Nutritional Factors for Patients with Crohns Disease

According to Hart & Ng (2011), “Crohn’s disease is a chronic inflammatory bowel disease (IBD)”. Kavic (2015) explained, “This disease is characterized by periods of relapsing symptoms caused by immune mediated inflammation”. Around two million people in the world are affected by Crohn’s disease (CD) and includes anywhere of the gastrointestinal tract being affected by chronic inflammation and majorly affect the large bowel and the terminal ileum (Rajesh & Sinha, 2015). The etiology is majorly unknown, but may due to the association of immunological, genetic and environmental factors (Rajesh & Sinha, 2015). Strictures are resulted from gastrointestinal tract inflammation (Rajesh & Sinha, 2015). This kind of stricturing is more on intestine than colon and can further develop into semi-acute and complete obstruction of intestine (Rajesh & Sinha, 2015). Zhu et al., (2015) described indications for surgery are particular CD complications such as strictures or fistula and which can not be manage by treatment of drug. This essay would be focusing on nutritional therapy as preoperative nursing care and surgical site Infection as the postoperative complication, assessment and management for CD patients undergoing bowel resection will be discussed.

Nurses are responsible and play a vital part to provide nutritional therapy besides consulting with dieticians during pre-operative evaluation (van Noort et al., 2019).  Nurses need to provide nutritional screening and nutritional care planning as pre-operative care for patients (Noort et al., 2019). Nutritional therapy is providing nutrition orally, such as regulating diet for therapy, enteral nutrition (EN) and total parental nutrition (TPN) (Noort et al., 2019). Post-operative complications were decreased in patients who received nutritional therapy with EN or TPN, and hospitalization period has significantly reduced (Noort et al., 2019).

Active CD patients who were hospitalized commonly suffered from malnutrition, incidence ranging from 25 to 80% majorly resulted from increased intestinal loss, anorexia and systemic inflammation (Wang et al., 2016). Post-surgery morbidity and two-stage procedure risk can be caused by poor nutritional state (Zerbib et al., 2010).


Lashner, Evans & Hanauer (1989) has illustrated that for CD patients, TPN with bowel rest is a predominant therapy. Lashner, Evans & Hanauer (1989) had conducted research to examine the importance of TPN as additional treatment for CD patients undergoing bowel resection. They specifically examined preoperative TPN for CD patients can affect the mortality and morbidity from operation, the length of bowel needing resection, and the recurrence rate of 1 year (Lashner, Evans & Hanauer, 1989). Pre-operative TPN evidently decreased small bowel length requiring resection for patients with fistula on ileocectomy (Lashner, Evans & Hanauer, 1989). The result of shorter small bowel resection has longer hospitalization in both pre and post-operative periods (Lashner, Evans & Hanauer, 1989).

Some research evidences had shown EN is as predominant as steroids in accomplishing short-term remission in CD patients (Wang et al., 2016). Exclusive EN provides a hundred percent of nutritional needs for a CD patient from orally liquid nutrition formula or through a feeding tube (Wang et al., 2016). Exclusive EN had shown significant benefits for inducing mucosal healing and decreasing inflammation (Wang et al., 2016). A research had been conducted to investigate whether providing pre-operative four weeks EN therapy is predominant in decreasing post-operative complications and recur rates in active CD patients (Wang et al., 2016). The results showed CD patient received exclusive EN had lower incidence for infectious and non-infectious disease than those who did not have exclusive EN (Wang et al., 2016). And decreased endoscopic recur rates after bowel resection in six months had been discovered for those who had exclusive EN for 4 weeks prior of surgery (Wang et al., 2016).

TPN was the suggested method to provide nutritional needs to hospitalized patients for many years but now EN has been argued to be the preferred way (Jeejeebhoy, 2001). EN is thought to facilitate the function of gut and avoid intestinal bacteria translocation, which decreasing occurrence of sepsis in severely sick patients (Jeejeebhoy, 2001). As a result, TPN has been largely disagreed as a riskier form of treatment compared to EN (Jeejeebhoy, 2001). Critical review of data has been proposed that for human, TPN does not lead to mucosal atrophy or raise intestinal bacteria translocation (Jeejeebhoy, 2001). However, overfeeding can explain why the studies have presented that sepsis has been increased by TPN (Jeejeebhoy, 2001). Moreover, the risks of TPN-associated complications have been over-exaggerated (Jeejeebhoy, 2001). TPN is equally predominant and safe when malnutritional risk presents and when CD patients cannot tolerate EN (Jeejeebhoy, 2001).

Guo et al., (2017) argued that “surgical site infection (SSI) is one of the most common post-operative complication”. The rates of SSI performed after bowel resection appears higher than other disease (Guo et al., 2017). SSI majorly constituted of two types- incisional and organ/ space SSI (Hu et al., 2018). Incisional SSI is one of the most typical post-surgery complications for intestinal resection among CD patients and is co-related to negatively affect patient’s life quality (Hu et al., 2018). SSI was categorized into 3 types depends on the depth of infection- superficial, deep and organ space (Alavi et al., 2010). Superficial SSI are presented on the skin and subcutaneous tissues, whereas deep SSI presented in the fascia and muscle layer, organ space SSI presents anywhere of the anatomy involved in the surgery such as intestine after a bowel resection for CD patients (Alavi et al., 2010).

Infection occurs when wound containing necrotic tissue or blood supply is reduced, immune function in patients is decreased (using immune-suppressing drugs, eg. Corticosteroids), under and malnutrition, multiple stressors and hyperglycaemia in diabetic patients (Brown & Edwards, 2014). The major way of microbes enter human body is through the skin and mucosal surfaces of the gastrointestinal, respiratory and urogenital tracts (Brady, McCabe & McCann, 2013). Once interacting with microbes, bacteria then colonizes epithelial surfaces, it then co-exists with the host, it later develops into a complex open ecosystem created by the association of resident and temporally present microbes


(Brady, McCabe & McCann, 2013). Gram-negative bacteria located inside the digestive tract frequently resulted SSI after abdominal surgery which is classified as endogenous infections (Brady, McCabe & McCann, 2013). Deep organ space infection (DOSI) are infections after bowel resection, which are related with anastomotic dehiscence or intra-abdominal catastrophe that leads in major clinical pain (Benjamin et al., 2015). Thus, it is important for nurse to perform comprehensive care for patients who develop SSI after bowel resection.

The nursing assessment is vital for post-operative patients, nurses needs to watch out for wound care, and to conduct assessment for SSI, such as monitor any sings of infection (redness, heat, pain, oedema, inflammation ) (Dryden, 2012). According to Surgical site infection (2013), it described that most infections can be managed by giving antibiotic medications to patients. Moreover, adequate wound and dressing care enhance recovery and decreases the chances of surgical site infection (Surgical site infection, 2013). It is vital for nurses to conduct assessment to monitor patient’s conditions, assessment includes- patient’s history, the presenting symptoms, physical observations and examination (vital signs: temperature, blood pressure, heart rate and respiratory rate), perform investigation such as endoscopic investigation, a full blood count, vitamin B12 level, C-reactive protein level and stool samples for occult (Brady, McCabe & McCann, 2013).

Nurses also need to conduct initial A-G assessment to check patient’s status, ask patient about feelings of nausea, assess the severity using numerical scale or verbal description (Lewis et al., 2017). If vomiting occurs, nurses need to identify the amount, types and the color of the vomitus (Lewis et al., 2017). Nurses then need to listen to all four quadrants for bowel sounds to see the presence, frequency and types of the sound (Lewis et al., 2017). To ensure the patient can back to normal bowel motility is to assess by passing gas or feces and the patient is able to tolerate oral intake without nausea or vomiting (Lewis et al., 2017).

Nurses need to check the surgical wounds every 15 to 30 minutes, and during the first 24 hours nurses are expected to see average quantity of serosanguineous drainage for abdominal incision (Lewis et al., 2017). Drainage should be changed from red to pink to clear yellow (Lewis et al., 2017). However, infection of wound would be purulent drainage (Lewis et al., 2017). Nurses need to record the drainage type, amount, colour and odor, if any abnormal or excessive drainage or major vital signs changes then nurses need to notify surgeon/ physician as soon as possible (Lewis et al., 2017).

Furthermore, pain assessment is vital as well, using FACES pain scale can assess the severity of patient’s pain and verbal description from patient is also a good indicator of pain (Lewis et al., 2017). The most reliable way for pain assessment is to let patients do a self-report (Al Samaraee, 2010). There are various pain scales to be used to check pain such as visual analogue scale, verbal numerical rating scale and The short form McGill Pain Questionnaire (Al Samaraee, 2010).

Nurses possess a vital role in the pain management after surgery because nurses need to administer drugs to patients (Al Samaraee, 2010). Nurses need to ask patients direct questions regarding to pain assessment and use tool for assessing the patients and not only to rely on nurses’ own judgement about patients’ pain assessment (Al Samaraee, 2010). There are five most up-to-date guidelines- involvement of patients in the pain management plan, immediate identification and treatment of pain, monitoring processes, results of pain management and re-assess and adjust the pain management plan if required (Glowacki and Glowacki, 2015). Provision of predominant pain education and information on the expected post-operative experience need to involve the variety causes and effects of pain, accompanied with different types of therapies available to patients (Glowacki and Glowacki, 2015). Provision of pain education can decrease patients’ stress, anxiety, quantity of symptoms and signs and enhance functional status (Glowacki and Glowacki, 2015). What the patient knows and believes regards to pain is vital in affecting response to the pain treatment given (Glowacki, 2015). Pain education is one of the most predominant therapy given by healthcare providers (Glowacki, 2015).

Esposito et al. (2004) had conducted research to examine the occurrence of post-operative infections and to evaluate management of antibiotic surgical prophylaxis. The result has shown that this study recommends the need for keep-on-track and precise monitoring of post-operative infections and suggest executing adequate guidelines to enhance surgical prophylaxis management (Esposito et al., 2004). Lumbers (2018) stated that the appropriate post-operative wound dressing include- post-operative island dressing is suggested to be used for post-operative wounds with low or non-exudates, dressings selection needs to be depended on where the wound is located, wound closure type, exudate type and expected wear time, post-operative wounds needed to be covered for at least 24 to 48 hours, dressings must be waterproof for those wounds needed to be covered up to 7 days.

Throughout this essay, a range of studies had been discussed. For pre-operative area, Lashner, Evans & Hanauer (1989) did not use a large sample size that only less than a hundred patients were being involved. Wang et al. (2016). also used a small sample size, prospective and multi-center study should be conducted to obtain a more generalized conclusion. For the post-operative area, Esposito et al. (2004) conducted the study only restricted to patients in Italy which can not be implied the same result in a global context. Lumbers (2018) did not use enough research evidence to support statements in the article, with only 16 research evidences being used in the whole research review article. More evidence from different studies are needed to deliver a more generalized evidence.

Reference List

• Alavi, K., Sturrock, P., Sweeney, W., Maykel, J., Cervera-Servin, J., Tseng, J., & Cook, E. (2010). A Simple Risk Score for Predicting Surgical Site Infections in Inflammatory Bowel Disease. Diseases of the Colon & Rectum, 53(11), 1480–1486. https://doi.org/10.1007/DCR.0b013e3181f1f0fd
• Al Samaraee, A., Rhind, G., Saleh, U., & Bhattacharya, V. (2010). Factors contributing to poor post-operative abdominal pain management in adult patients: a review. The Surgeon, 8(3), 151–158. https://doi.org/10.1016/j.surge.2009.10.039
• Benjamin, E., Siboni, S., Haltmeier, T., Inaba, K., Lam, L., Demetriades, D., & Benjamin, E. (2015). Deep organ space infection after emergency bowel resection and anastomosis: The anatomic site does not matter. The Journal of Trauma and Acute Care Surgery, 79(5), 805–811. https://doi.org/10.1097/TA.0000000000000840

• Brady, A., McCabe, C., & McCann, M. (2013). Fundamentals of medical-surgical nursing : s systems approach. Hoboken: Wiley
• Brown, D., & Edwards, H. (2014). Lewis’s medical-surgical nursing: assessment and management of clinical problems (4th ed.). Marrickville, N.S.W: Elsevier Australia. Chapter 16 ‘Postoperative Care’
• Dryden, L. (2012). Surgical site infection. Nursing Standard, 27(13), 59–59. Retrieved from http://search.proquest.com/docview/1268081269/?pq-origsite=primo
• Esposito, S., Ianniello, F., Leone, S., Noviello, S., Marvaso, A., Iannantuoni, N., … Patrelli, G. (2004). Surveillance of Post-Operative Infections and Management of Antibiotic Surgical Prophylaxis in an Italian Region. Journal of Chemotherapy, 16(2), 160–165. https://doi.org/10.1179/joc.2004.16.2.160
• Glowacki, D., & Glowacki, D. (2015). Effective pain management and improvements in patients’ outcomes and satisfaction. Critical Care Nurse, 35(3), 33–41; quiz 43. https://doi.org/10.4037/ccn2015440
• Gordon D, Dahl J, Miaskowski C, et al. (2005). American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med., 165(14):1574-1580.
• Guo, K., Ren, J., Li, G., Hu, Q., Wu, X., Wang, Z., … Li, J. (2017). Risk factors of surgical site infections in patients with Crohn’s disease complicated with gastrointestinal fistula.(Report). International Journal of Colorectal Disease, 32(5), 635–643. https://doi.org/10.1007/s00384-017-2751-6
• Hart, A., & Ng, S. (2011). Crohn’s disease. Medicine, 39(4), 229–236. https://doi.org/10.1016/j.mpmed.2011.01.004
• Hu, T., Wu, X., Hu, J., Chen, Y., Liu, H., Zhou, C., … Lan, P. (2018). Incidence and risk factors for incisional surgical site infection in patients with Crohn’s disease undergoing bowel resection. Gastroenterology Report, 6(3), 189–194. https://doi.org/10.1093/gastro/goy007
• Jeejeebhoy, K. (2001). Enteral and parenteral nutrition: evidence-based approach. Proceedings of the Nutrition Society, 60(3), 399–402. https://doi.org/10.1079/PNS2001103
• Kavic, S. (2015). Surgery for Crohn’s disease . New York: Nova Science Publishers, Inc.
• Lashner, B., Evans, A., & Hanauer, S. (1989). Preoperative total parenteral nutrition for bowel resection in Crohn’s disease. Digestive Diseases and Sciences, 34(5), 741–746. https://doi.org/10.1007/BF01540346
• Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Kwong, J., & Roberts, D. (2017). Medical-surgical nursing : assessment and management of clinical problems (10th edition). St Louis, Missouri: Elsevier.
• Lightner, A., Mckenna, N., Tse, C., Hyman, N., Smith, R., Ovsepyan, G., … Lightner, A. (2018). Postoperative Outcomes in Ustekinumab-Treated Patients Undergoing Abdominal Operations for Crohn’s Disease. Journal of Crohn’s & Colitis, 12(4), 402–407. https://doi.org/10.1093/ecco-jcc/jjx163
• Lumbers, M. (2018). Selecting appropriate postoperative dressings to support wound healing and reduce surgical site infection. British Journal of Nursing, 27(6), S32–S35. https://doi.org/10.12968/bjon.2018.27.6.S32
• Rajesh, A., & Sinha, R. (2015). Crohn’s disease : current concepts . Cham: Springer.
• Surgical site infection. (2013). Nursing Standard (through 2013), 28(16), 23. https://doi.org/10.7748/ns2013.12.28.16.23.s26
• van Noort, H., Ettema, R., Vermeulen, H., & Huisman-de Waal, G. (2019). Outpatient preoperative oral nutritional support for undernourished surgical patients: A systematic review. Journal of Clinical Nursing, 28(1-2), 7–19. https://doi.org/10.1111/jocn.14629
• Wang, H., Zuo, L., Zhao, J., Dong, J., Li, Y., Gu, L., … Zhu, W. (2016). Impact of Preoperative Exclusive Enteral Nutrition on Postoperative Complications and Recurrence After Bowel Resection in Patients with Active Crohn’s Disease. World Journal of Surgery, 40(8), 1993–2000. https://doi.org/10.1007/s00268-016-3488-z
• Zerbib, P., Koriche, D., Truant, S., Bouras, A., Vernier-Massouille, G., Seguy, D., … Zerbib, P. (2010). Pre-operative management is associated with low rate of post-operative morbidity in penetrating Crohn’s disease. Alimentary Pharmacology & Therapeutics, 32(3), 459–465. https://doi.org/10.1111/j.1365-2036.2010.04369.x
• Zhu, W., Guo, Z., Zuo, L., Gong, J., Li, Y., Gu, L., … Li, J. (2015). CONSORT: Different End-Points of Preoperative Nutrition and Outcome of Bowel Resection of Crohn Disease: A Randomized Clinical Trial. Medicine, 94(29), e1175–e1175. https://doi.org/10.1097/MD.0000000000001175