Intestinal and Rectal Disorders

Inflammatory Bowel Disease - IBD

Unit 6

Chapter 23

Wolters Kluwer

Learning Objectives

• At the end of this lesson, the student will be able to:
  • Compare and contrast regional enteritis and ulcerative colitis regarding their pathophysiology.
  • Identify care needs of the patient with inflammatory bowel disease.
  • Discuss medical, surgical, and nursing management for regional enteritis and ulcerative colitis.
  • Discuss complications related to regional enteritis and ulcerative colitis.

Inflammatory Bowel Disease (IBD)

• Chronic inflammatory gastrointestinal (GI) disorders include:
  • Regional enteritis (also known as Crohn’s disease)
  • Ulcerative colitis (UC)

Regional Enteritis (Crohn’s Disease)

• Occurs at any age, most commonly during teenage years or early adulthood.
• Affects males and females equally.

Pathophysiology of Crohn's Disease

• Characterized by chronic inflammation of the GI tract.
• Exact cause is unknown but includes autoimmune-related factors.
• Predisposing factors:
  • Family history
  • Environmental factors
  • Immune dysregulation
• Ulceration in Crohn's Disease differs from that in ulcerative colitis.

Comparison of Patterns of Inflammation

Healthy Tissue vs. Crohn's Disease vs. Ulcerative Colitis

• Crohn's Disease:
  • Fat wrapping
  • Muscle hypertrophy
  • Cobblestone appearance
  • Fissures
  • Ulceration occurs within the mucosa.

Clinical Manifestations & Assessment of IBD

• General Assessment:
  • History and physical examination
  • Symptoms include:
  • Right lower quadrant abdominal pain
  • Crampy abdominal pain
  • Diarrhea (may include steatorrhea)
  • Weight loss and malnutrition
  • Fatigue and fever
  • Fluid and electrolyte imbalance

Complications of Crohn's Disease

• Major Complications:
  • Abscess formation
  • Fistulas and fissures
  • Intestinal obstruction due to strictures
  • Malnutrition from malabsorption
  • Intestinal perforation
  • Secondary anemia
  • Increased risk of colon cancer

Systemic Complications of IBD

• Extraintestinal Manifestations:
  • Joint disorders
  • Eye disorders
  • Skin disorders
  • Liver failure potentially from sclerosing cholangitis

Diagnostic Studies for IBD

• Important diagnostic methods include:
  • Esophagogastroduodenoscopy (EGD) and colonoscopy
  • Stool studies
  • Blood studies such as:
  • Complete blood count (CBC)
  • Serum electrolyte levels
  • Serum protein levels
  • Erythrocyte Sedimentation Rate (ESR)
  • C-reactive protein (CRP)
  • Barium studies
  • CT scan

Ulcerative Colitis (UC)

• Description:
  • Chronic, relapsing inflammatory bowel disease.
  • Involves colon and rectum only.
  • Inflammation is limited to mucosa and submucosa lining.
  • Risk Factors:
  • Family history and Jewish heritage
  • High risk for colorectal cancer

Pathophysiology of UC

• Autoimmune-related condition.
• Characteristics include:
  • Mucosa becomes red, inflamed, and ulcerated.
  • Bleeding occurs due to ulcerations.
  • Continuous lesions from rectum towards colon.

Clinical Manifestations & Assessment of UC

• Symptoms include:
  • Bloody diarrhea with mucus
  • Lower left quadrant abdominal pain
  • Fever
  • Weight loss
  • Fatigue and anemia
  • Dehydration
  • Electrolyte imbalance

Complications of Ulcerative Colitis

• Potential Complications:
  • Colon perforation
  • Toxic megacolon (colonic dilation)
  • Significant bleeding
  • Increased risk of colorectal cancer
  • Extraintestinal manifestations
  • Nutritional issues
  • Hypercoagulability
  • Hypocalcemia

Diagnostic Studies for UC

• Diagnostic tools include:
  • Colonoscopy with biopsy (avoid during exacerbation)
  • Stool studies
  • CBC/WBC count
  • Albumin levels
  • CRP and ESR measurements
  • Fluids and electrolytes checks
  • Barium studies

Management Goals for IBD

• Overall goals include:
  • Decrease the number and severity of acute exacerbations.
  • Maintain normal fluid and electrolyte balance.
  • Achieve freedom from pain or discomfort.
  • Ensure medication compliance.
  • Achieve nutritional balance.
  • Improve quality of life.

Nursing Priorities in IBD Management

• Key Nursing Considerations:
  • Rest the diseased bowel.
  • Monitor intake and output (I&O).
  • Conduct daily weight assessments.
  • Assess bowel sounds regularly.
  • Prevent skin breakdown.
  • Monitor for complications.
  • Suppress inappropriate immune responses.
  • Reduce inflammation.

Priorities and Support for IBD Patients

• Important Focus Areas:
  • Monitor stool consistency.
  • Maintain fluid and electrolyte balance.
  • Manage pain and cramping effectively.
  • Provide nutritional support.
  • Offer emotional support.
  • Encourage smoking cessation.
  • Provide vitamin supplementation.
  • Educate on medication adherence.

Nutritional Support for IBD Patients

• Dietary Modifications:
  • Avoid milk products; use soy milk as a substitute.
  • Avoid high-fat foods.
  • Avoid cold foods.
  • Avoid high-fiber foods.

Patient Education for Managing IBD

• Education Topics Include:
  • Managing chronic illness effectively.
  • Importance of rest and dietary management.
  • Perianal care.
  • Understanding drug actions and side effects.
  • Identifying symptoms of disease recurrence.
  • Recognizing when to seek medical care.
  • Strategies for reducing stress.
  • Guidance to educational resources.

Supportive Care in IBD Management

• Goals for Supportive Care:
  • Establish rapport with patients.
  • Encourage discussions about self-care strategies.
  • Fully explain all procedures and treatments to build trust, reduce apprehension, and increase self-control.

Acute Phase Support During Exacerbations

• During acute exacerbations, focus on:
  • Ensuring hemodynamic stability.
  • Pain control.
  • Managing fluid and electrolyte imbalance.
  • Providing nutritional support.

Medication Therapy for IBD

• Common Medications Used:
  • Aminosalicylates (5-ASA) formulations:
  • Sulfasalazine (Azulfidine)
  • Sulfa-free aminosalicylates like Mesalamine (Pentasal)
  • Antibiotics:
  • Metronidazole (Flagyl)
  • Corticosteroids:
  • Prednisone
  • Hydrocortisone
  • Anti-tumor necrosis factor (anti-TNF) agents:
  • Infliximab (Remicade)
  • Vedolizumab (Entyvio)
  • Ustekinumab (Stelara)
  • Adalimumab (Humira)
  • Immunomodulators:
  • Methotrexate
  • Azathioprine (AZT)
  • Cyclosporine

Surgical Interventions for IBD

• Types of Surgical Procedures:
  • Strictureplasty:
  • Opens narrowed areas obstructing the small bowel.
  • Used specifically for treating regional enteritis and reduces the risk of developing short-bowel syndrome.
  • Intestinal transplant as a potential option.
  • Restorative proctocolectomy with ileal pouch.
  • Total proctocolectomy with permanent ileostomy.
  • Intestinal resection with ostomy.

Preoperative Care for Surgical Patients

• Key Preoperative Measures:
  • Intensive fluid replacement.
  • Conducting laboratory blood tests.
  • Ensuring nutritional balance—important proteins.
  • Medication therapy management.
  • Patient education regarding the procedure.

Ostomy/Stoma Procedures

• Definition:
  • A surgically created opening on the abdomen for fecal elimination.
• Types of Ostomies:
  • Ileostomy: located in the right lower quadrant (RLQ).
  • Colostomy: depends on the location in the colon.

Types of Stomas

• Stoma Variants:
  • Ileostomy - involves the small intestine.
  • Colostomy - commonly resides in the large intestine.
  • Transverse Colostomy - specific type of colostomy.
  • Jejunostomy.

Postoperative Care for Ileostomy/Colostomy

• Key Observations Post-Surgery:
  • Assess stoma viability.
  • Monitor mucocutaneous junction for separation.
  • Check fecal drainage for any abnormalities.

Postoperative Management for IBD Patients

• Focus Areas Post-Surgery:
  • Managing fluid and electrolyte imbalance.
  • Assessing for hemorrhage.
  • Monitoring for signs of infection.
  • Checking for bowel obstruction.
  • Ensuring skin integrity is maintained.

Gerontologic Considerations in IBD Management

• Age-related Considerations:
  • Greater risk of complications in frail older patients due to:
  • Adverse events from corticosteroids.
  • Increased infection and malignancy associated with drug therapy.
  • Risk of volume depletion and electrolyte imbalances from diarrhea.
  • Physical limitations can impact self-care capabilities.

Evaluation of IBD Management

• Expected Outcomes Include:
  • Decreased number of diarrheal stools.
  • Maintenance of body weight within normal range.
  • Freedom from pain and discomfort.
  • Use of effective coping strategies by the patient.

Questions for Review

• A client must undergo surgical intervention for creation of an ileostomy. Which comment indicates that additional instruction about the care of his new ileostomy is needed?

  • Options:
  1. “I should change the appliance daily to prevent odors.”
  2. “When I change the appliance, I should check the skin for irritation.”
  3. “I should clean around the stoma with mild soap and water and pat dry.”
  4. “I’ll need to alter the appliance opening when the stoma becomes smaller as the area heals.”

• What symptoms may be suggestive of an intestinal obstruction in a patient with an ileostomy?

  • Options:
  1. Continuous flow of liquid stools and belching.
  2. Hypervolemia and hyperkalemia.
  3. Muscle spasms and numbness of the extremities.
  4. Nausea and abdominal distention.