lecture 15: Management of Inflammatory Bowel Disease Flashcards
what is inflammatory bowel disease
- GI tract disorders
- Characterized by idiopathic inflammation and ulceration
- varied clinical manifestations
- autoimmune**
- can be debilitating
what does inflammatory bowel disease have
unpredictable periods of remission and exacerbation
what is the etiology of inflammatory bowel disease
- etiology unclear; multifactorial
potential causes:
- infectious agents, autoimmune response, environmental influences or allergies, genetics
who has elevated risk of developing IBD
immigrants from non-western countries who arrive in Canada as children and their Canadian-born offspring have increased risk than immigrants who arrive later in life
ulcerative colitis
- inflammation and ulceration of the colon and rectum
- diffuse inflammation of the mucosa and submucosa
crohn’s disease
- inflammation can also occur in the small intestine, mouth, esophagus, and stomach
- inflammation occurs deeper in the intestinal wall
out to inside of the intestine
OUT
serosa
muscularis externa
submucosa
muscosa
onset of ulcerative colitis
- any age
- usually starts 15-25
- 2nd, smaller peak between 60-80
- both sexes equally
- runs in all families
most common clinical manifestations of ulcerative colitis
- abdominal pain
- bloody diarrhea
- fever, malaise, anorexia, anemia, tachycardia, and dehydration
mild ulcerative colitis
up to 4 loose stools per day, stools may be bloody, mild abdominal pain
moderate ulcerative colitis
4-6 stools/day, stools may be bloody, moderate abdominal pain, anemia
severe ulcerative colitis
more than 6 bloody loose stools per day, fever, anemia, and tachycardia
very severe (fulminant) ulcerative colitis (about stools)
10+ loose stools/day, constant blood in stools, abdominal tenderness/distension, may require transfusion, potentially fatal
intestinal complications of ulcerative colitis
abscesses, pseudopolyps, hemorrhage, perforation, toxic megacolon, and colonic dilation
extraintestinal complications of ulcerative colitis
can involve the joints, skin, mouth, eyes, and hematological system
- cause of this is unknown
how many patient with ulcerative colitis have complications
50%
someone who has had ulcerative colitis for 10+ yrs is at greater risk of
colorectal cancer
2 most important risk factors of colorectal cancer
- extent of colitis
- duration of disease
pts w IBD are at higher risk for ____________ and related ____________ as well as _______________
- osteoporosis
- fractures
- arthritis
one of the most frequent co-morbidities seen in ppl w ulcerative colitis
diabetes mellitus
- suggests genetic component
components to diagnosis of ulcerative colitis
- history and physical
- colonoscopy or sigmoidoscopy
- ultrasound
- CT scan
- barium enema
- blood tests
- stool tests
what is a sigmoidoscopy
view the rectum, sigmoid colon, and descending colon
colonoscopy
view the entire large intestine
what does normal colon lining look like
mucosa is healthy and pink
what does mildly active ulcerative colitis look like?
- mucosa edematous and red
- white areas are superficial ulcers with mucous exudate
active ulcerative colitis
- mucosa is very red and inflamed
- mucosa is very edematous with bleeding occurring
barium enema
- night prior: instructed to drink magnesium citrate; will cause diarrhea
- x-ray of colon after filling colon with barium, a chalky white solution
- barium shows clear view of colon, and any abnormalities present
3 types of blood studies for ulcerative colitis
- complete blood cell count (CBC)
- hemoglobin: blood loss
- high leukocyte: may indicate toxic megacolon or perforation - electrolytes
- decreases in sodium, potassium, chloride, bicarbonate, magnesium due to fluid/electrolyte losses - serum protein levels
- hypoalbuminemia - present with severe disease due to breakdown of cells
aminosalicylates
- contain 5-aminosalicyclic acid (5-ASA)
- help control GI inflammation
- can be given orally or rectally
sulfasalazine
- drug to control ulcerative colitis
- combo w sulfapyridine and 5-ASA
- anti-inflammatory and antibacterial properties
- side effects: nausea, vomiting, heartburn, diarrhea, and headache
- maintenance dose is usually continued 1 yr
what does the sulfapyridine component do in sulfasalazine
- carries anti inflammatory 5-ASA to intestine
other 5-ASA agents
oral:
- olsalazine
- mesalazine
- balsalazide
suppositories:
- mesalazine
ascending colon
orally given
- local release of mesalamine
decending colon
enemas
- reach the splenic fissure
sigmoid colon
foams
rectum
suppositories
corticosteroids
- oral prednisone: mild-moderate disease
- IV methylprednisolone or hydrocortisone: moderate to severe disease or 5-ASA ineffective
not recommended long-term
corticosteroid sympt
- weight gain, acne, facial hair, hypertension, diabetes, mood swings, increased risk of infection
not recommended for long-term use
immunosuppressants
- reduce inflammation by suppressing immune response (used in more severe cases of ulcerative colitis)
- for pts who have not responded to 5-ASAs or corticosteroids or who are dependent on corticosteroids
- slow acting and may take 6+ months b4 full benefit
- ex: azathioprine, cyclosporine
newer immunosuppressants (immunomodulators)
- biologics: infliximab, adalimumab, golimumab
- associated w risk of infection and certain cancers
other meds
- antibiotics
- antidiarrheal meds
- pain relievers (acetaminophen)
- *NOT NSAIDS
- iron supplements
what causes imbalanced nutrition
- less than body requirements
- decreased intake, decreased absorption, increased loss by:
anorexia, weight loss, weakness, lethargy, anemia
what is nutritional therapy
mild->moderate disease or flare up
- high calorie, high protein, low residue diet may be prescribed
low residue diet
Excludes:
- alc and fruit juices w pulp
- whole grain breads and cereals
- fried, smoked, pickled or cured meats
- fried or uncooked eggs
- most cheeses and fruit yogurt
- raw and unstrained vegetables, beans
- raw fruits, skins, seeds, nuts
if sympt of UC become severe
- nutritional supplements
- NPO
- parenteral nutrition
- total parenteral nutrition (TPN)
goal of TPN
- to meet client’s nutritional needs and allow growth of new body tissue
- short or long term
commercially prepared TPN solutions
- available for central and peripheral use
- standardized or customized
- peripheral: 10-12.5% dextrose supplies 340-425 Kcal/L
- central: 20-50% dextrose supplies 680-1700 Kcal/L
*trace elements and electrolytes added by pharmacy
methods of administration
- central parenteral nutrition: given thru catheter whos tip lies in SVC
- peripherally inserted central catheters: placed and advanced into central circulation
- peripheral parenteral nutrition: short term
central vs. peripheral parenteral nutrition
- differe in tonicity which is measured in milliosmoles
- standard IV solutions of D5W are essentially close to isotonic (280)
- central TPN are hypertonic - at least 1600 - must be infused in a central vein
- PPN is hypertonic but less so - can be admin thru large peripheral vein
infection complications of TPN
- fungus (gram +’ve, gram -‘ve)
- all TPN is prepared under strict aseptic technique
- placement of PICC catheter is done under sterile conditions
- local manifestations of infection
metabolic complications of TPN
- hyper/hypoglycemia
- at beginning - hyperglycemia can occur
- to prevent, solution is infused at a gradually increasing rate for 24-48 hrs
- blood glucose levels checked every 4-6 hrs w a glucose testing meter
- keep glucose below 8 mmol/L
administering of solution
- infusion pump
check every 30-60 min - independent double check**
mechanical complications of TPN
- insertion (air embolus, pneumothorax, hemothorax, hemorrhage)
- dislodgement
- thrombosis of great vein
- phlebitis
never increase or decrease flow rate by more than…
10%
% of pts requiring surgery to remove colon
25-40
complications requiring emerg surgical intervention for UC
- perforation of colon
- massive bleeding in colon
- sudden, severe ulcerative colitis
- toxic megacolon
standard surgical procedure for ulcerative colitis is
proctocolectomy
(removes colon and rectum)
unlike crohn’s disease, which can recur after surgery, ulcerative colitis is…
“cured” once colon and lining of rectum is removed
what is total proctocolectomy w permanent ileostomy
- 1 stage surgery
- removal of colon, rectum and anus
- end of terminal ileum forms a stoma in RLQ
what is a total colectomy with ileoanal reservoir
- pt must be highly motivated
- must b free of crohn’s and colorectal CA
- must have competent anorectal sphincter
1-3 stages 12 weeks apart
postoperative care
- routine care for abdominal surgery
- stoma viability and output
- peristomal and perianal skin integrity
- urinary cath
- IV fluids
- psychosocial
- education
