Crohn’s Disease: Treatment Plan and Prognosis
Table of Contents Diagnosis: Crohn’s Disease Differential Diagnoses Treatment Plan Patient Education Prognosis Follow up References Diagnosis: Crohn’s Disease Crohn’s disease is a chronic relapsing inflammatory intestinal disorder classified as an inflammatory bowel disease (IBD) alongside ulcerative colitis. The incidence of Crohn’s disease varies strongly on geography, environment, and ethnic composition of the population. The annual incidence in North America is 3.1-20.2 per 100,000 individuals and prevalence of 201 per 100,000. Crohn’s disease is a heterogeneous disorder where the combination of genetics and environmental influence result in its manifestation (Gajendran et al., 2018). Crohn’s disease presents a variety of symptoms including abdominal pain, chronic diarrhea, fever, anemia, and weight loss. Chronic diarrhea is most common but not necessarily applicable to all patients. Patients will also experience additional symptoms such as fatigue and fever. Abdominal pain is present in the right lower quarter of the abdomen. Anemia is characterized by vitamin and mineral deficiencies. Crohn’s disease is clinically diagnosed since there are no unique pathognomonic features. It is necessary to have endoscopic, histologic, and radiographic evidence of chronic intestinal inflammation alongside laboratory tests to arrive at this diagnosis (Lichtenstein et al., 2018).
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Differential Diagnoses The first differential diagnosis is ulcerative colitis which is also categorized as inflammatory bowel disease. However, this condition is characterized by inflammation and ulcers in the digestive tract. It is very similar to Crohn’s in clinical presentation, particularly symptoms such as diarrhea and abdominal pain that develop over time. Ulcerative colitis only affects the colon and the inner lining of the colon, while Crohn’s disease can occur in any part of the digestive tract and affects all layers of the bowel walls (Crohn’s & Colitis Foundation, n.d.b). The second differential diagnosis is appendicitis which is the inflammation of the appendix nearby the colon. Similarly, to other conditions, appendicitis creates sharp pain in the lower right abdomen, gradually becoming severe. Appendicitis should be investigated as it is an urgent condition that may require surgery. However, in many symptoms, and a radiological exam should easily identify differences as to which organ is inflamed (Mayo Clinic, 2019). The final differential diagnosis is an intestinal obstruction which is a condition that prevents normal digestion by creating a partial or total blockage in the small or large intestine. If not treated immediately, this may result in pressure building up and rupturing the intestine, becoming a life-threatening complication. Symptoms include abdominal pain, nausea and vomiting, and severe bloating. This can be clinically diagnosed and distinguished from other conditions via physical exams as well as radiological exams to identify blockage which makes it evident that intestinal obstruction is ongoing (Marcin, 2018). Treatment Plan The therapeutic treatment plan will vary for patients depending on the location, severity, complications, and prognosis of Crohn’s disease. The current medical approach focuses on a sequence of treating acute disease, inducing remission, and maintaining remission. The use of therapeutic drug monitoring is most common in Crohn’s disease management, with guidelines recommending infliximab ≥7.5 μg/ml, adalimumab ≥5 μg/ml, and certolizumab pegol ≥20 μg/ml (Lichtenstein et al., 2018). The medication is targeted at suppressing inflammation unique to the patient and providing relief for common symptoms such as pain, fever, and diarrhea. The drugs often seek to decrease the frequency of symptom flare-ups which will be periodic for patients diagnosed with Crohn’s disease. Diet and nutrition will have to undergo massive changes, even if an individual maintained an inherently normal or healthy diet prior to diagnosis. Nutrition will have to be maintained to ensure that all micronutrients are consumed and not lost and to prevent flareups that occur as a reaction to spicy, high-fiber, or fatty foods. Long-term, Crohn’s disease may require surgery as 70% of diagnosed patients eventually undergo it as medications stop having a profound effect in managing the disease. The surgery helps to conserve portions of the GI tract and increase the quality of life (Crohn’s & Colitis Foundation, n.d.a). Patient Education Patient education regarding Crohn’s disease should be comprehensive as this is a chronic condition that they will have to manage and live with for the rest of their lives. The foundation of the patient education should be a simple explanation of the pathophysiology of the condition which leads to the necessity of its management for a healthy life going forward. Patients should be educated on the various prescribed pharmacological treatments and encourage adherence. Finally, a significant emphasis should be put on lifestyle management which will be critical to managing Crohn’s disease and ensuring longevity without complications. Nutritional, behavioral, and health-related elements should be addressed ensuring that the patient is aware of what diets are appropriate and what can exacerbate the symptoms. Patients should be encouraged to not smoke, drink, and avoid stress as these behaviors worsen the condition. Patients should also be made aware that flare-ups will occur and what should be done in such scenarios. Prognosis The prognosis for Crohn’s disease is positive as most patients enjoy healthy and active lifestyles. The disease is not curable but manageable, thus treatments can keep it in remission and prevent dangerous complications. Lifestyle and nutritional changes will have to be made alongside regular preventive diagnostic tests such as colonoscopies. The exact cause for the condition is unknown and it presents itself highly different for each patient. However, those diagnosed with Crohn’s disease will experience ‘flare-ups’ or severe bouts of abdominal pain and other symptoms. Some patients have these often while others rarely. Patients have a slightly higher risk of mortality from complications than the general population, but this is not an acute risk (Billiet et al., 2016).
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Follow up It is recommended to the patient that an appointment be scheduled with a gastroenterologist who specializes in digestive diseases as soon as possible. There is no need to return to the emergency room or a general practitioner unless symptoms begin to be exacerbated again. Further treatment, which will have to be highly specialized based on the patient’s condition and state of the disease should be continued with the gastroenterologist which will likely conduct a variety of additional tests such as an endoscopy to evaluate the severity of Crohn’s disease. References Billiet, T., Cleynen, I., Ballet, V., Ferrante, M., Van Assche, G., Gils, A., & Vermeire, S. (2016). Prognostic factors for long-term infliximab treatment in Crohn’s disease patients: a 20-year single centre experience. Alimentary Pharmacology & Therapeutics, 44(7), 673–683. Web. Crohn’s & Colitis Foundation. (n.d.a). Crohn’s Disease treatment options. Web. Crohn’s & Colitis Foundation. (n.d.b). What is ulcerative colitis? Web. Gajendran, M., Loganathan, P., Catinella, A. P., & Hashash, J. G. (2018). A comprehensive review and update on Crohn’s disease. Disease-a-Month: DM, 64(2), 20–57. Web. Lichtenstein, G. R., Loftus, E. V., Isaacs, K. L., Regueiro, M. D., Gerson, L. B., & Sands, B. E. (2018). ACG clinical guideline: Management of Crohn’s Disease in adults. The American Journal of Gastroenterology, 113(4), 481–517. Web. Marcin, J. (2018). Intestinal obstruction. Web.
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Mayo Clinic. (2019). Appendicitis. Web.