WORKU and YADETA AHN-II Group Assignment.pptx

SALALE UNIVERSITY
COLLEGAE OF HEALTH SCIENCE
DEPARTMENT OF ADULT HEALTH NURSING
Presentation on :Intractable Bowel diseases(IBD)
Presented To : Mr. Tadele K (Ass’t Professor)
Presented by: Worku D ( ID RMO-193/15) &
: Yadeta K (ID RMO-194/15)
Sep,2023
Fiche Ethiopia

Outline
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 Introduction
 Classifications
 Clinical features
 Diagnosis
 Management
 Summary
 Referance

Objectives
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At the end of this sessions the students will be able to:
 Describe the Defn-of IBD and IBS ,cause and clinical feature of IBD
and IBS
 Know the two forms of idiopathic inflammatory bowel disease (IBD).
 To Compare and contrast Crohn’s disease and ulcerative colitis
 Know the Diagnosis and managements of IBD and IBS
 know Complication of IBD and IBS

Inflammatory Bowel Diseases And Irritable Bowel Syndrome
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Introduction
Inflammatory bowel diseases(IBD) are sill intractable lifelong
diseases and it includes two conditions that cause irritation and
swelling ; crohn’s diseases and ulcerative colitis. Irritable bowel
syndrome(IBS) Is condition in which content move too fast or too
slow through the intestine usually accompanied by abdominal pain.

Cont…
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 IBS is a group of symptoms that occur together, including
repeated pain in your abdomen and changes in your bowel
movements, which may be diarrhea, constipation, or both.
 IBS is the most common cause of GI referral .
 Young females are affected 2-3 times more than men.

Inflammatory bowel disease
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Inflammatory Bowel Diseases(IBD)
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 Inflammatory Bowel Disease (IBD ) is characterized by a tendency
for chronic or relapsing immune activation and inflammation within
the gastrointestinal tract (GIT).
 Crohn’s disease (CD) and ulcerative colitis (UC) are the 2 major
forms of idiopathic IBD.

Classification IBD
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 Major:
 Crohn’s disease
 Ulcerative colitis
 Indeterminate(up to 15 %)
 Others (microscopic colitides)
 Collagenous colitis
 Lymphocytic colitis

Etiology of IBD
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 The exact cause of IBD is unknown, but IBD is the result of a
weakened immune system. The Possible causes are:
 The immune system responds incorrectly to environmental triggers,
such as a virus or bacteria, which causes inflammation of the
gastrointestinal tract.
 There also appears to be a genetic component. Someone with a
family history of IBD is more likely to develop IBD.

Genetics
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 IBD is a polygenic disorder
 About 1/3 of genetic risk factors are shared between CD and UC
 Studies suggested that 1st degree relatives of an affected patient have a
risk of IBD that is 4-20 times higher than that of general population.
 The best replicated linkage region, IBD1, on chromosome 16q contains
the CD susceptibility gene.
 Having one copy of the risk alleles confers a 2–4-fold risk for developing
CD, whereas double-dose carriage increases the risk 20–40-fold

Environmental Precipitants
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 Factors:
 NSAIDs use altered intestinal barrier and
 Early appendectomy (increase UC incidence)
 Smoking (protects against UC but increases the risk of CD).

Mucosal immune systems/ immunoregulatory defect
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 Functional studies suggest that inappropriate responses to bacterial
components may alter signaling pathways of the innate immune
system, leading to
 the development and persistence of intestinal inflammation.
 Initiating pathogen?
 Infectious?
 Possibly non-pathogenic commensal enteric flora

Common symptoms of IBD?
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 Persistent diarrhea.
 Abdominal pain.
 Rectal bleeding/bloody stools.
 Weight loss.
 Fatigue.

Crohn’s disease (CD)
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Crohn’s disease (CD) is
 Condition of Chronic inflammation potentially involving any
location of the GIT from mouth to anus.
 It is a lifelong disease arising from an interaction between genetic
and environmental factors

Crohn’s disease location
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 Terminal ileitis ,Regional enteritis , granulomatous colitis
 When fully developed it is characterized pathologically by
1. sharply delimited and typically transmural involvement of the bowel
by an inflammatory process.
2. The presence of non caseating granuloma
3. Fissuring with formation of fistulas

Cont…
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 CD may involve duodenum, stomach, esophagus and even
mouth but very rarely
 the intestinal wall is rubbery and thick the result of edema,
inflammation, fibrosis and hypertrophy
 classic feature is the sharp demarcation of diseased bowel
segments from adjacent uninvolved bowel

Cont…
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 When multiple bowel segments are involved the intervening bowel is
essentially normal ( skip lesions) and the mucosa acquires a
coarsely textured cobblestone appearance
 linear ulcers develop
 Narrow fissures develop between the folds of the mucosa often
penetrating deeply leading to fistula or sinus tract formation
 Mucosal inflammation

Cont…
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 Chronic mucosal damage
 Ulceration
 Trans mural inflammation affecting all layers
 Non caseating granulomas

Clinical features of CD
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 Symptoms Depend on
 Disease location
 Severity
 Presence of complications
 Usually relapsing and remitting course
 In some patients the onset is more abrupt with acute right lower
quadrant pain fever and diarrhea

Extrainstestinal manifestations
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 Upto 1/3
• skin
– erythema nodosum
– pyoderma gangrenosum
 Rheumatologic
– axial skeleton (sacroiliitis, ankylosing spondylitis)
– peripheral arthritis
• eyes: iritis, uveitis
• liver
– sclerosing cholangitis

Dermatologic manifestations
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Erythema
nodosum

Ulcerative colitis
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 An ulcero inflammatory disease limited to the colon and affecting
only the mucosa and submucosa except in the most severe cases.
 Incidence is slightly greater than Crohn’s disease
 Onset peaks between 20 and 25 years
 UC involves the rectum and extends proximally in a retrograde
fashion to involve the entire colon in the more severe cases

Cont…
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 UC is a disease of continuity and skip lesions like crohn’s disease
are not found
 In10% of patients the distal ileum may develop mild mucosal
inflammation ( backwash ileitis)
 Isolated islands of regenerating mucosa bulge upward to create
pseudopolyps
 Mural thickening does not occur in UC and the serosal surface is
usually completely normal

Clinical features of UC
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 present as a relapsing disorder marked by attacks of bloody
mucoid diarrhea that may persist for days, weeks or months, then
subside & recur
 abdominal pain and in minority constipation
 the most feared long term complication of UC is cancer

CD VS UC
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Ulcerative colitis
Crohn’s disease
 Superficial inflammation(mucosa , sub mucosa)
 No skip lesions
 Architectural distortion
 Normal small bowel(except backwash ileitis)
 Trans mural inflammation
 Deep ulcers /fissures
 Non caseating granulomas
 Skip lesions
 Patchy architectural
distortion

Microscopic colitis
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 Microscopic colitis is an inflammation of the large intestine (colon)
that causes persistent watery diarrhea.
 The disorder gets its name from the fact that it's necessary to
examine colon tissue under a microscope to identify it,
 since the tissue may appear normal with a colonoscopy or flexible
sigmoidoscopy

Etiology of MC
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 It's not clear what causes the inflammation of the colon found in
microscopic colitis. But believe that the causes may include:
 Medications that can irritate the lining of the colon.
 Bacteria that produce toxins that irritate the lining of the colon.
 Viruses that trigger inflammation.

Cont…
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 Autoimmune disease associated with microscopic colitis, such
as rheumatoid arthritis, celiac disease or psoriasis.
Autoimmune disease occurs when your body's immune system
attacks healthy tissues.
 Bile acid not being properly absorbed and irritating the lining of
the colon

Risk factors of MC
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Risk factors for microscopic colitis include:
 Age. Microscopic colitis is most common in people ages 50 to 70.
 Sex. Women are more likely to have microscopic colitis than are men.
 Autoimmune disease.
 Genetic link
 Smoking.

Classification of MC
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 There are different subtypes of microscopic colitis:
 Collagenous colitis is in which a thick layer of protein (collagen)
develops in colon tissue
 Lymphocytic colitis is in which white blood cells (lymphocytes)
increase in colon tissue
 Incomplete microscopic colitis is in which there are mixed features
of collagenous and lymphocytic colitis.

Signs and symptoms
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 Signs and symptoms of microscopic colitis include:
 Chronic watery diarrhea
 Abdominal pain, cramps or bloating
 Weight loss
 Nausea
 Fecal incontinence
 Dehydration

Diagnosis of IBD
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 Clinical
 Tests to R/O differntial dx
 Imaging (Barium studies,CT and MRI enterography
 Endoscopic ,colonoscopy,
 Histopathology
 Serologic tests

Histopathology:UC
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Nursing diagnosis of IBD
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 Diarrhea R/t to inflammation of bowel AEB loose watery stool ,
abdominal cramping and pain , increased urgency to defecate ,
tenesmus and increased bowel sounds
 Imbalance nutrition related to altered absorption of nutrients.
 Acute pain related to abdominal muscle spasm secondary to IBD

Treatment of IBD
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Goals of RX:
 Ameliorate/ Improve symptoms
 Improve quality of life
 Maintain adequate nutrition
 Prevent complications

Components of RX
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 Medical
 5 ASAs
 Glucocorticoids
 Immunomodulators eg
• Methotrexate
• Cyclosporine
• Tacrolimus

Cont…
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 Surgical
 Nutritional
 Bowel rest and total parenteral nutrition
 Comparable effect to glucorticoids for induction of remission but
lower efficacy for maintenance in CD
 No reduction of inflammation in UC

Nursing Interventions
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 Enhancing bowel function and managing diarrhea
 Prevent dehydration
 Reduce anxiety and providing emotional support
 Manage acute pain
 Provide adequate nutrition

Irritable bowel syndrome (IBS)
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 A functional gastrointestinal (GI) disorder, meaning symptoms are
caused by changes in how the GI tract works.
 People with a functional GI disorder have frequent symptoms;
however, the GI tract does not become damaged.
 IBS is a group of symptoms that occur together, not a disease.

Cont…
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 In the past, IBS was called colitis, mucous colitis, spastic colon,
nervous colon, and spastic bowel.
 The name was changed to reflect the understanding that the disorder
has both physical and mental causes and is not a product of a
person’s imagination.

Cont…
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 IBS is diagnosed when a person has had abdominal pain or discomfort
at least three times a month for the last 3 months without other disease
or injury that could explain the pain.
 The pain or discomfort of IBS may occur with a change in stool
frequency or consistency or be relieved by a bowel movement.

Etiology of IBS?
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 The causes of IBS are not well understood.
 Researchers believe a combination of physical and mental health
problems can lead to IBS;
 Brain-Gut Signal Problems
 GI Motor Problems
 Hypersensitivity

Cont…
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 Mental Health Problems
 Bacterial Gastroenteritis
 Small Intestinal Bacterial Overgrowth
 Body Chemicals
 Genetics
 Food Sensitivity

How common is IBS and who is affected?
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 Studies estimate IBS affects 3 to 20 percent of the adult population,
with most studies ranging from 10 to 15 percent.
 However, only 5 to 7 percent of the adult population has been
diagnosed with the condition.
 IBS affects about twice as many women as men and is most often
found in people younger than age 45yrs

Classification of IBS
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IBS is often classified into four subtypes based on a person’s usual
stool consistency.
These subtypes are important because they affect the types of
treatment that are most likely to improve the person’s symptoms.

Cont…
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The four subtypes of IBS are:
1. IBS with constipation (IBS-C)
– hard or lumpy stools at least 25 percent of the time
– loose or watery stools less than 25 percent of the time
2. IBS with diarrhea (IBS-D)
– loose or watery stools at least 25 percent of the time
– hard or lumpy stools less than 25 percent of the time

Cont…
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3. Mixed IBS (IBS-M)
– hard or lumpy stools at least 25 percent of the time
– loose or watery stools at least 25 percent of the time
4. Unsubtyped IBS (IBS-U)
– hard or lumpy stools less than 25 percent of the time
– loose or watery stools less than 25 percent of the time

Clinical features
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 The most common symptoms of IBS are abdominal pain or
discomfort, often reported as cramping, along with changes in bowel
habits.
 To meet the definition of IBS, the pain or discomfort will be
associated with at least two of the following three symptoms:

Cont…
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 Bowel movements that occur more or less often than usual.
 Bowel movements that improve the discomfort.
 Stool that appears less solid and more watery, or harder and more
lumpy, than usual.
Other symptoms of IBS may include •
diarrhea—having loose, watery stools three or more times a day and
feeling urgency to have a bowel movement

Cont…
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 Constipation—having fewer than three bowel movements a week.
 Feeling that a bowel movement is incomplete.
 passing mucus
 Abdominal bloating.
 Symptoms may often occur after eating a meal.
 To meet the definition of IBS, symptoms must occur at least three
times a month.

Alarm features in IBS
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 Age > 50 years, male gender.
 Weight loss.
 Nocturnal symptoms.
 Family history of colon cancer.
 Anemia.
 Rectal bleeding.

Diagnosis of IBS
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 To diagnose IBS, a health care provider will conduct a physical exam
and take a complete medical history.
 The medical history will include questions about symptoms, family
history of GI disorders, recent infections, medications, and stressful
events related to the onset of symptoms.
 An IBS diagnosis requires that symptoms started at least 6 months prior
and occurred at least three times a month for the previous 3 months.

Cont…
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 Stool test is the analysis of a sample of stool.
 A lower GI series is an x ray that is used to look at the large intestine.
 Flexible sigmoidoscopy and colonoscopy

Nursing Diagnosis of IBS
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 Diarrhea r/t segmental narrowing of lumen.
 Risk for deficient fluid volume r/t excessive losses sever frequent
diarrhea and vomiting
 Ineffective coping r/t poor coping mechanisms

Rome 3 criteria for diagnosis of IBS
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 Recurrent abdominal pain or discomfort at least 3ds/m in the last
3ms with 2 or more of the following:
1. Improvement with defecation.
2. Onset associated with a change in frequency of stool.
3. Onset associated with a change in form ( appearance) of stool.

Management and Treatments IBS
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Though IBS does not have a cure, the symptoms can be treated with a
combination of
 Changing in eating, diet, and nutrition.
 Medications
 Probiotics -are live microorganisms, usually bacteria, that are similar
to microorganisms normally found in the GI tract.
 Therapies for mental health problems

Eating, Diet, and Nutrition
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 Large meals can cause cramping and diarrhea, so eating smaller
meals more often, or eating smaller portions.
 Eating meals that are low in fat and high in carbohydrates, such as
pasta, rice, whole-grain breads and cereals, fruits, and vegetables.
 Certain foods and drinks may cause IBS symptoms in some people,
such as foods high in fat, some milk products, drinks with alcohol or
caffeine, drinks with large amounts of artificial sweeteners

Medications
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 Laxatives may help constipation.
 Loperamide is an antidiarrheal that has been found to reduce diarrhea.
 Antispasmodics, such as hyoscine, help to control colon muscle spasms
and reduce abdominal pain.
 Lubiprostone (Amitiza) improve abdominal pain or discomfort, stool
consistency, straining, and constipation severity. •
 Linzess is relieve abdominal pain and increase the frequency of bowel

Therapies for Mental Health Problems
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 Talk therapy may reduce stress and improve IBS symptoms.
 Two types of talk therapy used to treat IBS are cognitive behavioral
therapy and psychodynamic, or interpersonal, therapy.
 Cognitive behavioral therapy focuses on a person’s thoughts and
actions.
 Psychodynamic therapy focuses on how emotions affect IBS
symptoms.

Nursing Intervention
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 Identify triggers and risk factors of IBS
 Increase fiber intake
 Psychological support
 Avoiding gas form foods

Summary (conclusion) IBD
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 IBD is characterized by a tendency for chronic or relapsing immune
activation and inflammation within the gastrointestinal tract (GIT).
 It Need long term management with primary goal to induce then
maintain remission and prevent complications of both the disease and
drugs
 IBS is a group of symptoms that occur together, not a disease.
 IBS Is condition in which content move too fast or too slow through the
intestine usually accompanied by abdominal pain

Reference
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 Russell RK, Satsangi J. Does IBD run in families? Inflamm Bowe Dis.
2008;14(S2):S20-S21
 Noble CL, Arnott IDR. What is the risk that a child will develop inflammatory bowel
disease if one or both parents have IBD? Inflamm Bowel Dis. 2008;14(S2):S22-S23.
 Bennett RA, Rubin PH, Present DH. Frequency of inflammatory bowel disease in
offspring of couples both presenting with inflammatory bowel disease.
Gastroenterology.
1991;100:1638-1643.
 CDC/NCHS national hospital discharge survey: United States,2010. Centers for
Disease Control and Prevention website.
www.cdc.gov/nchs/data/nhds/10Detaileddiagnosesprocedures/
2010det10_numberalldiagnoses.pdf. (PDF, 1,506 KB)* Accessed May 2, 2013.
 Kappelman MD, Rifas-Shiman SL, Porter CQ, et al. Direct health care costs of
Crohn’s disease and ulcerative colitis in US children and adults. Gastroenterology.
2008;135(6):1907-1913.

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