Inflammatory Bowel Disease

Inflammatory Bowel Disease

1. Ulcerative Colitis

   • Disease Characteristics
     • Rectum to Cecum (Continuous)
     • Mucousal & Submucousal Layer
     • Pseudopolyps
       • Tongue Like Projections into the Bowel Lumen
     • Onset Teens to Mid 30's
     • Fibrosis
       • Rigid pipe like (Surgery becomes Necessary)
     • Diagnostic Test: Colonoscopy/ Sigmoidoscopy (Biopsy)/ Double Contrast Barium Enema,
       • GOlYTELY
         • Contraindicated for Patients w/ Bowel obstruction, Perforation, Toxic Megacolon!! (Caution w/ severe colitis) Adverse Reactions (Abdominal Fullness & bloating)
         • 8oz glass q 10min until 1 gallon is ingested
   • Signs & Symptoms
     • Protein Loss through Stool
     • Bloody Diarrhea
       • Fluid & Electrolyte Loss
         • Water & Electrolytes cannot be absorbed through inflammed Mucosa
       • Severe (Tachycardia/anemia/dehydration) 10-20 stools
     • Abdominal pain
     • Toxic Megacolon "Preforation" (More common in Ulcerative Colitis)
       • Emergency Colorectomy
       • Dilation & Paralysis of the Colon
     • Tenemus
       • Cramping Rectal pain
     • Fever (Acute Attacks)
     • Stricutures (Occassional)

2. Crohn's Disease

   • Disease Characteristics
     • Can Effect ANY part of the GI tract from the mouth to the Anus
     • Most often terminal Ileum & Colon
     • Transmural
       • Effects All layers of the Bowel 
     • Skip Lesions
     • Cobblestoning Mucosa
       • The appearance ot the intestines/Colon will look Cobblestone. 
     • Onset Teens- Mid 30s
     • Diagnostic Test: Capsule Endoscopy, Small Bowel Series (Barium) "Biopsy cannot be obtained
   • Signs & Symptoms
     • Weight Loss (Small Intestine Involved)
       • Small intestine impairs Nutrient absorption. 
     • Diarrhea
     • Colicky Abdominal Pain
     • Bowel Obstruction
       • Strictures
     • Peritonitis
       • Microscopic Leaks can allow content from bowel enter the peritoneal cavity & produce abscess/ or Peritonitis. 
       • Preforation
     • Fistulas
       • Can occur between adjacent areas of bowel. *Bowel & Bladder  *Bowel & Vagina * Skin to Outside the Body
       • UTI
       • Feces in Urine? Feces on Skin?
     • Anal Abscess
     • Fever (Intermittent)
   • Diagnostics

3. IBS interventions

   • Surgical
     • Treatment has failed & Diarrhea is intractable 
     • Colon Removed (Ileostomy or Ileoanal Resovoire formed
     • Stricturplasty in crohn's to widen narrow bowel
   • Medications
     • 5ASA
       • Decrease Bowel Inflammation through direct contact of Bowel Mucosa. 
       • Suppositories, Enema & Foam
       • Yellow/orange Urine/skin (Not harmful)
       • Photosensitivity
       • Sulfasalazine w/ Sulfapyridine (Orally)
       • Alternative: Mesalamine, Osalazine, Balsalazide,
       • Folic Acid
         • Medication effects this, the patient will need a folic acid supplement!!!!
     • Antimicrobials
       • Metronidazole, Ciproflaxacin
     • Immunosuppressants
       • NOT for Acute Flare ups (Delayed onset)
       • azathiopine, 6-MP, Methotrexate, Cyclosporine
       • Monitor CBC
       • Methotrexate (shown to be effective)
         • NOT FOR PREGNANT WOMEN
     • Corticosteroids
       • Prednisolone
       • Budesonide
       • Shortest Time Possible, Taper off when Surgery is planned!
       • Will need Ca+ Supplement
       • Potassium!
         • Leads to Sodium Retention, and loss of Potassium!!!
     • Biologic & Target Therapy (Immunodulators)
       • Need to be tested for TB! & cannot have live virus vaccines. Need to be taught signs of infection.
       • TNF (-mab)
         • Infliximab (IV) , adalimumab (Self Administered SC 1-2w), certolizumab by a HCP q 4w, golimumab x2 first month & then q 4w) 
       • natalizumab
         • Prevent Migration of Leukocyte from bloodstream to inflammed Tissue. IV q 28days *Special Monitoring Program
     • Antidiarrheals
     • Anticholinergics/sedative
       • Cholinergic effect PNS (Rest & Digest) The bowel are hypermobile so this Decreases this response.
     • Anemia
       • Oral (Iron Gluconate/Ferrous Sulfate) if cannot tolerate give parental
       • Severe iV/IM (iron Dexteran)

4. IBS Interventions

   • Nutrition
     • Fat Malbapsorption & Anemia
       • Cobalamin (Vitamin B12) in injection form monthly, oral or nasal daily
       • Cholestyramine (Ion exchange Resin)
         • Binds to unabsorbed Bile fats. This helps control diarrhea.  
       • Zinc
         • Zinc Deficiency: May contribute to diarrhea
     • Liquid Enteral Feeding Preferred over Parental
     • High calories, high vitamin, high protein, Low Residue, lactose free Diet
     • Small Frequent meals & Avoid Spicy food
   • Screen for Cancer
   • Teach Smoking Cessation! (increase bowel motility)
   • Hospital Care
     • Monitor # of stools
     • Monitor I&O
     • Dibucaine, witch hazel , sitz bath for perianal care
   • Exacerbation?
     • IV F&E replacement
     • REST BOWELS
     • TPN
       • Good for 24hrs
       • Capillary Glucose (Monitor)
         • Insulin
           • Sliding Scale
       • Large Guage (PICC/CVAD)
       • start low & go slow

5. Chronic, recurrent inflammation of the intestinal Tract

   • Periods of Remission Interspersed with Exacerbation. 

6. Recognizing Peritonitis

   • Severe Abdominal Pain
   • Rebound Tenderness
   • Abdominal Distention
   • Decrased Bowel Sounds
     • Paralytic Ileus, N&V
   • Fever

7. Diagonistics

   • CBC (Blood Loss?)
   • WBC (Preforation? Megacolon?)
   • Fluid & Electrolyte Loss Na+, K+, Cl-, Bicarbonate, Mg2+,
   • Hypoalbuminemia (protein Loss)
     • Poor Nutrition or Protein Loss
   • Elevated Erythrocyte Sedimentation rate, C-Reactive Protein, WBC (Inflammation?)
   • Stool Occult
     • Examined for Blood, Pus & Mucous in stool.