Inflammatory bowel disease Flashcards
inflammatory bowel disease
- a term encompassing a number of chronic inflammatory disorders leading to damage of the GI tract
- among the most common digestive ailments affecting more than 1.4 million Americans
- IBD includes ulcerative colitis and Crohn’s disease
IBD cont
- autoimmune disease
- chronic inflammation with remissions and exacerbations
- inflammation and consequences are different for UC and CD
- serious digestive problems
etiology
- unknown
- genetic and environmental factors
- infectious agents
- altered immune responses
- autoimmunity
- lifestyle (smoking)
- UC possiby due to previous bacteria/viral infection
extraintestinal manifestations of IBD
- muscoloskeletal: peripheral arthritis, sacroilitis, ankylosing spondylitis, ostesporosis
- dermatologic: erythema nodosum, pyoderma gangrenosum, aphthous stomatitis
- hepatobiliary diease: primary sclerosing cholangitis
- ocular: uveitis, sclerosis, episcleritis
- vascular: thromboembolitic events
- renal: nephrolithiasis
therapies used by interdisciplinary team
- diagnostic tests
- pharmacologic therapy
- complementary & alternative therapy
- surgery, inlcuding ostomies
risk factors
- occurs more frequently in US and northern European nations
- American Jews of European decent 4-Xmore likely to develop IBD
- African American and whites> hispanics and asians
- smoking increases risk of CD
- use of NSAIDS and antibiotics increases risk of UC
- peaks at 15-30 years of age
- second peak in 50s
- equally in men and women
clinical manifestations of Crohn’s disease
-cobblestone appearance of bowel wall with patchy distribution (skip lesions) from mouth to anus
Symptoms of CD
- fevers, night sweats, weight loss due to nutrition deficit
- abdominal pain
- N/V
- diarrhea and/or constipation
- rectal bleeding
clinical manifestations: intestinal complications
- intestinal obstruction
- abscesses
- fistulas
- perforation
- massive hemorrhage
- colon cancer
physical examination in CD
- weight loss and pallor
- clubbing of the fingers
- abdominal distention
- tenderness in the area of involvement
- abnormal bowel sounds
- presence of inflammatory mass are common
- perianal abscess, fistula, skin tags, anal stricture
Labs
- Anemia: defiencies in iron, vit. B12, folic acid; anemia of chronic disease
- leukocytosis
- thrombocytosis
- elevated ESR ad Creactive protein levels
- decreased serum albumin levels
- prometheus
- urinalysis commonly demonstrates calcium oxalate crystals
- stool analysis for fecal eukocytes
- serologic markers with high specificty for CD
- Anti-saccharomyces antibody (ASCA)
imaging studies
- plain abdominal X-ray
- barium studies: small bowel enema (enteroclysis/follow through); large bowel enema
- U/S abdomen and pelvis/transrectal U/S
- CT abdomen and pelvis
- MRI
- sigmoidoscopy
endoscopy (CD)
- upper and ower
- capsule
Mild to moderate CD
- ACG practice guidelines- definition
- ambulatory pts
- pts. who are able to tolerate oral meds
- pts without manifestations of:dehydration, toxicity, abdominal tenderness,painful mass, obstruction, >10%weight loss
Moderate- severe CD
- ACG practice guidelines- definition
- pts who have failed to respond to treatment for mild-moderate CD
- pts with more prominent symptoms of: fever, significant weight loss, abdominal tenderness or pain, intermittent nausea or vomiting (w/o obstructive finding), significant anemia
severe CD
- pts with persistent symptoms despite the introduction of steroids as out pt
- presenting with: high fever, persistent vomiting, evidence of intestinal obstruction,rebound tenderness, cachexia or evidence of abscess
CD in remission
- pts who are asymptomatic or without inflammation
- pts who have responded to acute medical intervention or have undergone surgical resection without gross evidence of residual disease
- **pts requiring steroids to maintain well-being are considered to be “steroid-dependent” and are usually not considered in remission
current goals for CD therapy
new approach: top-down
-induce clinical remission
-maintain clinical remission
-improve quality of life
PLUS
-heal mucosa
-decrease hospitalization/surgery/overall costs
-minimize disease related and therapy-related complicationsAminosalicylates (5-ASA compunds)
-first line of therapy: treats mild-moderate CD & UC
-drug used to: -decrease GI inflammation
-effective in achieving and maintaining remission
-mild to moderate episodes
-causes fewer adverse effects than sulfasalazine
-inexpensive and effective for many pts. that tolerate it
- oral delayed release
Exampes:- Pentasa, apriso: release 5ASA directly into small intestine/colon or ileum
-olsalazine, balsalazide: to colon only
*combined with antibiotics lead to sensitive skin
Antibiotics
- frequenty used with flareups
- used when abscesss forms
- examples: metronidzole, ciprofloxacin, rifaximin (usually used)
- lots of SE
immunomodulators
- suppress immune response
- most useful in those who do not respond to aminosalicylates, antibiotics, or corticosteroids
- require regular CBC monitoring
- if body does not tolerate it, leads to adverse reaction which could lead to death
- watch for lymphodema
- promethius test done before giving
- examples: azathioprine
- 6-mercaptopurine-BW& Prometheus test. SE:HA, N/V, diarrhea, fatigue
- cyclosporine: affects kidney function, diabetes, increase cholestero, swollen gums, increase facial hair, HTN, seizures
- tacrolimus
- methotrexate: flu like symtoms, decreased WBC, RBC, damage to liver, diabetes, drinking alcohol
corticosteroids
- decrease inflammation
- used to achieve remission
- helpful for acute flare ups
- ***if pt on steroids but not showing symptoms, still not considered to be in remission
- examples: prednisone, mehtylprednisolone, hydrocortisone, budesonide (less SE for young men/women)
- severe CD
biologic therapies
- block a small inflammatory protein called tumor necrosis factor alpha that promotes inflammation in IBD
- induce an maintain remission
- examples: infliximab: only on approved for UC
- natalizumab: only for CD
- adalimumab: approved for both
- certolizumab pegol: only for CD
- do not give immunomodulators and biologics together because they increase the risk for cancer in men under 30
- severe CD
once a pt is off 5-ASA
they cannot track backwards in meds
nursing considerations
- nonadherance
- lack of knowledge
- concerns about side effects
- lack of trust in meds
- diminished sense of priority for meds
- burden of taking prescribed med
- treatment cost
complementary and alternative therapy
- encourage pts to discuss all potential therapies with the primary care provider
- complementary and alternative may interact with prescribed meds
- includes: herbal, OTC
complementary and alternative therapy cont
- antidiarrheal
- probiotics
- Vit. B12
- zinc
- iron
- folate acid
- calcium
- potassium
severe CD treatments
- hospitalization
- high recurrence rate
- surgery: -strictureplasty
- exploratory laparotomy
- excessive bleeding
- obstruction
- peritonitis
- most pts. will have first surgery w/in 10 yrs of diagnosis
Severe CD cont
- parenteral broad spectrum antibiotics: high fever toxic appearence, inflammatory mass
- nutritional support: (elementa or TPN): TPN in addition to steroids plays no specific role
- indications: pediatric age groups, pre-op management, for pts unable to maintain nutritional requiremnts after 5-7 days
- central line preferred
UC definition
a chronic diease characterized by diffuse mucosal inflammation limited to the colon
UC only affects
the mucosal layer of the colon
UC clinical manifestations
- 5-30 stools per day with bood and mucous (severe)
- cramping in LLQ abdomen relieved by BM
- common nutritional deficits
- anemia, decreased albumin, weight loss
- fever RARE
severe UC
- a bloody stool frequency of >5/day with any one of the following: -tachycardia (HR >90 bmp)- pain, dehydration
- temperature >37.8C
- anemia (Hg30mm/h)- inflammation factor
clinical manifestations: severe complications
- arthritis in 1 or more joints
- skin and mucous membrane lesions
- uveitis
- thromboemboli
- sclerosing cholangitis
- hemorrhage with anemia
- perforation
- rupture of bowel
- toxic megacolon
- carcinoma-coo-rectal;colon
- leg swelling
physical exam of UC
- weight loss and pallor
- abdominal distention
- tenderness in area of involvement
- abnorma bowels sounds
- presence of an inflammatory mass are common
- peri-anal abscess, fistula, skin tags, or anal strictures
UC medical therapy
medication therapy based on severity of symptoms
-5 major classes used: 5-ASA, glucocorticoid, immunomodulators, antobiotics, boilogic
US dianosis
- rule out other infectious causes through stool cultures
- blood work up:check for anemia and infection
- prometheus panel
- small bowel follow through
- chromoendoscopy
- endoscopic examintaions: sigmoidoscopy; total colonoscopy
goals for management of acute UC
- induction of remission
- prevention of relapse
- treatment of complications
US surgery implications
-fails to repsond to treatment
-exacerbations are frequent and debilitating
-massive bleeding, perforation, strictures, &/or obstruction
-tissue changes suggest dysplasia is occurring
-cancer
25-40% of pts will need surgery
surgery
2 steps:
step 1: colectomy, rectal mucosectomy, ileal reservoir contruction (temp. ileostomy-smaller stoma than colostomy)
step 2: closure of ileostomy to direct stool toward new reservoir
-adaptation to reservoir 3-6 months
-results: decrwased # of BMs/day, control of defecation at anal sphinter
ileostomy
-type of ostomy
-opening into ileum to allow paasage of intestinal content.
intestine is sutured onto skin surface creating a stoma
-all portions of large intestine are removed
-can be permanent or temporary
colostomy
opening into colon to allow passage of intestinal content
-intestine is sutured onto skin surface creating a stoma
pre-op care
- psychological support & explanations
- enterostomal clinician will see optimal placement of stoma
- diet: increase calorie, protein, carbs. decrease residue week before. NPO after midnight
- general preop teaching
- NGor intestinal tube post op
- antibiotics day before surgery (eg-erythromycin)
- laxatives, enemas evening before and morning of surgery
ileostomy
- usually done for CD
- permanent ostomy in RLQ abdomen
- pouch must be worn at all times for liquid to semi-iquid drainage
- skin breakdown and fluid/electrolyte imbalance occur easily
ileostomy dietay concerns
- Goal: return to normal presurgical diet and avoid foods that cause diarrhea, gas, or obstruction
- low fiber diet 4-6 weeks
- prone to food blockage with non-digestible fiber intake (know signs)
- use care when eating high fiber foods
blockage
- keep NPO
- remove pouch if stoma swollen
- warm bath 15 mins
- peri-stomal massage (knee chest position if possible)
- may use warm saline irrigation if other measures do not work
- do not irriagate routinely to regulate frequency of bm (could lead to perforation–> septicemia)
- call doctor, ostomy nurse, or go to ER if blockage asts more than 2 hrs or if pt starts to vomit
ascending colostomies
- RUQ abdomen
- all portions distal are removed
- permanent colostomy
- feces semi-liquid
- skin break down common
Transverse double barrel colostomy
- usually temporary
- may be permanent if distal portion is removed later
- semi-liquid to semi-formed feces
- distal end left to mature; has mucus in it
sigmoid colostomy
- single barrel
- usually permanent
- formed feces
- drainage may be regulated by irrigation
- ostomy appliance may eventually not be needed
foods that thicken stool
apple sauce, creamy peanut butter, bananas, boiled milk, buttermilk, cheese, pasta, rice, pretzels, tapioca pudding, toast, yogurt
foods that loosen stool
alcohol, broccoli, green beans, fresh fruits (excpet banans), grape juice, prunes or prune juice, spicy foods, spinach
foods that cause gas and stool odor
beans, beer, broccoli, brussel sprouts, cabbage, carbonated beverages, corn, cauliflower, cucumbers, mushrooms, spinach, peas
-asparagus, eggs, fish, garlic, onions, some spices
-foods that may contribute to food blockage
-apple peels, raw cabbage, corn, raw celery, coconut, Chinese veggies, dried fruits, grapes, meats w/ casings (hot dogs, sausage), mushrooms, nuts. pineapple, popcorn, potato peels, large seeds.
foods that may discolor stool
-beets, red gelatin
irrigating colostomy
- only colostomy can be irrigated- distal colon or rectum
- never use enema set to irrigate colostom
- 50-1000ml lukewarm water through lubricated cone slowly over 5-10 min
- remove cone and allow 30-45 mins for the solution and feces to return
- close off irrigating sleeve after 10-15 mins, most has returned (to ambulate)
- clean, rinse, and dry the peristomal skin well. apply stoma cap or pouch
- wash and rinse all equipment and hang to dry
perfect stoma
- preoperatively sited
- budded
- visible to pt
- no complications
imperfect stoma
- flush
- -retracted or recessed
common post op complications
- necrosis
- bleeding
- prolapse
- parastomal hernia
- mucocutaneous separation
diet with flare ups
- **low residue diet=low fiber diet
- small frequent meals
- avoid trigger foods
- limit sugar, sweeteners, spicy foods, caffeine, lactose
- replace fluid & electrolyte loss
- parenteral IV fluids or enteral feedings
- TPN FOR BOWEL REST
- prevent weight loss
diet in remission
- Goal: adequate nutrition without exacerbating symptoms
- balanced diet- high protein & calorie; Low fat and fiber
nursing interventions to promote rest during flare ups
- frequent breaks and rest
- good quality sleep
- alternative therapies such as acupuncture, yoga, homepathy
- planning ahead and reducing stress
- physiotherapy and exercise
- flexible working hours
intervention: body image
- listen to pts. feelings and self-perception
- encourage pt to discuss physical changes
- encourage pt to discuss concersn about the diease and treatment on close personal relationship
- encourage the pt to make choices and decisions about own care (increase sense of control)
discharge teaching
- importance of rest
- perianal care
- action and SE of meds
- symptoms of recurrent disease
- when to seek medical care
- use of diversional activities to reduce stress
- teaching resources from the Crohn’s and Colitis foundation of America
summary: Crohn’s vs. UC
Crohn’s: -affects end of small intestine (ileum) and beginning of colon, but can also affect any part of GI tract from mouth to anus
-inflammation affects al layers of intestinal lining
UC: -limited to large intestine (colon) and rectum.
-inflammation only occurs on mucosa, or surface layer of intestinal lining
similarities between UC and CD
- develop in teens and young adults
- affects men and women equally
- symptoms are very similar’
- unknown causes
- treated according to symptoms
- similar contributing factors: environmental, genetic, and an inappropriate response by the bodys immune system
