SECTION 4 Gastrointestinal Disorders 32 Father with DM, mother with HTN. Older sister with Crohn's disease SH CROHN'S DI
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- Section 4 Gastrointestinal Disorders 32 Father With Dm Mother With Htn Older Sister With Crohn S Disease Sh Crohn S Di 1 (62.83 KiB) Viewed 129 times
- Section 4 Gastrointestinal Disorders 32 Father With Dm Mother With Htn Older Sister With Crohn S Disease Sh Crohn S Di 2 (64.46 KiB) Viewed 129 times
& 0x 3, CNII-XII intact, 5/5 upper and lower extremity strength
bilaterally
_ Labs
Na 139 mEq/L
Hgb 11 g/dl.
K2.9 mEg/L
Hct 33%
CI 100 mEg/L
RBC 286 X
CO, 28 mEq/L
10%/m'
BUN 18 mg/dL
Pit 400 × 10%/mm'
SCr 1.2 mg/dL
MCV 72 um'
Glu 104 mg/dL. Phos 3.9 mg/dL.
Ca 8.7 mg/dL
ESR 130 mm/h
WBC 19.7 × 10¾m'
Neutros 67%
Bands 19
Eos 2%
Lymphs 26%
Monos 4%
Stool O & P (-)
Stool C. Diff toxin (-)
AST 25 IU/L
ALT 28 IU/L
Alk phos 50 IU/l
Total bili 1.2 mg/dL
Direct bili 0.6 mg/dI.
Albumin 3.8 g/L
I Assessment
38 yo man presenting with new-onset Crohn's disease involving
the terminal ileum and ascending and transverse colon requiring
treatment
QUESTIONS
Problem Identification
1.a. Create a list of this patient's drug therapy problems.
1.b. What signs, symptoms, and laboratory alterations in this
patient are consistent with Crohn's disease?
1.c. How would you classify the severity of this patient's Crohn's
disease? Provide the rationale for your answer.
1.. What factors could lead to the development or exacerbation of
Crohn's disease in this patient?
1.e. What extraintestinal manifestations can develop in patients
with Crohn's disease?
Desired Outcome
2. Develop a list of pharmacotherapeutic goals for this patient.
Therapeutic Alternatives
3.a. What drug therapies could be used to treat this patient's
Cohn's disease?
3.b. When is surgical intervention indicated in patients with Crohn's
disease?
Optimal Plan
4. Develop a complete treatment plan for managing this patient's
Cohn's disease.
Outcome Evaluation
5. What parameters should be monitored to assess both the efficacy
and toxicity of your selected drug regimen?
Patient Education
6. How will you educate the patient about his Crohn's disease
therapy in order to enhance compliance, minimize adverse
effects, and promote successful therapeutic outcomes?
CLINICAL COURSE
Mr. Jensen returns to his gastroenterologist for one of many follow-
up visits. It is now 18 months after treatment was started. He
achieved remission after 3 months of initial treatment and had onlv
a few intermittent episodes of diarrhea and abdominal pain for the
next 13 months. However, these episodes have become much more
frequent over the last 2 months and appear to be increasing in
severity. He has also developed two areas of skin breakdown on his
right lower abdomen that are continually draining a cloudy, foul
smelling fluid. Upon further examination, these areas are deter.
mined to be enterocutaneous fistulae.
- FOLLOW-UP QUESTIONS
1. Given this new information, how would you modify the patient's
drug therapy?
2. Should this patient undergo baseline testing to prevent or detect
bone loss?
- SELF-STUDY ASSIGNMENTS
1. Search for websites containing information about local support
groups in your area to which you may refer patients with Crohn's
disease for help and support.
2. Construct a table outlining the major differences between
Crohn's disease and ulcerative colitis.
3. Review the FDA pregnancy categories for the major drug classes
used for treatment of both active Crohn's disease and mainte.
nance of remission
99
CHAPTER 32
Cohn's Disease
CLINICAL PEARL
Hospitalized patients with active Crohn's disease are at high risk for
blood clots due to their inflammatory state and should be placed on
prophylactic therapy for deep vein thrombosis
REFERENCES
1. Hanauer SB, Sandborn W. Practice Parameters Committee of the
American College of Gastroenterology. Management of Crohn's dis-
ease in adults. Am I Gastroenterol 2001:96:635-643.
2. Podolsky DK. Inflammatory bowel disease. N Engl J Med 2002:
347:417-429.
3. Kethu SR. Extraintestinal manifestations of inflammatory bowel dis-
eases. I Clin Gastroenterol 2006:40:467-475.
. Buning C, Lochs H. Conventional therapy for Crohn's disease. World
J Gastroenterol2006;12:4794-4806.
5. American Gastroenterological Association Institute technical review
on corticosteroids, immunomodulators, and infliximab in inflamma-
try bowel disease. Gastroenterology 2006;130:940-987.
6. Guslandi M. Antibiotics for inflammatory bowel disease: do they
work? Eur ] Gastroenterol Hepatol 2005;17:145-147.
7. Hancock L, Windsor AC, Mortensen NJ. Inflammatory bowel disease:
The view of the surgeon. Colorectal Dis 2006;8(Suppl 1):0-14.
8. Bressler B, Sands BE. Review article: medical therapy for fistulizing
Crohn's' disease. Aliment Pharmacol Ther 2006:24:1283-1293.
9. Bernstein CN, Leslie WD, Leboff MS. AGA technical review on osteopo-
rosis in gastrointestinal disease. Gastroenterology 2003;124:795-841
SECTION 4 Gastrointestinal Disorders 32 Father with DM, mother with HTN. Older sister with Crohn's disease SH CROHN'S DISEASE Married with two children ages 2 and 4. Works as a sales represen A Sense of Urgency Level 1 tative for a pharmaceutical company. Occasional alcohole on the weekend Smokes Ppd 10 year. Brian A Hemstreet, PharmD, BCPS Meds Lansoprazole 15 po PRN Cetirizine 10 mg po once daily LEARNING OBJECTIVES Fluticatione prays each nostril once daily Malos 2 tablespoons po PRN After completing this case study, students should be able to Ketoprofen 12.5 mg po Q 4-6 h PN pain • Describe the typical dinical presentation of active Crohn's dis Albuterol MEX PRN prior to exercise ease, including signs, symptoms, and disease distribution and AR severly Codeine Glut) • dently exacerbating factors and potential complications of Sulfa drugs (severe rash) Crohn's disease ROS Recommend appropriate pharmacologic treatment for active Crohn's disease Reports five to six loose stools per day with intermittent blood, crampy abdominal pain, and canal leven. Feels very fatigued • Review major tonicities of drugs commonly used for managing and thirsty, Ne recent weight loss er sick contacts. Heartburn three Crohn's disease to four times a wek and thinorrhea one to two times a week. No Educate a potent on the proper use of medications used to cough, , MA or mental status change. Na knee we joint pain. No jaundice or rashesNo . Physical Examination PATIENT PRESENTATION Gen Well-developed Caucasian male in mild distres Chiel Complaint VS T'm having a lot of diarrhea and I feel really run down." Sitting: HP 139/89, P 92, Standing 12 136/70, P 99, RR 17. T.9°C WERS, HS John Jensen is a 3-year-old man with a 4-month history of intermittent episodes of watery diarrhea and crampy abdominal pain. He states that recently his episodes have increased in fre Pallor, dry flaky skin. no lesions or the quency, and he is now having five to six loose bowel movements day. He reports intermittent fevers as well as mabase and fatigue HEENT Over the last 2 weeks, he has also noticed blood in some of his PERRLA, EOMI, pale conjunctivac, dry mucous membranes, intact Mools, These symptoms have caused significant problems with his dentition, oropharynx clear job, as he is a sales representative for a pharmaceutical company and spends a lot of time driving. He has tried OTC ketoprofen for the Nechlymph Nodes abdominal pain and Peto Bimal for the diarrhea, both which Trachte midline, thyromegaly. -lymphadenopathy. (-) VD have provided little relief. He has two children, both in daycare, who have not been sick in the last few months. He does not recall any Lungs Thorax exposure to other sick contacts. He reports no recent intematonal CTA bilaterally trave. His PCP erred him to a gastroenterologista colonoscopy revealed a patchy cobblestone pattern of inflammation in the CV terminalium and the ascending and transverse colon. The inflam Tachycardic, regalar rhythm, no MRG matory processestands below the intestinal mucosa, and there is evidence of mucosal friability and recent bleeding. A biopsy of the Abd intestinal mucosa revealed leukocyte infiltration and submucosal Diffuse upper and lower quadrant tendernes non-distende (+) granuloma consistent with active Crohn's daca BS. - HSM РМн Gemilect GERD Prostate sise WNI. (-) Sinusitis (last treated with antibiotice months ago) Heme +) stoel Seasonal allergic rhinitis Exercise-induced bronchoconstriction MS/Ex A repult of the right ke 2 years ago No CVA tenderness Skin
99 CHAPTER 32 Crohn's Disease Neuro CLINICAL COURSE A&OX CN II-XIl intact, 55 upper and lower extremity strength Mr.Jensen returns to his gastroenterologist for one of many follow- bilaterally up visits is now 18 months after treatment was started. He Labs achieved emission alter 3 months of initial treatment and had only few intermittent prodes of diarrhea and abdominal pain for the WATSIL next 13 month. However, the episodes have become much more கோரக ALT CM Alto frequent over the last 2 months and appear to be increasing in 002 tal பட writy. He has a developed two area of skin breakdown on his BON NOW Det right lower abdomen that are continually draining a doudy, foul OLUL MCV 72 More Alyt Anelling fluid. Upon further examination, the areas are deter- GO mined to be enterocutaneous fistele 130 Assesment FOLLOW-UP QUESTIONS 38 yo man presenting with new.omet Crohn's disease involving 1. Given this new information, how would you modify the patime's the terminal ileum and ascending and traverse colon requiring drug therapy treatment 2. Should this patient undergo baseline testing to prevent or detect below! QUESTIONS SELF-STUDY ASSIGNMENTS 1. Search for websites containing information about local support Problem Identification group in your area to which you may refer patients with he's La Create a list of this patient's drug therapy problem disease for help and support 1. What is wmpoms, and laboratory testions in thi 2. Construct a table outlining the major differences between patient are consistent with Crohn's disease Crohn descan and ulcerative colitin 1. How would you danify the very of this patient's Crohn's Review the FDA pregnancy conegories for the major drug desses disease Provide the rationale for your answer used for treatment of both active Grohn's disease and mainte tance of mission. 1d. What factors could lead to the development of exacerbation of Crohn's disease in this patient 1. What extruintestinal manifestation can develop in patients CLINICAL PEARL with Crohn's disease Hospitalised patients with active Crohn's disease are this is for Desired Outcome blood clots due to their inflammatory state and should be placed on 2. Develop a list of pharmacotherapeutic goal for this patient prophylactic therapy for deep in thrombosi Therapeutic Alternatives REFERENCES 3a. What drug therapies could be wed to treat this patient" 1. Hanauer S, Sandbor W. Pati Parameters Committee of the Crohn's disease American College of Gastroenterology Management edha's die 3. When is surgical intervention indicated in patients with Crohn's awe is dat Am I Grote 2-63 disease? 2. Podoldy D Infantry bouddiese Engl Med 200 1741 Optimal Plan Kethel utca testinal munitions of inflammatory bond mes. Clin Gastroenterol 2007-05 4. Develop a complete treatment plan for managing the patient' Ling Clodu Iloa therapy for Child Wild Crohn's disease Gastro 2006.12:479-420 American Gastroenterological Association Intimate technical Outcome Evaluation பா மாலயா, பாயாயாயdalaare கார் பாலியல் பாரியா tory bowel die Gastroentendig 2001.00-987 5. What parameters should be monitored to as both the efficacy Gold M. Antibioti fi ammory w do they and tonicity of your selected drug regiment waktual Hepatol 2000:17:105-10 7. Hanck , Winter AC Mon N Industry bowel die Patient Education These of the warco. Colorectal Suppl 110-14 Bresse B Sante B Review artide medical therapy for futulining 6. How will you educate the patient about his Crohn's disease Crohn de Alimest Pharmacol Ther 200201283-293 therapy in order to enhance compliance, minimize adverse Bem CN, WILMS MGA tem review effects, and promote successful therapeutic outcomest in gestremnestinal doce Gastroenterology 2000/124795-6.