Ulcerative Colitis

Ulcerative Colitis

1. Risk Factors

   • Genetics (Ulcerative Colitis, 2019)
     • up to 20% of people with UC have an immediate relative with UC
       • You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease
       • more than 200 genetic mutations associated with the development of ulcerative colitis
   • Overweight (Gearry, Richardson, Frampton, Dodgshun, & Barclay, 2010)
     • The prevalence of obesity has risen in parallel with the rise in ulcerative colitis, suggesting a possible shared environmental link between these two conditions
   • Smoking (Gearry et al., 2010
     • more common among those who have quit smoking
       • Former smokers are about 1.7 times more likely to develop the disease than those who have never smoked
     • The relative risk of developing ulcerative colitis among current smokers is about 40 percent
   • Environmental Factors
     • some research suggests that environmental factors, such as industrialization, urban settings, and northern geographical latitudes, may be related to differences in rates of UC (Ulcerative Colitis, 2019)
   • Ethnicity
     • there is a higher rate of UC among whites than non-whites, and Jewish people of Eastern European descent are also at greater risk (Sicilia, et al., 2008)
   • Nutrition
     • Dietary factors may have a strong influence on the intestinal microbiome
     • Studies suggest that a western diet, one with higher consumption of fats and refined sugars, and reduced consumption of dietary fibre, changes our gut's microbiome. (Ungaro, Mehandru, Allen, Peyrin-Biroulet, & Colombel, 2017)
       • Processed foods and pervasive fast food popular in western diet may also be contributors to developing UC (Ungaro et al., 2017)

2. Clinical Manifestations

   • Mild (NICE, 2019).
     • Up to 4 bowel movements per day
       • small amounts of blood in stools
     • Temperature < 37.8°C.
     • Pulse rate does not exceed 90 bpm.
     • No anaemia
     • erythrocyte sedimentation rate < 30mm/hr
   • Moderate(NICE, 2019).
     • 4-6 stools per day with mild to severe amount of blood,
     • erythrocyte sedimentation rate at 30mm/hr or below
   • Severe(NICE, 2019).
     • 6 or more bowel movements per day with visible amount of blood
     • temperature > 37.8°C++++
     • Anaemia
     • erythrocyte sedimentation rate above 30 mm/hr
     • Pulse rate elevated above 90bpm
   • Extraintestinal (Levine & Burakoff, 2011 & Varicka et al., 2015)
     • SKIN:
       • Erythema nodosum
         • results in raised, tender, red, inflammatory subcutaneous nodules on the anterior extensor surface of lower extremities such as the knees
       • Pyoderma gangrenosum
         • Can develop after any type of trauma from small injuries such as needle sticks from venipunctures to postsurgical wounds.
         • Characterized by the onset of a pustule or erythematous papule or nodule that quickly breaks down to form an ulcer with undetermined borders that present as a violet color.
       • Sweet’s Syndrome
         • Acute inflammatory dermatitis
       • Aphthous stomatitis
         • Indistinguishable from canker sores
         • Typically occurs on the buccal mucosa and lips
     • HEPATIC:
       • Primary sclerosing cholangitis
         • Chronic, progressive disorder with no known etiology, presents as inflammation, structuring and fibrosis of both medium and large intra- and extrahepatic bile ducts.
       • portal vein thrombosis
         • blockage of the portal vein (the blood vessel that brings blood to the liver from the intestines) by a blood clot
       • cholelithiasis
       • drug-induced pancreatitis
       • drug-induced hepatotoxicity.
     • OCULAR:
       • Episcleritis
         • Inflammation of the blood rich episclera
       • Scleritis
         • Can impair vision and presents as frequently pink or violet natural light appearance of the sclera
       • Uveitis
         • anterior
         • intermediate
         • posterior
         • panuveitis
     • MSK:
       • Peripheral arthralgia/arthritis
         • classified into type 1 known as pauciarticular (large joints) and polyarticular (small joints).
       • Axial arthropathies.
         • ankylosing spondylitis
           • Characterized by severe onset of back pain at a young age revealing limited spinal flexion on physical examination. Disease course is progressive and results in permanent skeletal damage
         • Sacroiliitis
           • inflammation of the sacroiliac joint and is characterized by gradual onset with daily appearance of lower back or buttock pain amongst young individuals (Slobodin, Hussein, Rosner & Eshed, 2018)

3. Pathophysiology

   • Affects the colon (large intestine) , rectum & anus via inflammation of the inner lining of the shallow mucosal. ( Crohn’s & Colitis Canada, 2019; Keshteli, Madsen& Dieleman, 2019)
     • chronic inflammation of the mucosa by polymorphonuclear leukocytes and mononuclear cells
     • Exact causes are unknown by researchers
       • The overactive immune system in intestines
         • Abnormal immune rxn in the intestine. The body’s own immune mechanism to protect may be identifying the lining of the intestine as foreign and attacking it. ( i.e. Interleukin 13)
         • (1)
       • Genes
         • Studies have found certain abnormal genes in families that may be indicative of heredity in the disease process
       • Environment
         • Not as common, but studies have found an environment with use ofNSAIDS, antibiotics and oral contraceptives may increase the chance
           • High stress
           • High Fat diet
             • Keto

4. Diagnosis

   • Diagnostic Studies
     • Endoscopy &Biopsy is the gold standard and essential for establishing a diagnosis and differentiating between Crohn’s disease and Ulcerative colitis. (Crohn's & Colitis UK, 2017; Spiceland & Lodhia, 2018).
       • Endoscopy
         • It allows for direct look inside the digestive system. Insertion of a long, thin, flexible tube and at the end both a light and a video camera attached.
           • Gastroscopy ( Through the oral cavity)
       • Biopsy
         • A small sample of tissues may be taken by scraping of cells from the lining of the gut. Samples are taken from both affected and normal appearing mucosa.
       • Sigmoidoscopy
         • Examines the rectum and sigmoid colon and useful for IBD limited to the left side of the colon
       • Colonoscopy
         • Examines the colon and often used to diagnose and assess the degree of Ulcerative Colitis
   • Stool
     • Protein (Canadian Society of Intestinal Research, 2018)
       • Inflammation Markers
         • Calprotectin
           • a protein contained in white blood cells. When found in the stool has a direct relationship to bowel damage as a consequence of neutrophil degranulation.
             • Large amounts of calprotectin enhance the likelihood that the patient has inflammatory bowel disease as opposed to inflammatory bowel syndrome. This test can identify disease activity and the effectiveness of the treatment regimen based on the results.
               • In Canada, the Alberta and Quebec provincial health plans are the only to cover this test
         • Lactoferrin
           • Helps to identify active inflammation
     • Fecal Occult Test
       • Checks a stool sample for blood that is not visible to the naked eye. Blood in the stool is a sign of bleeding in the digestive tract (University of Rochester Medical Center)
   • Labs
     • Complete Blood Count (CBC) (Crohn's & Colitis UK, 2017).
       • : Identifies infection, anemia, inflammation and monitors medications
         • White Blood Cell ( WBC)
           • can be raised when there is inflammation in the body
             • Neutrophils
             • Lymphocytes
             • Eosinophils
             • Monocytes
             • Basophils
         • Red Blood Cell (RBC)
           • Indicates inflammation and anaemia
             • In combination with haemoglobin these measurements indicate if a person has anaemia, when there is a low amount of haemoglobin and/or low count of RBC
             • Erythrocyte Sedimentation Rate increases as a result of inflammation. During the inflammation process, fibrinogen enters the blood in high amounts and causes red blood cells to stick together, raising the ESR (Tennant, 2014).
         • Platelets
           • Can be a sign of inflammation if levels are high
         • Hemoglobin
     • Electrolyte Imbalances (Barkas, Liberopoulos, Kei, & Elisaf, 2013; Crohn's & Colitis UK, 2017)
       • Mucosal inflammation and reduced secretion and absorption of electrolytes results in acid-base and electrolyte imbalances
         • Metabolic Alkalosis
       • Reduced due to intestinal inflammatory process
         • Sodium
         • Chloride
         • Calcium
       • Increased during inflammation
         • Potassium
     • Proteins
       • C-Reactive Protein
         • Marker for inflammation non-specific to the gut
         • Produced in the liver by hepatocytes in response to circulating interleukin-6, CRP is found in plasma and binds to phosphocholine on apoptosis (programmed cell death) cells to activate the immune system which enhances phagocytosis by macrophages (Cioffi, Rosa, Serao, Picone & Vietri, 2015;Tennant, 2017)
   • Imaging Tests
     • Barium Studies
       • Barium is not absorbed by the body and works as a temporary coating on the intestines. Provides a more clear outline of the gut than an X-Ray (Crohn's & Colitis UK, 2017).
         • Barium Enema is used to visualize the colon, whether it is narrowed, has pockets or sacs in the intestinal wall
         • Double Contrast Barium Enema may show areas of granular inflammation with ulcerations (Lewis, Dirksen, Byrhcer, Heitjemper & Camera, 2014)
           • A Double Contrast Study is effective in detecting mucosal abnormalities seen in ulcerative colitis (Lewis et al., 2014).
     • Computed Tomography Enterography (CTE)
       • CT scanning with intravenous contrast improving visual details of the intestines (Crohn's & Colitis UK, 2017).
     • Magnetic Resonance Enterography
       • Uses a magnetic field to create images of the intestines.(Crohn's & Colitis UK, 2017).

5. Nursing Management

   • (Crohn’s & Colitis Canada, 2019; Davis, Robinson, Vess, & Lebel 2018; Lewis et al., 2014;National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 2014).
     • Nutrition
       • Patients need to be educated to eat a proper diet to prevent mucosal permeability & dysfunction with the immune system. This would prevent relapses of UC
         • Probiotics
           • Yogurt
           • OTC pills
         • Diet
           • Decrease carbohydrates
           • Low Fiber
           • High protein
           • Avoid foods that one may have a hypersensitivity/allergies to
           • Low-Residue
             • Avoid alcohol, bread or cereal with whole grain flour or bran, nuts, fried, smoked, pickled or cured meats and raw fruits and vegetables.
     • Patient Education
       • Physical Activity
         • An increase in physical activity aids in suppressing inflammation through glucocorticoid production.
       • Mental Health
         • Coping mechanisms
           • Anxiety & Depression can be caused due to flare-ups and medications like Prednisone.
             • May need medications or professional help
               • Antidepressant treatment
         • Stress Reduction
           • Manging UC and flare-ups can be stressful on top of regular daily activities. It's important to practice self-care to reduce further relapses due to stress.
       • Diet
         • A study has shown that participants avoided crucial food groups like dairy (Davis et al., 2018).
           • Experts suggest that an increase in energy consumption is required by UC patients
       • Illeostomy Care
         • Pre-Operation
           • Patient education involves preparing patient for surgery and post-operative & new lifestyle
             • Patient Questions & Emotions
               • Fears
               • Anxiety
               • Self-body Image
             • Surgery
               • Prophylaxis preparation
                 • Prescription of Antibiotics
                 • Bowel cleanse/Prep
                   • Medications: PEG
                   • NPO before surgery
         • Post-Operation
           • Diet
             • Small meals, slow eating and low-fiber for first 6 weeks
             • Hydration
               • Water
               • Sports drink for electrolytes
                 • Gatorade Zero to not further increase blood sugars due to corticosteroid use
           • Ileostomy Pouch
             • Empty pouch when 1/2 full to prevent leakage
               • Empty before first meal when bowels are least active
             • Skin Barrier
               • Proper cleansing and barrier creams to prevent infection & burning around site
           • Complications
             • Stoma
               • If stoma site is pale due to low hemoglobin or dark red/black due to poor circulation inform HCP urgently
             • Electrolyte imbalance/ Dehydration
     • Assessment
       • Subjective Data
         • Increased urgency to urinate and pass bowel movement
         • Fatigue / Weakness / Tiredness
       • Objective Data
         • Anemia
           • Complications
             • Peritonitis
             • Toxic Megacolon
         • Abdominal distention
         • Fever
         • Abdominal Pain
         • Tachycardia
         • Hypoactive / Absent bowel sounds
         • Dehydration
         • Tenderness in Abdo
         • Frequency of bowel movements
           • Monitor weight
             • Monitor fluid balance
           • (3)
         • Hypertension
           • Can be a S/E of corticosteroid use
         • Rectal bleeding
       • Frequently Asked Questions
         • What are your symptoms? How often do they appear or last?
         • How many bowel movements do you have per day and of those have you noticed any amount of blood?
         • Have you been experiencing any joint pain or soreness, eye irritation, rashes or diarrhea?
         • Are you of European (specifically Ashkenaiz Jewish) or South Asian descent?

6. Treatment

   • Medication (Crohns Colitis Foundation, 2014)
     • Corticosteroids
       • Given orally/ injection/ rectally/ intravenously
         • If not used appropriately, patients can become steroid dependent or resistant
         • Prednisone
         • Prednisolone
         • Methylprednisolone
         • Budesonide
       • Steroids are not intended for long-term use due to side effects
         • S/E: Hyperglycemia; Moon Face; Weight Gain; Hypertenstion
           • (2)
       • best suited for short-term control of IBD symptoms
         • given to help with moderate to severe UC symptoms
           • helps reduce inflammation by suppressing the immune system
     • Immunomodulator drugs
       • orally or injected
         • suppress the immune system response that starts the process of inflammation
           • Azathioprine (Azasan, Imuran)
           • mercaptopurine (Purinethol, Purixan)
             • Taking these medications requires that you follow up closely with your doctor and have your blood checked regularly to look for side effects, including effects on the liver
           • Cyclosporine (Gengraf, Neoral, Sandimmune).
             • This drug may be used for people who haven't responded well to other medications
               • not for long-term use
           • Tofacitinib (Xeljanz)
             • Can reduce symptoms in as early as 2 weeks
               • Can improve the appearance of the intestinal lining
                 • Provide lasting steroid-free remission
     • Biologics
       • Drugs made of living cells
         • given intravenously or injected
           • They stop/reduce inflammation by blocking key cells or chemicals inducing the inflammation process
             • tumor necrosis factor (TNF) inhibitors
               • they work by neutralizing a protein produced by your immune system
                 • Infliximab
                 • adalimumab
                 • golimumab
             • gut-specific medication
               • works by blocking Inflammatory cells from getting to the site of inflammation
                 • Vedolizumab
     • Antibiotics
       • used when infections occur or to treat complications of ulcerative colitis
         • Metronidazole
         • ciprofloxacin
     • Aminosalicylates
       • given orally or rectally
         • these drugs work to decrease inflammation in the lining of the intestines
           • treat mild to moderate UC symptoms
       • Contain 5-aminosalicylic acid
     • Non-Prescription/ OTC
       • Antidiarrheals
         • To treat diarrhea
           • Do not take these during a flare-up as they may cause other complications
       • Ointments & suppositories
         • applied around hemorrhoids to reduce swelling, itching, and inflammation.
         • Most of these ointments contain a steroid such as hydrocortisone and will help to shrink inflamed tissue.
       • Antispasmodics
         • Relax muscles in the wall of the GI tract to reduce cramping
       • Bulk formers for stool
         • Soak up water in the stool, thereby firming it up and lessening looseness as well as frequency
       • Bile salt binders
         • Prevent irritation of the gut by capturing bile salts
       • Stool softeners
         • For softening feces to ease bowel movements if they have hemorrhoids or anal fissures
       • Analgesics
         • For pain reduction
       • Non-steroidal anti-inflammatory drugs
         • For pain control
       • Acid-reducing drugs
         • For “heartburn"/ acid reflux
       • Vitamins & minerals
         • May be needed as supplements due to poor absorption in intestines
   • Lifestyle ( Crohn's Colitis Foundation, 2014; Ratini, 2019)
     • Diet & Nutrition
       • avoid fizzy drinks
       • avoid popcorn, vegetable skins, nuts, or other foods that are high in fiber
         • Allows the intestines to rest as they need to work harder to digest these items
       • drink plenty of water
       • eat little and often
       • (4)
     • Probiotics
       • Probiotics act as a barrier. They line your bowels so bad bacteria doesn’t reach the intestinal wall
         • It also changes the makeup of your gut biome, adding good bacteria to balance out the bad. This lowers inflammation and helps calm the reaction.
     • Vitamins
     • Aloe Vera
       • help wounds heal and to relieve pain
   • Surgery (Crohns Colitis Foundation, 2014)
     • Proctocolectomy ileostomy (aka stoma)
       • when the anus is surgically removed with the colon and rectum
       • creates a hole in the abdomen (called a stoma) above waistline through which solid waste is emptied into a pouch
     • Proctocolectomy with ileal pouch-anal anastomosis (IPAA)
       • the colon and the rectum are removed, but the anus and anal sphincter muscles are preserved
       • The ileum is fashioned into a J, S, or W shaped pouch
       • No need for an external pouch
       • Side effects
         • More frequent watery stools
         • Fecal incontinence
         • Infertility in women
   • Goals
     • Reduce / Not to induce remissions
     • maintain remissions
     • Reduce the relapse
     • minimize side effects of treatment
     • improve the quality of life
     • minimize risk of cancer

7. Complications

   • (Crohn’s & Colitis Canada,2019; National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 2014)
     • Blood Abnormalities
       • Blood Clots
       • Anemia
     • Malnutrition
       • Lack of absorption of SI leading to abnormally low nutrients and electrolytes in the blood
     • Joint Inflammation "Enteropathic arthropathy"
       • Redness, heat, pain, stiffness of joints
     • Eye Inflammation
       • Result to redness, burning, tearing, headache, blurred visions & eye pain
     • Liver / Hepatic
       • Upto 5% Develop Primary Sclerosing Cholangitis ( PSC)
         • Inflammation of the small blood vessels transporting bile from liver to small intestine; eventually lead to liver failure
           • Jaundice
     • Developmental / Growth
       • Common in children due to malnutrition and corticosteroid use- stunts growth
     • Osteoporosis / Osteopenia
       • The weakening of the bones
         • Due to malnutrition, malabsorption of nutrients from the small bowel, medications interfering with calcium/vitamin D
           • Corticosteroid use ( i.e. Predisone) can cause this
     • Skin Conditions
       • Erythema nodosum (EN)
         • Dark red/purple painful bumps on the skin usually near the shins
           • Appear when bowel flareups
             • (7)
       • Pyoderma gangrenosum (PG)
         • Appear on legs or near ileostomy site, start off red and tender progress to blister appearance
           • May require dressings if large and filled with fluid
             • (6)
       • Psoriasis
         • More common in Crohn’s, however, may appear in UC.
           • Itchy red patches covered with scales
             • (5)
     • Spondyloarthritis
       • Inflammatory arthritis of the spine, eyes, skin and GI tract
     • Bowel Perforation
       • hole in the wall of the small intestine or the colon
     • Colorectal Cancer
       • development of cancer from the colon or rectum
     • Megacolon
       • Inflammation spread through to the deep tissue area of the large intestine leading to no activity in the portion.

8. There are 4 types (Crohns Colitis Foundation, 2014; Ulcerative Colitis, 2019))

   • Acute severe ulcerative colitis- aka Pancolitis
     • rare form of colitis
       • inflammation involves the entire colon
     • severe pain, profuse diarrhea, bleeding, fever and inability to eat
   • Proctosigmoiditis
     • Inflammation involves the rectum and sigmoid colon (lower end of the colon)
     • Signs and symptoms include bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in spite of the urge to do so (tenesmus)
   • Left colitis/ Distal Colitis
     • Inflammation extends from the rectum up through the sigmoid and descending colon.
     • Bloody diarrhea, abdominal cramping and pain on the left side, and unintended weight loss
   • Ulcerative proctitis
     • Inflammation is confined to the area closest to the anus (rectum)
     • Rectal bleeding may be the only sign of the disease
     • This form of ulcerative colitis tends to be the mildest.
   • (8)

9. Epidemiology

   • Ulcerative colitis is more prevalent than Crohn's disease. (Kaplan et al., 2018).
     • North America and Northern Europe have the highest incidence and prevalence rates
       • In 2018 there were approximately 120,000 people living with ulcerative colitis
   • (Ordas, Eckmann, Talamini, Baumgart & Sandborn, 2012).
     • Onset
       • No preference for sex
       • Second smaller peak between 50 to 70 years
       • Onset peaks between 15 and 30
     • Genetic Factors
       • More common in Caucasian Europeans, especially those of Ashkenazi Jewish descent (who lived in Eastern Europe or Russia)
         • Those of Ashkenazi Jewish descent are 3-5 times higher than that of other ethnic groups (Kaplan et al., 2018).
     • Incidence
       • High incidence in Canada among the first-generation offspring of South Asian immigrants or those from the United Kingdom (Kaplan et al., 2018).
         • Immigrants who arrive in Canada at a younger age are at an increased risk and for every decade earlier in life that they arrive in Canada, the risk of IBD increases by almost 10%
       • Incidence is higher in developed countries in urban versus rural areas (Ordas, Eckmann, Talamini, Baumgart & Sandborn, 2012)
         • Smoking
           • More common amongst non-smokes with incidence 3 times higher than that of smokers
           • Patients who smoke tend to have a more mild disease course compared to non-smokers
             • Risk and disease activity are increased in individuals who quit smoking
         • Appendicitis
           • diagnosed before age 10 protects against ulcerative colitis
         • Nutrition
           • A Western diet can profoundly change the guts microbiome such as one with a higher consumption of fats and refined sugars as well as reduced consumption of dietary fiber profoundly changes the gut’s microbiome
     • Environmental Factors

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