remission when signs and symptoms aren't noticeable.4 Common intestinal-related clinical manifestations include crampy abdominal pain; persistent diarrhea; the rectal passage of blood, mucus, or both; fever; and constipation.4,7 Some patients experience symptoms for years before diagnosis.7 Occasionally, the first sign of the disease is a bowel obstruction, perforation, or bleeding.8
Besides GI effects, nearly 25% of all patients have some extraintestinal manifestations, such as anemia, primary sclerosing cholangitis, erythema nodosum, inflammatory arthropathies, nephrolithiasis, osteoporosis, uveitis, episcleritis, and venous and arterial thromboembolism.1,2 Because of these extraintestinal manifestations and associated inflammatory/immune disorders, Crohn disease is defined as a systemic inflammatory disease.4 Patients may also have other systemic signs and symptoms such as fever, anorexia, weight loss, fatigue, night sweats, and loss of normal menstrual cycle.1,3
As the disease progresses, the intestine's mucosal absorptive surface may be disrupted, resulting in nutritional deficiencies. Consequently, the disease can cause retardation of growth and physical development in children.3
During the course of the illness, one-third of patients experience a perirectal abscess, fissure, or fistula.1 (See Gut-wrenching characteristics of Crohn disease.) Fistulas can develop between parts of the GI tract or between the GI tract and other sites. Common sites for fistulas include communication of the intestine to the bladder (enterovesical), vagina (enterovaginal), bowel (enteroenteric), and skin (enterocutaneous).7 In the first 10 years following diagnosis, approximately half of patients will require fistula surgery, with as many as 80% requiring surgery over a lifetime.9
In adults, the Crohn disease diagnosis is typically first made in the outpatient setting; with children, it's usually first diagnosed in the inpatient setting.8 Diagnosis includes obtaining a thorough health history, performing a physical examination, and obtaining lab values for key indicators. (See Key lab findings in patients with Crohn disease.)
Diagnostic endoscopic and imaging studies of the bowel include colonoscopy, wireless capsule endoscopy, barium studies, computed tomography (CT), and magnetic resonance (MR) enterography.7A CT scan can help establish the initial diagnosis, define the extent and location of the disease, and rule out perforation and abscess. MR enterography can help pinpoint the location of diseased bowel.2
Management goals include controlling signs and symptoms of the disease and inducing and maintaining clinical remission.1 Several groups of drugs can be used to suppress the immune system and manage inflammation. (See Drugs commonly prescribed for Crohn disease.)
Besides medication to treat Crohn disease, dietary modifications are important because some foods and beverages can aggravate signs and symptoms. In general, patients should limit dairy products and foods high in fat, avoid foods that cause gas, and drink plenty of liquids.3 Advise patients to eat frequent small meals throughout the day as opposed to three large meals. Patients with malnutrition may require support with enteral or parenteral nutrition.1
For patients who smoke, encourage smoking cessation. Smoking aggravates the disease course, promotes fistula formation, and contributes to a suboptimal response to medical therapy.1,4
Patients may also develop chronic anemia from disturbed iron metabolism related to chronic inflammation. It's sometimes treated with I.V. iron combined with exogenous erythropoietin.4
During the course of their lifetime, most patients will require surgery and many requiring multiple surgeries. For example, surgery may be indicated to drain abscesses, close fistulas, dilate strictures, remove diseased bowel, and form colostomies.2 Preparation for surgery varies. Bowel preps are indicated before most procedures with the exception of surgery for fibrostenotic strictures.2 In cases of severe obstruction, it could lead to massive dilation of the bowel proximal to the diseased segments and enteric spillage during the procedure. Antibiotic prophylaxis with a broad-spectrum antibiotic with anaerobic coverage is common.
Following GI surgery, patients have a threefold risk of venous thromboembolic events, so mechanical and pharmacologic prophylaxis during the perioperative period is standard.2 Mechanical prophylaxis can be accomplished with graded compression stockings, intermittent pneumatic compression, and early, aggressive postoperative ambulation. Pharmacologic prophylaxis includes unfractionated heparin or low-molecular-weight heparin, depending on individual risk factors.
Possible complications of surgery include bleeding, infection, bowel leakage, anastomotic dehiscence, and short bowel syndrome (SBS). Because patients with SBS have less than 200 cm of small intestine, they experience manifestations of malabsorption, malnutrition, diarrhea, steatorrhea, and fluid/electrolyte disturbances.2 In extreme cases, patients become dependent on parenteral nutrition.
Helping patients manage signs and symptoms
Nursing management of Crohn disease revolves around its numerous signs and symptoms. We'll discuss each sign/symptom individually along with the associated nursing care.
• Diarrhea is secondary to inflammation. Nursing care for patients with diarrhea involves preventing dehydration, ensuring proper skin care, and providing comfort measures. Replace fluids and electrolytes as prescribed and document daily weights. Assess skin turgor for tenting and mucous membranes for moistness, document fluid intake and output, monitor serum electrolytes and hematocrit and hemoglobin (H&H) levels, and regularly assess vital signs, particularly BP and heart rate. An increase in H&H levels may indicate severe dehydration. Diarrhea can also cause a decrease in certain electrolytes, such as potassium; these changes affect other systems, such as the cardiac and neurologic systems.
Hypotension and tachycardia commonly accompany dehydration. Because the patient may become dizzy, institute appropriate safety measures to prevent falls.1,10
Regularly assess the abdomen, including bowel sounds; hyperactive bowel sounds are generally associated with diarrhea. Also palpate for tender areas. Stool cultures may be indicated to rule out other causes of diarrhea.
• Abdominal pain/cramping. Patients with Crohn disease typically experience severe abdominal pain due to ulcerations, scar tissue, lesions, and strictures. A comprehensive pain assessment and optimal pain management are extremely important for these patients. This type of severe pain interferes with nutritional status, sleep, mood, and activities of daily living. Patient-controlled analgesia is often prescribed.
Monitor the patient's C-reactive protein and erythrocyte sedimentation rate results to assess for an increase in inflammation, which may indicate active disease or disease flare.1,10
- GI bleeding. Assess stools and emesis for the presence of gross or occult blood. Because prolonged GI bleeding can cause anemia, monitor the patient's skin color, complete blood cell (CBC) count results, BP, and heart rate. GI bleeding can cause dizziness, so institute patient safety measures. Perform frequent abdominal assessments.1,10
- Fever. Monitor the patient's temperature. A fever may reflect the inflammatory process or be associated with abscess formation, peritonitis, or bowel perforation.7
- Anorexia/weight loss. Patients with abdominal pain and diarrhea may experience anorexia. Monitor their nutritional intake as well as CBC results and serum levels of albumin, total protein, lipids, vitamins, trace minerals, and iron levels. Weigh the patient daily. Consult with a dietitian to help patients choose palatable foods in smaller portions. In some cases, patients may need parenteral nutrition to give the colon a rest while they receive needed fluids, electrolytes, and calories.
- Psychological concerns. Because Crohn disease is a chronic, life-altering illness, assess patients for signs and symptoms of depression and provide emotional support. Report any signs of depression or anxiety to the patient's healthcare provider for referral.
Monitor all patients for signs and symptoms of complications such as bowel obstruction related to fibrosis and strictures. Communicate any abnormal physical assessment findings, such as new or worsening abdominal pain and distension, vomiting, diarrhea, or constipation to the healthcare provider promptly.
Learning to live with Crohn disease
Some patients manage Crohn disease for years without flares, others experience flares more frequently. Explain the importance of adhering to the prescribed medication regimen and following up with their healthcare providers as recommended. Encourage smoking cessation as indicated.
Teach patients how to recognize the signs and symptoms of complications such as a bowel obstruction, and to call their healthcare provider immediately if these occur. They should also call the healthcare provider if their usual signs and symptoms, such as abdominal pain, diarrhea, and anorexia, persist or worsen.
No standard dietary restrictions are recommended for patients with Crohn disease; using trial and error, they should determine which foods exacerbate their signs and symptoms and avoid these. Advise them to eat a nutritious diet, avoid alcohol, and check food labels for potentially troublesome substances. For example, carrageenan, a food additive used to provide texture, has been implicated in inflammatory bowel disease.11
Patients diagnosed with Crohn disease face a wide array of possible complications and an unpredictable quality of life. Nurses must use all their assessment skills to identify problems early and help them manage their condition for a lifetime.
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