Crohns Disease

Crohn's disease is a chronic inflammation of the digestive tract -- usually the small intestine and/or colon. No one knows what causes Crohn's, but some think it's affected by genetics, the immune system, and environmental issues. New research shows that certain genes can lead to an increased risk of Crohn's disease. Remission of Crohn's can last from months to years. Treatment is usually the cause of remissions. There's no evidence that irritable bowel syndrome (IBS) eventually leads to Crohn's disease.

Causes
The exact cause of Crohn's disease remains unknown. Immune system. It's possible that a virus or bacterium may trigger Crohn's disease. When your immune system tries to fight off the invading microorganism, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too. Heredity. Crohn's is more common in people who have family members with the disease, leading experts to suspect that one or more genes may make people more susceptible to Crohn's disease. However, most people with Crohn's disease don't have a family history of the disease.

Risk factors
Age. Ethnicity. Family history. Cigarette smoking. Where you live.

Pathophysiology
Sub acute and chronic inflammatory of GIT (transmural lesions) extends through all layers The disease process begin with edema and thickening of mucosa Ulcers begins continous contact with one another by normal tissues Cluster of ulcer (cobble stone) round large pebble Fistula, fissures and abscess form as inflammation extends into the peritoneum As the disease advances the bowel walls thickens and become fibrotic and the intestinal lumen narrows Disease bowel loops sometimes adhere to another loop in another needle Crohns Disease

Clinical Features of Crohn's Disease

Common complaints Abdominal pain Diarrhea Fever Fatigue Rectal bleeding Weight loss Anorexia Nausea Common physical examination findings Abdominal tenderness Palpable mass Guaiac-positive stool Common laboratory and radiographic findings Mild anemia Mild leukocytosis Elevated erythrocyte sedimentation rate Small bowel involvement Fistulas Strictures

Diagnostic Tests
Blood tests. Fecal occult blood test. Colonoscopy. Flexible sigmoidoscopy. Computerized tomography (CT). Magnetic resonance imaging. Capsule endoscopy Double balloon endoscopy. Small bowel imaging. Barium enema

Management of Crohn's Disease

The medical management of Crohn's disease is based on the location and severity of disease and extraintestinal complications.

Therapy has two goalsto treat the acute disease flare-ups and to maintain remission. Because no gold standard exists to define disease severity, working definitions of disease activity have been established to help guide therapy.

Extra-intestinal Manifestations of Crohn's Disease

Joint manifestations (25 percent) Arthralgia Arthritis Skin manifestations (15 percent) Erythema nodosum Pyoderma gangrenosum Aphthous ulcers of the mouth Ocular manifestations (5 percent) Episcleritis Uveitis Recurrent iritis

Working Definitions of Crohn's Disease Activity

Mild to moderate disease The patient is ambulatory and able to take oral alimentation. There is no dehydration, high fever, abdominal tenderness, painful mass, obstruction, or weight loss of more than 10 percent. Moderate to severe disease Either the patient has failed treatment for mild to moderate disease OR has more pronounced symptoms including fever, significant weight loss, abdominal pain or tenderness, intermittent nausea and vomiting, or significant anemia. Severe fulminant disease Either the patient has persistent symptoms despite outpatient steroid therapy OR has high fever, persistent vomiting, evidence of intestinal obstruction, rebound tenderness, cachexia, or evidence of an abscess. Remission The patient is asymptomatic OR without inflammatory sequelae, including patients responding to acute medical intervention.

Treatment Options in Crohn's Disease

Treatment Salicylates Corticosteroids Examples Mesalamine (Rowasa), sulfasalazine (Azulfidine) Results Problems with use Beneficial for mild to Inconclusive maintenance moderate active disease, of remission, risk of GI proctosigmoiditis bleed or upset Oral prednisone, Beneficial for moderate to Side effects from longbudesonide (Entocort), IV severe active disease, term use, budesonide not preparations generally accepted approved for use in the

Treatment Antibiotics

Examples Metronidazole (Flagyl), ciprofloxacin (Cipro)

Results therapy Beneficial in treatment of mild to moderate disease, maintenance of remission

Immunosuppressants

Antibody to human tumor necrosis factor alpha

Azathioprine (Imuran), 6- Beneficial in treatment mercaptopurine and in maintenance of (Purinethol), methotrexate remission, beneficial to (Rheumatrex), cyclosporine decrease steroid use (Sandimmune), others Infliximab (Remicade) Significant improvement Costly, IV administration, when compared with mild infusion reactions placebo might be seen

Problems with use United States Specific antibiotic side effects include metallic taste in mouth, disulfiram effects, GI upset, peripheral neuropathy Questionable risks for neoplasia, leukopenia (requires blood monitoring)

Surgery for Crohn's Disease

Partial Bowel Resection Resection is usually performed when a portion of intestine has been so damaged by disease that a permanent partial obstruction has formed. The most common areas removed are the terminal ileum, the ileocecal valve, and a small portion of the large intestine.

Strictureplasty is a procedure that opens up small strictures. An incision is made down the length of stricture. The incision is pulled together and sewn across the stricture, shortening the intestine slightly but widening the formerly narrowed area.

Correcting Fistulas Fistulas that connect the intestine to another internal organ, such as the bladder, must be surgically closed in order to keep intestinal contents from draining into the organ and causing infection.

Draining Abscesses When an abscess does not respond to medical treatment, it must be drained to promote healing. Needle aspiration is the most common method. A hollow needle is inserted through the skin and into the abscess, then used to withdraw the infectious material. In another method, a surgeon exposes the abscess surgically, removes the infectious material, and places a wick to promote drainage and healing from the inside.

Complications
Bowel obstruction. Ulcers. Fistulas. Anal fissure. Malnutrition. Colon cancer. Other health problems.

Nursing Interventions:
Immunodilator agents No cigarettes smoking Fecal diversion- ileustomy or colonostomy Low residue diet Antibiotics/ anticholinergics (broad-spectrum) Monitor bowel, sounds and characteristics of the stool Medications Anti-diarrheal Total parenteral nutrition Offer foods rich in proteins Restricts clients activity- to reduce intestinal activity Yes to vitamins and ferrous supplements

Cushings disease

Cushings disease is a condition in which the pituitary gland releases too much adrenocorticotropic hormone (ACTH). The pituitary gland is an organ of the endocrine system. Cushing's disease is a form of Cushing syndrome.

Causes, incidence, and risk factors

Cushing's disease is caused by a tumor or excess growth (hyperplasia) of the pituitary gland. This gland is located at the base of the brain. People with Cushing's disease have too much ACTH. ACTH stimulates the production and release of cortisol, a stress hormone. Too much ACTH means too much cortisol. Cortisol is normally released during stressful situations. It controls the body's use of carbohydrates, fats, and proteins and also helps reduce the immune system's response to swelling (inflammation).

Clinical Features of Cushing's Syndrome

Sudden weight gain Central obesity Hypertension Facial plethora Proximal muscle weakness Glucose intolerance or diabetes mellitus Decreased libido or impotence Depression or psychosis Osteopenia or osteoporosis Easy bruising Hyperlipidemia Menstrual disorders Violaceous striae wider than 1 cm Recurrent opportunistic or bacterial infections Acne Hirsutism

Pathophysiology of Cushing's Disease

When stimulated by ACTH, the adrenal gland secretes cortisol and other steroid hormones. ACTH is produced by the pituitary gland and released into the petrosal venous sinuses in response to stimulation by corticotropinreleasing hormone (CRH) from the hypothalamus ACTH is released in a diurnal pattern that is independent of circulating cortisol levels: peak release occurs just before awakening, and ACTH levels then decline throughout the day. Control of CRH and ACTH release is maintained through negative feedback by cortisol at the hypothalamic and pituitary levels. Neuronal input at the hypothalamic level can also stimulate CRH release.

FIGURE 2. Hypothalamic-pituitary-adrenal axis. (CRH = corticotropin-releasing hormone; ACTH = adrenocorticotropin hormone)

Although the adenomas of Cushing's disease secrete excessive amounts of ACTH, they generally retain some negative feedback responsiveness to high doses of glucocorticoids. Ectopic sources of ACTH, usually in the form of extracranial neoplasms, are generally not responsive to negative feedback with high doses of glucocorticoids. However, some overlap exists in the response to negative feedback between pituitary and ectopic sources of excessive ACTH.

Classification of Cushing's Syndrome

ACTH dependent Cushing's disease Ectopic ACTH syndrome Ectopic corticotropin-releasing hormone syndrome*
ACTH = adrenocorticotropin hormone. *Accounts for 1 percent or less of cases.

ACTH independent Iatrogenic Adrenal adenoma Micronodular hyperplasia* Macronodular hyperplasia*

Diagnostic Tests
Tests are done to confirm there is too much cortisol in the body, then to determine the cause. These tests confirm too much cortisol: 24-hour urine cortisol Dexamethasone suppression test (low dose) These tests determine cause: Blood ACTH level Brain MRI Corticotropin-releasing hormone test, which acts on the pituitary gland to cause the release of ACTH Dexamethasone suppression test (high dose) Petrosal sinus sampling - measures ACTH levels in the veins that drain the pituitary gland

Treatment
Treatment involves surgery to remove the pituitary tumor, if possible. After surgery, the pituitary may slowly start to work again and return to normal. During the recovery process, you may need cortisol replacement treatments. Radiation treatment of the pituitary gland may also be used. If the tumor does not respond to surgery or radiation, you may get medications to stop your body from making cortisol. If these treatments are not successful, the adrenal glands may need to be removed to stop the high levels of cortisol from being produced. Radiation Radiation can be a useful treatment when pituitary tumors cannot be completely removed by surgery. Radiation of pituitary tumors reduces cortisol levels in about half of adults and most children with Cushing's disease. Because this cortisol-lowering effect takes time (3 to 12 months), medications that lower adrenal cortisol production may be given while waiting for the effects of radiation. These medications include ketoconazole, metyrapone, and aminoglutethimide. Adrenalectomy Surgical removal of the adrenal glands (adrenalectomy) is a final measure that may be recommended if other treatments are not successful. Adrenalectomy stops excess cortisol production but requires that you begin lifelong daily glucocorticoid and mineralocorticoid replacement therapy.

Expectations (prognosis)
Untreated, Cushing's disease can cause severe illness, even death. Removal of the tumor may lead to full recovery, but the tumor can grow back

Complications
Compression fractures Diabetes High blood pressure Infections Kidney stones Psychosis

Nursing Interventions Maintain muscle tone Provide ROM exercises Assist with ambulation Prevent accidents or falls and provide adequate rest Protect client from exposure to infection Maintain skin integrity o Provide meticulous skin care o Prevent tearing of skin: use paper tape if necessary o Minimize stress in the environment o Monitor vital signs; observe for hypertension, edema o Measure I&O and daily weights o Provide diet low in calories, sodium and high in protein, potassium, calcium, and vitamin D. o Monitor urine for glucose and acetone; administer insulin if ordered Provide psychologic support and acceptance Prepare client for hypophysectomy or radiation if condition is caused by a pituitary tumor Prepare client for an adrenal tumor or hyperplasia Provide client teaching and discharge planning concerning o Diet modifications o Importance of adequate rest o Need to avoid stress and infection o Change in medication regimen (alternate day therapy or reduced dosage) if cause of the condition is prolonged corticosteroid therapy