Inflammatory Bowel Diseases

Alka Ingnam

Inflammatory bowel disease (IBD)

Refers to two chronic inflammatory GI disorders: regional enteritis (i.e. crohn's disease)

&ulcerative colitis.

Both have striking similarities but as the same time several differences.

Incidence In the US, has increased in the past

century: over 30,000 new cases occur annually.

15 and 30 years of age at the greatest risk, followed by people between 50 and 70.

Women and men are equally affected.

Aetiology• Unknown• Believed is caused by a

combination of these factors: Immune system problemsGeneticsEnvironmental factors

Regional enteritis /crohn's disease/crohn syndrome

• Chronic inflammatory condsition • May affect any part of GIT from mouth to

anus• Most commonly occur in distal ileum and

colon• usually first diagnosed in adolescents or

young adults but can appear at any time of life.

• Incidence shows rise over past 30 years

Pathophysiology• extends through all layers (i.e. transmural lesion)• characterized by remissions and exacerbations.• Disease process begins with edema and thickening

of mucosa• Deep ulcers appears on the inflamed mucosa-

separated by normal tissue• Take on classic "cobblestone" appearance • Fistulas• Perianal fissures and abscesses • Granulomas in 50% of the cases• Bowel wall thickens, become fibrotic• Intestinal lumen narrows

Cobblestone mucosa

Clinical features

• Unpredictable exacerbations and remissions.

• Quality of life is diminished • Overall mortality is 2x of general populationFeatures depend on site and extent of bowel

affected:• Abdominal pain

Most frequently in Rt lower quadrant due to involvement of terminal ileum and Rt side of colon

Crampy abdominal pain, usually after food

• Mass palpable on abdominal and rectal examination

• Nausea and vomiting • Excessive borborygmi• Colicky pain, Recurrent episodes• Diarrhea and fever • Sometimes diarrhea may contain

blood if has affected colon.• Anorexia, Weight loss• Malaise, lethargy, • Nutritional deficiency , anemia • Psychosocial issues

Assessment and diagnostic findings

1. Endoscopy– Colonoscopy – best for dx- a "cobblestone ulcer is seen- Biopsy may be done along

2. Radiology– Barium meal and follow through of upper GIT: shows

the classic ‘string sign’ on x-ray– Barium enema

3. Laboratory– Stool examination– Complete blood count– Albumin and protein

String sign on barium study

Complications

• Intestinal obstruction/ stricture formation

• Perianal disease• Fluid and electrolyte imbalance• Malnutrition• Fistula and abscess. Commonly

enterocutaneous fistula• Colon cancer: increased risk

Ulcerative colitis• Recurrent ulcerative and inflammatory

disease of the mucosal and submucosal layers of the colon and rectum.

• Peak incidence is between 30 and 50 years of age

• Serious disease accompanied by systemic complications and a high mortality rate.

• 10 to 15 % of these patients develop colon carcinoma

Pathophysiology

• Disease process begins at rectum and spreads proximally to entire colon

• Contiguous lesions • Affects the superficial mucosa• Multiple ulcerations• Inflammation• Desquamation or shedding of colonic epithelium• Bleeding occurs• Edematous and inflamed mucosa- pseudopolyposis• Abscesses form, infiltrate seen in mucosa• Bowel narrows, shortens and thickens

Clinical features

• Bloody diarrhea is the hallmark• Lower left quadrant abdominal pain• Tenesmus • Rectal bleeding• Anorexia, weight loss, fever, vomiting and dehydration• Cramping• Fecal urgency• Passage of 10-20 liquid stools each day.• Hypocalcemia and anemia • Rebound tenderness in right lower quadrant• Extraintestinal symptoms such as skin lesion (erythema

nodosum), eye lesions(uveitis), joint abnormalities(eg. arthritis) and liver disease

Assessment and diagnostic findings

• Laboratory : hematocrit, sedimentation rate, and serum albumin reflect severity of disease, stool for routine examination and occult blood

• Plain abdominal x-ray • Sigmoidoscopy, colonoscopy- mucosa appears

edematous, friable, mucopus and eroded• Barium enema- to find out severity and extent• CT and MRI are used to indentify abscesses and

perirectal involvement

Complications

• Toxic megacolon• Perforation and hemorrhage• Peritonitis• Nutritional deficiency• Colon cancer• Osteoporotic fractures- due to

decreased bone mineral density

Medical management of chronic IBD

Focuses on:• reducing inflammation• suppressing inappropriate immune

responses• providing rest for the diseased bowel• improving quality of life• preventing or minimizing complications

Nutritional therapy

• Oral fluids• Low residue, high protein and high calorie

diet• Supplemental vitamin• Iron replacement• IV therapy in fluid and electrolyte

imbalances• Avoid milk in those with lactose intolerance• Avoid cold food and smoking • Parenteral nutrition

Pharmacologic therapy

1. Aminosalicylate formulations; sulfasalazine (azulfidine)

- treat inflammation and prevent recurrences

2. Antibiotics; metronidazole & ciprofloxacin- In secondary infections

3. Corticosteroids- suppress the acute clinical symptoms

4. Immunomodulators; (eg. Azathioprene [Imuran], 6mercaptopurine, methotrexate)

- Alter immune response

Surgical management

• Total colectomy and ileostomy- procedure of choice for crohn’s disease.

• Intestinal transplant- not a cure, to improve quality of life for some who are terminally ill.

• Almost 25% of ulcerative colitis patients require surgery. Surgical excision usually improves life.

• Proctocolectomy with ileostomy• Ileoanal anastomosis• Strictureplasty- blocked and narrowed section of

bowel is widened, leaving the bowel intact

Nursing Management

Nursing ProcessAssessment

Health history regarding ◦Abdominal pain: onset,

duration and characteristics◦presence of diarrhea, ◦fecal urgency, tenesmus, ◦nausea and vomiting, ◦anorexia, weight loss, ◦family history of IBD.

• Dietary patterns• Patterns of bowel elimination: – character, frequency– presence of blood, pus, fat or mucus,

• Allergies and food intolerance especially milk.• Sleep disturbances if diarrhea and pain occurs

at night• Assess abdomen: – bowel sound– tenderness or pain, – distension, – evidence of fistula, – signs of dehydration

• Assess stool, rectal bleeding

Nursing Diagnoses

1. Acute pain related to increased peristalsis and GI inflammation

2. Diarrhea related to the inflammatory process3. Fluid volume deficit related to anorexia, nausea

and diarrhea4. Anxiety related to impending surgery 5. Imbalanced nutrition, less than body

requirements related to dietary restrictions, nausea and malabsorption

Nursing Interventions

Relieving pain

• Identifying type of pain, onset before/after food, pattern, if relieved with medication or not?

• Position changes, heat application, diversional activities

• Prevention of fatigue to decrease pain• Administer antichonilergics as prescribed 30

min prior to food to decrease intestinal motility • Give analgesics as prescribed

Maintaining normal elimination patterns

• Identifying precipitating factors such as food, activity, stress, etc. if any and avoiding those.

• Provide ready access to bathroom, commode or bedpan

• Keep the environment clean and odor free• ‘administer anti diarrheal agents as prescribed• Record frequency and consistency of stool

before, during and after therapy• Encourage bed rest to decrease peristalsis

Maintaining fluid intake

• Record oral and IV fluids intake and outputs• Assess daily weight for fluid gains or losses• Look for signs of fluid deficit; decreased skin

turgor, oliguria, dry skin and mucosa, increased hematocrit, hypotension

• Encourage oral fluid intake and maintain IV intake• Measures to decrease diarrhea; dietary

restriction, stress reduction, anti diarrheal agents

Maintaining optimal nutrition

• Parenteral nutrition when symptoms are severe; monitors weight, fluid intake and output. The patient should gain 0.5kg daily during PN therapy

• Monitor Feedings high in protein and low in fat and residue• Note for intolerance; signs are nausea, vomiting, diarrhea

or abdominal distention• Restrict activity to conserve energy, reduce peristalsis and

reduce calorie requirements• If oral foods are tolerated; small, frequent, low residue

feedings to avoid over distending the stomach and stimulating peristalsis

ANY QUESTIONS?

Thank you