IBD: Chrohn's Flashcards
IBD Definition
term encompassing a number of chronic inflammatory disorders leading to damage of the GI tract
IBD includes…
- Ulcerative colitis
- Chrohn’s Diz
IBD is…
- autoimmune dz
- chronic inflammation with remissions and exacerbations
- inflammation and consequences are different for CD and UC
- Serious digestive problems
Etiology of IBD
- unknown
- infectious agents
- altered immune responses
- autoimmunity
- lifestyle (smoking)
Musculoskeletal Manifestations of IBD
- peripheral arthritis
- sacroilitis
- ankylosing spondylitis
- osteoporosis
Dermatologic Manifestations of IBD
- erythema nodosum
- pyoderma gangrensoum
- aphthous stomatitis
Hepatobiliary Disease
primary sclerosing cholangitis
Ocular Manifestations of IBD
- uveitis
- scleritis
- episcleritis
Vascular Manifestations of IBD
Thromboemoblic events
Renal Manifestations of IBD
Nephrolithiasis
Therapies used by interdisciplinary Team
- diagnostic tests
- pharmacologic therapy
- complementary and alternative therapy
- surgery, including ostomies
Risk factors for IBD
- more frequent in US and northern europe
- american jews of european descent 4-5x more likely to develop IBD
- AA and white more than hispanics or asians
- smoking increased risk of CD
- use of NSAIDs and antibiotics
- peaks at 15-30 yrs of age
- second peak in the 50s
- equally in men and women
Crohns Disease Manifestations
-cobblestone appearance of bowel wall with patchy distribution from mouth to anus
Symptoms of CD
- fevers, night sweats and weight loss (nutrition deficit)
- abdominal pain
- N/V/D (or constipation)
- rectal bleeding
Clinical Manifestations Intestinal Complications
- intestinal obstruction
- abscesses
- fistulas
- perforation
- massive hemorrhage
- colon cancer
Physical Examination in CD
- weight loss/pallor
- clubbing of fingers
- abdominal distension
- tenderness in the area of involvement
- abnormal bowel sounds
- presence of an inflammatory mass are common
- perianal abscess, fistula, skin tags, or anal stricture
Lab Studies
- Anemia
- Luekocytosis
- Thrombocytosis
- Elevated ESR and C-reactive protein levels
- Decreased serum albumin levels
- Prometheus
- Urinalysis commonly demonstrates calcium oxalate crystals
- stool analysis for fecal leukocytes
- serologic markers with high specificity for CD
Anemia
-deficiencies of iron, vitamin B12, folic acid
Imaging Studies
- plain abdominal xray
- barium studies
- U/S abdomen and Pelvis
- CT abdomen and pelvis
- MRI
- Sigmoidoscopy
Mild-Moderate CD
- ambulatory patients
- patients who are able to tolerate oral meds
- patients without manifestations
Moderate-Severe CD
- patients who have failed to respond to tx for mild-moderate disease
- patients with more prominent symptom of fever, wt loss, abdominal pain or tenderness, intermittent N/V, significant anemia
Severe CD
- patients with persistent symptoms despite the introduction of steroids as out patient
- individuals presenting with high fever, persistent vomiting, evidence of intestinal obstruction, rebound tenderness, cachexia, or evidence of abscess
CD in Remission
- patients who are asymptomatic or without inflammatory
- patients who have responded to acute medical intervention or have undergone surgical resection without gross evidence of residual disease
- patients requiring steroids to maintain well-being are considered to be “steroid-dependent” and are usually not considered to be “in remission”
Current Goals for CD Therapy
Top-Down:
- induce clinical remission
- maintain clinical remission
- improve quality of life
plus:
- heal mucosa
- decreases hospitalization/surgery/overall costs
- minimize disease-related and therapy-related complications
Tx for Mild-Moderate CD
Mild: antibiotics and aminosalicylates
Moderate: immunomodulators and corticosteroids
First Line of Therapy
Aminosalicylates (4-ASA compounds)
Drugs used:
-decrease GI inflammation
-effective in achieving and maintaining
remission
- for mild to moderate episodes
- causes fewer adverse effects than sulfasalazine
- inexpensive and effective for many patients that tolerate it
- oral delayed-release
Pentasa/Apriso
-release 5 ASA directly to small intestine/colon or to the ileum
Olsalazine(Dipenteum) or Balsalazide(Colazal)
to colon only
Antibiotics
- used with flare ups
- used when abscesses form
Metronidazole
Flagyl
Antibiotic
Ciprofloxacin
Cipro
Antibiotic
Rifaximin
Xifaxan
Antibiotic
Immunomodulators
- suppress immune response
- most useful in those who do not respond to aminosalicylates, antibiotics, or corticosteroids
-require regular CBC monitoring
Azathoprine (Imurna, Azasan)
Immunomodulators
6-mercaptopurine (6-MP, Purinethol)
Immunomodulators
Cyclosporine A (Sandimmune, Neoral)
Immunomodulators
Tacrolimus (Prograf)
Immunomodulators
Methotrexate
Immunomodulators
Corticosteroids
- decrease inflammation
- used to achieve remission
- helpful for acute flare ups
Prednisone
Deltasone
Corticosteroids
Methylprenisolone
Medrol, Solu-Medrol
Corticosteroids
Hydrocortisone
Corticosteroids
Buedesonide
Entocort or UCERIS
Corticosteroids
Tx for Moderate-Severe CD
- Cortcosteroids
- Biologic Therapies
- Surgery
Biologic Therapies
block a small inflammatory protein called tumor necrosis factor alpha that promotes inflammation in IBD
- induces and maintains remission
- newest IBD drugs
Infliximab
Remicade
-only approved for UC
Natalizumab
Tysabri
-only approved for Chrohn’s
Adalimumab
Humira
-biologic approved for both UC and Crohn’s
Certolizumab pegol
Cimzia
-only approved for Chrohn’s
Nursing considerations for IBD
- nonadherence
- lack of knowledge
- concerns about side effects
- lack of trust in meds
- diminished sense of priority for meds
- burden of taking the meds
- tx cost
Complementary and Alternative Therapy
- Encourage patients to discuss all potential therapies with the primary care provider
- may interact with prescribed meds
- includes herbals and OTCs
Types of Alternative and Complementary Tx
- antidiarrheal
- probiotics
- vitamin b12
- zinc
- iron
- folate acid
- calcium
- potassium
Tx for Severe CD
- Hospitalization
- High recurrence rate
- surgery
- Parenteral broad spectrum antibiotics
- nutritional support (elemental or TPN)
Parenteral broad spectrum antibiotics
- high fever
- toxic appearance
- inflammatory mass
Nutritional Support
- TPN in addition to steroids plays no specific role
- indications: patients unable to maintain nutritional requirements after 5-7 days
- preop management
- pediatric
Proven efficacy for perianal fistulas in CD
infliximab
Possible efficacy for perianal fistulas in CD
- antibiotics
- AZT/6-MP
- Cyclosporine
