Read The Case Study And Discuss The Questions ✓ Solved

Read The Following Case Study And Discuss the Questions

Read the following case study and discuss the questions: Mr. Enson comes to the clinic reporting abdominal pain and watery diarrhea. “Sometimes, it’s pretty severe,” he says. “It’s been that way for 2 days. The scary part is that I have a lot of blood in my stool now. It’s not like before. This is way more intense.” Mr. Enson has a history of Crohn disease, which is now exacerbated by extensive inflammation. His history indicates that he has been taking anti-inflammatory agents for several years despite complaining of nausea and heartburn from the drugs. “I’ve already tried the steroid route,” he says. “I don’t want to ever do that again. I prefer the sulfasalazine. The trouble is that it doesn’t seem to be helping anymore. What can we try next?” He has already been in drug trials for a new immune system suppressor, with no significant clinical change. Dr. Holly, Mr. Enson’s physician, suspects a resection may be necessary. Dr. Holly examines his abdomen for tenderness, requests a white blood cell count, and assesses his pain. She also orders a computed tomography (CT) scan of his large intestine.

Mr. Enson’s white-cell count is high, which Dr. Holly had expected, and the CT scan reveals significant new damage to Mr. Enson’s gastrointestinal tract. She schedules him for a surgical procedure to close the fistulas, drain several abscesses, and remove a section of Mr. Enson’s colon.

Questions

1. At one time, Mr. Enson assumed he had ulcerative colitis (UC) because both his brother and sister have it. What is the difference between UC and Crohn disease? How can a medical practitioner distinguish between the two?
2. In preparing her patient for his surgery, Dr. Holly explains that Mr. Enson will undergo surgical resection of the most severely damaged segment of his colon. She will then create an artificial anus on Mr. Enson’s abdominal wall by incising the colon and bringing it out to the surface. She explains, “There are actually two procedural options for your resection, but I am confident this choice is the better of the two for your condition.” What are the two surgical options, and which one has she chosen?
3. If Dr. Holly had chosen to remove a portion of Mr. Enson’s small intestine, then he would have been at increased risk for what syndrome?

Sample Paper For Above instruction

The case study presents a complex clinical scenario involving Crohn’s disease, a chronic inflammatory bowel disease characterized by transmural inflammation that can affect any part of the gastrointestinal tract. To fully understand Mr. Enson’s condition and the implications of surgical intervention, it is essential to distinguish between Crohn’s disease and ulcerative colitis (UC), understand surgical options, and recognize potential postoperative complications such as short bowel syndrome.

Differences Between Crohn’s Disease and Ulcerative Colitis

Crohn’s disease (CD) and ulcerative colitis are both inflammatory bowel diseases (IBD) but differ significantly in their pathology, distribution, and clinical manifestations. Crohn’s disease is a granulomatous inflammation that can involve any segment of the gastrointestinal tract from the mouth to the anus, often affecting the entire wall of the bowel (transmural). It is characterized by skip lesions—patchy areas of healthy tissue interspersed with inflamed segments—and typically involves the ileum and colon (Hanauer, 2006). Fistulas, strictures, and abscesses are common complications owing to transmural involvement.

Ulcerative colitis, on the other hand, is confined to the colon and rectum, affecting only the mucosal and submucosal layers of the bowel wall (Silverberg et al., 2007). It presents as continuous inflammation starting from the rectum and extending proximally. Unlike Crohn’s, UC rarely causes fistulas or transmural abscesses but is associated with a higher risk of colon cancer with longstanding disease.

Clinicians can distinguish between Crohn’s disease and UC through endoscopic, histologic, radiologic, and clinical evaluations. Typical findings in Crohn’s include skip lesions, granulomas, and transmural inflammation seen on biopsy, whereas UC exhibits continuous mucosal inflammation. Imaging such as CT enterography or MRI can reveal transmural involvement and fistula formation in Crohn’s, while colonoscopy shows diffuse mucosal ulceration in UC, primarily affecting the rectum.

Surgical Options and the Chosen Procedure

When surgical intervention becomes necessary in Crohn’s disease, the primary goal is to remove diseased segments and manage complications such as fistulas and abscesses. There are two main surgical options: a resection with primary anastomosis or a procedure resulting in an ostomy, such as ileostomy or colostomy.

Dr. Holly has chosen to perform a resection of the severely damaged colon and create a stoma—a surgically formed artificial opening (stoma) on the abdominal wall—by bringing a portion of the colon to the surface. This procedure is known as a colectomy with exteriorization, often leading to a permanent or temporary colostomy or ileostomy depending on the extent of resection and reconstruction possibilities (D'Haens et al., 2007). This option avoids immediate reconstruction and may be preferable when disease extent or inflammation complicates primary anastomosis.

The alternative surgical approach would be a resection followed by an anastomosis—connecting the remaining parts of the colon directly. This is often favored when the patient’s condition is stable, and the tissue quality permits safe reconnection to avoid a permanent ostomy.

Given the severity of Mr. Enson’s damage and the presence of abscesses and fistulas, Dr. Holly’s decision to create an ostomy likely reflects a cautious approach prioritizing control of infection and healing.

Risk of Short Bowel Syndrome from Small Intestine Resection

If Dr. Holly had opted to resect a portion of Mr. Enson’s small intestine, the patient would be at increased risk for short bowel syndrome (SBS). SBS is a malabsorptive condition resulting from significant resection of the small intestine, leading to decreased nutrient and fluid absorption (Gordon & O’Keefe, 2008). This syndrome manifests with diarrhea, dehydration, electrolyte imbalances, malnutrition, and weight loss.

The risk is particularly high if the terminal ileum or significant lengths of the small intestine are removed because these areas are crucial for absorbing nutrients such as vitamin B12, bile acids, and fats. Patients with extensive resection require nutritional support, including parenteral nutrition and long-term vitamin supplementation, to prevent complications associated with nutrient deficiencies (Schaefer et al., 2012).

Hence, in Crohn’s disease, careful consideration of the extent of resection is necessary to balance disease control with preservation of intestinal function. Short bowel syndrome remains a significant postoperative complication that can substantially impair quality of life if not properly managed.

Conclusion

In summary, differentiating Crohn’s disease from ulcerative colitis involves clinical, endoscopic, histologic, and radiologic evaluation — crucial for appropriate management. Surgical options depend on disease severity and extent, with procedures aimed at removing diseased tissue and managing complications. The choice of surgical technique can significantly influence postoperative outcomes and quality of life, especially considering risks like short bowel syndrome following extensive small intestine resection.

References

• Gordon, P. B., & O’Keefe, S. J. (2008). Short bowel syndrome: Pathophysiology and management. Nutrition in Clinical Practice, 23(3), 213-218.
• Hanauer, S. B. (2006). Inflammatory bowel disease: Epidemiology, pathogenesis, and therapeutic opportunities. Inflamm Bowel Dis, 12(Suppl 1), S3–S19.
• Schaefer, M., et al. (2012). Nutritional management of short bowel syndrome. Gastroenterology Research and Practice, 2012, 852716.
• Silverberg, M. S., et al. (2007). Toward an integrated clinical, molecular, and serologic classification of inflammatory bowel disease: Report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol, 21 Suppl A, 5A–36A.
• D'Haens, G., et al. (2007). Surgery in Crohn’s disease. In: Sarcoidosis, Crohn's disease, and ulcerative colitis: Management and Treatment. Springer.