2. Inflammatory bowel disease
(IBD)
Refers to two chronic inflammatory
GI disorders:
regional enteritis (i.e. crohn's disease)
&
ulcerative colitis.
Both have striking similarities but as
the same time several differences.
3. Incidence
In the US, has increased in the past
century: over 30,000 new cases occur
annually.
15 and 30 years of age at the greatest
risk, followed by people between 50
and 70.
Women and men are equally affected.
4. Aetiology
• Unknown
• Believed is caused by a
combination of these
factors:
Immune system problems
Genetics
Environmental factors
5. Regional enteritis /crohn's
disease/crohn syndrome
• Chronic inflammatory condsition
• May affect any part of GIT from mouth to
anus
• Most commonly occur in distal ileum and
colon
• usually first diagnosed in adolescents or
young adults but can appear at any time
of life.
• Incidence shows rise over past 30 years
6.
7. Pathophysiology
• extends through all layers (i.e. transmural lesion)
• characterized by remissions and exacerbations.
• Disease process begins with edema and thickening
of mucosa
• Deep ulcers appears on the inflamed mucosaseparated by normal tissue
• Take on classic "cobblestone" appearance
• Fistulas
• Perianal fissures and abscesses
• Granulomas in 50% of the cases
• Bowel wall thickens, become fibrotic
• Intestinal lumen narrows
9. Clinical features
• Unpredictable exacerbations and
remissions.
• Quality of life is diminished
• Overall mortality is 2x of general population
Features depend on site and extent of bowel
affected:
• Abdominal pain
Most frequently in Rt lower quadrant due to
involvement of terminal ileum and Rt side of
colon
Crampy abdominal pain, usually after food
10. • Mass palpable on abdominal and
rectal examination
• Nausea and vomiting
• Excessive borborygmi
• Colicky pain, Recurrent episodes
• Diarrhea and fever
• Sometimes diarrhea may contain
blood if has affected colon.
• Anorexia, Weight loss
• Malaise, lethargy,
• Nutritional deficiency , anemia
• Psychosocial issues
11. Assessment and diagnostic findings
1. Endoscopy
–
-
Colonoscopy – best for dx
a "cobblestone ulcer is seen
Biopsy may be done along
2. Radiology
– Barium meal and follow through of upper GIT: shows
the classic ‘string sign’ on x-ray
– Barium enema
3. Laboratory
– Stool examination
– Complete blood count
– Albumin and protein
14. Ulcerative colitis
• Recurrent ulcerative and inflammatory
disease of the mucosal and submucosal
layers of the colon and rectum.
• Peak incidence is between 30 and 50
years of age
• Serious disease accompanied by systemic
complications and a high mortality rate.
• 10 to 15 % of these patients develop
colon carcinoma
15. Pathophysiology
• Disease process begins at rectum and spreads
proximally to entire colon
• Contiguous lesions
• Affects the superficial mucosa
• Multiple ulcerations
• Inflammation
• Desquamation or shedding of colonic epithelium
• Bleeding occurs
• Edematous and inflamed mucosa- pseudopolyposis
• Abscesses form, infiltrate seen in mucosa
• Bowel narrows, shortens and thickens
16. Clinical features
•
•
•
•
•
•
•
•
•
•
•
Bloody diarrhea is the hallmark
Lower left quadrant abdominal pain
Tenesmus
Rectal bleeding
Anorexia, weight loss, fever, vomiting and dehydration
Cramping
Fecal urgency
Passage of 10-20 liquid stools each day.
Hypocalcemia and anemia
Rebound tenderness in right lower quadrant
Extraintestinal symptoms such as skin lesion (erythema
nodosum), eye lesions(uveitis), joint abnormalities(eg.
arthritis) and liver disease
17. Assessment and diagnostic findings
• Laboratory : hematocrit, sedimentation rate, and
serum albumin reflect severity of disease, stool
for routine examination and occult blood
• Plain abdominal x-ray
• Sigmoidoscopy, colonoscopy- mucosa appears
edematous, friable, mucopus and eroded
• Barium enema- to find out severity and extent
• CT and MRI are used to indentify abscesses and
perirectal involvement
19. Medical management of chronic IBD
Focuses on:
• reducing inflammation
• suppressing inappropriate immune
responses
• providing rest for the diseased bowel
• improving quality of life
• preventing or minimizing complications
20. Nutritional therapy
• Oral fluids
• Low residue, high protein and high calorie
diet
• Supplemental vitamin
• Iron replacement
• IV therapy in fluid and electrolyte
imbalances
• Avoid milk in those with lactose
intolerance
• Avoid cold food and smoking
• Parenteral nutrition
22. Surgical management
• Total colectomy and ileostomy- procedure of
choice for crohn’s disease.
• Intestinal transplant- not a cure, to improve
quality of life for some who are terminally ill.
• Almost 25% of ulcerative colitis patients require
surgery. Surgical excision usually improves life.
• Proctocolectomy with ileostomy
• Ileoanal anastomosis
• Strictureplasty- blocked and narrowed section of
bowel is widened, leaving the bowel intact
23. Nursing Management
Nursing Process
Assessment
Health history regarding
◦ Abdominal pain: onset,
duration and characteristics
◦ presence of diarrhea,
◦ fecal urgency, tenesmus,
◦ nausea and vomiting,
◦ anorexia, weight loss,
◦ family history of IBD.
24. • Dietary patterns
• Patterns of bowel elimination:
– character, frequency
– presence of blood, pus, fat or mucus,
• Allergies and food intolerance especially
milk.
• Sleep disturbances if diarrhea and pain
occurs at night
• Assess abdomen:
–
–
–
–
–
bowel sound
tenderness or pain,
distension,
evidence of fistula,
signs of dehydration
• Assess stool, rectal bleeding
25. Nursing Diagnoses
1. Acute pain related to increased peristalsis and
GI inflammation
2. Diarrhea related to the inflammatory process
3. Fluid volume deficit related to anorexia, nausea
and diarrhea
4. Anxiety related to impending surgery
5. Imbalanced nutrition, less than body
requirements related to dietary restrictions,
nausea and malabsorption
27. Relieving pain
• Identifying type of pain, onset before/after food,
pattern, if relieved with medication or not?
• Position changes, heat application, diversional
activities
• Prevention of fatigue to decrease pain
• Administer antichonilergics as prescribed 30 min
prior to food to decrease intestinal motility
• Give analgesics as prescribed
28. Maintaining normal elimination
patterns
• Identifying precipitating factors such as food,
activity, stress, etc. if any and avoiding those.
• Provide ready access to bathroom, commode or
bedpan
• Keep the environment clean and odor free
• ‘administer anti diarrheal agents as prescribed
• Record frequency and consistency of stool before,
during and after therapy
• Encourage bed rest to decrease peristalsis
29. Maintaining fluid intake
• Record oral and IV fluids intake and outputs
• Assess daily weight for fluid gains or losses
• Look for signs of fluid deficit; decreased skin
turgor, oliguria, dry skin and mucosa, increased
hematocrit, hypotension
• Encourage oral fluid intake and maintain IV intake
• Measures to decrease diarrhea; dietary
restriction, stress reduction, anti diarrheal agents
30. Maintaining optimal nutrition
• Parenteral nutrition when symptoms are severe;
monitors weight, fluid intake and output. The patient
should gain 0.5kg daily during PN therapy
• Monitor Feedings high in protein and low in fat and
residue
• Note for intolerance; signs are nausea, vomiting,
diarrhea or abdominal distention
• Restrict activity to conserve energy, reduce peristalsis
and reduce calorie requirements
• If oral foods are tolerated; small, frequent, low residue
feedings to avoid over distending the stomach and
stimulating peristalsis
