Question

Jordan James is a 25-year-old male. Jordan has been admitted to hospital with a five day history of right lower abdominal cramping pain, a feeling of abdominal bloating, nausea and bilious vomiting, and an increased amount of abdominal gurgling and rumbling. Jordan stated that over recent weeks, he has experienced persistent diarrhoea, lower right abdominal pain and tenderness, fatigue and malaise. Jordan stated he has not been able to keep up with his work demands and is not getting quality rest and sleep. Due to his diarrhoea and current vomiting Jordan states that he has been reluctant to eat or drink much during the past five (5) days. He reported that he has lost seven kilograms in the last three weeks. Jordan was diagnosed with Crohn’s disease when he was 17 years old. His Crohn’s disease was diagnosed after Jordan presented to his general practitioner (GP) with a perianal abscess. Since his diagnosis and surgical management of his perianal abscess, Jordan’s Crohn’s disease has been managed with pharmacological (infliximab) and dietary strategies, and medical monitoring. During this time, Jordan has had a number of exacerbations of Crohn’s disease.

Jordan’s observations on admission were:

– Blood pressure: 92/52 mm/Hg

– Pulse rate: 112 beats/minute

– Weak peripheral pulses

– Respiratory rate: 24 breaths/minute

– Temperature: 38.3C

– Sa02: 97% in room air

– Weight: 75 kilograms

– Height: 188 cm

– Urinalysis: specific gravity: 1035; dark coloured urine; no other abnormalities noted

On examination, Jordan had a distended abdomen, a tender mass in his right lower abdominal quadrant and audible bowel sounds. His skin was pale and dry with poor turgor. His extremities were cool to touch. The medical officer (MO) noted that Jordan had poor capillary refill and flat neck veins.

The MO ordered some preliminary blood tests and an abdominal CT scan. Initial pathology results

– Haemoglobin: 109 g/L (120-180g/L). 7

– Haematocrit: 51% (35 - 47%)

– WBC: 13.9 X 109/L (4.3 - 10.8 X 109/L)

– Erythrocyte sedimentation rate (ESR): 26.5mm/hour (0 - 13 mm/hour)

– C-reactive protein (CRP): 30.7mg/dl (20 mg/dl)

– Albumin: 30.5g/L (35 - 50 g/L)

The MO returns to discuss the results of the CT scan with Jordan.

Jordan has developed a stricture causing a bowel obstruction in his terminal ileum. Jordan is referred to a gastroenterological surgeon. The surgeon explains to Jordan that he will require a surgical resection of the affected ileum and an end-to-end anastomosis of the ends of the ileum. The surgeon also tells Jordan that he has numerous large patches of inflamed mucosa and submucosa throughout his small bowel and colon.

The MO orders the following

– Morphine 15mg intamuscularly (IM) QID PRN

– metoclopramide (’Maxolon’) 10mg IMI TDS

– 1000mL Hartman’s solution over 6 hours via IVI

– methylprednisolone 20mg IVI TDS

– nil by mouth

1. Explain the structural and functional changes in the disease process that led to Jordan’s weight loss
2. Explain the pain pathway and how Morphine alters the conscious perception of pain.

3. Explain the clinical manifestations that may indicate the deterioration of Jordan’s Crohn’s condition and explain why they occur.

4. Explain the characteristics of the intravenous fluid that was ordered for Jordan and explain the rationale for the administration of the IV fluid relating to Jordan’s specific fluid balance.

Answer 1

Answer 1- The reasons for weight loss this patient of Crohn's disease are

1. Functional
   1. Crohn's disease is an inflammatory condition.
   2. Inflammation causes release and inhibition of certain factors in the body that reduces the appetite and causes weight loss
   3. Inflammation causes the release of tumor necrosis factor-alpha that reduces the appetite
   4. Inflammation reduces ghrelin and leptin. They are responsible for making you feel hungry.
2. Structural
   1. Mucosal ulceration leads to loss of absorptive surface.
   2. This reduces the absorption of nutrients.
   3. Strictures are fibrous tissues that constrict the bowel.
   4. This blocks the passage of the bowel contents and reduces their absorption.d

Answer 2

Pain pathway :

1. Nocireceptors -
   1. these are receptors stimulated by pain (mechanical, chemical stimuli)
   2. They are located all over the body skin, viscera
   3. Inflammation can lead to the release of H ion, bradykinin, serotonin, prostaglandins
   4. These chemicals stimulate the nociceptors
2. Primary afferent fibers
   1. These are A-beta, A-delta and C fibers carry pain signals from the nociceptors to the spinal cord.
3. Secondary afferent fibers
   1. TheA-delta and C fibers synapse with secondary afferent fibers in the dorsal horn of the spinal grey matter.
   2. These secondary afferent fibers synapse with interneurons in the spinal cord.
   3. Various excitatory neurotransmitters are released like glutamate and substance P
4. Ascending tracts in the spinal cord.
   1. There are two tracts that carry pain signals to the higher centers in the brain.
      1. spinothalamic tract - the secondary afferent neurons fibers cross over at the same level or level above to the other side of the midline of the spinal cord.
      2. They move upwards on the contralateral side of the spinal cord.
      3. These tracts end in the thalamic nuclei
      4. From the thalamic nuclei, the third-order nuclei relay the signal to the somatosensory cortex and periaqueductal grey matter
      5. This tract helps to localize pain
   2. Spinoreticular tract.
      1. these fibers also cross over to the other side of the midline.
      2. The spinoreticular tract travels on the contralateral side of the spinal cord.
      3. it terminates into the reticular formation.
      4. From there it relays into the thalamus and hypothalamus
      5. This pathway is concerned with the emotional aspects of pain.
   3. Cortex ( higher center)
      1. Primary and secondary somatosensory cortex
      2. Insular
      3. Anterior cingulate cortex
      4. prefrontal cortex.

• Morphine is a opioid receptor agonist
• It is a mu - opioid receptor agonist.
• On stimulation of the mu -opioid receptors following changes take place
  • It stimulates the descending pain inhibitory pathways - they act on the periaqueductal gray matter and nucleus reticularis paragigantocellularis - this reduces pain
  • This leads to stimulation of the enkephalin- containing neurons and hydroxytryptamine containing neurons
  • These neurons, in the dorsal horn, reduce the pain signal transmission from the nociceptors.

Answer 3

Symptoms suggestive of exacerbation

1. Nausea
2. Vomiting (bilious)
3. Diarrhea
4. Pain in the lower abdomen
5. Weight loss
6. Loss of appetite

Signs of exacerbation

1. distended abdomen
2. Mass in the lower abdomen
3. loss of audible bowel sound.

• Unopposed Th1 response leads to the release of Th-12 and TNF -alpha
• This, in turn, leads to the release of pro-inflammatory substances like arachidonic acid metabolites, platelet-activating factor, free radicals. These substances lead to tissue damage.
• Neutrophilic infiltration leads to abscess formation

Answer 4

Hartmann's fluid

Characteristics

constituents	concentration
sodium	131
chloride	111
Na:Cl	1.18:1
Potassium	5
Bicarb	29 (lactate)
Calcium	2
glucose	0
pH	5-7
Osmolarity	278

The rationale behind the use of Hartmann solution in this patient is

• dehydration - evident by increased hematocrit, loss of skin turgor, reduce capillary filling, collapse neck views.
• Hypotension due to fluid loss
• Metabolic acidosis is secondary to the loss of bicarb in the diarrheal fluid.
• To replace the lost electrolytes in the diarrheal fluid.
• The liver converts lactate in the Hartmann fluid into bicarbs.