Crohn's Disease (CD): A Historical Background
Crohn’s disease is a persistent inflammatory bowel disease (IBD) that may impact any part of the gastrointestinal path, however, normally impacts the ileum (Yamada, 2009). It usually occurs to individuals of age 21 or under (Wilson et al., 2010). The CD may affect the quality of life (Baumgart & Sandborn, 2007; Morrison et al., 2009). It may need surgery (Pihl-Lesnovska et al., 2010).
There is a steady global rise in the occurrence of Crohn’s Disease and it represents an increased hospitalization (Gibson, 2009; Morrison et al., 2009; Wilson et al., 2010). In 2009, the CD cases in Australia were about 4,000 (ABS, 2009).
The CD was first identified as a distinctive disease some decades ago. Though the major advances has been accomplished regarding this disease which throw light on its molecular pathogenesis, diagnosis, and treatment. Its etiological roots continue to be limited. Presently, the distinctive disease is thought as a consequence of complex interaction between hereditary, immune-focused, and transmittable triggers that unite into growth of CD (Gaya et al., 2006). The ongoing research on both local and organized immune reaction changes in Crohn’s Disease patients has significantly developed new curing alternatives, though this immune dysregulation may, in fact, be a phenomenon and not a real activist. Various endeavors to implicate specific contagious causes in the sources of Crohn’s Disease are emerging, involving amongst others vague pathogens. Moreover, the interpretations of etiological importance have been counter-challenged by other researchers.
The epidemiologic researches are of vital significance in studying CD etiology. A large body of scientific research on this disease occurrence noted has normally endorsed the concept of the disease of the industrialized world, with a distinctive north–south European characteristic (Binder, 2004). The rationale underlying this occurrence has been incoherent; the mainstream research has been localized, retrospective, and, therefore, conditional on insufficient data compilation, normally ranging restricted time eras. However, the major cohort research studies pointed out a major CD occurrence, increase in the 20th century. The basis of this rise continues to be speculative.
Crohn's Disease: An Introduction
The CD is a debilitating long-lasting inflammatory syndrome of the gastrointestinal path classified in the medical terminology as Inflammatory Bowel Disease (IBD). It is a major source of deaths in children and the youths. It should be noted that IBD consists of two significant entities, namely CD and Ulcerative Colitis (UC). It is based on scientific, lab, radiologic, endoscopic and histological characteristics. In 10% of CD cases the results are imprecise and thus known as indeterminate colitis (IC) (Kirschner, 1988). Approximately 25-30% of the CD exists before the age of 20 years and therefore pediatricians need to recognize the varied presentations of this disorder (Baldassano & Piccoli, 1999).
Epidemiology
The occurrence of Crohn’s Disease in young children is significantly lower than that noted in the youths (Mamula et al., 2003). It is more extensive in the European countries rather than to Asian and African countries. The occurrence of pediatric Crohn’s Disease varies from 0.2-8.5/100,000 (Mamula et al., 2003). Of late, there have been studies of this disease from Africa, PR China and Japan.
Crohn’s Disease can take place in all age groups and abide by the same bimodal model of age frequency as IBD. The percentage of the affected patients with this disease less than 20 years of age ranges between 25-40% with approximately 10% being under 10 years of age (Mamula et al., 2003). The average age of presentation is nearly 12 years (Cosgrove et al., 2006). Early occurrence of IBD i.e. signs earlier than the five years of age is a distinctive subgroup comprising about 4% of pediatric IBD (Baldassano & Piccoli, 1999). In this subgroup, it is complex to distinguish between Ulcerative Colitis and the Crohn’s Disease. In the USA there appears to be a prevalence of CD in boys (Mamula et al., 2003) whilst in India it was more common in the girls (Sathiyasekaran et al., 2005). The impact of breastfeeding and cigarette smoking continued to debate. The CD takes place with a greater incidence in the patients with Turner’s syndrome, and glycogen storage syndrome type 1B (Cuffari & Darbari, 2002).
CD could symbolize an ongoing disease with a difficult organism or an unusual and protracted response to a common disease. Different organisms have been related to CD though none of them is obvious in the etiopathogenesis. In hereditarily vulnerable persons, the micro-vascular wound created by these diseases could lead to micro-vascular thrombosis, multifocal gastrointestinal infarction, and finally results in ulcers, fistulas, fibrosis, and structures.
Pathophysiology
The current hypothesis concerning the pathogenesis of Crohn’s Disease is an interface between ecological features and a changed immune reaction in hereditarily disposed children, creating constant swelling of the gastrointestinal path. In CD, there is a chaotic regulation of mucosal and universal immune reaction causing in the continuation of the inflammatory surge. A dysregulated TH1 reaction appears to be critical in the changeover of physiologic to pathologic irritation. The immunological outline in the Crohn’s Disease is mainly a cell-mediated reaction. The dynamic mucosal irritation of the small and large intestine causes diarrhea, protein-absent enteropathy, blood loss, abdominal ache and structure creation.
Pathology & Distribution
The swelling and irregular involvement is the distinctive traits of Crohn’s Disease. The distribution of the wounds in Crohn’s Disease although irregular may entail any part of a gastrointestinal path from the oral opening of the colon. In the Western countries detached, colonic relationship is noted in 10-20%, ileo-colonic syndrome in 50-70% and disperses small bowel disease in 10-15% (Hyams, 1999). Gastroduodenal syndrome may be noted in below 5% patient whilst endoscopic and histologic gastroduodenal syndrome may be about 30-40% of patients. The involvement of the small intestine differentiates CD from UC and is a pointer for diagnosis. Perirectal disease is seen in 20% of patients and is associated with rectosigmoid inflammation. Noncaseating granuloma is the hallmark of CD (Baldassano & Piccoli, 1999).
Clinical Presentation
The clinical presentation of Crohn’s Disease is conditional upon the place of engagement of the gastrointestinal path. Abdominal ache and general symptom are normally critical in the disease. Dyspeptic-type soreness is noted in the children with gastroduodenal involvement. Diarrhea takes place in about 66% of impacted children. In children with a mostly ileal connection, constipation might be a rare case. The blood in the feces is atypical with detached small bowel ailment and more frequent when the colon is entailed. Fever takes place in just about 50% cases. Weakness, weight loss and decrease in growth velocity are other presenting indications amongst the children. Crohn’s Disease is sub-categorized as mainly inflammatory, fistulizing or structuring syndrome based on the clinical phenotype.
Crohn’s Disease Complications
Bleeding, obstruction, perforation, sores and fistula creation are common in Crohn’s Disease. Perianal disease may show with sore creation, perirectal and perianal fistulization can precede the intestinal symptom in several years. Perforation with internal fistulae in the CD is another critical problem. Carcinoma of the colon amongst the patients is a long-term trouble of irritation of bowel ailment. The two recognized risk characteristics of the disease are the extent and gravity of the CD. The problems like perianal and the rectovaginal fistula requires surgery.
Diagnosis
The preliminary assessment of children with the supposed CD consists of a thorough response of medical, family and treatment account of a physician. The children or youths with recurring abdominal ache linked with or without fever, diarrhea and growth failure, are potential candidates for Crohn’s Disease and necessitates thorough evaluation. A scrupulous evaluation of the patients is vital. The abdominal study may not be causative if a mass is an obvious one may think CD or TB. A rectal study is important to notice skin tags, cracks and fistulae. The lab exams should be incorporated in the study.
An ultrasound evaluation of the abdomen might identify clotted bowel loops, simulated kidney syndrome and inflated lymph knots in Crohn’s Disease. The physician should check children for a thorough assessment. The diagnosis of Crohn’s Disease in children is comprised of a mix of medical interpretation and supported by lab findings. Crohn’s Disease can be grouped as mild, modest and critical based on the experimental display. One of the most popular grading systems for CD is known as the PCDAI that assists in evaluating the seriousness of the syndrome.
Endoscopic Assessment
In Crohn’s Disease the typical wounds are the skip lesions, aphthous abscess of different sizes with regular intervening mucosa. Rectal sparing is characteristics of the CD. Histopathologically is the diagnosis of Crohn’s Disease though normally complex to distinguish it from Tuberculosis.
Risks associated with Crohn’s Disease
The cure of CD is intended to enhance the symptoms and to deter the various medical problems. Normally, the aim is to advance the quality of life. Mismanagement of CD may cause an analogous quality of life, and patients have to make several hospital visits, time loss, as well as high health care expenditures. The surgery in CD can be a successful cure method, and an important part of the treatment. In accordance to Dr. Munkholm et al. in 1993, about 40% of patients with CD have surgery following the first-year of the ailment, nearly 50% have surgery by 5 years, and about 80% experience at least one surgery following 20 years of disease (Munkholm et al., 1993). Regrettably, these incidents have not altered significantly over the past few decades (Cosnes et al., 2005).
Patients often ask about the risk of dying from Crohn’s disease. Although a large population-based cohort study showed a statistically significantly increased standardized mortality ratio of 1.4, in complete terms, this change to just about 57 casualties/10,000 patient-years in patients with IBD against the 50 demises/10,000 patient-years in the general public (Hutfless et al., 2007).
The increased deaths take place normally due to viruses, respiratory illness, and digestive trouble instead of IBD. An assessment of a big database from the UK concurred that CD was related to increased mortality and that it is linked to those patients with more critical disease and are vulnerable to the high risk. Thus, the efficient management of the CD does not only create symptomatic control, however, seemingly a mortality benefit.
WOC Nurses’ role in Crohn’s Disease preoperative, intraoperative, & postoperative
CD creates a distinctive and complex challenge for the surgeon and the WOC nurses. This disease is not treated by the surgery only; hence, the medical practitioners and patients try to delay surgical treatment. This delaying normally implies that the CD patients can present themselves in a destabilized, weakened condition with major immune-suppression. Moreover, the growth of intra-abdominal swellings or fistula is the usual evolution of CD and makes it complex for WOC management of the patient.
Preoperative Immunotherapy
Nearly all the CD patients take immune-modulator treatment when they are presented for surgery. A number of patients will be on the combination of multiple agents. The effect of these immune-suppressive agents on surgical results is controversial. Tay et al. (2003) carried out a study of 100 patients who experienced segmental anastomosis whilst on immune-modulators. They had about 10% incidence of intra-abdominal infection troubles and noted that those patients on immunotherapy, in fact, had a considerably reduced intra-abdominal septic problem against those who were not on therapy.
Colombel et al. (2004) studied the operating on patients with CD and were on immune-suppressants. They treated 270 patients on various immune-modulators. The results were that 19% of the patients had septic troubles that included wound virus, anastomotic leakage, intra-abdominal sores, and extra-abdominal viruses. Moreover, they observed no relationship between the utilization of any of the immune-modulators preoperative and postoperative infected complication incidents.
On the other hand, Yamamoto et al. (2000) noted a considerably advanced intra-abdominal infection incident in their patient population that experienced abdominal surgery for CD whilst being treated with steroids. The above analysts carried out a multivariate study on 343 CD patients who experienced 566 surgery operations. They noted that in case of the utilization of steroids preoperatively, intra-abdominal septic or fistula were the risk factors for greater postoperative intra-abdominal troubles. Contradictory studies have been written about the risks of carrying out bowel anastomoses in CD patients through immune-modulators.
Marchal et al (2004) also studied the risk of surgery on the CD patients who were getting infliximab treatment. They carried out a case control analysis of 40 patients who got infliximab treatment within 3 months of surgery to 39 patients who did not have such treatment. The analysts did not see a statistical disparity in the complication incidents or the duration between the two groups.
Controversy, however, exists as to the dangers of postoperative complexities in those CD patients getting immune-modulators before the surgery. Especially, the dangers of infliximab are debated intensively. Besides, the immune-modulator the patient is undertaking, the number of drugs may be problematical. No researches have been written about the danger of being on several immune-modulators, though various presentations have been made in at scientific seminars showing high complication incidents in CD patients taking infliximab as well other immune-modulator like steroids. Though not entirely inadvisable, care should be taken when carrying out bowel anastomoses in weak patients on various immune-modulators.
Preoperative Nutrition
The patients with CD are vulnerable for acquiring medical complications as a result of undernourishment. The utilization of parenteral diet in the CD patients is extensively applied if patients' ailment conditions are dynamic and they are unable to bear enteral diet. As such Total parenteral nutrition (TPN) might be utilized as an add-on to get ready the patients for surgical treatment by enhancing their dietary condition, or utilized together with medical treatment to prevent surgical treatment in cases of difficult CD.
Evans et al. (2003) studied the usefulness of utilizing short course TPNs for the patients with critical CD as program to avoid extended hospitalization before surgery or to avert the operation. 12 of the 15 patients in the research successfully concluded TPN with planned development to eventual surgery amongst 8 CD patients or the solution of states needing TPN in 4 patients. One of the patients acquired infection and the other acquired dehydration necessitating hospitalization.
The usefulness of preoperative TPN in CD was studied by Lashner et al. (1989). The writers carried a background study of 103 people evaluating the patients with CD who experienced bowel surgery with and without preoperative TPN. They noted that those patients who got preoperative TPN and experienced bowel surgery had considerably less intestine surgery than those patients who did not get TPN. The patients had considerably longer postoperative hospitalization. No disparities were observed in the patients experiencing colon surgeries. On the other hand, Seo et al. (1999) observed that dispensation of TPN to patients with critical resulted in decision of symptoms and avoidance of surgery in 11 of the 12 CD patients analyzed.
Malnutrition has been considered to be an independent risk factor for postoperative troubles in CD patients. In spite of this fact, there are scanty data in the utilization of preoperative TPN in malnourished CD patients to reduce postoperative problems. Fasth et al (1987) studied the usefulness of postoperative TPN in CD patients. The authors noted that CD patients with data of undernourishment preoperatively did not essentially have a greater complication incidents and that dealing postoperatively with TPN did not lower postoperative mortalities. So far, no strong researches, either forthcoming or retrospective, have explored the benefits of preoperative management of TPN in CD patients experiencing surgery. As stated above, poor nutrition has been shown to be an independent risk factor for postoperative troubles, and if the patients are critically malnourished, dealing with preoperative TPN may reduce the chances of those postoperative troubles.
WOC nurse role and fistula, post operation management
The research has proved that those patients who were managed by WOC nurse nurses had better chances of healing rates as well as the costs of care in contrast to the patients taken care by the traditional nurses (Arnold & Weir, 1994; Bolton et al., 2004; Harris & Shannon, 2008; Peirce, Tiffany, Kinsey & Link, 2008).
The wounds of all kinds are a growing trouble and the increased focus on fistula and post operation management has drawn considerable focus by WOC nurses. WOC nurses have the required education, skills, and qualifications to offer excellent wound care especially regarding the fistula. WOC nurses have detailed knowledge and excellent perception of the wound healing procedures and its treatment. WOC nurses are qualified through education and experience to create and apply wound management programs to deliver excellent care for fistula as well as provide supervision to improve the healing results.
The WOC nurses stress on protective care, especially for the families who strongly care for aging relatives with functional troubles (WOCN, 2010). WOC nurses are proficient in providing the comprehensive prevention measures and care planning for fistula post operation management vital to decrease the frequency of these complexities.
Management of Intra-abdominal Sepsis in Patients with Crohn's Disease
The patients with CD commonly develop intra-abdominal sepsis on account of fistulizing ailment; they may display free gap of feces or pus. These CD patients need primary fluid recovery after laparoscopic assessment. If the CD patients are unsound, the launching of pressors may be needed before the dispensation of general anesthesia.
The emergence with a limited intra-abdominal sore is at first managed with percutaneous drainage instead of surgical treatment if the sore cavity is easily taken in hand. The academic advantage in dealing with intra-abdominal soars with antibiotics and drainage before the surgery is to reduce the irritation response in the abdomen hence utilizing the surgery. Alves et al. (2007) studied 161 CD patients who experienced primary surgery without change for CD. The authors carried out a multivariate study and noted that the existence of an intra-abdominal abscess was an independent danger aspect of postoperative septic problems.
Drainage of sores found before the surgery may be considered with the key anastomoses with no the risk of postoperative. A number of researches have shown the security and the viability of percutaneous drainage of intra-abdominal sores (Gutierrez et al., 2006; Golfieri et al., 2006; Harisinghani et al., 2003).
The effective management of intra-abdominal sore in CD patients has altered in the last few decades. In 1996, Ayuk et al. (1996) stated 40 CD patients were put on observation. The patients had 54 sores, the mainstream of which were dealt with laparotomy, drainage, and bowel surgery. The results were radically different from those written by Rypens et al. (2007). The authors studied 14 patients with intra-abdominal who experienced percutaneous drainage. Just about 50% of the drainage trials caused the complete decision of the septic and twelve patients underwent surgery with major anastomosis.
The treatment of intra-abdominal sores with or with no percutaneous drainage may help surgical treatment to be deferred or prevented completely. Lee et al. (2006) studied twenty four patients who were hospitalized for CD abscess more than a 7-year period. 19 of the 24 patients were given treatment with five patients having percutaneous drainage of their abscesses. They had about 67% success rate with the non-surgical method and had a 12.5% abscess reappearance rate in seven months.
Conclusions
CD creates a distinctive and complex challenge for the surgeon as well as the WOC nurses. This disease is not treated by the surgery only; hence, the WOC nurses try to delay surgical treatment. This delaying normally implies that the CD patients can present themselves in a destabilized, weakened condition with major immune-suppression.
Moreover, the growth of intra-abdominal swellings or fistula is the usual evolution of CD and makes it complex for WOC management of the patient.
However, the rationale underlying CD occurrence and treatment has been incoherent; the mainstream research has been localized, generally retrospective, and, therefore, conditional on insufficient data compilation, normally ranging restricted time eras. However, the major cohort research studies pointed out a major CD occurrence, increase in the 20th century. The basis of this rise continues to be tentative.
References
ABS (Australian Bureau of Statistics) (2009). Population by age and sex, Australian states and territories Jun 2009, Cat 3201.0. Canberra: Australian Bureau of Statistics.
Alves, A., Panis, Y., Bouhnik, Y., Pocard, M., Vicaut, E., & Valleur. P. (2007). is Colon Rectum; 50 (3): 331–336.
Arnold, M., & Weir, D. (1994). Retrospective analysis of healing in wounds cared for by ET nurses versus staff nurses in a home setting. Journal Wound. Ostomy Continence Nursing, 24, 456-60.
Ayuk, P., Williams, N., Scott, N.A., Nicholson, D.A., & Irving, M.H. (1996). Management of intra-abdominal abscesses in Crohn's disease. Ann R Coll Surg Engl; 78 (1): 5–10.
Baldassano, R.N., & Piccoli, D.A. (1999). Inflammatory bowel disease in Pediatric and Adolescent patients. Gastroenterol Clin North Am; 28: 445-455.
Baumgart, D.C., & Sandborn, W.J. (2007). Inflammatory bowel disease: clinical aspects and established and evolving therapies, Lancet, 369 (9573), 1641-1657.
Binder, V. (2004). Epidemiology of IBD during the twentieth century: an integrated view. Best Pract Res Clin Gastroenterol; 18: 463– 479.
Bolton, L., McNees, P., van Rijswijk, L., de Leon, J., Lyder, C., Koba, L., et al. (2004). Wound-healing outcomes using standardized assessment and care in clinical practice. Journal Wound. Ostomy Continence Nursing, 31, 65-71.
Colombel, J.F., Loftus, E.V., Jr., Tremaine, W.J., et al. (2004). The safety profile of infliximab in patients with Crohn's disease: the Mayo clinic experience in 500 patients. Gastroenterology; 126 (1): 19–31.
Cosgrove, M., Al-Atia, R.F., & Jenkins, H.R. (1996). The epidemiology of pediatric inflammatory bowel disease. Arch Dis Child; 74: 460-461.
Cosnes, J., Nion-Larmurier, I., Beaugerie, L., Afchain, P., Tiret, E., & Gendre, J.P. (2005). Impact of the increasing use of immunosuppressants in Crohn’s disease on the need for intestinal surgery. Gut; 54 (2): 237–241.
Cuffari, C., & Darbari, A. (2002). Inflammatory Bowel disease in the pediatric and adolescent patients. Gastroenterol Clin N Am; 31: 275-291.
Evans, J.P., Steinhart, A.H., Cohen, Z., & McLeod, R.S. (2003). Home total parenteral nutrition: an alternative to early surgery for complicated inflammatory bowel disease. J Gastrointest Surg; 7 (4): 562–566.
Fasth, S., Hulten, L., Magnusson, O., Nordgren, S., & Warnold, I. (1987). The immediate and long-term effects of postoperative total parenteral nutrition on body composition. Int J Colorectal Dis; 2 (3): 139–145.
Gaya, D.R., Russell, R.K., Nimmo, E.R, et al. (2006). New genes in inflammatory bowel disease: lessons for complex diseases? Lancet; 367: 1271–1284.
Gibson, P.R. (2009). Overview of inflammatory bowel disease in Australia in the last 50 years. Journal of Gastroenterology & Hepatology, 24 (Suppl 3), S63-S68.
Gutierrez, A., Lee, H., & Sands, B.E. (2006). Outcome of surgical versus percutaneous drainage of abdominal and pelvic abscesses in Crohn's disease. Am J Gastroenterol; 101 (10): 2283–2289.
Golfieri, R., Cappelli, A., Giampalma, E., et al. (2006). CT-guided percutaneous pelvic abscess drainage in Crohn's disease. Tech Coloproctol; 10 (2): 99–105.
Harris, C., & Shannon, R. (2008). An innovative enterostomal therapy nurse model of community wound care delivery. Journal Wound. Ostomy Continence Nursing, 35, 169-183.
Harisinghani, M.G., Gervais, D.A., Maher, M.M, et al. (2003). (Transgluteal approach for percutaneous drainage of deep pelvic abscesses: 154 cases. Radiology; 228 (3): 701–705.
Hutfless, S.M., Weng, X., Liu, L., Allison, J., & Herrinton, L.J. (2007). Mortality by medication use among patients with inflammatory bowel disease, 1996–2003. Gastroenterology; 133 (6): 1779–1786.
Hyams, J.S. (1999). Crohn’s disease. In Wyllie R, Hyams JS, Eds. Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. WBSaunders. Philadelphia: 401-418.
Kirschner, B.S. (1988). Inflammatory Bowel Disease in Children. Pediatr Clin North Am; 1: 189-208.
Lashner, B.A., Evans, A.A., & Hanauer, S.B. (1989). Preoperative total parenteral nutrition for bowel resection in Crohn's disease. Dig Dis Sci; 34 (5): 741–746.
Lee, H., Kim, Y.H., Kim, J.H., et al. (2006). Nonsurgical treatment of abdominal or pelvic abscess in consecutive patients with Crohn's disease. Dig Liver Dis; 38 (9): 659–664.
Mamula, P., Markowitz, J.E., Baldassano, R.N. (2003). Inflammatory bowel disease in early childhood and adolescence: special considerations. Gastroenterol Clin North Am; 32: 967-995.
Marchal, L., D'Haens, G., Assche, G. Van, et al. (2004). The risk of post-operative complications associated with infliximab therapy for Crohn's disease: a controlled cohort study. Aliment Pharmacol Ther; 19 (7): 749–754.
Morrison, G, Headon, B et al (2009). Update in inflammatory bowel disease, Australian Family Physician, 38 (12), 956-961.
Munkholm, P., Langholz, E., Davidsen, M., & Binder, V. (1993). Intestinalcancer risk and mortality in patients with Crohn’s disease. Gastroenterology; 105 (6): 1716–1723.
Peirce, B., Tiffany, M., Kinsey, H., & Link, M. (2006). Using OASIS data to quantify the impact of WOC nursing on patient outcomes in home healthcare: a multicenter study. ABSTRACT. Journal of Wound Ostomy Continence Nursing, 33, Supplement 1, 532.
Rypens, F., Dubois, J., Garel, L., Deslandres, C., & Saint-Vil, D. (2007). Percutaneous drainage of abdominal abscesses in pediatric Crohn's disease. AJR Am J Roentgenol; 188 (2): 579–585.
Sathiyasekaran, M., Raju, B.B., Shivbalan, S., & Rajarajan, K. (2005). Pediatric Crohn’s disease in South India. Indian Pediatr; 42: 459-463.
Seo, M., Okada, M., Yao, T., Furukawa, H., & Matake, H. (1999). The role of total parenteral nutrition in the management of patients with acute attacks of inflammatory bowel disease. J Clin Gastroenterol; 29 (3): 270–275.
Tay, G.S., Binion, D.G., Eastwood, D., & Otterson, M.F. (2003). Multivariate analysis suggests improved perioperative outcome in Crohn's disease patients receiving immunomodulator therapy after segmental resection and/or strictureplasty. Surgery; 134 (4): 565–572.
Wilson, J, Hair, C et al (2010). High incidence of inflammatory bowel disease in Australia: A prospective population-based Australian incidence study, Inflammatory Bowel Diseases, 16 (9), 1550-1556. 82.
WOCN (2010). Wound, Ostomy and Continence Nursing. Scope & Standards of Practice. Mt. Laurel, NJ; Author.
Yamada, T. (2009). Textbook of gastroenterology, 5th Edn. Chichester, West Sussex; Hoboken, NJ: Blackwell.
Yamamoto, T., Allan, R.N., & Keighley, M.R. (2000). Risk factors for intra-abdominal sepsis after surgery in Crohn's disease. Dis Colon Rectum; 43 (8): 1141–1145.
