Crohn’s Disease Essay Example

the body is affected by Crohn’s and ultimately how Crohn’s patients are susceptible to septic complication. Clinical case The patient was brought into the emergency department with signs and symptoms of dehydration, bloody stools and was suffering from severe hypotensive septic shock.

Past medical history includes: crohn’s disease, jejunostomy, multiple thrombotic conditions (mesenteric vein thrombosis, portal vein thrombosis) and has also received treatment for thrombocytopenia and neutropenia.The patient was admitted to the intensive care unit were she received treatment including: rehydartion, blood transfusions, hyperkatemic therapy and a consultation for thromb clinic. CT of the abdomen and pelvis with contrast was performed and results indication an intra-abdominal abscess. As the patient’s immune system was already suppressed from the crohn’s disease, the body was not able to fight off the infection and in turn the patient went septic. It is now the responsible for the immune system to return the body to homeostasis.Physiology of Immune system In regards to homeostasis, the human body is built with its own immunity system, providing the body with defenses against foreign substances and prevents disease.

The immune system is made up of tissues, organs, proteins and multiple cells in the body that has the ability to help defend against foreign substances called antigens from entering the body. With this being said, an antigen is a molecule that can come in the form of a microorganism, bacteria, virus and fungi (Cunneen, 2004).On that note, the human body has the ability to fight and protect itself from injury and infection against foreign substances and has in place three lines of defense to help eliminate foreign substances in the body. Firstly, the innate immune

system controls the first line of defense as it consists of the physical, mechanical and biochemical barriers. These barriers included the skin, mucous and cilia that line the respiratory, genitourinary and gastrointestinal tracts.

Their job is to protect the body from invasion by trapping and destroying any antigens that attempt to seek entity into the human body (McCance & Huether, 2006). Secondly, once an antigen has successful accomplished entity into the body, the focus of defense is redirected and enters into the second line of defense which is the non-specific response to infection. The first to emerge on to the site of a foreign substance is the innate defense system as it appears within minutes responding to protect the body (Marieb & Hoehn, 2007).The innate defense system primary response to antigens is triggered by the release of leukocytes, which in turn releases phagocytes cells including neutrophils that ingest the invading organisms and lymphocytes cells that are reasonable for the memory and recognize of previous invaders and also help protect the body by destroying them (Marieb & Hoehn, 2007). The third line of defense the adaptive response composed of highly specialized cells is initiated by lymphocytes as they come into contact with the foreign antigen that has entered the human body.

B lymphocytes and T lymphocytes have different jobs to do after they become immunocompetent in the thymus and bone marrow (Marieb & Hoehn, 2007). This step educates the B lymphocytes to bind to the invaders and immobilize the antigen, as for the T lymphocytes they seek and destroy the invaders The innate and acquired immune system have the ability to protect the body by fighting off the

antigens and also play a very is important in the defense against diseases (Marieb & Hoehn, 2007). Pathophysiology of InflammationAfter the body has sustained injuries, which can be caused by bacteria, trauma to the site, exposure to heat, or any other cause of injury, the Inflammation response is triggered by chemical alarm signals released by infected or injured cells in attempt to protect the site from further injury as tissue injury (Cunneen, 2004). The goals of the inflammatory response is to rid the body of injurious agents by delivering nutrients to the site of injury, which promotes healing and to increase the presences of blood cells at the site of injury to destroy antigens.When tissue is injured, mast cells and platelets release chemicals including histamine and kinin, igniting the inflammatory process. With this being said, the acute inflammatory response occurs promptly as the body reacts within a few hours after the initial injury or infection has occurred (Fleisher & Bleesing, 2000).

In this clinical case, the patient was admitted with sever pain in the abdominal area, anorexia, dehydration, severe hypotensive septic shock and bloody stools (hemorrhage).The patients past medical history also indicated a diagnosis of thrombocytopenia, this is important to note as the body is attempting to maintain a normal platelet count within the body as it increases the number of immature platelets thus in turn increases the patient’s risk of experiencing a hemorrhage (Pagana & Pagana, 2006). Within the inflammatory response there are two subheadings: vascular response and the cellular response. The primary physical response to inflammation is the vascular response as the body needs to increase the blood circulation to the affected area

(Sommers, 2003).This takes place as the body vasoconstricts the arterioles, for a brief moment, and closes to the site of infection allowing the blood to slow, causing the increase of blood flow to the affected sites (McCance & Huether, 2006). This triggers the vasodilation of arterioles, venules and capillaries causing hyperaemia (increased blood flow), in the attempt to increase the vascular capacity to the area.

In particular, the release of histamine increases capillary permeability and blood vessel diameter, this initiates the blood vessels around the site of inflammation to dilate, enhancing the blood flow to the area.As a result of the increased blood flow, the immune responses become stronger as the vasodilation of the vessels allows for the larger cells including blood plasma and platelets enter into the affected area (Marieb & Hoehn, 2007). Fluid and blood proteins leave the capillaries and enter into the interstitial spaces, causing leakage of fluid into the tissues resulting in swelling at the site, warmth, redness and possible pain. This takes place as the enhanced blood flow increased the present of red blood cells at the site (Cunneen, 2004).

In association with the vascular response, the plasma protein systems consist of three systems: complement system, kinin system and coagulation system, contribute in the protection of the body (Cunneen, 2004). Firstly, the complement system is a series of proteins, consists of three pathways, all converging at the (C3) third component produced in the liver, to work along side the antibodies. The classical pathway is activated through the antigen-anitbody complexes in association with component C1 which consists of C1q, C1s and C1r molecules, eventually bind to the antigens (McCance & Huether2006).The lectin

pathway is activated by plasma proteins mannose-binding lectin (MBL), binding to mannose-rich pathogen molecular patterns then eventually split the C2, C4 into a/ b which bind together to form the C3 convertase. Lastly, with respect to this system, is the aalternative pathway which is activated by C3b binding to microbial surface of antibody molecules and initiates the cell’s lysis signaling to the phagocytes (McCance & Huether, 2006).

Essentially, it is indicated that the cell needs to be removed. Secondly, is the coagulation system, triggered by the release of collagen, kallikrein, plasmin and proteinases.The function of the coagulation system is to form clotting by producing a fibrous mesh network that functions to obstruct the bleeding, isolate and contain the spreading of the infection by keeping the microorganisms and antigens at the site of inflammation (Flesiher & Bleesing, 2000). This system is made up of an intrinsic and extrinsic pathway. After injury to the cells the pathways signal prothrombin (inactive in the plasma) to convert into thrombin and fibrinogen is converted into fibrin, resulting in the assembly of the fibrin mesh (clotting factor) (Sommers, 2003).

The kinin system is the third and final stage in the plasma protein systems. This system is responsible for assisting the coagulation system in trapping the invading pathogens and also activating and assist with the inflammatory cells (Sriskandan & Altmann, 2008). The generation of bradykinin and kallidin peptides assists the inflammatory response by causing dilation of blood vessels, increasing vascular permeability, prompt contraction of the smooth muscle cells, induces pain at the site of infection and also increases signals to chemical messengers.These signals attract the body’s natural defense cells; specifically, chemotaxis cells are

attracted to the site (McCance & Huether, 2006).

Cellular Response When the body has detected physical injury it activates the mast cells in the body. The mast cells colonize in the connective tissues as they carry granules rich in histamine and heparin sulphate. With the release of histamines, mast cells initial the flare up response resulting in the bodies’ cellular response to the injury (Marieb & Hoehn, 2007). With this said, the increase of chemotaxis triggers the migration of leukocytes (white blood cells) to the injured site.Leukocytes cells work together to destroy bacteria, viruses, as they are the fighting cells of the immune system.

White blood cells manufactured in the bone marrow, mature from stem cells into specific leukocyte cells (Sommers, 2003). The patient’s blood work on admission states: white blood count 2. 1, platelets 113. Even through there is a decrease in white blood count this may be the result of a overwhelming infections and autoimmune disease in which case the patients past medical history states the diagnosis of crohn’s disease and is currently suffering from server septic shock and blood loss (Pagana & Pagana, 2006).Leukocytes are separated into groups: granlocytes, lymphocytes, monocytes and each play on important role in inflammatory response. Granulocytes are the largest group, making up over half of the leukocytes and consist of neutrophils, eosinphils and basophils (Sommers, 2003).

Neutrophils are initially attracted by chemotaxis arriving on the site within hours after injury and are accountable for the majority of the immune response. Since neutrophils have a short life span, their primary goal is to find foreign particles, phagocyosis and the formation of pus with cell death (Sommers, 2003).Eosinophils supply

the body with protection against parasites and assist in the regulation of the vascular medicator that are discharged from mast cells, where as basophils are simular to mast cells as they carry histamines to the site causing inflammation (McCance & Huether, 2006). The second group of leukocytes is lymphocytes consisting of B cells, T cells and natural killer cells.

Natural killer cells cause cell death towards the antigens through the release of cytoplasmic granules proteins: perforin and granzyme (Fleisher & Bleesing, 2000).B and T cells work together as T cells (mature in the thymus) directly attack the antigens to neutralize them, where B cells (mature in the bone marrow) form antibodies that directly attach themselves to the antigens resulting in the deactivation of the antigens making them susceptible to destruction (Fleisher & Bleesing, 2000). Monocytes are the last group and can be found circulating in the bloodstream after being released from the bone marrow. Monocytes are attracted to damaged site by chemotaxis and arrive at the site of inflammation within 3 to 7 days after injury, were they mature into macrophages (McCance & Huether, 2006).Macrophages play an important role in the acute and chronic inflammation responses as they kill off foreign pathogens, clean up dead neutrophils and assist in the healing process by secreting molecules called cytokines.

On that note, cytokines are critical in the functioning of the immune system and can be classified as interleukins (ILs) or interferon’s (IFNs) (McCance & Huether, 2006). Produced primarily by macrophages, pro-Inflammatory interleukins (IL-1) acts on the hypothalamus regulating the thermostat and also increases the bodies innate and acquired immunity by stimulating lymphocytes and phagocytes (Cunneen, 2004).Cytokines also

work to enhances plasma proteins production in the liver, increase the activity of neutrophils and bounds T cells to interleukin (IL-1) to form interleukin 2 (IL-2) promoting T cells to divide quickly (McCance & Huether, 2006). With the destruction of the foreign antigens the immune system works hard to repair the damaged tissues and to return the body back to a homeostasis state. Ggastrointestinal system In the case of crohn’s disease (inflammatory bowel disease) the body produces a chronic inflammation and ulceration in the intestines; it primarily affects the small intestine (ileum).

In terms of the immune system the body has mistaken itself as a foreign antigen resulting in the activation of the inflammatory response and the attack on itself (Saibil, 2003). Crohn’s disease can also affect any part of the gastrointestinal tract from the mouth to the anus. Since crohn’s disease can affect any part of the gastrointestinal tract, this can make meal times an unpleasant task as food particles can get stuck causing pain, cramping, infections and possible a blockage (Saibil, 2003).It is also important to follow a healthy diet, take nutrition supplements, drink plenty of fluids to hydrate the body and prevent weight loss as several individuals suffer from malnutrition and dehydration (Kastin & Buchman, 2002).

Malabsorption of necessary vitamins (iron, calcium, folic acid and vitamin B12) and minerals can result from the inability to absorb due to inflammation in the bowel, episodes of bleeding, diarrhea and some treatment medications also cause absorbs problems (Kastin & Buchman, 2002). Total parental nutrition (TPN) is an intravenous feeding that is used in individual that need complete bowel rest.To ensure the individual is receiving the appropriate

nutrition supplements, TPN is a solution consisting of proteins, lipids, vitamins, electrolytes, carbohydrates and trace elements that are individually tailored to the clinical case (Kastin & Buchman, 2002). Physiology of the gastrointestinal system The digestive system consists of ingestion, digestion, absorption and defecation process (Marieb & Hoehn, 2007). To assist the body through these processes the digestive tract is sorted into two groups: the alimentary canal and the accessory digestive organs.The alimentary canal extends from the mouth to the anus and consists of the mouth, pharynx, esophagus, stomach, small intestine, and large intestine.

The accessory digestive organs consist of the teeth, tongue, salivary glands, gallbladder, liver and pancreas (Marieb & Hoehn, 2007). The four stage process begins with the ingestion of food via the mouth. As food is placed in the mouth, the accessory organs: teeth, tongue and salivary glands began the mechanical digestion through chewing, and mixing the food into what is called bolus.The tongue then assists in the swallowing processes by pushing small amounts of bolus to the back of the mouth (pharynx) triggering an involuntary swallowing reflex to prevent food from entering into the lungs, this directs the bolus down the esophagus (Marieb & Hoehn, 2007). The action of peristalsis (contraction of muscles) forces the bolus down the esophagus and in the stomach. The stomach then contributes further to the digestion and breaking down of the bolus by the release three major hormones: gastrin, secretin, cholecystokinin (Chaudhri, Small, & Bloom, 2006).

The presents of food in the stomach stimulates the hormone peptide YY which inhibits the appetite. Gastrin in the stomach promotes the release of gastric juices containing hydrochloric acid and pepsinogen assisting

in the digestion of phase. Secretin also stimulates the stomach to produce pepsin, an enzyme that digests protein and promotes the liver to produce bile (Chaudhri, Small, & Bloom, 2006). From the stomach the chyme (mix of acid and food in the stomach) passes into the small intestine.The release of secretin and cholecystokinin in the duodenum, signals the pancreas to activate the digestive enzymes lipase and bile produced by the liver, stored in the gallbladder to be release as it assists the body to absorb fat.

The small intestine is now able to breaks down the chyme and absorbs most of the vitamins, minerals, proteins, carbohydrates and fats (Chaudhri, Small, & Bloom, 2006). After the bolus has been passed through the small intestine, it enters the large intestine. The large intestine consists of the caecum, appendix, colon and rectum.The large intestine at this time reabsorbs water, vitamins and minerals assisting the fluid balance of the body, forms feces out of the remaining waste, which is then stored in the rectum until passing of a bowel movement (Marieb & Hoehn, 2007). Pathophysiology of Crohn’s disease Building on the aforementioned information, the complications of the digestive system can be a result of Crohn's disease (Inflammatory bowel disease).

As specified, this is a lifelong condition, which must be managed. Aalthough it can be found along any part of the gastrointestinal tract, it is most commonly detected in the small intestine.An abnormal immune system may be a factor in the case of the disease as the body’s inflammatory response act to defend the mucosa layer in the intestines from antigens (Reyonolds & Stellato, 2001). Normally the inflammatory response would

not response to bacteria, antigens or other substances in the intestinal tract.

In the case of Crohn’s disease the immune system malfunctions and actively reacts to the self invasion in turn sending neutrophils and cytokines to the site, only to causes more inflammation and injury to the area.Cytokines regular duty is to regulate the inflammatory response in Crohn’s disease, however the overproduction of proinflammatory cytokines affect the normal balance between the production of proinflammatory and anti-inflammatory cytokines. As a result the immune system is not able to repair the damage to the tissue and the inflammation continues to spread (McCance & Huether, 2006). With this being said inflammation is an early stage of the disease and is followed by the symptoms: abdominal pain, diarrhea, rectal bleeding, and fever.

Initially crohn’s disease develops as inflammation in the epithelium layers of the intestinal tract expand into the deep longitudinal and transverse colon causing the thickening of the wall of the bowel, and narrowing the passageway. (Thoreson & Cullen, 2007) The inflammation of the epithelium layers are affected with patches of healthy tissues and areas of diseased tissues, as the condition progresses the epithelium layers of the bowel may all become affected and can result in the presents of ulcers (cobblestoned). Ulcers may pierce or erode the intestinal wall, causing abscesses and fistulas to form.Abscesses are pus like pockets that form from an infection, resulting from the collection of fluid that cannot drain (Thoreson & Cullen, 2007). Fistulas are abnormal connecting passageways between two structures that typically link between the loops of the intestinal tract. Crohn’s disease of the upper gastrointestinal tract is not as common and only affects

a small number of people, affecting the digestive system by causing the narrowing of passageways, thickening of folds, formation of ulcers and cobblestones (Reyonolds, & Stellato, 2001).

As a result of Crohn’s disease the digestive system becomes inflamed and weak, making digestion of food difficult and possible painful as the tissues become tender and swollen (Reyonolds & Stellato, 2001). Inflammation and damaged wall impairs the ability of the small intestine to process and absorb food, affecting the motility of the digestive system, in return decreasing the time available for digestion and absorption. Interference with digestion system can ultimately lead to malabsorption and malnutrition (Kastin & Buchman, 2002).Episodes of flare ups of Crohn’s disease can additionally affect the nutritional intake as several people experience weight loss, as a result of periods of diarrhea, vomiting and loss of appetite (Kastin & Buchman, 2002).

With this said, there is no set diet plan for Crohn’s disease patients, instead it is recommend eating a healthy well rounded diet and take nutritional supplements as it is important to making sure the body is receiving a healthy amount of vitamins, minerals and amino acids.Alternate nutritional supplements are available to boost the patient’s nutrition intake, special formulas are given to patients in order to maintain or increase their body weight (Kastin & Buchman, 2002). Medications/Treatment Following the diagnosis of Crohn’s disease in 1995, the patient was placed on infliximab and was intermittently on steroids, in attempt to delay the progression of the disease. Infliximab is a chimeric monoclonal antibody used to treat autoimmune disorders.This medication is to be given by intravenous infusion over several hours and causes the blocking of the tumor necrosis

factor, inhibiting the cytokines ability to trigger the inflammatory response (Conroy & Cattell, 2001).

In addition to infliximab, a course of steroids (corticosteroids) were taken to eases the symptoms of crohn’s disease as they reduce inflammation and suppress the body's immune system. Normally symptoms would improve with a few weeks after starting the medication and for safe reasons corticosteroids were only taken intermittently for flare up’s and stopped when the symptoms ease off (Thoreson & Cullen, 2007).Even after receiving treatment the patient’s disease continued to progress, in 1995 the patient went in for surgery receiving an ilecocal resection and again in 1997 received a jejunostomy. Surgical resections become necessary when the disease causing an obstruction in the intestinal tract has damaged a portion of the intestine.

After the removal of the affected area a part of the small bowel was brought to the surface creating an opening called a stoma. From this opening the body rids waste products by empting into a pouch attached to the abdomen (Thoreson & Cullen, 2007).Currently the patient is receiving cefazolin 1g IV Tid for 14 days, hydrocortisone sodium succinate 100mg = 2ml IV Bid for the treatment of septic shock. Cefazolin was ordered, as it is a medication to treat the intra-abdominal abscess and any other infection in the body, as cefazolin is an antibiotic is used to treat bacterial infection (Powers & Jacobi, 2006). Hhydrocortisone sodium succinate is classified as a glucocorticosteroid and is widely used in the treatment of septic shock as it relieves inflammation.Metabolized by the liver it produces an anti-inflammatory process within the body and also inhibits the accumulation of inflammatory cells at the site

of infection by phagocytosis (Sprug, Annane, Keh, Moreno, Singer, & Freivogel, et al.

2008). The patient also has orders for: heparin 7500units =0. 75ml sc Bid used as an anticoagulant to prevent the formation of clots, this is necessary as the patient is on bed rest with decreased mobility as well an order for total parental nutrition (TPN) total 24hr 1800ml =75ml/hr is to be given assisting the in the rehydration, weight gain and also promoting bowel rest (Powers & Jacobi, 2006).In addition to these orders the patient can also receive medications on an as needed base to treat pain, anxiety and nausea. Conclusion After reviewing the clinical case, evidence shows that the diagnosis of Crohn’s disease and the affect that this disease has had on the patient’s immune system is connected to the patient’s diagnosis of sever hypotension septic shock. Seeing as the patient’s Crohn’s disease had already spread to the small intestine, it quite possible that it is affecting the upper gastrointestinal tract and resulting in the development of the intra-abdominal abscess.

Since the body is already experiencing abnormal immune responses it is clear that is it, and has been, unable to fight off infection. As a consequence, the body went into septic shock. The connection between Crohn’s disease and inflammatory response is an important link for medical professionals to be aware of as inflammation plays a large part in many diseases and is often caused by infection.With this being said, it is important to maintain a healthy lifestyle, to ensure that the body receives the vitamins, minerals and antioxidants it requires to supplement its immune system. Furthermore, for those for whom Crohn’s disease

is a reality, it is pivotal to their continual health and to the body’s ability to defend itself, that the disease be properly managed and that they receive the necessary care to cope with the full spectrum of complications that may arise.