Week 12: Chp 58: Inflammatory Bowel Disease (IBD) Flashcards
IBD is an umbrella term for two very similar chronic diseases of the GI tract which are?
- Crohn’s Disease
- Ulcerative Colitis
Causes of IBD
exact cause is unknown but has been linked to genetic predisposition, environmental conditions, and defects in immune regulation
- the genetic predisposition may manifest as an overactive immune response to bacteria located in the GI Tract; it may then be triggered by an environmental response such as infection, medication, or smoking
- whereas the immune system usually attacks foreign invaders, in people with IBD, the immune response has an inappropriate response in the intestinal tract causing inflammation; this inflammation affects the ability to absorb nutrients resulting in diarrhea and weight loss in some patients
What is the immune system like in a patient with IBS
whereas the immune system usually attacks foreign invaders, in people with IBD, the immune response has an inappropriate response in the intestinal tract causing inflammation
-this inflammation affects the ability to absorb nutrients resulting in diarrhea and weight loss in some patients
Clinical Manifestations
IBS is chronic in nature, and the severity ranges from mild to severe, with periods of remission and exacerbations
-exacerbations often are precipitated by physical or emotional stress
Similarities of Crohn’s disease and Ulcerative Colitis
persistent diarrhea, abdominal pain or cramps, fever, weight loss, fluid imbalances, malnutrition, mouth ulcers, anemia, blood from the rectum, joint, skin, or eye irritations, and delayed growth
Extraintestinal Manifestations seen in IBD
- uveitis (intraocular inflammatory disorder)
- sclerosing cholangitis (inflammation of the hepatic ducts)
- nephrolithiasis (renal stones)
- cholelithiasis (gallstones)
- joint disorders
- skin disorders
- oral ulcerations
Patients with Crohn’s disease are at higher risk for what?
cancer of the small bowel
Patients with Ulcerative colitis have a higher risk for what?
colon cancer
What cures ulcerative colitis in the GI tract?
colectomy (removal of the large intestine)
Colectomy
removal of the large intestine
-cures ulcerative colitis
Patients with Crohn’s disease who undergo resection of diseased sections of the bowel are at increased risk of what?
reoccurrence at the sites of the anastomoses (the area where the two sections of the bowel were reattached after removal of the diseased bowel)
anastomoses
area where the two sections of the bowel were reattached after removal of the diseased bowel
Crohn’s Disease
can affect any portion of the GI tract from mouth to anus, but more common in terminal ileum and colon
-affects small bowel and malabsorption is most common in this disorder
-it is transmural, affecting all layers of the bowel
-not uniform in appearance, noted for having skip lesions with normal-appearing bowel between lesions
-the lesions cause deep ulcerations between layers of edematous tissue, creating a cobblestone appearance
-with each exacerbation, the intestine becomes more scarred, which then leads to less ability to absorb nutrients
-diarrhea is less severe than in ulcerative colitis
-stools are typically soft or semiliquid and do not usually contain blood unless there has been a perforation
-nutritional deficits arise from the inability to absorb nutrients, and electrolyte disturbances are common
-abdominal pain is usually worse in the RLQ
>no known cure for Crohn’s disease
Because Crohn’s Disease is transmural, what complications does this lead to?
it may actually penetrate the bowel wall, leading to complications such as fistulas, abscesses, and peritonitis
-strictures and adhesions are also common
Fistulas
abnormal tracts between two or more body areas
-patients with Crohn’s disease may develop anovaginal and rectovaginal fistulas
How does Crohn’s Disease Manifest?
patchy involvement throughout all layers of the bowel
-it may skip areas of the bowel and can occur anywhere in the GI tract from mouth to anus
How does Ulcerative Colitis Manifest?
begins in the rectum and proceeds in a continuous, diffuse pattern towards the cecum
-affects the large intestine
Ulcerative Colitis
affects the large intestine and involves only the mucosa and submucosa
-disease spreads uniformly beginning at the rectum and spreading upward toward the cecum
-diarrhea is common, often with more than 20 stools per day with losses of several liters of fluid per day
-blood, mucus, and pus are common with ulcerative colitis
-abdominal pain and tenderness that is worse in the LLQ
-patients may manifest tenesmus; which involves spasms of the anal sphincter and persistent desire to empty the bowel
-a lesion called a crypt abscess releases secretions that result in a purulent discharge from the bowel mucosa
-abscesses may form in ulcerated areas
-scar tissue is common, interfering with absorption of nutrients
>total colectomy is surgical cure for ulcerative colitis
Indeterminate Colitis
this is the diagnosis when healthcare providers are unable to determine if the patient has ulcerative colitis or Crohn’s disease
Tenesmus
happens in people with ulcerative colitis
-involves spasms of the anal sphincter and persistent desire to empty the bowel
Clinical Manifestations of Ulcerative Colitis
- diarrhea
- blood, mucus, and pus in stool
- abdominal pan and tenderness in LLQ
- tenesmus
- crypt abscess releases secretions that result in purulent discharge from the bowel mucosa
- abscesses may form in ulcerated areas
- scar tissue is common, interfering with the absorption of nutrients
Crypt abscess
seen in ulcerative colitis
-a lesion that releases secretions that result in purulent discharge from the bowel mucosa
Primary Goals of Treatment
to rest the bowel and control the inflammation
-other goals are to combat infection, correct malnutrition, alleviate stress, provide symptomatic relief, and improve quality of life
What does treatments include?
medications, surgery, and correction of nutritional deficits and involve many psychosocial needs
- IBD cannot be cured with medication but, there are medications to help control the disease and treat or prevent exacerbations
- additional tests: CBC, serum electrolytes, serum albumin, and stool samples for pathogens
What is used in the diagnosis of both Crohn’s disease and Ulcerative Colitis?
colonoscopy, sigmoidoscopy, and barium enema
Colonoscopy Findings
assist in differentiating Crohn’s disease and ulcerative colitis
- Crohn’s disease: the colonoscopy detects early mucosal changes including inflammation, stricture, and fistulae
- Ulcerative Colitis: swollen, friable bowel mucosa with multiple ulcerations
Barium Enema Findings
may provide data regarding the depth of the disease involvement
Besides a colonoscopy, sigmoidoscopy and barium enema, what other diagnostic tests can you include?
CBC, serum electrolytes, serum albumin, and stool samples for pathogens
What type of management is crucial for the patient with Ulcerative Colitis?
Fluid and electrolyte management
-when the bowel is inflamed, and the patient is exhibiting severe diarrhea, absorption of fluids and nutrients is compromised
>patient is encouraged to rest frequently to decrease bowel motility
Nutrition: Malnutrition
malnutrition is common with IBD and can lead to many other complications such as poor wound healing, decreased muscle mass, and a decreased immune system
-more common in Crohn’s disease because it affects mostly the small bowel
Nutritional abnormalities can be caused by?
malabsorption, decreased food intake, medications, and/ or intestinal losses
>patient may need to be hospitalized for bowel rest and receive total parenteral nutrition (TPN)
What may be necessary in patients with Crohn’s disease who have the inability of the ileum to absorb this nutrient?
monthly B12 injections
Nutritional Deficits
zinc, potassium, magnesium, and vitamins
>liquid vitamin preparations are usually necessary because tablets or capsules may be excreted intact because of the frequency of diarrhea
-vitamin b12 injections may be necessary for patients with Crohn’s disease
Albumin Levels
frequently used to determine nutritional status, but other factors may alter albumin levels such as inflammation, infection, or cancer
Foods to Avoid
milk, gluten, caffeine, cocoa, chocolate, citrus juices, cold or carbonated drinks, nuts, seeds, popcorn, and alcohol
Complementary and Alternative Medicines
patients often reluctant to mention this to provider for fear of being judged
- marijuana, turmeric and curcumin, fish oil, probiotics, aloe Vera, Androphigus paniculata (e.g. India echinacea), Boswellia (e.g. frankincense), Tripterygium wilfordii Hook F (thunder god vine), wheat grass, and wormwood
- acupuncture, moxibustion, mind-body therapies, and exercise
Exacerbations of IBD may occur when?
during times of emotional or physical stress
-patients with IBD are concerned with how others view them; there may be a perceived, or actual, loss of independence, sense of control, privacy, body image, healthy self, peer relationships, self-confidence, productivity, and ways of expressing sexuality, therefore increasing risk of depression
Surgical Management: Crohn’s disease
- Crohn’s disease: is reserved for patients when medical management has failed and/ or who experience complications from the disease like strictures, abscesses, intestinal obstruction, perforation, hemorrhage, or cancer.
- when a diseased portion of the bowel is removed, it frequently recurs in another section of the bowel; surgery does not cure Crohn’s disease
Surgical Management: Ulcerative Colitis
for whom medical management has failed or who have experienced complications may undergo a colectomy and be cured of the disease but not of the extra-intestinal manifestations
>standard procedure: is an ileal pouch anal anastomosis (IPAA); the entire colon and rectum are removed, a pouch is created to collect waste, and the patient is able to defecate normally
Standard Procedure In surgical Management of Ulcerative Colitis
Ileal Pouch anal anastomosis (IPAA)
-the entire colon and rectum are removed, a pouch is created to collect waste, and the patient is able to defacate normally
Proctocolectomy with permanent ileostomy
patients with ulcerative colitis may undergo this procedure
- includes the removal of the colon and rectum and permanent closure of the anus
- the ileostomy is permanent
Proctocolectomy with a Kock or Koch Pouch
a continent ileostomy
- patients with ulcerative colitis
- a portion of the ileum is used to create a reservoir that can be catheterized to remove stool
Complications
- perineal abscesses and fistulas occurs in patients with Crohn’s disease
- strictures and fistulas more common in Crohn’s disease
- intestinal obstruction occurs secondary to inflammation and edema
- fibrosis and scarring over time may also cause narrowing of the bowel, leading to an obstruction
- malnutrition frequently develops because of malabsorption of nutrients, severe diarrhea, and anorexia due to the fear that eating may cause an exacerbation of symptoms
- anemia from hemorrhage and malnutrition may lead to patients needing blood transfusions and patients are often prescribed iron supplements to treat anemia
Extraintestinal Complications
- joint swelling and pain
- ankylosing spondylitis
- osteoporosis
- kidney stones
- eye inflammation
- mouth sores
- skin lesions
During Inflammation, what may the patient experience?
- fever
- anorexia
- and malaise
Anal Fissures
tears in the anal wall
-develop secondary to severe bouts of diarrhea
Surgical Complications
anal canal strictures, pelvic sepsis, pouch failure, fecal incontinence, pouch dysplasia/cancer, sexual dysfunction, and female infertility
Chronic Pouchitis
complication associated with the IPAA procedure
-one probiotic preparation may be effective in the prevention of recurrent pouchitis (VSL #3)
Fistulas
more common in Crohns Disease
-can often cause other complications such as sepsis, skin irritation, and malnutrition, dehydration, and fluid and electrolyte imbalances
>Enterocutaneous Fistula (between skin and intestine)
>Enteroenteral Fistula (between intestine and intestine)
>Enterovesicular Fistula (between bowel and bladder)
>Enterovaginal Fistula (between bowel and vagina)
Skin Irritation and Excoriation often occur because of what?
intestinal secretions being rich in enzymes; protection of the skin is of utmost importance
-skin may become in contact with secretions through fistulas and ostomies (surgical openings in an organ), such as an ileostomy (opening in the ileum) and colostomy (opening in the colon)
> the anus can also become irritated from frequent diarrhea
Toxic Megacolon
colonic dilation of greater than 5 cm
- occurs more frequently in ulcerative colitis and requires emergency colectomy
- bacterial overgrowth contributes to toxic megacolon
Short Bowel Syndrome
can occur if more than 100 cm of small bowel is removed because absorption is greatly affected
- the jejunum is where most carbohydrate and protein absorption takes place, and the ileum is where absorption of fats, fat-soluble vitamins, and b12 takes place; if the jejunum is removed, the ileum assumes the function of fat absorption; the removal of the ileum accounts for more complications because it is responsible for the absorption of fats, vitamins, bile salts, and B12
- patients having 50% to 70% of the small intestine removed experience malabsorption but can usually be managed with dietary supplementation
Narcotic Bowel Syndrome
characterized as chronic, intermittent, and cramping abdominal pain associated with the effects of the narcotic analgesic wearing off
Nursing Management: Assessment and Analysis
assessment of intake and output and daily weight s will help determine nutritional status of patients with suspected IBD
- frequent diarrhea leads to extreme losses of fluids and potassium, or hypokalemia
- patients with IBD are often victims of social isolation because of the fear of incontinence in public or having the need to be close to a bathroom at all times
- patients with IBD often report exacerbations as related to a stressful event
- clinical manifestations: persistent diarrhea, abdominal pain or cramps, fever, weight loss, fluid imbalances, mouth ulcers, anemia, melena,
- extraintestinal manifestations: uveitis, sclerosing cholangitis, nephrolithiasis, cholelithiasis, joint disorders, and skin disorders
Nursing Diagnoses
- Deficient fluid volume r/t diarrhea
- Diarrhea r/t intestinal inflammation and malabsorption of nutrients
- Imbalanced nutrition: less than body requirements r/t inability to absorb nutrients secondary to inflammation
- Ineffective coping r/t chronic disease
Nursing Interventions: Assessment
- vital signs
- nutritional intake
- frequency and characteristics of stools and note any presence of blood
- intake and output
- daily weight
- fluid and electrolyte status
- psychosocial assessment and support systems
Assessment: Vital Signs
with significant fluid loss, the patient may develop signs of decreased fluid volume including a low-grade fever, elevated heart rate, and decreased blood pressure
Assessment: Nutritional intake
assisting the patient to maintain a intake diary will assist in monitoring nutritional status
-frequent diarrhea is associated with malabsorption of nutrients
Assessment: Frequency and characteristics of stools and note any presence of blood
excessive losses result in complications such as fluid and electrolyte imbalances
-blood may be noted in the stool of the patient with ulcerative colitis but is unusual in Crohn’s disease
Assessment: Intake and Output
patients often do not attempt to eat or drink in fear of exacerbating clinical manifestations
-urine output should be monitored for at least 30 mL/hr to provide information regarding renal perfusion
Assessment: Daily Weight
weight is the best measurement for nutritional needs
Assessment: Fluid and Electrolyte Status
patients tend to loose many electrolytes through diarrhea, particularly potassium and magnesium
Assessment: Psychosocial Assessment and support systems
the patient frequently is a victim of social isolation because of fears of incontinence and/or frequent trips to the bathroom
Nursing Actions
- encourage smaller frequent meals
- encourage the patient to engage in mealtimes with family
- encourage periods of rest
- establish a therapeutic relationship
- make appropriate referral to interprofessional team
- pain management
- provide meticulous skin care
Actions: Encourage smaller frequent meals
decreases gastric motility
Actions: encourage periods of rest
help decrease gastric motility and conserve energy
Actions: Establish a therapeutic relationship
helps develop trust between patient and healthcare provider
Actions: Make appropriate referrals to interprofessional team
inflammatory bowel disease is a complex disease and requires a team approach including a case manager, dietician, and any local support group
Actions: Pain Management
positioning and maintaining a quiet environment may promote comfort
-pain medications may be ordered; if administered monitor for side effects like constipation
Actions: Provide meticulous skin care
having frequent diarrhea needs special attention to the rectal area because the feces contain enzymes that may cause excoriation to the skin surrounding the anus
Teachings
- importance of adequate nutrition
- indications, actions and side effects of prescribed medications
- importance of regular follow-ups and annual colonoscpy
Teachings: Importance of adequate nutrition
malnutrition due to malabsorption is common with IBD
- adequate nutrition is required for healing and maintaining a stable weight
- a daily multivitamin may be prescribed, but vitamins with iron may be controversial due to poor tolerance and may worsen symptoms
- reducing fiber and fat intake during exacerbation, drinking plenty of fluids, and avoiding milk and milk products during exacerbations are important
