Critical Care: Exam 1- IBD

What are the two main diseases associated with inflammatory bowel disease (IBD)?

Crohn's disease and ulcerative colitis

What is inflammatory bowel disease (IBD)?

An immune-mediated inflammatory disorder that causes chronic inflammation of the GI tract

Is IBD the same as irritable bowel syndrome (IBS)?

No, IBD and IBS are different conditions

What happens during the pathophysiology of IBD?

A cell-mediated immune response causes inflammatory changes and release of inflammatory cytokines, leading to chronic GI inflammation and ulceration

What causes IBD?

The exact cause is unknown and is likely multifactorial

What factors may contribute to IBD?

Genetic susceptibility, environmental triggers, changes in the intestinal microbiome, and abnormal immune responses

Where is IBD more prevalent geographically?

Industrialized countries such as the United States, Canada, and Europe

What are risk factors for IBD?

Caucasian race, Ashkenazi Jewish descent, living in the northern hemisphere, family history, and certain age groups

What are the common age groups for IBD onset?

Adolescents to young adults, with a second peak after age 60

What are common symptoms of IBD?

Frequent stools and crampy abdominal pain

What are disease-specific risk factors for ulcerative colitis?

Former smoking and nonsmoking status may be associated with increased risk, while high vegetable intake may decrease risk

What are disease-specific risk factors for Crohn's disease?

Current smoking and NSAID use may increase risk, while high fiber and fruit intake may decrease risk

What part of the GI tract does ulcerative colitis primarily affect?

The colon and rectum, especially the rectum and rectosigmoid colon

How does ulcerative colitis typically spread?

It starts in the rectum and extends continuously toward the cecum

Can ulcerative colitis affect the entire colon?

Yes

Which layers of the bowel are primarily affected by ulcerative colitis?

The mucosal and submucosal layers

What does the bowel look like with ulcerative colitis?

Hyperemic, reddened, edematous, inflamed, and friable

What part of the GI tract can Crohn's disease affect?

Any part of the GI tract from the mouth to the anus

What is the most common area affected by Crohn's disease?

The distal ileum and proximal colon

What is transmural inflammation?

Inflammation that extends through the entire wall of the bowel

What happens to the bowel wall in Crohn's disease?

The wall becomes thickened and fibrotic, causing narrowing of the lumen and development of strictures

What are skip lesions?

Areas of inflamed tissue separated by healthy tissue

What is the cobblestone appearance in Crohn's disease?

Deep longitudinal ulcerations separated by areas of edematous mucosa

How do the lesions of ulcerative colitis spread?

Continuously

How do the lesions of Crohn's disease spread?

As skip lesions

Where is abdominal pain commonly located with ulcerative colitis?

The left lower quadrant (LLQ)

Why is LLQ pain common with ulcerative colitis?

Inflammation commonly begins in the rectum and sigmoid colon, which are located in the lower left abdomen

What type of diarrhea is common with ulcerative colitis?

Frequent diarrhea that is often bloody during exacerbations and may contain mucus or pus

How many stools per day may occur with severe ulcerative colitis?

More than 6 stools per day

What is tenesmus?

A feeling of needing to have a bowel movement even when the bowel is empty

What systemic symptoms can occur with ulcerative colitis?

Pallor, anemia, fatigue, fever, dehydration, and electrolyte imbalances

Where is abdominal pain commonly located with Crohn's disease?

The right lower quadrant (RLQ)

Why is RLQ pain common with Crohn's disease?

The distal ileum is commonly affected

When can Crohn's disease abdominal pain worsen?

After meals

What type of diarrhea is common with Crohn's disease?

Diarrhea that is usually non-bloody unless ulcerations are present

What is steatorrhea?

Fatty, greasy stools caused by fat malabsorption

What symptoms can occur with Crohn's disease?

Crampy abdominal pain, diarrhea, steatorrhea, anorexia, weight loss, malnutrition, dehydration, fever, leukocytosis, and anemia

What GI complications can occur with ulcerative colitis?

Toxic megacolon, bleeding, anemia, hemorrhage, perforation, and increased risk of colon cancer

What GI complications can occur with Crohn's disease?

Fissures, granulomas, fistulas, strictures, bowel obstruction, perforation, perianal abscesses, and increased risk of small intestine and colon cancer

What is the most common type of fistula in Crohn's disease?

Enterocutaneous fistula

What are strictures?

Narrowing of the intestinal lumen caused by inflammation and scar tissue

What is a fistula?

An abnormal connection between two organs or between an organ and the skin

What systemic manifestations can occur with IBD?

Arthritis, uveitis, erythema nodosum, nephrolithiasis, fluid and electrolyte abnormalities, and malnutrition

What is uveitis?

Inflammation of the uvea of the eye

What is erythema nodosum?

Inflammatory, tender red nodules that commonly occur on the shins

Why is malnutrition common in Crohn's disease involving the terminal ileum?

The terminal ileum is important for absorption of vitamin B12, bile salts, iron, and folate

What nutrient deficiencies can occur with terminal ileum involvement?

Vitamin B12, iron, and folate deficiencies

Why can Crohn's disease cause steatorrhea?

Bile salt and fat absorption can be impaired

What other manifestations can occur with Crohn's disease?

Mouth ulcers, arthritis, uveitis, erythema nodosum, hydronephrosis, nephrolithiasis, and cholelithiasis

What can cause nephrolithiasis in patients with IBD?

Dehydration and changes in intestinal absorption

What can cause cholelithiasis in Crohn's disease?

Impaired bile salt absorption related to terminal ileum disease

What stool findings may occur with ulcerative colitis?

Blood, mucus, and pus

Why are stool cultures obtained in suspected IBD?

To rule out an infectious cause of GI symptoms

What CBC finding may occur with IBD?

Increased WBC count

What does an increased CRP indicate in IBD?

Inflammation

What does an increased ESR indicate in IBD?

Inflammation

What does decreased H/H indicate in IBD?

Anemia

What can decreased albumin indicate in IBD?

Malnutrition or protein loss

What electrolyte abnormalities can occur with IBD?

Decreased sodium, potassium, chloride, bicarbonate, and magnesium

Why can metabolic acidosis occur with IBD?

Diarrhea can cause loss of bicarbonate

What antibody may be increased in some patients with ulcerative colitis?

p-ANCA

What diagnostic study is the gold standard for IBD?

Colonoscopy

What may be seen on colonoscopy with ulcerative colitis?

Friable mucosa, pseudopolyps, and ulcerations

What may be seen on colonoscopy with Crohn's disease?

Ulcerations separated by areas of normal tissue

What can sigmoidoscopy show in ulcerative colitis?

Inflamed mucosa

What can barium studies show in ulcerative colitis?

Diffuse involvement without narrowing or stenosis of the colon

What can barium studies show in Crohn's disease?

Skip lesions, mucosal edema, bowel wall thickening, narrowing, and fistulas

What can CT, MRI, or ultrasound identify in IBD?

Abscesses and areas of intestinal or perirectal involvement

What can CT show in Crohn's disease?

Bowel wall thickening, mesenteric edema, obstruction, abscesses, and fistulas

What is MRI especially useful for in Crohn's disease?

Identifying pelvic and perianal abscesses and fistulas

Why may capsule endoscopy be avoided in Crohn's disease?

Because strictures can increase the risk of capsule obstruction

What are common treatments for IBD?

Aminosalicylates, corticosteroids, biologic therapies, and immunomodulators

What may be required during a severe IBD exacerbation?

NPO or bowel rest, IV fluids, electrolyte replacement, blood products if needed, corticosteroids, and parenteral nutrition when indicated

What additional treatment may be used for severe Crohn's disease exacerbations?

Antibiotics

What are aminosalicylates?

Medications that decrease inflammation and suppress cytokines and other inflammatory mediators

What are examples of aminosalicylates?

Mesalamine and sulfasalazine

What is the main goal of aminosalicylates?

To induce and maintain remission

For which IBD is aminosalicylate therapy more effective?

Mild to moderate ulcerative colitis

How effective are aminosalicylates for Crohn's disease?

They have limited effectiveness

How can mesalamine be administered for rectal inflammation?

As a suppository or enema

What are common side effects of aminosalicylates?

Headache, nausea, fatigue, diarrhea, and decreased sperm production

What should be considered when giving sulfasalazine?

Use caution in patients with a sulfa allergy; sulfa-free alternatives are available

What are examples of corticosteroids used for IBD?

Prednisone and methylprednisolone

How can corticosteroids be administered for IBD?

Orally, IV, or topically as a suppository or enema

What is the purpose of corticosteroids in IBD?

To rapidly decrease inflammation and suppress immune-mediated inflammation

When are corticosteroids used in IBD?

To induce remission during acute exacerbations

How long are corticosteroids generally used for IBD?

Short term

Why must corticosteroids be tapered?

To prevent complications from adrenal suppression and allow the body to adjust

What are adverse effects of corticosteroids?

Decreased wound healing, increased blood glucose, mood changes, increased infection risk, decreased bone mineral density, and adrenal suppression

What are anti-TNF biologics?

Biologic medications that block tumor necrosis factor-alpha (TNF-α), decreasing inflammation

What are examples of anti-TNF biologics?

Adalimumab (Humira) and infliximab (Remicade)

What is the goal of anti-TNF biologics?

To induce and maintain remission

What are common side effects of anti-TNF biologics?

Upper respiratory infections, UTIs, and infusion or injection reactions

What can occur during an infusion reaction to a biologic?

Fever, chills, itching, swelling, pain at the injection site, and hypotension

What serious infection risks are associated with anti-TNF biologics?

Opportunistic infections and reactivation of tuberculosis and hepatitis

What should be screened for before starting anti-TNF biologics?

Latent tuberculosis and hepatitis

What type of vaccines should be avoided while taking biologic immunosuppressive therapy?

Live vaccines

What should patients taking biologics be taught about infection?

They should practice infection prevention and report signs and symptoms of infection

What is vedolizumab (Entyvio)?

A gut-specific integrin inhibitor used for moderate to severe IBD

What is ustekinumab (Stelara)?

A biologic that blocks IL-12 and IL-23 inflammatory pathways