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Crohn's Disease, When pt's disease is not controlled with low-dose…

- - - - Weight loss
      - Malaise
      - Moderate to severe abdominal pain
      - Abdominal cramping
      - Flatulence
      - Soft or semiliquid stools
      - Steatorrhea
      - Sudden, violent diarrhea occurring nocturnally
      - Periods of acute exacerbation alternating with complete remission
    - - Gross rectal bleeding is rare, except in
        75‒85% of cases of Crohn colitis.
      - Fistula, mass, and abscess development
        is common
      - Fever
      - Weight loss
      - Strictures
  - - - NIH Theory: An autoimmune reaction. Experts think bacteria in your digestive tract can mistakenly trigger your immune system. This immune system response causes inflammation, leading to symptoms of Crohn's disease
- - - - Severe cases
        
        Bowel Rest: Few days to a couple weeks
        
        Can drink liquids, with nutrients or hospital admission with IV therapy
        
        Surgery
        
        Indications:
        
        Small Bowel resection
        
        fistulas
        
        intestinal obstructions
        
        Bleeding that life threatening
        
        Subtotal Colectomy
        
        Proctocolectomy
        
        Ileostomy
        
        Symptoms that can not improrve by medications
        
        Side effects from medications that are life threatening
      - Diet
        
        Low-residue diet when obstructive s/s present.
        
        Avoid foods high in fiber: whole grain bread, cereal, fresh fruit & veggies, seeds & nuts
        
        Pt's can have canned fruits and vegetables and should only have white bread.
        
        In-between attacks, pt's can eat whatever they can tolerate
        
        Parental nutrition or oral supplementation for malnutrition pts can sometimes be indicated in severe cases.
      - Rest & stress management to decrease bowel motility and to promote healing
        
        Guided imagery
        
        Refer for concealing
    - - Prednisone 1st line treatment for Mild to Mod:
        
        Initial outpatient treatment: 40mg-60mg/day PO
        
        Tapper after 2-4 months
      - Budesonide
      - Hydrocortisone
      - Methylprednisolone
    - - Antibiotics prevent or treat complications involving infection: abscesses and fistulas. Metronidazole, Cipro, Ampicillin and Tetracycline all show aid in controlling CD ileitis & ileocolonic
    - - Good for patient's who are unresponsive to other first line treatments
      - Good for severe CD pt's who are dependent on high-dose steroids or nonhealing fistulas
      - 6-mercaptopurine (6-MP)
      - Azathioprine
      - Cyclosporine
      - Methotrexate
      - Can cause bone marrow suppression and life threatening infections
    - - Anti-TNF-alpha therapies: adalimumab, certolizumab, and infliximab
        
        Can cause bone marrow suppression & increased risk for life threatening infection.
      - Anti- Integrins (Monoclonal Antibodies): Natalizumab and Vedolizumab
        
        Can cause progressive multifocal leukoencephalopathy in immunocompromised pts. Common SE: fatigue and allergic reaction
      - Anti-IL 12/23 Antibodies: Ustekinumab
        
        No increase in severe infections or malignancy as this is a Human IG Monoclonal Antibody
    - - Proper inflammatory management can reduces the risk of penetrating complications (fistulas/abbesses)
  - - - Iron deficiency and macrocytic anemia which result from inflammation of the terminal ileum and poor absorption of folate.
      - Hypocalcemia and Vitamin D deficiency, hypoalbuminemia, and steatorrhea resulting from bile salt deficiency
  - - - Educate on stress management techniques such as guided imagery and mindfulness
  - - - Avoid foods high in fiber, inclding whole grain breads and cereals, fresh fruits and vegetables, seeds and nuts.
      - Pts can eat canned fruits and vegetables and white breads only
      - Oral elemental or parenteral nutrition may be necessary if unresponsive to treatment or if growth retardation is treatment
      - Avoid dairy products if intolerant to lactose
      - If not in acute attack, may eat what they can tolerate
    - - PNA
      - Shingrix
      - TDAP-tetanus every 10 years
      - HPV ages 9-26
      - HEP A/HEP B
      - Meningococcus for college students and military
      - Flu/COVID every fall
      - No live vaccines while immunosuppressed
- - - - Aim to keep the cultural influences in
        the diet wherever possible
        
        Focus on swapping out trigger ingredients for better tolerated alternatives for patient satisfaction
        
        Example: Spicy foods: sriracha, chili powder
        
        Try removing heat-producing chilies and add flavor in other ways, such as with fresh cilantro, lime juice, and green onions
        
        Alternatively, the patient may reduce the heat-producing chili in the recipe to a level where they no longer experience symptoms.
- - - - Watch for signs of PTSD
  - - - When your patient presents
        with one or more of the
        following:
        
        Tenesmus
        (Fecal Urgency)
        
        Fever
        
        Female patients before attempting pregnancy or who are pregnant
        
        Bloody diarrhea or
        GI bleeding
        
        Chronic abdominal pain
        
        Weight Loss
        
        Joint pain, swelling, or redness
        
        Signs of anemia
        
        Cutaneous signs such as: Oral lesions,
        erythema nodosum, pyoderma gangrenosum
    - - Ocular Manifestations such as episcleritis, scleritis, iritis, or uveitis