Elimination

Inflammatory Bowel Disease (IBD)

  • Types:

    • Crohn's Disease (CD)

    • Ulcerative Colitis (UC)

  • Characteristics:

    • Chronic inflammation with periods of remission and exacerbation

  • Etiology:

    • The exact cause is unknown; believed to be a combination of genetic and environmental factors

  • Pathophysiology:

    • Tissue damage and inflammation due to autoimmune disease attacking intestinal cells

  • Risk Factors:

    • 20-40 years old; in 60s

    • Genetic links

  • Consequences:

    • Ulcerations

    • Fistulas

  • Management:

    • No cure available

    • Medication: Reduce inflammation and maintain remission

    • Surgical interventions: patients who do not respond to medication or develop complications

Manifestations

  • Abdominal pain

  • Mouth/stomach ulcers

  • Diarrhea

  • Rectal bleeding

  • Loss/change in appetite

  • Fatigue

  • Weight loss

  • Fever

  • Changes in menstrual cycle

  • Severe

    • intermittent fever

    • Emaciation

    • Fatigue

    • Dehydration

    • Abdominal tenderness

    • Hyperactive bowel sounds.

Complications

  • Malnutrition and malabsorption

    • Kidney stones

    • Gallstones

  • Anemia

  • Perforated bowel and bleeding

  • Intestinal obstruction and strictures

  • Fluid and electrolyte imbalances

  • Formation of fistulas, strictures, and abscesses

  • Eye complications (soreness/redness)

  • Increased risk of osteoporosis

  • Significantly elevated risk of colon cancer

  • Arthritis and other inflammatory conditions

Diagnosis of IBD

  • Rule out other conditions through a comprehensive assessment.

  • CBC to check for anemia.

  • WBC count for indicators of toxic megacolon and perforation.

  • Electrolytes analysis due to losses from diarrhea and vomiting.

  • Stool studies to check for pus.

  • Colonoscopy for definitive diagnosis.

Nursing Interventions

  • Enhancing Bowel Function and Managing Diarrhea:

    • Monitor onset, pattern, frequency, and characteristics of diarrhea.

    • Observe for associated symptoms such as fever, pain, and bloody stools.

    • Facilitate bed rest and provide commode access if necessary.

  • Special Dietary Adjustments:

    • Restrict irritating foods and gradually reintroduce oral fluids.

    • Decrease dietary fat intake.

    • Administer prescribed medications like corticosteroids and antibiotics as indicated.

    • Consider prescribing probiotics or fish oil.

  • Preventing Dehydration:

    • Closely monitor intake/output (I&O) and the volume/number of stools.

    • Regular vital signs assessment and daily weight monitoring.

    • Testing stool for occult blood and watching for signs of weakness, dehydration, and electrolyte imbalance.

    • Provide bland, high-protein, low-residue diet and administer IV fluids or blood as necessary.

  • Mental Health Support:

    • Encourage expression of frustrations and provide a calm environment.

    • Educate about coping mechanisms for chronic illnesses.

  • Managing Acute Pain:

    • Assess pain severity and location, encouraging feedback from the patient.

    • Offer comfort measures and assist with skin care around sensitive areas.

  • Patient Education:

    • Discuss disease processes and potential medication side effects, especially regarding long-term steroid use.

    • Emphasize the importance of adherence to follow-up appointments and the prescribed diet.

Treatment Goals

  • Rest the bowel and control inflammation

  • Combat infections and correct nutritional deficiencies

  • Provide symptomatic relief and improve quality of life

Medications

  • Aminosalicylates:

    • Sulfasalazine, Mesalamine

    • Reduce inflammation by direct contact with bowel mucosa

  • Antibiotics:

    • Flagyl, Cipro

    • Prevention/treatment of infection

  • Corticosteroids:

    • Prednisolone

    • Reducing inflammation

  • Immunosuppressants:

    • Azathioprine/Imuran

    • Suppress immune response

  • Biologics (Anti-TNF agents)

    • Infliximab (Remicade)

    • Adalimumab (Humira)

      • Administers for moderate to severe CD and UC when other treatments fail.

      • Mechanism of action: Binds to TNF and inhibits its activity, thus reducing inflammation.

    • Certolizumab pegol (Cimzia)

    • Golimumab (Simponi)

    • Natalizumab (Tysabri)

    • Reduce leukocyte infiltration into inflamed tissues

Considerations for Geriatrics

  • Elderly patients present unique challenges:

    • Vascular issues

    • Medication side effects

  • Careful management and follow-up.

Comparison of Crohn's Disease and Ulcerative Colitis

Feature

Crohn's Disease

Ulcerative Colitis

Site of Origin

Terminal ileum

Rectum

Pattern of Progression

"Skip" lesions, irregular

Proximally contiguous

Layers Affected

Transmural, affecting all layers

Mucosal layer only, localized

Symptoms

Crampy abdominal pain, diarrhea

Bloody diarrhea

Complications

Fistulas, abscesses, obstruction

Hemorrhage, toxic megacolon

Radiographic Findings

String sign on barium X-ray

Lead pipe colon on X-ray

Risk of Colon Cancer

Slight increase

Marked increase

Surgery

For complications (stricture)

Curative

Crohn's Disease

  • Inflammation Characteristics:

    • Affects all bowel layers, can occur anywhere from mouth to anus, primarily affecting the terminal ileum and colon.

    • Presents with normal bowel segments interspersed with abnormal areas (cobblestone appearance) and potential obstructions due to strictures.

    • Formation of fistulas can occur, leading to complications like fecal incontinence

  • Manifestations:

    • Diarrhea

    • Colicky abdominal pain

    • Weight loss

    • Rectal bleeding (less frequent)

  • Surgical treatment:

    • Approximately 75% will experience recurrence

    • Considered when other treatments fail

Ulcerative Colitis

  • Inflammation Characteristics:

    • Disease usually originates at the rectum and progresses towards the cecum, primarily affecting the colon and rectum

    • Ulcerations present only in the mucosal layer, typically without fistula formation due to the lack of penetration through the bowel wall

    • Associated with significant fluid and electrolyte loss, diarrhea may be bloody

  • Manifestations:

    • Bloody diarrhea

    • Abdominal cramping

    • Increased stool frequency (10-20 bowel movements per day)

    • Tachycardia

    • Dehydration

    • Fever

    • Weight loss

  • Surgical treatment:

    • Surgery is less common

    • Can be curative

Irritable Bowel Syndrome (IBS)

  • Chronic functional disorder with intermittent abdominal pain and stool irregularities (diarrhea and/or constipation)

  • Exact cause unknown; potential factors include altered bowel motility and psychological influences

  • Widespread prevalence, particularly in Western countries

  • Affects more women than men.

Triggers

  • Emotional stressors

  • Specific foods (e.g., chocolate, dairy)

  • Physical influences such as antibiotics

  • Eating disturbances

Manifestations

  • Abdominal pain/distension

  • Flatulence

  • Bloating

  • Alternating patterns of diarrhea/constipation

  • Mucus in stools and disturbances in sleep patterns.

Diagnostic Criteria

  • Rome Criteria:

    • Abdominal pain/discomfort lasting at least three months with onset at least six months prior, with at least two of the following:

      • Relief upon defecation.

      • Associated with changes in stool frequency.

      • Associated with changes in stool appearance.

  • Tests:

    • Stool studies

    • X-rays

    • Proctoscopy

    • Contrast studies

    • Barium enema

    • Colonoscopy to rule out other diagnoses

Treatment Approaches for IBS

  • Emphasis on dietary adjustments to eliminate triggering substances.

  • Supplements or medications may assist with symptoms.

    • Example medications: Antidiarrheal agents, bulk-forming laxatives, antispasmodics.

Medications

  • Imodium:

    • Reduces intestinal transit time and enhances water absorption.

  • Alosetron (Lotronex):

    • Specifically for severe cases in women.

  • Probiotics:

    • Help decrease bloating and gas.

  • Amitiza and Linzess:

    • Indicated for constipation-linked IBS.

Patient Education

  • Diet

  • Regular meal times

  • Adequate hydration

  • Avoidance of alcohol/tobacco

Distinction: IBD vs. IBS

  • Inflammatory Bowel Disease (IBD) Characteristics:

    • Causes damage to the gastrointestinal system and may present extra-intestinal symptoms.

    • Characterized by inflammatory changes in the bowel detectable via diagnostic tests.

    • Symptoms include abdominal pain, anemia, weight loss, and fever. Increases risk of colon cancer.

  • Irritable Bowel Syndrome (IBS) Characteristics:

    • A group of symptoms causing chronic stomach pain, discomfort, diarrhea, and/or constipation.

    • Caused by disturbed brain-gut interactions, often exacerbated by stress.

    • Typically presents no signs of pathology on diagnostic examinations and does not heighten colon cancer risk.