GI Lecture Flashcards
Irritable bowel syndrome (IBS)
- Functional problem
- Does not cause intestinal inflammation or damage the bowel
- Affects muscle contractions and sensitivity to the colon
Irritable bowel Disease (IBD)
- Ulcerative colitis and crohn’s
- Causes inflamation and dmg to the bowel
Symptoms of IBS
- Non inflammatory, characterized by recurrent abdominal pain and altered bowel habits
- Diarrhea or constipation (or both alternating)
- Bloating and abdominal pain, distension
- Tenesmus can occur as well
- Affects frequency of defecation and consistency of stool
- Causes are unknown
Symptoms of IBD
- Inflammation or ulceration of the intestional lining
- Can affect certain segments or entire GI tract
- Acute and chonic IBD can result in nutritional deficits, Altered bowel elimination , infection, pain and fluids and electrolyte imbalances
IBS diagnosis
Recurrent abdominal pain at least 1 day a week for the last 3 mo plus 2 other criteria
* Related to defecation (pain)
* Either increasing or improving pain
* Associated with a change in stool frequency
* Associated with change in stool appearance/ form
Goal of IBS treatment
Relive abdominal pain and control diarrhea or constipation
Tenesmus
Constant urge to deficate
med Mgmt of IBS
Meds IBS with diarrhea
* Loperamide
* Psyllium
* Alosetron
Meds IBS with constipation
* Lubiprostone
* Linaclotide
Nursing mgmt of IBS
- Incourage self care
- Avoid trigger foods
- Keep a food and bowel diary
- Increase fluid intake (Increase natural sources rather than supplements)
- Increase fiber intake
- Avoid large heavy meals
- Good sleep habits/ avoid sleep deprivation
- Teach stress reduction; yoga exercise regimen, meditation
- Referral for anxiety depression, CBT
Loperamide
- Decreases peristalsis: Helps control diarrhea and fecal urgency
- Used in IBS
- Risk of constipation
Slows motility
Psyllium
Bullk forming lax
Giving this with constipation makes the constipation worse
Given for IBS
Alosetron
- IBS specific medication, that specifically blocks 5-HT3 receptors which are responsible for innervation of the viscera
- Increases firmness in stools and decreased urgency and frequency of defication
- Decreases peristalsis can cause severe constipation
- Only really used in severe diarrhea
Low FODMAP diet
- Fermentable
- Oligosaccharides
- Diasaccharide
- Monosaccharide
- and
- Polyols
Probably dont need to know
Lubiprostone
IBS specific med, for constipation
* Increase fluid secretion in the intestine to promote intestional motility
* Cant be given in a bowel obstruction
Linaclotide
Given for IBS with constipation
Increases fluid and motility in the intestine, reliving cramping and pain
What is IBD charecterized by
- Frequent stools
- Cramping abdominal pain
- Periods of exasperations and remission
Cause of IBD
Unknown,
* Genetic, Ashkenazi jewish
* Altered immune response
* Altered response to bacteria in gut
Basically its autoimmune
Things that trigger IBD
- Environment
- Food
- Tobacco
- Viral illness
Ulcerative colitis: cause
Unknown, autoimmune response, genetic
Ulcerative colitis: Location
Large intestine only (Rectum and sigmoid most commonly)
Ulcerative colitis: Affected layers
Superficial/ inner lining (Mucosa and submucosa)
- **Abscesses, fistulas and fissures are uncommon bc only the unner layers of the colon are affected **
Ulcerative colitis: Pattern
Continious, affected areas are not interupted
Ulcerative colitis: Stools per day
15-20
Liquidy, watery loose, bloody
This number seems super high, she said it tho
Ulcerative colitis: Complications
- Toxic Megacolon
- Hemorrhage
- Peritonitis
Ulcerative colitis: Surgery
Can cure the disease
Ulcerative colitis: Colon cancer risk
Very high risk
Crohn’s: Cause
Unknown, genetic , auto immune
Crohn’s: Location
Anywhere along the GI tract (ileum most commonly affected)
Mouth to anus
Crohn’s: Affected layers
All layers down to the serosa
Crohn’s: Pattern
Skip lesions, healthy areas of tissue between inflammed areas
Crohn’s: Stools per day
5-6, non bloody (Can be bloody but more from rectal bleeding)
Crohn’s: Complications
- Fistulas
- Fissures
- Strictures: Scarring leading to tightening
- Abscess
- Partial bowel Obstruction: More common in crohns because the deeper tissue layers are affected
- Perforation or sudden rupture of the bowel
- Malabsorption and malnutrition: More prone due to a larger area being affected
Fistula
Symptom of crohns, where the lesion tunnels leading to stool going where it shouldnt, including out the abdomen
Crohn’s: Surgery
Only useful for mgmt of complications
Stricture
Narrowing of the intesting
Ulcerative colitis (UC)
Chronic recurring episodes of inflammation and ulceration in the mucosa and submucosa layers of the colon and rectum
* Bleeding from ulcerations
* Bowel narrows, shortens and thickens (Causing partial bowel obstruction)
* Several episodes and with time it can involve the entire colon
Mild UC
Less than 4 BM a day
Moderate UC
4-6 BM a day
Severe UC
6+ a day with severe bleeding
Manifestations of UC
- Diarrhea with pus, mucus or blood (6+ stools)
- LLQ pain (rectal/sigmoid area)
- Cramping
- Intermittent tenesmus
- Anemia , pallor, fatigue with bleeding
- anorexia, weight loss (DOesn’t want to eat because symptoms suck)
UC Labs
- Hematocrit and hemoglobin: Decreased (Bleeding)
- WBC: Increased (from inflammation)
- Erythocyte sedimentation rate (ESR): Increased (Inflammation)
- C-reactive protein: Increased (Inflammation)
- Albumin: Decreased (Malnutrition)
- K+, Na, Mg, Ca, Cl: Decreased (Vomiting and diarrhea)
- Stool Guiac: Occult blood
Toxic megacolon
Complication of UC
* Nonobstructive distentsion of the colon from inflammation, extending into the muscle layer (Cant contract)
* Fever, abdominal pain, distension, Vomiting , fatigue
* Treatment needs to happen within 72 hours, ng for suction, IVF, electrolytes, corticosteroids and antibiotics
* May need emergent surgery
* Life threatening
Complications of UC
- Toxic megacolon
- Peritonitis
- Perforation requring surgery (Stool into peritoneal cavity)
- Bleeding
- Colorectal cancer (High risk)
Crohns disease
- Inflammation extends through all the layers of the intestine
- Can affect any part of the GI but most commonly affects distal ileum and ascending colon (RLQ pain)
- Starts with crypt inflammation and abscesses which develop into ulcers, which deepen and extend seperated by normal tissue, creating a cobblestone appearance
- Lesions are sporatic and sharply demarcated with normal tissue in between, skip lesions
- Later into disease bowel thickes, narrows and becomes fibrotic
- Malabsorption and malnutrition can develop when jejunum and ileum become involved
Manifestations of Crohns
- Abdominal pain and cramping (Usually RLQ)
- Abdominal bloating and distension
- Tenderness and firmness on palpation/ guarding
- High pitched bowel sounds (from inflammation)
- Ulcers (Mouth to anus)
- Diarrhea (5+ per day with mucus or pus)
- Rectal bleeding
- Steatorrhea: Fatty stool (Floats)
- Fever
- Anorexia, weight loss
Labs of crohn’s
- Hematocrit and hemoglobin: Decreased (Bleeding)
- ESR: Increased
- C-reactive protein: Increased
- WBC: INcreased (Infection)
- Albumin: Decreased (Malnutrition)
- Folic acid and B12: Decreased
- Urinalysis: WBC (Infection)
- K+, Mg, and Ca: Decreased
What form of anemia is Crohns prone to
Pernicious anemia, due to Crohns commonely affecting the small intestine, leads to malabsorption of B12
Diagnosis for IBD
- Xray: Can see free air, bowel dilation and obstruction
- Endoscopy, Video capsule endoscopy, proctosigmoidoscopy, sigmoidoscopy and colonoscopy
- Barium edema: Visualize rectum and large intestine: Can dif UC from other disease processes
- CT, MRI and Ultrasound can identify the presence of abscesses, thickening
- Magnetic resonance enterography: Detailed images of small intestine
- Stool examination: Presence of parasites or microbes
Need to rule out other causes/ etiology
Goals of therapy for IBD
- Reduce inflamation
- Induce and maintain remission
- improve QOL
- Prevent and minimize complications
Pharm mgmt of IBD: Drugs that are used
- Anti-inflammatories (first line)
- Corticosteroids
- Antibiotics
- Immunomodulators and immunosuppressants
- Anti-diarrheals
- Pain relieivers
More than likely depending on the extent of the disease they will be on more than one drug
Pharm mgmt of IBD: Anti inflammatories
- 5- aminosalicylic acid: First line treatment for mild to moderate inflamation and is used in long term maintenance, Cant be given with sulfa allergy
- Sulfa free aminosalicylates: Mesalamine, balsalazide, osalazine
5- aminosalicylic acid:
First line treatment for mild to moderate inflamation and is used in long term maintenance, Cant be given with sulfa allergy
1. Monitor CBC Kidney and hepatic function (agranularcytosis, thrombocytopenia and all that)
2. Oral and rectal prep
3. Take meds with full glass of water right before or after meals
4. Increase fluid intake
5. Can take 2-4 weeks for theraputic effect
6. Can cause urine and skin to turn orange (Normal)
Anti-inflammatory
Sulfa free aminosalicylates
- Mesalamine, Balsalazide, osalazine
- Effective at preventing and treating recurrence of inflammation
- may be contraindicated if the pt has a salicylate or sulfa allergy
- Monitor for kidney tox
- Adverse effects not as serious as 5 aminosalicylic acid
Anti-inflammatory
Pharm mgmt of IBD: Corticosteroids
- Reduces inflammation and pain
- Used to treat Severe disease
- Can be given orally or rectally
- Can cause immunosuppression
- Used to induce remission
- Not for long term use due to adverse effects
- Reduce or slowly taper off: Do not discontinue suddenly for risk of adrenal insufficency
- Helps immediately
Prednisone, Hydrocortisone, Budesonide
Pharm mgmt of IBD: Antibiotics
Ciprofloxacin
Metronidazole
Sulfamethoxazole/Trimethoprim
Pharm mgmt of IBD: Immunomodulators and immunosuppressants
- Used second line because its expensive
- Effective in reducing inflammation
- Decreases need for steroids. hospitalizations and surgery
- Takes time to be effective (2mo where you might need steroids)
- Moderate to severe IBD
- High risk of infection and cancer from immune supression
- No live vaccines while on these meds
- Check for TB and Hep prior to starting, can activate latent infections
Pharm mgmt of IBD: Immunosuppresants
- Azathioprine
- Mercaptopurine
- Thioguanine
- Methotrexate
- Cyclosporine
Probably dont need to know
Pharm mgmt of IBD: Anti- integrins
Vedolizumab
Probably dont need to know
Pharm mgmt of IBD: Janus kinase inhibitors
Tofacitinib
Probably dont need to know
Pharm mgmt of IBD: Anti-tumor necrosis factor (Anti-TNF)
Infliximab
Adalimumab
Certolizumab (Crohn’s only)
Golimumab (UC only)
Probably dont need to know
Pharm mgmt of IBD: Anti-diarrheals
Loperamide: Suppresses the number of stools
* Used to decrease risk of FVD and electrolyte imbalance
* Reduces discomfort
* Use of antidiarheals can lead to toxic megacolon; use cautiously
Pharm mgmt of IBD: Pain relivers
Tylenol: Avoid Nsaids as this can cause a flare up
Surgical therapy in IBD
- Can be curative in UC
- Used if non surgical methods dont provide relief
Surgical indications for UC
- Colon cancer
- Dysplasia, polyps
- Toxic megacolon
- Severe intractable bleeding
- preforation
- Strictures
Surgical indications in Crohn’s
- Small bowel obstruction
- Abscess
- Perforation
- hemorrhage
- Fistula formation
- strictures
Stricturoplasty
Widens intestine at stricture without resectioning intesting
* Usually for crohns
* Less invasive
Protocolectomy and total colectomy with ileostomy
- Resection of the colon and rectum with stoma formation from ileum
- severely diseased colon and rectum refractory to med treatment
- Curative in UC not crohns
- Ileostomy needed for total colectomy or proctocolectomy
Restorative protocolectomy with ileal pouch anal anastomosis
- Severe UC: Procedure of choice because it saves the rectum
- Connects ileum to anal pouch made from small intestine segment
- temp diverting loop ileostomy when healing, later closed
- Voluntary defecation and continence preserved
- Complications: Leaking of stool, stricture, pelvic abscess, fistula, SBO , pouchitis, infertility from pelvic disection
Diet in IBD
- High cal high protein, low fiber
- Avoid fiber
- Small frequent meals
- No caffine :(
- Take supplements with iron, pernicious anemia
- Avoid hard to digest foods (Nuts popcorn, corn, meats)
- Avoid triggering foods (Dairy, spicy, fatty foods)
- Stay hydrated
- Probiotics might help
- TPN if severly malnushed, or post surgical
Peritonitis
Complication of IBD
* Life threatneing inflammation of the peritoneum and lining of the abdominal cavity
* Often caused by bacteria entering the peritoneal cavity (From intestine)
Characterized by rigid or board like abdomen
Peritonitis mgmt
- Place pt in fowlers or semi fowlers position to promote drainage of peritoneal fluid and improve lung function
- Monitor resp status
- Admin o2
- NG suction
- NPO
- Monitor fluids and electrolyte status
- IV antibiotics
Toxic megacolon mgmt
- NG suction, IV fluids and antibioics
- Surgery
Fluid and electrolyte imbalance IBD
- Occurs from loss of fluid from diarrhea, vomiting and NG suctioning
- Mgmt is focused on monitoring labs, and giving fluids
- Monitor weight, I+O and signs of dehydration
Nursing interventions: IBD
- Vitals
- Assess bowel movements (Quantitiy, blood, mucus, formation)
- Focused GI assessment
- Bowel sounds
- NPO
- IV fluids
- Treat lyte imbalances
- I+O monitoring for dehydration
- Regular colon cancer screenings especially in UC
- Ostomy care
- Help pt understand disease
A nurse is reviewing the serum laboratory data of a patient who has an acute exacerbation of Crohn’s disease. Which of the following laboratory tests should the nurse expect to be elevated? (Select all that apply):
A. Hematocrit
B. Erythrocyte sedimentation rate
C. WBC
D. Folic Acid
E. Albumin
B. Erythrocyte sedimentation rate
C. WBC
A nurse is assessing a patient who has been taking Prednisone following an exacerbation of inflammatory bowel disease. The nurse should recognize which of the following findings as the priority?
A. Client reports difficulty sleeping
B. The client’s urine is positive for glucose.
C. Client reports having an elevated body temperature.
D. Client reports gaining four pounds in the last six months
C. Client reports having an elevated body temperature.
Elevated temp will kill you faster than increased glucose. While B is concerning, C is priority
A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching?
A. “Take the medication two hours after eating.”
B. “Discontinue this medication if your skin turns yellow-orange.”
C. “Notify the provider if you experience a sore throat.”
D. “Expect your stools to turn black.”
C. “Notify the provider if you experience a sore throat.”
Immune compromised is a huge concern with these people
A nurse in the clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching?
A. “I will plan to limit fiber in my diet.”
B. “I will restrict fluid intake during meals.”
C. “I will switch to black tea instead of drinking coffee.”
D. “I will try to eat three moderate to large meals a day.”
A. “I will plan to limit fiber in my diet.”
Fiber reduction is part of the plan for UC
What type of anemia is UC related to
related to blood loss more so than malabsorption
