Detailed pictorial explanation of causes , Pathology and nursing measures with specific nursing diagnosis

1. MS.MUTHU RAJATHI, M.SC (N)
ASST., PROFESSOR
DEPARTMENT OF MEDICAL SURGICAL NURSING
GANGA INSTITUTE OF HEALTH SCIENCES
COIMBATORE

2. CROHNS DISEASE

3. INTRODUCTION
• Belongs to the wide spread category of inflammatory
bowel disease.
• Only pathological, endoscopical changes differs it
from ulcerative colitis.
• It is a relapsing and remitting disease.
CROHNS
DISEASE
ULCERATIVE
COLITIS
INFLAMMATORY BOWEL DISEASE

4. SIGNIFICANT ANATOMY & PHYSIOLOGY

5. SIGNIFICANT ANATOMY &
PHYSIOLOGY
 Crohns disease can affect any part of gi tract from
mouth to the anus .
 Commonly affects the ileocecal region, terminal
part of small intestine - ileum and first part of
large intestine.
 Diseased part of the intestine is often separated by
a normal bowel which is known as “skip areas of
disease” .
 Involves transmural layer extending to the level of
serosal layer.

6. DEFINITION
• Also known as “REGIONAL ENTERITIS”.
• Chronic, idiopathic, transmural granulomatous
inflammation of terminal ileum and adjoining colon
resulting in stricture, ulceration, fistula and abscess
formation.

7. FEATURES OF CROHNS DISEASE
Since it causes cobble stone appearance of the intestine ,
commonly known it as “cobble stone disease”.

8. DIFFERENCE BETWEEN CROHNS
DISEASE & ULCERATIVE COLITIS
CROHNS DISEASE ULCERATIVE COLITIS
Often present with abdominal
pain & perianal disease
Often present with gastro
intestinal bleeding.
Signficantly shows cobble
stone mucosa & apthous
ulcer in intestine.
Significantly shows diffused
continuous involvement of
intestinal mucosa.
Causes fistula and ileal
involvement .
Does not causes ileal
fistulizing symptoms.
Mucosal discontuity is the
common feature.
Continuous involvement of
mucosa is a common feature.

9. INCIDENCE AND PREVALENCE
 In 2010, India considered to be second highest incidence of IBD,
1.4 million cases. Next to USA.
 Ulcerative colitis is more common than crohns disease.
 Age : commonly affects teens and twenties age group.
 Personal habits : smokers are three times highly affect by crohns
than the non smokers.
 Sex: males and females are equally affected.
 Region : western industrialized regions countries are commonly
affected.

10. ANATOMICAL DISTRIBUTION OF
CROHNS DISEASE

11. CLASSIFICATION – ACCORDING TO
THE REGION – COMMON FORM
• Involves terminal ileum and
ileocecal region.
ILEOCOLIC
CROHNS
• Only involves in ileal part
of the small intestine.ILEITIS CROHNS
• Affects the segments of
colonic region.
COLIC CROHNS

12. CLASSIFICATION – ACCORDING TO
THE REGION – RARE FORM
• Involves stomach and
duodenum
GASTRODUODENAL
CROHNS
• Involves only in upper half
of small intestine, the
jejunal part.
JEJUNAL CROHNS
• Affects around the anal
region.
PERIANAL CROHNS

13. CLASSIFICATION OF CROHNS DISEASE

14. CLASSIFICATION – ACCORDING TO
CHARACTERISTIC FEATURES
The inflammatory type
affects 30% of patients,
remains localized to
the mucosa and
submucosa, and
causes diarrhea and
pain from acute partial
obstruction
INFLAMMATORY CROHNS

15. CLASSIFICATION – ACCORDING TO
CHARACTERISTIC FEATURES
Affects 20% of patients
who have ileitis.
Aggressive transmural
inflammation leads to
intra-abdominal fistulae
from the diseased bowel
wall to another bowel
loop, or to a nearby organ
like the urinary bladder.PERFORATING CROHNS

16. CLASSIFICATION – ACCORDING TO
CHARACTERISTIC FEATURES
About 50% of
patients with ileitis
follow this route.
STRICTURING CROHNS

17. CAUSES AND RISK FACTORS
FACTORS CAUSES
Genetic factor Family history of IBD – 20%
Identical twins – 35%
Immune factor Exaggerated t4 lymphocyte
response
Abnormal production of
cytokines, TNF, interleukins
Autoimmune disorder
Environmental
factor
Intestinal helminthes infection
Other factors Smoking
Long term use of NSAIDS&
Antibiotics, contraceptive pills

18. RISK FACTORS

19. PATHOPHYSIOLOGY

20. CLINICAL MANIFESTATIONS

21. PHYSICAL EVALUATION FINDINGS
Factor Findings
Diarrhoea Very frequent
Bleeding May occur
Mucus Occur
Pain Frequent
Anal lesions Present
Scope and
appearance
Mucus inflamed with apthous
ulcer
Histology Transmural inflammation. Deep
ulceration, fissures, granulomas
Barium studies Fistulas, fissure, fat enwrapping
of intestine

22. DIAGNOSTIC EVALUATION

23. MANAGEMENT
MEDICATIONS
LIFE
STYLE
CHANGES
SURGERY

24. MANAGEMENT - MEDICATIONS
• Anti inflammatory drugs
– 5 amino salicylate agents
– sulfasalazine
• Anti biotics
– Metronidazole, ciprofloxacin
• Oral corticosteroids
– Prednisolone 40 – 60mg/DAY
• Immunomodulator drugs
– Azathioprine. 6 mercaptopurine,
– Methotrexate

25. MANAGEMENT - MEDICATIONS
• Biological therapy
– Infliximab
• Anti diarrhoeals
– Loperamide
• Fluid replacement therapy
• Plasma & blood transfusions are given for anemia &
hypoproteinaemia.

26. MANAGEMENT - LIFE STYLE CHANGES
High protein, high calorie diet
Low fat diet or milk free diet improves lactose deficiency
or malabsorption.
 Low residue or high fibre diet is also supplemented to
reduce colics.
Supplementation of iron, folic acid, calcium, vitamin d,
electrolytes whenever deficiency occurs.
 Total parenteral nutrition (tpn) has been demonstrated
to be effective in controlling the disease actively &
complications of crohn’s disease.

27. MANAGEMENT - SURGERY
OBJECTIVES OF SURGERY
REMOVE
DAMAGED
PORTIONS
OF GI
TRACT
CLOSE
FISTULAS
REMOVE
THE SCAR
TISSUE

28. REMOVAL OF ILEUM AND CECUM
WITH ANASTOMOSIS

29. REMOVAL OF ILEUM AND CECUM
WITH ILEOCOLONIC ANASTOMOSIS

30. COLECTOMY WITH ILEORECTAL
ANASTOMOSIS

31. ILEAL OBSTRUCTION WITH
STRICTUROPLASTY

32. COMPLICATIONS

33. NURSING MANAGEMENT
• Diarrhea related to inflammation of the bowel mucosa as evidenced
by increased bowel sounds.
• Imbalanced nutrition less than body requirement related to fear
that eating may cause diarrhea as evidenced by reluctant to eat
• Impaired anal skin integrity related to repeated episodes of
diarrhea as evidenced by redness in the anal skin.
• Risk for impaired skin intergrity related to fistula formation

34. REFERENCE
• LEWIS , TEXTBOOK OF MEDICAL SURGICAL NURSING
• BRUNNER & SUDDHARTH’S , TEXTBOOK OF MEDICAL SURGICAL
NURSING
• JOYCE.M.BLACK, TEXTBOOK OF MEDICAL SURGICAL NURSING
• ANTONY.S , BOOK OF ANATOMY & PHYSIOLOGY
• WWW. GASTRICASSOCIATION.COM
• WWW. PUBMEDINDIA.COM