Inflammatory Bowel Disease

Inflammatory Bowel Disease

1. Crohn's Disease

   • Etiology and Pathophysiology (Lewis, 2014)
     • Complications (CCFA, 2011)
       • fistula
         • ulcers that cause tunnels (fistula) to another part of the intestine, skin or ogan
       • stricture
         • narrowing of the intestine caused by scarring
           • can lead to intestinal blockage
       • abscess
         • collection of pus
           • can develop in the abdomen, pelvis, or anal are
       • perforated bowel
         • hole along intestinal wall
           • due to chronic inflammation that weakens the wall
       • malnutrition
         • due to malabsorption
           • includes mineral and vitamin deficiencies
     • Causes
     • inflammation of segments of the GI tract
       • commonly seen in the terminal ileum and the colon
     • skip lesions; patchy inflammation
       • normal bowel in between diseased portions
     • cobblestone appearance
       • due to deep ulcerations that penetrate through inflamed mucosa
     • inflammation extend through all layers of bowel wall
   • Nursing Process
   • Diagnosis (Lewis et al., 2014)
     • History and Physical
       • Patient and Family History
       • Lifestyle; smoking, diet, NSAID use. All are aggravating factors.
       • Abdominal exam; Inspection, Palpation, Auscultation
     • CBC and serum chemistries (Mazal, 2014)
       • erythrocyte sedimentary rate (ESR), C-reactive proteins (CRP), leukocyte and platelet counts which are indicatory of Crohn's disease
     • Stool test for occult blood
       • distinguish between UC and Crohn's
     • Radiological studies with barium contrast
       • determines location and extent of disease
         • reveals stricture formations, cobblestoning, fistulas, and other abnormal and normal mucosa
       • barium enemas determine pressence of the degree of ileal involvement
     • Sigmoidoscopy and colonoscopy with biopsy
       • detects early mucosal changes such as patchy inflammations, ulcerations and skip lesions
       • biopsies done to see pressence of granulomas
   • Collaborative care
     • Medication
     • Surgery
     • Nutritional Therapy
       • High-calorie, high-vitamin, high-protein, low-residue, dairy-free diet

2. Ulcerative Colitis

   • Nursing process (Bettany & Gardiner, 2013; Lewis et al., 2014)
     • Nursing care
       • prevent complications of immobility
         • reposition patient
         • range of motion exercises
       • schedule activities around rest schedule
       • establish good working relationship
       • patient kept clean, dry, free of odour
         • perianal skin care
         • bedside commode
     • Assessment
       • Subjective
         • symptoms
           • bloody stools with pus or mucus
           • fecal urgency; incontinence
           • nausea and vomiting; weight loss
           • fatigue, malaise
           • lower abdominal pain and cramping
         • past health and family history
         • medications
       • Objective
         • fever
         • intake and output
         • poor turgor, dry mucous membranes, pale skin
         • abdominal distention, hyperactive bowel sounds
         • tachycardia , hypotension
     • Individual care (Chadda, 2013)
       • careful emotional counsel and reassurance
       • patient education
       • supporting concordance with medication
       • directing patients to support groups
         • Crohn's and Colitis UK
       • offer a choice of care strategies where possible and appropriate
     • Nursing education
       • empower patients to understand their condition and its management
         • achieve the best quality of life
       • explanation of procedures and treatment
         • medication safety and efficacy
         • reduce anxiety
     • goal: improve quality of life
   • Etiology and Pathophysiology (Lewis et al., 2014)
     • Inflammation of mucosa and submucosa
       • Exacerbation and remission
       • spreads continuously beginning from rectum to colon
     • Abscesses develop and break through the submucosa causing ulcerations
       • destroy mucosal epithelium
         • fluid and electrolyte loss
         • bleeding and diarrhea
         • can cause pseudopolyps
         • Thickening
           • shortening of colon
     • Causes
       • inflammatory response
         • tumour necrosis factor a
       • Intestinal microbiota (Biedermann & Rogler, 2015)
     • Complications
       • perforation
       • Toxic megacolon
       • Carcinoma
         • screening with colonoscopy
   • Collaborative care (Lewis et al., 2014)
     • Medication (Kizior, Hodgson, Hodgson, & Witmer, 2017
       • Vitamins
         • correct anemia and promote healing
           • Vit. D, calcium, iron, magnesium
       • 5-Aminosalicylates
         • Decrease GI inflammation
           • e.g. Sulphasalazine (Salazopyrin)
       • Antimicrobial
         • prevention or treatment of secondary infection
           • e.g. Metronidazole
             • medication taken as directed
       • Corticosteroids
         • decrease inflammation
           • e.g. cortisone, prednisone, budesonide
             • SE: insomnia, headache, nausea, weight gain and increased blood glucose
       • Immunosuppresants
         • suppress immune response
           • e.g. azathioprine (Imuran), cyclosporine (Neoral)
     • Surgery
       • Can effectively eliminate UC because colon and rectum can be removed (Bartle et al., 2013; Camilleri-Brennan et al., 2003, as cited in Bettany & Gardiner, 2013)
         • Last option
         • Permanent ileostomy or stoma
           • challenge for the individual
       • Indications
         • Fails to respond to treatment
         • Frequent and debilitating exacerbations
         • massive bleeding, perforations, strictures or obstruction
         • dysplasia is occurring
         • development of carcinoma
       • Types
         • Total proctocolectomy with permanent ileostomy
           • removal of colon, rectum, and anus, with closure of the anus
           • Formation of ostomy or stoma
         • proctocolectomy with ileoanal reservoir
           • Patient requirements
             • absence of colorectal cancer
             • small intestine free of disease
             • competent anorectal sphincter
             • physical status can handle lengthy surgery
             • motivated and can understand self-care instructions
     • Nutritional Therapy
       • goal: to provide adequate nutrition without exacerbating symptoms
       • Acute phase: NPO
       • High-calorie, high-protein, low-residue diet
         • avoid cold and high fiber foods
           • No whole grain bread or cereals
           • No processed or fried meats
           • No nuts, beans, legumes, seeds
           • No raw vegetables or fruits, fruit skins, pulp
           • No rich deserts
       • No smoking and avoid alcohol
         • Smoking increases GI motility
   • Diagnosis (Bettany & Gardiner, 2013; Lewis et al., 2014)
     • History and physical
       • Family history
       • Lifestyle
     • Blood Studies
       • CBC, electrolytes, BUN, creatinine, albumin
       • Not diagnostic of UC
       • Detect inflammation
       • Determine nutritive and hydrative state
     • barium Enema
       • Distinguish between UC and Crohn's
       • Show areas with inflammation or ulcerations
       • Useful in detecting mucosal abnormalities
     • Sigmoidoscopy (Orchard et al., 2011, as cited in Bettany & Gardiner, 2013)
       • Used to examine rectum, sigmoid colon, distal descending colon
       • Obtain biopsies
       • Monitor disease
     • Colonoscopy (Talley & Martin, 2006, as cited in Bettany & Gardiner, 2013)
       • Gold standard
       • Caution for those with severe UC; risk of perforation
       • Visualization of bowel wall and terminal ileum (Laufer, 2006, as cited in Bettany & Gardiner, 2013)
         • Lesions
         • Inflammation
         • Ulcerations
       • Consider risk posed to older adults (Smith, 2013, as cited in Bettany & Gardiner, 2013)
         • Sedation
         • Bowel preparation
         • Bleeding
     • Culture and sensitivity
       • Stool examined for blood, pus, and mucus
       • To rule out infectious causes of inflammation

3. 10,000 new cases in Canada annually (Lewis et al., 2014)

4. an autoimmune disease that refers to two disorders of the GI tract

   • Crohn's Disease
     • a chronic IBD of unknown origin that can affect any GI parts; from the mouth to the anus (Lewis et al., 2014)
   • Ulcerative Colitis
     • a chronic IBD characterized by inflammation and ulceration of the rectum and the colon (Lewis et al., 2014)

5. occur during teenage years and early adulthood but second peaks in the fifties or seventies

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