NSG1NMA Nursing Management And Assessment

1.

The patient Mr Bob Jackson is a 55 year old married man who have two children. He lives in Patersons Plains of Melbourne and is a sheep farmer. He has been admitted to the ED due to experiencing nausea, malaise, diarrhoea and increasing Left Lower Quadrant (LLQ) abdominal pain since one week. His surgical history and medical records points out that the most likely chronic disease that fits Mr Jackson’s symptoms is Crohn’s disease.

Aetiology:

Crohn’s disease is a chronic digestive tract inflammation that spreads into the deeper layers of the gut tissues and affects the normal digestion and bowel of the individuals. There are three major causes of Crohn’s disease, which are as follows:

• Infection: Several environmental agents can cause this disease, although it is not transmissible.
• Immuno-response: There are also chances of occurrence of the disease due to an immune responses generated against any antigens present in the gut. These are usually hypersensitive response to the gut microflora (Cleynen et al., 2016). Changes in these gut microbiome may result in Crohn’s disease.
• Vasculitis: There are also evidences of the gut mucosal ulceration which results from the ischaemic condition generated due to vasculitis of the submucosal vessels of the gut (Ishida, Iwai, Yoshida, Kagotani & Okabe, 2013).

Several other theories are also hypothesized but the exact pathogenesis of Crohn’s disease is yet to be known.

In Australia, the prevalence of Crohn’s disease or other inflammatory bowel diseases are the highest among the world. More than five million people suffer from the disease worldwide, out of which 75,000 are from Australia (De Cruz et al., 2015). The number of people affected is increasing at such an alarming rate, it is assumed that within ten years the number of reported cases of Crohn’s disease will be 100,000 in Australia. This is not a contagious disease. Although medication improves the inflammation, often surgery is required to eliminate the affected portions of the intestine.

The symptoms of the disease include diarrhoea, abdominal pain, nausea, vomiting: all of which are similar to the symptoms of Mr Jackson. Even though the reason behind this inflammatory bowel disease is still not known, it is thought that generation of an immune response due to invasion of a virus or bacteria can lead to the inflammation. Mr Jackson is a sheep farmer. Parasites that infect sheep, could have infected Mr Jackson and resulted in all the symptoms of Crohn’s disease (Laass, Roggenbuck & Conrad, 2014). Also, He has medical history of suffering from depression. But he is currently not on any anti-depressant medication. That is probably one of the reason behind his current malaise.

Pathophysiology:

This is considered as an autoimmune disease and is known to mostly affect individuals with genetic susceptibility. The inflammation mostly occurs in the small intestine and the colon of the GI tract. The disease may affect any part of the gastro-intestinal (GI) tract, but is mostly reported to appear in the terminal portion of the ileum and colon. The disease starts with inflammation of the crypts and formation of abscesses which are developed into small mucosal lesions or ulcers (Gecse et al., 2014). The spread of this inflammation thickens the walls of the bowel and develops lymphedema. Excessive inflammation results in fibrosis, and stricture formation, leading to obstructions in bowel.

According to the phenotypic characteristics, CD can be divided into three subtypes:

• Inflammatory: Inflammation of the GI tract (Neurath, 2014)
• Stricturing: Fibrosis and luminal narrowing resulting from the inflammation
• Fistulizing: Developed between the bowel and adjacent organs

The patient has medical history of piles.  About three months per year, he suffers from loose stool and has frequent bloody stool too. He also often suffers from watery diarrhoea from time to time and takes Gastro-stop medicine to treat it. On examining his GI tract it was found that his abdomen was soft and tender in the LLQ and his lower abdomen was found to be distended. All his symptoms are simultaneous with the symptoms of Crohn’s disease. The risk factors for the disease include infection in the GI tract, excessive alcohol consumption, smoking, increased stress and poor bowel habits (Gevers et al., 2014). The patient Mr Jackson consumes 6 stubbies of heavy beer every week. For the last 35 years he has been smoking 1 pack of cigarrette each day. Also he has history of hypertension along with quite poor bowel habits. All these factors strengthens the hypothesis of Crohn’s disease. Inappropriate diagnosis of CD, led to appendectomy surgery can cause CD later in life of the affected person. Mr Jackson had appendectomy surgery when he was a child.

Diarrhoea causes severe water loss and thereby dehydration in the body. It is known that properly functioning kidneys show SG levels between 1.002 and 1.030. If the person is dehydrated, the SG level goes above 1.010. The higher the value, the more dehydrated the person is. Mr. Jackson’s urinalysis shows specific gravity of 1.05. Therefore it can be concluded that Mr. Jackson is quite dehydrated, due to constant loss of water through diarrhea and vomiting. Dehydration results in mild to severe headache, muscle cramps and dizziness. Although Mr Jackson did not experience any dizziness or muscle cramps yet, but he is having mild headache from the last few days. Therefore, special care must be taken to ensure that he stays hydrated.

2.

The other chronic disease that supports Mr Jackson’s symptoms is diverticulitis which is an inflammatory disease of the intestine and forms diverticula or small pouch-like structures that are present on the walls of the intestine (Feingold et al., 2014). The symptoms of diverticulosis include bloody stool and pain in the left side of the lower abdomen, both of which are relevant to the symptoms of Mr Jackson.

The major symptoms of diverticulitis include constant and persistent pain in the left lower quadrant of the abdomen, nausea, vomiting, distension and tenderness of the abdomen, and diarrhoea. Diverticulitis develops due to pressure in the weak places of the colon, which then result in formation of the pouches. If these diverticula tear up and result in inflammation and infection, it turns into diverticulitis (Morris et al., 2014).

The factors that increase the risk of developing the disease are cigarette smoking and consumption of NSAIDs, both of these are consistent with the patient situation.

Diagnosis:

Several other diseased conditions mimic the symptoms of Crohn’s disease. Therefore, suspected patients should be assessed for infection and IBD.

For diagnosis of Crohn’s disease, the following tests are performed:

• Colonoscopy: to do a biopsy of the epithelial lining of the colon. If clusters of inflammatory cells or granulomas are found, then the diagnosis can confirm for Crohn’s disease (Gomollón et al., 2016).
• CT scan: to check for any presence of blockage, infection, abscesses or fistulas
• Endoscopy: this procedure is done to check for any internal abnormalities in the GI tract.
• MRI: to check up on the conditions of the internal organs that helps the doctors to identify the areas of inflammation and narrowing which are common symptoms of Crohn’s disease (Gecse et al., 2014).
• Blood tests: to check for signs of anaemia, which may result from excessive bleeding from the GI tract

For diagnosing diverticulitis, the tests performed are as follows:

• CT scan and abdominal ultrasound: to assess the condition of the GI tract by evaluating the images
• Blood and urine tests: to check for signs of infection, inflammation, kidney or liver issues (Andeweg et al., 2013).
• Liver enzyme tests: for ruling out liver related causes of abdominal pain.

The symptoms of inflammatory bowel diseases such as Crohn’s disease, and the symptoms of gastroenteritis are quite similar, therefore the doctors may ask for a sigmoidoscopy which is an invasive examination of the sigmoid colon, to evaluate the symptoms properly (Shahedi et al., 2013).

References

Andeweg, C. S., Mulder, I. M., Felt-Bersma, R. J., Verbon, A., Van Der Wilt, G. J., Van Goor, H., … & Bleichrodt, R. P. (2013). Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Digestive surgery, 30(4-6), 278-292. doi: 10.1159/000354035

Cleynen, I., Boucher, G., Jostins, L., Schumm, L. P., Zeissig, S., Ahmad, T., … & Brant, S. R. (2016). Inherited determinants of Crohn’s disease and ulcerative colitis phenotypes: a genetic association study. The Lancet, 387(10014), 156-167. doi: 10.1016/S0140-6736(15)00465-1

De Cruz, P., Kamm, M. A., Hamilton, A. L., Ritchie, K. J., Krejany, E. O., Gorelik, A., … & Bampton, P. A. (2015). Crohn’s disease management after intestinal resection: a randomised trial. The Lancet, 385(9976), 1406-1417. doi: 10.1016/S0140-6736(14)61908-5

Feingold, D., Steele, S. R., Lee, S., Kaiser, A., Boushey, R., Buie, W. D., & Rafferty, J. F. (2014). Practice parameters for the treatment of sigmoid diverticulitis. Diseases of the Colon & Rectum, 57(3), 284-294. doi: 10.1097/DCR.0000000000000075

Gecse, K. B., Bemelman, W., Kamm, M. A., Stoker, J., Khanna, R., Ng, S. C., … & Levesque, B. G. (2014). A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn’s disease. Gut, gutjnl-2013. doi: 10.1136/gutjnl-2013-306709

Gecse, K., Khanna, R., Stoker, J., Jenkins, J. T., Gabe, S., Hahnloser, D., & D’Haens, G. (2013). Fistulizing Crohn’s disease: diagnosis and management. United European gastroenterology journal, 1(3), 206-213. doi: 10.1177/2050640613487194

Gevers, D., Kugathasan, S., Denson, L. A., Vázquez-Baeza, Y., Van Treuren, W., Ren, B., … & Morgan, X. C. (2014). The treatment-naive microbiome in new-onset Crohn’s disease. Cell host & microbe, 15(3), 382-392. doi: 10.1016/j.chom.2014.02.005

Gomollón, F., Dignass, A., Annese, V., Tilg, H., Van Assche, G., Lindsay, J. O., … & Rieder, F. (2016). 3rd European evidence-based consensus on the diagnosis and management of Crohn’s disease 2016: part 1: diagnosis and medical management. Journal of Crohn’s and Colitis, 11(1), 3-25. https://doi.org/10.1093/ecco-jcc/jjw168 

Ishida, M., Iwai, M., Yoshida, K., Kagotani, A., & Okabe, H. (2013). Metastatic Crohn’s disease accompanying granulomatous vasculitis and lymphangitis in the vulva. International journal of clinical and experimental pathology, 6(10), 2263. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3796253/pdf/ijcep0006-2263.pdf 

Laass, M. W., Roggenbuck, D., & Conrad, K. (2014). Diagnosis and classification of Crohn’s disease. Autoimmunity reviews, 13(4-5), 467-471. doi: 10.1016/j.autrev.2014.01.029

Morris, A. M., Regenbogen, S. E., Hardiman, K. M., & Hendren, S. (2014). Sigmoid diverticulitis: a systematic review. Jama, 311(3), 287-297.  doi: 10.1001/jama.2013.282025

Neurath, M. F. (2014). Cytokines in inflammatory bowel disease. Nature Reviews Immunology, 14(5), 329. https://doi.org/10.1038/nri3661 

Shahedi, K., Fuller, G., Bolus, R., Cohen, E., Vu, M., Shah, R., … & Kurzbard, N. (2013). Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clinical gastroenterology and hepatology, 11(12), 1609-1613. doi: 10.1016/j.cgh.2013.06.020