Inflammatory bowel disease

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  • 1. Inflammatory Bowel Diseases Alka Ingnam
  • 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. 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
  • 7. Cobblestone mucosa
  • 8. 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
  • 9. • 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
  • 10. 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
  • 11. String sign on barium study
  • 12. Complications • Intestinal obstruction/ stricture formation • Perianal disease • Fluid and electrolyte imbalance • Malnutrition • Fistula and abscess. Commonly enterocutaneous fistula • Colon cancer: increased risk
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. Complications • • • • • • Toxic megacolon Perforation and hemorrhage Peritonitis Nutritional deficiency Colon cancer Osteoporotic fractures- due to decreased bone mineral density
  • 18. 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
  • 19. 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
  • 20. Pharmacologic therapy 1. Aminosalicylate formulations; sulfasalazine (azulfidine) - treat inflammation and prevent recurrences 2. Antibiotics; metronidazole & ciprofloxacin - In secondary infections 3. Corticosteroids - suppress the acute clinical symptoms 4. Immunomodulators; (eg. Azathioprene [Imuran], 6mercaptopurine, methotrexate) - Alter immune response
  • 21. 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
  • 22. 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.
  • 23. • 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
  • 24. 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
  • 25. Nursing Interventions
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. ANY QUESTIONS?
  • 31. Thank you