Crohn’s Disease

Patient Presentation:
D.H. is a 49 year old, male who presented to the emergency department complaining of diarrhea for the past week.  He also complained of abdominal pain and cramping associated with the diarrhea and has had a fever of 101.5 ̊ F for the past three days.  Patient has a history of Crohn’s disease and has episodes of exacerbation followed by episodes of remission.  He already underwent a small bowel resection two years ago during a previous “flare up” of his Crohn’s disease.

Diagnosis:
It's clear from the patient's history and symptoms that this is an exacerbation of Crohn’s disease.  An abdominal x-ray and CT scan of D.H.’s abdomen and pelvis was ordered to re-evaluate the extent of his Crohn’s disease.  CT scan showed increased inflammation.

Crohn’s disease is a type of IBD that often affects the small bowel.  It is a slowly progressive and unpredictable disease that has periods of remission and recurrence.  Skip lesions are characteristic of Crohn’s disease and in some cases can be visualized on x-rays.  Some possible complications of Crohn’s disease include severe malabsorption, anemia, fistulas, bowel strictures, abscesses or cancer.  Currently, there is no known cure for Crohn’s disease.

Treatment:
D.H. and his surgeon decided to proceed with surgery.  D.H. underwent a total colectomy.  He also had a permanent ileostomy created.

Outcome/Prognosis:
Postoperatively, D.H.’s pain was managed with a hydromorphone PCA.  He had a NG tube in place to low continuous wall suction and was initially only permitted to have small sips of water and ice chips.  A PICC line was placed so that he could begin on total parenteral nutrition (TPN) at 80 mL/hr for nutritional support.  At the same time, he was also on IV fluids at 60 mL/hr for hydration.  D.H. was started on low dose corticosteroids t.i.d. to help reduce inflammation associated with Crohn’s disease.

On post operative day 6, D.H.’s ileostomy began putting out greenish watery liquid and on post operative day 7, the consistency of this output thickened to about the consistency of apple sauce.  Despite this passage of stool, D.H. did not begin to pass gas so his NG tube remained in place until he finally began passing gas on post operative day 10.  D.H. spent time working with the wound/ostomy nurses to learn how to care for his new ileostomy.