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Adult Health II > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

Inflammatory Bowel Disease (IBD)

A
  • Umbrella Term
    • Crohn’s Disease
    • Ulcerative Colitis
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2
Q

IBD Etiology

A
  • Thought to be complex interplay
    • Genetics
    • Immunes system
    • Environmental factors
  • Genetic Predisposition
    • Positive family history is highest risk for IBD
      • 1st degree relatives
    • Gene mutation on chromosomes 5 and 6 (just FYI)
  • Smokers 2 – 4 x’s risk for Crohn’s
    • More aggressive disease
  • Non-smokers greater risk for ulcerative colitis
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3
Q

IBD Epidemiology

A
  • Worldwide
    • Usually industrialized nations
      • Urban area
      • Cold climate
      • USA and Northern Europe
        • Jewish greatest prevalence
        • Native American, Asian, Hispanic least prevalent
      • Caucasian women
        • 15 -25 years peak
          • Another peak 55 – 65 years
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4
Q

Pathophysiology of IBD

A
  • Inflammation
  • Exacerbation and remission
  • Crohn’s vs Ulcerative colitis
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5
Q

Ulcerative Colitis

A

Bowel mucosa

  • Diffuse and continuous inflammation
    • Edema and shallow ulceration
  • Distal colorectal area – 40 -50%
  • Left sided : colorectal to splenic flexure 30 – 40%
  • Severe disease : extends up to hepatic flexure
  • Rectum only (very small %) ulcerative proctitis.
  • Mucosa is fragile
    • Bleeds spontaneously
      • Trauma
  • Becomes thickened and edematous
    • Scars form
      • Lose elasticity and absorptive capability
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6
Q

UC S/S

A
  • Bloody Diarrhea
    • 3-4 x’s/day up to hourly
      • Small in volume
      • Mushy
      • Mixed with blood, mucus, and pus
  • Abdominal pain
    • Left-sided
    • Colicky
    • Relieved by emptying bowel
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7
Q

Crohn’s Disease

A

Affects any portion of the digestive tract

  • Most often proximal colon and ileocecal junction
  • “Right-sided” disease
  • 40% confined to cecum and ileum
    • May be in more than one site
  • Transmural
    • All layers of the intestinal wall
    • “Skip” or “Cobblestone” pattern
      • Affected tissue separated by normal tissue
  • What do the lesions do?
    • Perforate
    • Form fistulas
    • Scar tissue
      • ↓ absorption
    • Strictures
      • Bowel obstruction
    • Polyps
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8
Q

Chron’s S/S

A
  • Varies according to location and severity
  • Diarrhea
    • Small intestine
      • 3 – 5 large semi-solid stool/day
        • Contains mucus and pus
          • No blood
    • High small intestine
      • Steatorrhea
        • Fatty stool, foul smelling
      • Poor absorption of fat soluble vitamins
        • A, D, E, and K
  • Abdominal pain
    • Colicky and severe
    • Occurs after eating
      • Diffuse or
      • Localized in RLQ
        • May resemble appendicitis
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9
Q

Systemic Symptoms of IBD

A
  • Related to the intestines
  • Anorexia, Nausea, Weakness, Malaise
  • Weight loss
    • Nutritional deficiencies R/T poor absorption
  • Labs
    • Anemia – iron deficiency
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10
Q

Extraintestinal symptoms of IBD

A
  • Can involve every organ in the body
  • Etiology not well understood
  • Arthritis (up to 23%)
    • Large joints
      • As IBD improves, so does Arthritis
  • Ocular (up to 10%)
    • Uveitis, retinopathy
  • Renal (up to 23%)
    • Kidney stones
  • Skin (3 – 6%)
    • Erythema nodosum
      • Red, tender nodule on anterior tibia
  • Hepatobiliary (4 – 5%)
    • Cholelithiasis, Fatty liver
    • Cholangitis (70% have UC)
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11
Q

Complications of IBD

A

Primary

  • Hemorrhage
  • Obstructions
  • Perforation
  • Toxic megacolon
  • Cellular dysplasia or Cancer
    • Adenocarcinoma
      • UC 10 – 20 X’s more than general population
      • Crohn’s Dz 4 – 7 X’s more than general population
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12
Q

IBD Diagnostic Tests

A
  • Health history
    • Symptoms
    • Pattern of severity and duration
  • Labs
    • Stool cultures
    • Fecal leukocytes and parasites
    • CBC, ESR, Serum albumin
    • Serologic antibody assay
      • Preinuclear antineutrophil cytoplasmic antibodies (pANCA)
        • Ulcerative colitis
      • Anti-Saccharonyce cerevisiae antibodies (ASCA)
        • Crohn’s Disease
      • Differentiates IBD from IBS
  • Radiologic
    • Barium enema
      • Evaluate physical changes of colon
        • Structure of bowel
          • String lesions – Crohn’s Dz.
    • CT of Abdomen
    • Transabdominal ultrasound
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13
Q

IBD Medications

A
  • Stepped Approach
    • Progressed until a response occurs
  • Step 1 – Aminosalicylates
  • Step 1a – Antibiotics
  • Step 2 – Corticosteroids
  • Step 3 – Immunomodulatory agents
    • Monoclonal antibodies
  • Step 4 – Agents that have been shown to help selected types of patients
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14
Q

Step 1 (mild to moderate IBD)

A
  • Aminosalicylates
    • Sufasalazine (Azulfidine)
      • Developed in the 1930’s to treat arthritis
      • Combination of sulfa drug and aspirin
      • Broken down in colon into Sulfapyridine and 5-acetysailcylic acid (5-ASA)
        • 5-ASA not absorbed, so stays in colon to reduce inflamation
        • Sulfa does not really do anything
    • Olsalazine (Dipentum) 5-ASA
    • Mesalamine (Pentasa, Asacol)
      • pH sensitive coating – releases in colon
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15
Q

Step 1A

A
  • Antibiotic
    • Metronidazole (Flagyl)
    • Ciprofloxacin (Cipro)
    • Most often used in pre-op care
    • Can be used in seriously ill with infection
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16
Q

Step 2 (moderate to severe IBD)

A
  • Corticosteroids
    • Rapidly acting antiinflammatory agent
    • Not used as maintenance
      • Too many systemic effects
        • Electrolytes imbalance
        • Osteoporosis
        • Endocrine dysfunction
    • May be given IV, PO, PR
    • Prednisone
    • Budesonide (Entocort)
17
Q

Step 3 (Extensive disease)

A

Immune Modifiers

  • Potent immunosuppressive agents
  • Azathioprine (Imuran)
  • Mercaptopurine (6-MP, Purinethol)
  • May take up to 4 months to demonstrate effectiveness
    • Not used in acute situations
    • Effective in prolonging remission
    • Needs monthly CBC and Plt count
      • Neutropenia and pancytopenia
  • Methotreate – Crohn’s Dz
  • Cyclosporine (Sandimmune) Ulcerative colitis
  • Monoclonal Antibodies
    • Infliximab
      • Monoclonal immunoglobulin G1 antibody against tumor necrosis factor-alpha (TNF-alpha)
      • Used in Crohn’s Disease
      • TNF-alpha – inflammatory agent found in high amounts in patients with Crohn’s Dz.
    • Natalizumab
      • Monoclonal antibody
      • Used in Crohn’s Dz.
18
Q

Step 4

A

Clinical Trials

19
Q

Other Medications IBD

A

Meds for symptomatic relief

  • Anti-diarrheals
  • Fat-soluble vitamins
  • Bile acid binding agents
  • Acid suppression agents
  • Antispasmodics
20
Q

IBD Treatment

A
  • Daily enemas for rectal involvement
  • Management of skin breakdown R/T diarrhea
  • Severe episode
    • Bedrest
    • NPO
    • IV fluids
    • Hospitalization
      • High dose steroids
      • TPN
21
Q

Surgical Management – Crohn’s

A
  • Avoid as much as possible
    • High rate of reoccurrence in same area
  • 75% eventually have surgery
    • Uncontrolled disease
    • Manage complications
  • Focus
    • Spare and conserve as much of the bowel as possible – especially small bowel
    • >100 cm of Small Bowel loss à short bowel syndrome
  • Surgical procedure
    • Segmental resection
      • Remove 5 – 10 cm each side of diseased tissue
      • Reanastomosis
    • Strictureplasty
      • Most common complication
22
Q

Surgical Management - UC

A

When medical management no longer works

  • Curative
    • Removes the entire colon
  • Brook Ileostomy
    • Removal of anus, rectum, and colon
    • Anus permanently closed
    • Terminal ileum brought through abd wall
23
Q

Ileostomy

A
  • Problems
    • Loss of fluid
      • 800 ml each day
    • Loss of electrolytes
      • Sodium
    • Self-esteem
    • Fear
      • Leakage
      • Odor
      • Noise
24
Q

Continent Ileostomy (Kock)

A
  • Same as ileostomy, except
    • Forms a pouch in small intestine
      • Also called a K-pouch
    • Has a nipple valve
      • Easily blocked
    • Drain stool with a catheter
    • Rarely done anymore due to multiple complications
25
Q

Ileoanal Anatomosis (Ileorectostomy)

A
  • The colon is removed
  • The rectum remains
    • Able to absorb fluid & electrolytes
    • Can still get CA and UC
  • No stoma
26
Q

Ileoanal Pouch Anastomosis (IPAA)

A
  • Terminal ileum forms a pouch
  • Terminal ileum is sewn directly into rectum
    • Leaves anal sphincter intact, so less risk of incontinence
    • Can develop pouchitis
      • Inflammation of the pouch
        • Bleeding
        • Rectal pain
27
Q

Nursing Management

A
  • Health History
    • What is the patient’s knowledge of the Disease?
    • How is the pain assessed?
    • Constipation or diarrhea – pattern
    • Diet
      • Types of foods, weight loss, weight gain
    • Allergies
    • Family/Friend support
    • Impact of illness on aspects of patients life?

Physical Exam

  • Body Weight
  • Skin turgor
    • Condition of the mucus membranes
    • Perianal skin
  • Fever
  • Bowel sounds
  • Composition of stool
    • Fat, blood, mucus, pus

Nursing Diagnosis

  • Chronic Pain
  • Diarrhea
  • Imbalance nutrition: less than body requirements
  • Ineffective coping
  • Ineffective health maintenance
28
Q

Patient/Family Teaching

A
  • Diet and Fluids
    • High calorie, well balanced
    • Low fiber, low dairy
    • Multivits
    • 3 liters of fluid each day
      • Gatroade to help replace electrolytes
    • Use salt – especially during flare ups
  • Elimination
    • Take meds as prescribed
    • Keep rectal area clean and dry
    • Use of anti-diarrheals
    • Use of bulk-forming laxatives when severe diarrhea
    • Maintain daily weights
  • Rest and Coping
    • Regular sleep schedule
    • Schedule daily activities to avoid fatigue
    • Take rest periods
    • Use relaxation strategies to decrease stress
    • Talk with family and friends about concerns
    • Attend local support groups
  • Health Maintenance
    • Report signs requiring medical attention
    • Changes in pattern or frequency of diarrhea or pain
    • Constipation
    • Change in stool characteristics
    • Unusual discharge from rectum
    • Fever
  • Regular follow-up care

Adult Health II (4 decks)

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