Inflammatory Intestinal Disorders Flashcards
- Crohn's disease - Ulcerative colitis (82 cards)
1
Q
IBD
Characterized by chronic, recurrent inflammation of intestinal tract
- Periods of remission are interspersed w/periods of exacerbation
A
- Exact cause is unknown
- There is no cure
2
Q
On the basis of clinical manifestations, IBD is classified as either ulcerative colitis (UC) or Crohn’s disease
A
3
Q
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Is inflammation of any segment of GI tract from mouth to anus
A
Crohn’s disease
4
Q
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Is inflammation & ulceration of colon & rectum
A
Ulcerative colititis
5
Q
IBD
- May occur @ any age
> Common during teenage yrs & early adulthood
> 2nd peak in 6th decade
A
- Occurs more commonly in people of white & Ashkenazic Jewish origin
- Many have a family member w/the disorder
6
Q
An autoimmune disease
> Involves an immune reaction to a person’s own intestinal tract
> Some agent or combo of agents triggers an overactive, inappropriate, sustained immune response
> Results in widespread inflammation & tissue destruction
A
Involves a combo of factors
> Environmental factors
> Genetic predisposition
> Alterations in immune function
7
Q
Environmental factors
- Diet
> High intake of total fats, PUFAs, omega-6 fatty acids, & meat is assoc w/inc risk of IBD - Exposure to air pollution
- Stress
- Smoking
A
- More prevalent in industrialized countries
8
Q
High vegetable intake is associated w/a decreased risk of which condition?
A
Ulcerative colitis
9
Q
High fiber & fruit intake are assoc w/dec risk of Crohn’s disease
A
Oral contraceptives & NSAIDs exacerbate Crohn’s disease
10
Q
- Numerous genome-wide association studies have confirmed a genetic predisposition
- Certain genetic mutations are assoc w/Crohn’s disease, others assoc w/UC, & many assoc w/both
- IBD more likely to occur in those w/other genetic syndromes inc CF
A
- An inc prevalence occurs in the presence of other inflammatory disorders w/genetic susceptibility like psoriasis & MS
11
Q
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This was the 1st gene assoc w/Crohn’s disease
- Gene changes are assoc w/a form of Crohn’s disease that affects the ileum in persons of northern European descent
- Gene changes trigger an abnormal immune response that allows bacteria to grow unchecked & invade intestinal cells, causing chronic inflammation & digestive problems
A
NOD2
12
Q
A genetically susceptible person who is not exposed to a triggering agent will not become ill, & a person who is not genetically susceptible will not develop IBD even if exposed to a triggering agent
A
The pathway from genetic mutation to abnormal immune responses varies depending on which gene or genes are affected
> This variation may explain differences in pt responses to various rx therapies for IBD
13
Q
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This condition usually starts in the rectum & moves in a continual fashion toward the cecum
> Although mild inflammation may occur in the terminal ileum, it’s a dz of the colon & rectum
A
Ulcerative colitis
14
Q
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This condition can occur anywhere in the GI tract from the mouth to the anus, but most commonly involves the distal ileum & proximal colon
Segments of normal bowel can occur between diseased portions, so-called “skip” lesions
A
Crohn’s disease
15
Q
Inflammation patterns differ between Crohn’s disease & ulcerative colitis
A
- Chronic disorders
> Pts suffer mild to severe acute exacerbations that occur @ unpredictable intervals over many yrs
16
Q
The inflammation in Crohn’s disease involves all layers of the bowel wall
A
- Ulcerations are deep & longitudinal & penetrate between islands of inflamed, edematous mucosa, causing the classic cobblestone appearance
- Strictures @ areas of inflammation can cause bowel obstruction
- Since inflammation goes through entire wall, microscopic leaks can allow bowel contents to enter peritoneal cavity & form abscesses or produce peritonitis
- In active Crohn’s disease, fistulas are common
17
Q
- For UC, inflammation & ulcerations occur in the mucosal layer, the innermost layer of the bowel wall; fistulas & abscesses are rare since inflammation doesn’t extend through all bowel wall layers
- B/c water & electrolytes aren’t absorbed through inflamed mucosa, diarrhea w/large fluid & electrolyte losses is common
A
- Breakdown of cells results in protein loss through the stool
- Areas of inflamed mucosa form pseudopolyps, tongue-like projections into the bowel lumen
18
Q
Clinical Manifestations
- Diarrhea
- Weight loss
- Abd pain
- Fever
- Fatigue
A
19
Q
Diarrhea & cramping abdominal pain are 2 common symptoms in which condition?
A
Crohn’s disease
20
Q
Crohn’s disease
If the SI is involved, wt loss occurs from inflammation of the SI causing malabsorption
A
Rectal bleeding sometimes occurs w/Crohn’s disease, although not as often as w/ulcerative colitis
21
Q
The primary manifestations of ulcerative colitis are __ __ & __ __
A
bloody diarrhea; abdominal pain
> Pain may vary from the mild lower abd cramping assoc w/diarrhea to severe, constant pain assoc w/acute perforations
- Mild, moderate, severe
22
Q
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In __ dz, the pt has inc stool output (up to 10 stools/day), inc bleeding, & systemic sx’s (fever, malaise, mild anemia, anorexia)
A
moderate
23
Q
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In __ dz, diarrhea is bloody, contains mucus, & occurs 10-20x/day
A
severe
- In add’n, fever, rapid wt loss >10% of total body weight, anemia, tachycardia, & dehydration are present
24
Q
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In __ dz, diarrhea may consist of no more than 4 semi-formed stools daily that contain small amts of blood
> Pt may have no other manifestations
A
mild
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GI tract (local) complications
* Hemorrhage
* Strictures
* Perforation (w/possible peritonitis)
* Abscesses
* Fistulas
* CDI
* Colonic dilation (toxic megacolon)
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Pts w/toxic megacolon are @ risk of perforation & may need an emergency colectomy
Toxic megacolon is more common with which condition?
ulcerative colitis
27
Perineal abscesses & fistulas occur in up to a 3rd of pts w/which condition?
Crohn's disease
28
CDI (*Clostridium difficile* infection) inc in frequency & severity in pts w/IBD
Hemorrhage may lead to anemia & needs to be corrected w/blood transfusions & iron supplements
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Nutritional problems are esp common in Crohn's disease when the terminal ileum is involved
Bile salts & cobalamin are exclusively absorbed in the terminal ileum
Thus, dz in the terminal ileum can result in fat malabsorption & anemia
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* High risk for colorectal cancer
> Those w/Crohn's dz are @ inc risk for small intestinal cancer
* Systemic complications
> Joint, eye, mouth, kidney, bone, vascular, & skin problems
> Circulating cytokines trigger inflammation
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* Liver failure
> Routine LFT's important b/c **primary sclerosing cholangitis** is a complication of IBD & can lead to liver failure
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* In early Crohn's dz, the sx's are similar to those of IBS
* A CBC typically shows iron-deficiency anemia from blood loss
* An elevated WBC count may be an indication of toxic megacolon or perforation and possible peritonitis
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* Decreases in serum sodium, potassium, chloride, bicarbonate, & magnesium levels occur d/t fluid & electrolyte losses from diarrhea & vomiting
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___ is present w/severe dz b/c of poor nutrition or protein loss
Hypoalbuminemia
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* Elevated ESR, CRP level, & WBC count reflect inflammation
* Stool examination
> Pus
> Blood
> Mucus
* Stool cultures (can determine if infection is present)
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Diagnostic Studies
Imaging studies
* Double-contrast barium enema study
* Small bowel series/small bowel follow through
* Transabdominal ultrasonography
* CT
* MRI
* Colonoscopy
> Allows for examination of the entire large intestine lumen & sometimes most distal ileum
* Since a colonoscope can enter only the distal ileum, capsule endoscopy may be used to diagnose Crohn's disease in the SI
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Goals of IBD treatment
* Rest the bowel
* Control inflammation & combat infection
* Correct malnutrition
* Alleviate stress
* Relieve symptoms
* Improve quality of life
* Goals of drug treatment are to induce & maintain remission
> Aminosalicylates
> Antimicrobials
> Corticosteroids
> Immunosuppressants
> Biologic & targeted therapy
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* Drug selection depends on severity & location of inflammation
> Step-up approach
> Step-down approach
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Uses biologic & targeted therapy first
Step-down approach
40
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* Uses less toxic therapies 1st (aminosalicylates, antimicrobials)
* More toxic medications are started when initial therapies do not work
Step-up approach
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Aminosalicylates are more effective for which condition?
ulcerative colitis
However, they are first-line therapies for mild-to-moderate Crohn's disease, esp when the colon is involved
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* Exact mechanism of action of 5-ASA is unknown, but topical application to the intestinal mucosa suppresses proinflammatory cytokines & other inflammatory mediators
* Benefits of these drugs usually depend on the dose: the larger the dose, the more likely pts will improve during the acute phase & remain in remission
* H/e, may ppl cannot tolerate the side effects of sulfasalazine
> HA's, nausea, & fatigue occur @ the higher doses
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* In men, long-term sulfasalazine treatment may cause abn sperm production, leading to infertility; these effects are reversible if sulfasalazine is discontinued
* Sulfa-free rx's are as effective as sulfasalazine & better tolerated when given orally
> Olsalazine (Dipentum)
> Mesalamine (Pentasal)
* Topical 5-ASA preps include rectal suppositories & enemas
> Topical treatment delivers the 5-ASA directly to the affected tissue & minimizes systemic effects
* The combo of oral & rectal therapy is better than oral or rectal alone
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! Drug Alert ! - Sulfasalazine (Azulfidine)
* May cause yellowish orange discoloration of skin & urine
* Avoid exposure to sunlight & UV light until photosensitivity is determined
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Corticosteroids
* Used to achieve remission in IBD
* Given for the shortest possible time b/c of side effects assoc w/long-term use
* Pts w/dz in the left colon, sigmoid, & rectum benefit from suppositories, enemas, & foams b/c they deliver the corticosteroid directly to the inflamed tissue w/minimal side effects
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* Oral prednisone is given to pts w/mild to moderate dz who did not respond to either 5-ASA or topical corticosteroids
* Those w/severe inflammation may require a short course of IV corticosteroids
* Corticosteroids must be tapered to very low lvls when surgery is planned to prevent postop complications (e.g., infection, delayed wound healing, fistula formation)
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Immunosuppressants (i.e., 6-mercaptopurine, azathioprine [Imuran])
* Suppress immune response
* Maintain remission >corticosteroid induction therapy
* Require regular CBC [depress bone marrow] & chemistry [lead to inflammation of pancreas or liver] monitoring
* Have a delayed onset of action & are not useful for acute flare-ups
48
___ is most useful in Crohn's disease pts who can't stop corticosteroid use w/o a flare-up or in whom other rx's have been ineffective
Many pts have flu-like sx's w/use, & some develop bone marrow depression & liver dysfunction
> Careful monitoring of CBC & liver enzymes is essential
Women of childbearing age should avoid pregnancy b/c of birth defects & fetal death
Methotrexate
49
Biologic & targeted therapies
TNF (antitumor necrosis factor) agents
* Infliximab (Remicade)
* Adalimumab (Humira)
* Certolizumab (Cimzia)
* Golimumab (Simponi)
Integrin receptor antagonists [both given by IV infusion]
* Natalizumab (Tysabri)
* Vedolizumab (Entyvio)
> Inhibit leukocyte adhesion by blocking α4-integrin, an adhesion molecule
> The use of these rx's is limited to those who have not had an adequate response w/other therapies (corticosteroids, immunosuppressants, or TNF agents)
50
Infliximab is a monoclonal antibody to TNF (proinflammatory cytokine)
> Is given IV to induce & maintain remission in pts w/Crohn's disease & in pts w/draining fistulas who do not respond to conventional rx therapy
Side effects - most common adverse effects are
> upper respiratory & urinary tract infections
> HA's
> nausea, joint pain, abd pain
more serious effects
> reactivation of hepatitis & tuberculosis (TB) [pts are tested opportunistic infections & malignancies, esp lymphoma
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! Use is assoc w/inc risk of infection, hepatotoxicity, & hypersensitivity reactions
* B/c of risk of progressive multifocal leukoencephalopathy, natalizumab (Tysabri) is avail only through a restricted program
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* Biologic & targeted agents don't work for everyone
> Are costly & may produce allergic reactions
> Are immunogenic, meaning that pts receiving them freq produce antibodies against them
> Immunogenicity leads to acute infusion reactions & delayed hypersensitivity-type reactions
* These rx's are most effective when given @ regular intervals
* Infusion reactions are more likely if an rx is stopped & then restarted
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Nutritional Therapy
* Dietary consultant
Goals of diet management
1. Provide adequate nutrition w/o exacerbating symptoms
2. Correct and prevent malnutrition
3. Replace fluid & electrolyte losses
4. Prevent weight loss
54
* Nutritional deficiencies are due to
> Decreased oral intake
> Blood loss
> Malabsorption of nutrients
* Pts w/diarrhea often dec their oral intake to reduce diarrhea
* Inflammatory mediators reduce appetite
* Bloody diarrhea leads to iron-deficiency anemia, which may need treatment w/supplemental iron (ferrous sulfate or ferrous gluconate)
> Parenteral or IV iron may be needed for pts who cannot tolerate oral iron or if anemia is severe
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* Dz of the terminal ileum reduces absorption of __ and __
cobalamin; bile acids
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* Reduced cobalamin contributes to anemia, & bile salts are important for fat absorption & contribute to osmotic diarrhea
> Those who develop anemia should receive cobalamin injections
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___, an ion-exchange resin that binds unabsorbed bile salts, helps control diarrhea
Zinc deficiency can result from severe or chronic diarrhea, & supplementation may be necessary
Cholestyramine
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* Medications can contribute to nutritional problems
Pts receiving sulfasalazine should reduce what daily?
folate (folic acid)
59
Those receiving corticosteroids are prone to __ and need which 2 supplements?
osteoporosis
calcium; potassium
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Vitamin __ deficiency requiring supplementation is common
> May be d/t malabsorption d/t inflammation, surgical resection of intestine, reduced sunlight exposure, & dec dietary intake
D
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* During acute exacerbations
> Regular diet may not be tolerated
> Liquid enteral feedings are preferred
* High in calories & nutrients
* Lactose free
* Easily absorbed
* Regular foods introduced *gradually*
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* Foods that trigger exacerbations vary
* Food diary helps identify problems for individuals
> Lactose intolerance [Greek yogurt as a substitute]
> High-fat foods, cold foods, high-fiber foods [cereal w/bran, nuts, raw fruits w/peels] may trigger diarrhea
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* Exacerbations are debilitating & frequent
> Massive bleeding
> Perforation
> Strictures &/or obstruction
> Tissue changes indicating dysplasia or carcinoma
* Surgery is indicated if treatment fails
64
Surgical Therapy - procedures for chronic UC
* Total proctocolectomy w/ileal pouch/anal anastomosis (IPAA)
* Total proctocolectomy w/permanent ileostomy (can be done laparoscopically)
* B/c UC affects only the colon, a total proctocolectomy is curative
* UC can be cured w/a total colectomy, in as much as the colon & rectum aren't necessary for survival
65
Total proctocolectomy w/ileal pouch/anal anastomosis (IPAA)
* Most common surgical procedure for UC
* A diverting ileostomy is performed
* An ileal pouch is created & anastomosed directly to anus
* Combination of 2 procedures done approx 8-12 wks apart
* Initially may have 4-6 stools or more daily but adaptation over the next 3-6 mos will result in a dec # of BMs
* Pt is able to control defecation @ anal sphincter
! major complication is acute or chronic pouchitis (permanent ileostomy may be done if pouchitis doesn't resolve)
66
Total proctocolectomy w/permanent ileostomy
* 1-stage surgery
* Removal of colon, rectum, & anus w/closure
! Continence is not possible
* End of terminal ileum is brought out through abd wall to form a stoma (ostomy)
* Stoma is usually placed in RLQ below belt line
67
Surgical Therapy - Crohn's disease
* Commonly performed for complications
> Strictures
> Obstructions
> Bleeding
> Fistula
* Most pts eventually require a surgery
* Dz often recurs @ anastomosis site
* Most common surgery is a resection of the diseased segments & then the remaining intestine is re-anastomosed
68
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Occurs when there is too little SI surface area to maintain normal nutrition & hydration from dz or surgery
> Lifetime fluid boluses & parenteral nutrition may be needed
Short bowel syndrome
69
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> Opens up narrowed areas obstructing bowel
* Reduces risk of developing short-bowel syndrome & assoc complications b/c intestine remains intact
Strictureplasty (recurrences @ the site are uncommon)
70
Postoperative Care
Ileostomy
* Monitoring of
> Stoma viability
> Mucocutaneous juncture (area where the mucous membrane of the bowel interfaces w/the skin)
> Peristomal skin integrity
* Pt should return from surgery w/a clear ileostomy pouch in place
* Replace pouches if feces leak onto the skin
* If an NG tube is used, remove it when bowel function returns
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* Output may be as high as 1500-1800 mL per 24 hrs
Observe for
> Fluid & electrolyte imbalance
> Hemorrhage
> Abd abscess
> Small bowel obstruction
> Dehydration
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* Over a period of days to wks, the proximal small bowel adapts & inc fluid absorption. Then, feces will thicken to a paste-like consistency & the volume dec
* Pts, esp those w/Crohn's disease, are @ risk for developing small bowel obstruction during the 1st 30 days postop
* Transient incontinence of mucus is a result of intraoperative manipulation of the anal canal
* Initial drainage through the ileoanal anastomosis will be liquid
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* Start Kegel's exercises 4 wks >surgery to strengthen pelvic floor & sphincter muscles
* Perianal skin care to protect epidermis from mucous drainage & maceration
74
Nursing Assessment
* Autoimmune disorders, infection
* Use of prescribed & OTC medicines
* Family history
* Diarrhea (presence of blood)
* Wt loss
* Anxiety, depression
Nursing Diagnoses
* Diarrhea
* Imbalanced nutrition: less than body requirements
* Ineffective coping
75
Planning: Overall Goals
1. Decreased # & severity of acute exacerbations
2. Normal fluid/electrolyte balance
3. Freedom from pain or discomfort
4. Compliance w/medical regimen
5. Nutritional balance
6. Improved quality of life
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During acute phases, implement strategies that focus on
* Hemodynamic stability
* Pain control
* Fluid & electrolyte balance
* Nutritional support
* Manage hygiene until diarrhea is controlled
> Tend to odor control
> Prevent skin breakdown
* Monitor I&O
* Weigh daily
* Assess bowel sounds
* Consult w/dietitian
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* Dibucaine (Nupercainal), witch hazel, sitz baths, & other soothing compresses or ointments may reduce irritation & discomfort of the anus
78
Teaching includes
* How to manage this chronic illness [recurrent, unpredictable nature]
* Importance of rest & diet management
* Perianal care
* Rx action & side effects
* Symptoms of recurrence of dz
* When to seek medical care
* Ways to reduce stress
* Establish rapport
* Encourage discussion of self-care strategies
* Fully explain all procedures & treatments
> Helps build trust
> Decreases apprehension
> Increases self-control
* Quitting smoking as smoking is assoc w/more severe dz
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Assist in setting realistic goals [long & short term]
> Consider need for increased rest [fatigue can be severe, limiting energy]
> Schedule activities around rest periods [may lose sleep d/t freq eps of diarrhea & abd pain]
> Nutritional deficiencies & anemia leave pt feeling weak, listless
Emotional support
> Intermittent exacerbations & remissions of sx's can be common
- Frustration, depression, anxiety need management
* Therapy
* Stress management
* Support groups
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Expected Outcomes
> Decreased # of diarrhea stools
> Body wt maintained within normal range
> Freedom from pain & discomfort
> Use of effective coping strategies
81
Gerontologic Considerations
* 2nd peak in occurrence of IBD is in 6th decade
> Proctitis & left-sided UC are more common
* Diagnosis can be difficult & confused w/
> CDI
> Colitis is assoc w/diverticulosis or NSAID ingestion
* Greater risk of complications in frail older pts w/IBD
> Adverse events from corticosteroids
> Inc'd infection & malignancy risk assoc w/rx therapy [immunosuppressants & biologic therapy]
> Volume depletion & electrolyte imbalance from diarrhea
> Physical limitations that impact self care
> Colitis [from rx use & systemic vascular dz]
82
* NSAIDs, digitalis, sumatriptan (Imitrex), vasopressin, estrogen, & allopurinol (Zyloprim) have been assoc w/development of colitis in older pt
* Colitis may also be 2° ischemic bowel dz r/t atherosclerosis & HF
