Inflammatory Bowel Disease

Question 1

Inflammatory Bowel Disease (IBD)

Answer 1

• Umbrella Term
  
  • Crohn’s Disease
  • Ulcerative Colitis

Question 2

IBD Etiology

Answer 2

• Thought to be complex interplay
  
  • Genetics
  • Immunes system
  • Environmental factors
• Genetic Predisposition
  
  • Positive family history is highest risk for IBD
    
    • 1^st degree relatives
  • Gene mutation on chromosomes 5 and 6 (just FYI)
• Smokers 2 – 4 x’s risk for Crohn’s
  
  • More aggressive disease
• Non-smokers greater risk for ulcerative colitis

Question 3

IBD Epidemiology

Answer 3

• Worldwide
  
  • Usually industrialized nations
    
    • Urban area
    • Cold climate
    • USA and Northern Europe
      
      • Jewish greatest prevalence
      • Native American, Asian, Hispanic least prevalent
    • Caucasian women
      
      • 15 -25 years peak
        
        • Another peak 55 – 65 years

Question 4

Pathophysiology of IBD

Answer 4

• Inflammation
• Exacerbation and remission
• Crohn’s vs Ulcerative colitis

Question 5

Ulcerative Colitis

Answer 5

Bowel mucosa

• Diffuse and continuous inflammation
  
  • Edema and shallow ulceration
• Distal colorectal area – 40 -50%
• Left sided : colorectal to splenic flexure 30 – 40%
• Severe disease : extends up to hepatic flexure
• Rectum only (very small %) ulcerative proctitis.
• Mucosa is fragile
  
  • Bleeds spontaneously
    
    • Trauma
• Becomes thickened and edematous
  
  • Scars form
    
    • Lose elasticity and absorptive capability

Question 6

UC S/S

Answer 6

• Bloody Diarrhea
  
  • 3-4 x’s/day up to hourly
    
    • Small in volume
    • Mushy
    • Mixed with blood, mucus, and pus
• Abdominal pain
  
  • Left-sided
  • Colicky
  • Relieved by emptying bowel

Question 7

Crohn’s Disease

Answer 7

Affects any portion of the digestive tract

• Most often proximal colon and ileocecal junction
• “Right-sided” disease
• 40% confined to cecum and ileum
  
  • May be in more than one site
• Transmural
  
  • All layers of the intestinal wall
  • “Skip” or “Cobblestone” pattern
    
    • Affected tissue separated by normal tissue
• What do the lesions do?
  
  • Perforate
  • Form fistulas
  • Scar tissue
    
    • ↓ absorption
  • Strictures
    
    • Bowel obstruction
  • Polyps

Question 8

Chron’s S/S

Answer 8

• Varies according to location and severity
• Diarrhea
  
  • Small intestine
    
    • 3 – 5 large semi-solid stool/day
      
      • Contains mucus and pus
        
        • No blood
  • High small intestine
    
    • Steatorrhea
      
      • Fatty stool, foul smelling
    • Poor absorption of fat soluble vitamins
      
      • A, D, E, and K
• Abdominal pain
  
  • Colicky and severe
  • Occurs after eating
    
    • Diffuse or
    • Localized in RLQ
      
      • May resemble appendicitis

Question 9

Systemic Symptoms of IBD

Answer 9

• Related to the intestines
• Anorexia, Nausea, Weakness, Malaise
• Weight loss
  
  • Nutritional deficiencies R/T poor absorption
• Labs
  
  • Anemia – iron deficiency

Question 10

Extraintestinal symptoms of IBD

Answer 10

• Can involve every organ in the body
• Etiology not well understood
• Arthritis (up to 23%)
  
  • Large joints
    
    • As IBD improves, so does Arthritis
• Ocular (up to 10%)
  
  • Uveitis, retinopathy
• Renal (up to 23%)
  
  • Kidney stones
• Skin (3 – 6%)
  
  • Erythema nodosum
    
    • Red, tender nodule on anterior tibia
• Hepatobiliary (4 – 5%)
  
  • Cholelithiasis, Fatty liver
  • Cholangitis (70% have UC)

Question 11

Complications of IBD

Answer 11

Primary

• Hemorrhage
• Obstructions
• Perforation
• Toxic megacolon
• Cellular dysplasia or Cancer
  
  • Adenocarcinoma
    
    • UC 10 – 20 X’s more than general population
    • Crohn’s Dz 4 – 7 X’s more than general population

Question 12

IBD Diagnostic Tests

Answer 12

• Health history
  
  • Symptoms
  • Pattern of severity and duration
• Labs
  
  • Stool cultures
  • Fecal leukocytes and parasites
  • CBC, ESR, Serum albumin
  • Serologic antibody assay
    
    • Preinuclear antineutrophil cytoplasmic antibodies (pANCA)
      
      • Ulcerative colitis
    • Anti-Saccharonyce cerevisiae antibodies (ASCA)
      
      • Crohn’s Disease
    • Differentiates IBD from IBS
• Radiologic
  
  • Barium enema
    
    • Evaluate physical changes of colon
      
      • Structure of bowel
        
        • String lesions – Crohn’s Dz.
  • CT of Abdomen
  • Transabdominal ultrasound

Question 13

IBD Medications

Answer 13

• Stepped Approach
  
  • Progressed until a response occurs
• Step 1 – Aminosalicylates
• Step 1a – Antibiotics
• Step 2 – Corticosteroids
• Step 3 – Immunomodulatory agents
  
  • Monoclonal antibodies
• Step 4 – Agents that have been shown to help selected types of patients

Question 14

Step 1 (mild to moderate IBD)

Answer 14

• Aminosalicylates
  
  • Sufasalazine (Azulfidine)
    
    • Developed in the 1930’s to treat arthritis
    • Combination of sulfa drug and aspirin
    • Broken down in colon into Sulfapyridine and 5-acetysailcylic acid (5-ASA)
      
      • 5-ASA not absorbed, so stays in colon to reduce inflamation
      • Sulfa does not really do anything
  • Olsalazine (Dipentum) 5-ASA
  • Mesalamine (Pentasa, Asacol)
    
    • pH sensitive coating – releases in colon

Question 15

Step 1A

Answer 15

• Antibiotic
  
  • Metronidazole (Flagyl)
  • Ciprofloxacin (Cipro)
  • Most often used in pre-op care
  • Can be used in seriously ill with infection

Question 16

Step 2 (moderate to severe IBD)

Answer 16

• Corticosteroids
  
  • Rapidly acting antiinflammatory agent
  • Not used as maintenance
    
    • Too many systemic effects
      
      • Electrolytes imbalance
      • Osteoporosis
      • Endocrine dysfunction
  • May be given IV, PO, PR
  • Prednisone
  • Budesonide (Entocort)

Question 17

Step 3 (Extensive disease)

Answer 17

Immune Modifiers

• Potent immunosuppressive agents
• Azathioprine (Imuran)
• Mercaptopurine (6-MP, Purinethol)
• May take up to 4 months to demonstrate effectiveness
  
  • Not used in acute situations
  • Effective in prolonging remission
  • Needs monthly CBC and Plt count
    
    • Neutropenia and pancytopenia
• Methotreate – Crohn’s Dz
• Cyclosporine (Sandimmune) Ulcerative colitis
• Monoclonal Antibodies
  
  • Infliximab
    
    • Monoclonal immunoglobulin G₁ antibody against tumor necrosis factor-alpha (TNF-alpha)
    • Used in Crohn’s Disease
    • TNF-alpha – inflammatory agent found in high amounts in patients with Crohn’s Dz.
  • Natalizumab
    
    • Monoclonal antibody
    • Used in Crohn’s Dz.

Question 18

Step 4

Answer 18

Clinical Trials

Question 19

Other Medications IBD

Answer 19

Meds for symptomatic relief

• Anti-diarrheals
• Fat-soluble vitamins
• Bile acid binding agents
• Acid suppression agents
• Antispasmodics

Question 20

IBD Treatment

Answer 20

• Daily enemas for rectal involvement
• Management of skin breakdown R/T diarrhea
• Severe episode
  
  • Bedrest
  • NPO
  • IV fluids
  • Hospitalization
    
    • High dose steroids
    • TPN

Question 21

Surgical Management – Crohn’s

Answer 21

• Avoid as much as possible
  
  • High rate of reoccurrence in same area
• 75% eventually have surgery
  
  • Uncontrolled disease
  • Manage complications
• Focus
  
  • Spare and conserve as much of the bowel as possible – especially small bowel
  • >100 cm of Small Bowel loss à short bowel syndrome
• Surgical procedure
  
  • Segmental resection
    
    • Remove 5 – 10 cm each side of diseased tissue
    • Reanastomosis
  • Strictureplasty
    
    • Most common complication

Question 22

Surgical Management - UC

Answer 22

When medical management no longer works

• Curative
  
  • Removes the entire colon
• Brook Ileostomy
  
  • Removal of anus, rectum, and colon
  • Anus permanently closed
  • Terminal ileum brought through abd wall

Question 23

Ileostomy

Answer 23

• Problems
  
  • Loss of fluid
    
    • 800 ml each day
  • Loss of electrolytes
    
    • Sodium
  • Self-esteem
  • Fear
    
    • Leakage
    • Odor
    • Noise

Question 24

Continent Ileostomy (Kock)

Answer 24

• Same as ileostomy, except
  
  • Forms a pouch in small intestine
    
    • Also called a K-pouch
  • Has a nipple valve
    
    • Easily blocked
  • Drain stool with a catheter
  • Rarely done anymore due to multiple complications

Question 25

Ileoanal Anatomosis (Ileorectostomy)

Answer 25

* The colon is removed * The rectum remains * Able to absorb fluid & electrolytes * Can still get CA and UC * No stoma

Question 26

Ileoanal Pouch Anastomosis (IPAA)

Answer 26

* Terminal ileum forms a pouch * Terminal ileum is sewn directly into rectum * Leaves anal sphincter intact, so less risk of incontinence * Can develop pouchitis * Inflammation of the pouch * Bleeding * Rectal pain

Question 27

Nursing Management

Answer 27

* Health History * What is the patient’s knowledge of the Disease? * How is the pain assessed? * Constipation or diarrhea – pattern * Diet * Types of foods, weight loss, weight gain * Allergies * Family/Friend support * Impact of illness on aspects of patients life? Physical Exam * Body Weight * Skin turgor * Condition of the mucus membranes * Perianal skin * Fever * Bowel sounds * Composition of stool * Fat, blood, mucus, pus Nursing Diagnosis * Chronic Pain * Diarrhea * Imbalance nutrition: less than body requirements * Ineffective coping * Ineffective health maintenance

Question 28

Patient/Family Teaching

Answer 28

* Diet and Fluids * High calorie, well balanced * Low fiber, low dairy * Multivits * 3 liters of fluid each day * Gatroade to help replace electrolytes * Use salt – especially during flare ups * Elimination * Take meds as prescribed * Keep rectal area clean and dry * Use of anti-diarrheals * Use of bulk-forming laxatives when severe diarrhea * Maintain daily weights * Rest and Coping * Regular sleep schedule * Schedule daily activities to avoid fatigue * Take rest periods * Use relaxation strategies to decrease stress * Talk with family and friends about concerns * Attend local support groups * Health Maintenance * Report signs requiring medical attention * Changes in pattern or frequency of diarrhea or pain * Constipation * Change in stool characteristics * Unusual discharge from rectum * Fever * Regular follow-up care