Inflammatory Bowel Disease introduction. etiology, pathophysiology of ulcerative colitis and Crohns disease, clinical manifestation, diagnostic evaluation, therapeutic management and nursing management

1. Ms. Anna Brown
Shri Venkateshwara University
Gajraula. UP
Inflammatory Bowel Disease (IBD)

2. Introduction
• The term inflammatory bowel disease is used to designate to
chronic intestinal disorder: ulcerative colitis (UD) and Crohn's
disease (CD).
• Although these two diseases are classified as IBD because of their
similar epidemiological, Immunological and clinical features, they
are two distinct conditions with significant difference.
• The most important reason for differentiating between the two is
the prognosis.
• CD is considered the more serious and disabling disorder and
medical /surgical treatment is less effective than in UC.
• Growth failure is unique and important feature of IBD in the
paediatric population.
• CD is now more common than UC.
• Between 25% and 40% of patient with CD and 15% and 40% of
patient with UC are diagnosed in childhood and adolescence.

3. Etiology
• The etiology of IBD is unknown, although there is
evidence for a multifactorial etiology.
• Several genetics and environment factors influence
incidence of IBD:
1. There is familial tendency in about 20% to 25% of
patient.
2. More whites than non-whites are affected.
3. The incidence is several times greater in Jews living in
Europe and North America than in general population.
4. There is higher occurrence of disease in children living
in urban setting than in those living in rural areas.

4. Pathophysiology: Ulcerative Colitis
• The inflammation in ulcerative colitis is limited to the colon and
rectum.
• The distal colon and rectum are often the most severely affected
 producing bloody diarrhoea or occult fecal blood
 abdominal pain, and
 varying degree of systematic manifestation
 and growth abnormalities.
• Inflammation is usually limited to the mucosa and involve continuous
segment and along the length of the bowel with varying degree of
ulceration, bleeding and oedema.
• In long-standing disease of the bowel become narrowed, smooth and
inflexible with thin or absent mucosa heavily, infiltrated by scarce
tissue.

5. Pathophysiology: Chorn Disease
• CD is a chronic inflammatory process that may involve any part of GI
tract from mouth to anus but most often affects the terminal ileum.
• The disease characteristically involves all layer of the bowel wall
(Transmural).
• Acute oedema and inflammation eventually progress to deep, transfer,
or longitudinal ulceration often associated with fissure formation.
• The inflammation may result in:
 Ulceration
 fibrosis,
 Adhesion
 stiffening of the bowel wall
 stricture formation and
 fistula to other loop of bowel, bladder, vagina or skin.

6. Clinical manifestation
Characteristics Ulcerative Colitis Chorn Disease
Rectal bleeding Common Uncommon
Diarrhea Often severe Moderate to absent
Pain Less frequent Common
Anorexia Mild or moderate Can be severe
Weight loss Moderate Severe
Growth retardation Usually mild Often marked
Anal and perianal lesions Rare Common
Fistulas and stricture Rare Common
Rashes Mild Mild
Joint pain Mild to moderate Mild to moderate

7. Diagnostic evaluation
• History
• Physical examination
• Barium enema
• Mucosal biopsy is useful in demonstrating
characteristic bowel changes
• Stool examination is performed to rule out infection
• Blood test are completed and include a CBC with
differential, serum iron, total protein, albumin and
erythrocytes sedimentation rate.

8. Therapeutic Management
• The goal of therapy are as follows:
1. Control of inflammatory process to reduce or
eliminate the symptoms
2. To obtain long-term remission.
3. Promote normal growth and development
4. Allow as normal a lifestyle as possible.
Treatment must be individualized and managed
according to the severity of disease, and its
location and response to therapy.

9. Medical treatment
1. The drug sulfasalazine has provide useful in decreasing
the frequency of recurrence in patients with mild case of
IBD. Because it's interference with the absorption and
utilization of folic acid, daily supplement of folic acid are
prescribed.
• Side effects of sulfasalazine include:
 Headache
 Nausea, vomiting
 Neutropenia- the presence of abnormally few
neutrophills in the blood, leading to increase susceptibilty
to infection.
 Oligospermia- low sperm count

10. 2. Corticosteroid are most important and effective drugs for treating moderate and
severe IBD.
• Among the new corticosteroid, Budesonide (Rhinocort)has emerged as most
promising.
• Although high dose of corticosteroid can also interfere with growth.
• Significant growth can be achieved with judicious management and maintenance of
optimum Nutrition.
• Sometimes steroid enema are helpful in reducing the need of systemic
administration for children with the Recto-sigmoid involvement.
• Hospitalization and administration of IV Corticosteroid are prescribed for severe
disease.
• Complication of high - dose steroid therapy include:
• hypertension
• osteoporosis
• Glaucoma
• Cataracts
• Hirsutism
• Diabetes and
• Altered body composition

11. Other drugs
• other drugs include:
• Metronidazole for treatment of perianal CD
• Antispasmodic drug agents, which sometimes help
relieve the discomfort of diarrhea and cramping and
• Immunosuppressive agents which is effective in patients
receiving high dose of corticosteroid
• 6-Meracaptopurine, azathioprine and cyclosporine A
have been used with success in selected patients with IBD
the major risk of these drugs include:
 Immunosuppression and bone marrow suppression,
which can cause leukopenia and opportunistic infection.

12. Nutritional Support
• Increasing evidence supports the importance of Nutrition
therapy in children with IBD.
• Malnutrition is common feature in IBD.
• Nutritional deficiency is characterized by protein energy,
malnutrition and multivitamin (Vitamin B and D), the mineral
(calcium, magnesium, iron, and zinc) deficiency.
• Growth failure affects approx. 1/3rd of the paediatric
population is by characterized by:
 weight deficit
 Alteration in body composition
 Linear growth retardation and
 Delayed sexual maturation

13. Nutritional Support (conti….)
Goal: the goal of nutritional support include:
1. Correction of specific nutrient deficient and
replacement of ongoing losses.
2. Provision of adequate energy and protein
for healing.
3. Provision of adequate nutrition means to
promote normal growth.

14. Nutritional support (conti….)
• Nutritional support include both enternal or parenteral nutrition.
• A well-balanced, high protein, high Calorie diet is recommended for children,
whose symptoms do not prohibit an adequate oral intake.
• Supplementation with multivitamin, Iron and folic acid is generally
recommended.
• Special enteral formula, given either by mouth or continuous NG infusion
often at night may be required.
• Elemental formulas have been used successfully to improve nutritional status,
as well as to induce remission in Children and adolescents with CD.
• Element formulas are completely absorbed in the small intestine within most
no residue.
• Total parenteral Nutrition has been shown to improve nutritional status in
patients, with IBD
• Improvement of nutritional status is important, however, in preventing
deterioration of patient's health status and preparing the patient for sugery.

15. Surgical treatment
• UC can be cured by the performance of a
total colectomy.
• Surgical option include a subtotal
colectomy and ileostomy which leaves a
rectal stump as a blind pouch: and J
pouch or Koch pouch, consisting of
terminal ileum, which Aid the continence
and ileoanal pull- through, which
preserve normal pathway for defecation.
• Surgery is required by children with CD
when complication cannot be controlled
by medical and nutritional therapy.
• Local resection is not curative, however,
since the disease tend to recue, and
further surgery may be needed.

16. Prognosis
• Long period of quiescent (period of inactive) disease may follow
exacerbation (an increase in the severity of a disease or its signs and
symptoms).
• The outcome of disease process is influenced by the regions and the
severity of GI involvement as well as by appropriate therapeutic
management.
• Malnutrition, growth failure, GI bleeding are serious complication of
disease.
• The overall prognosis for UC is good.
• The development of carcinoma of the colon is a long-term
complication of IBD.
 In UC, removal of the dieased bowel prevent development of
carcinoma.
 In CD, However, surgical removal of the affected bowel does not
prevent bowel cancer there for routine screening of stool specimen is
needed for early detection

17. Nursing Management
• Many of nursing consideration relates directly to the
therapeutic Management in treating IBD colitis.
• The scope of nursing responsibilities, extend beyond the
immediate period of hospitalization and involves:
1. Continued guidance of families in term of dietry
management.
2. Coping with those factors that increase stress and
emotional liability.
3. Adjusting to a disease of remission and exacerbation of
one of chronic ill health.
4. When indicated, preparing the child and parent for the
possibility of diversionary bowel surgery.

18. • Since diet therapy is important the nurse and
nutritionists should collaborate to provide dietary
counselling for the child and family members.
• Encouraging the anorexic child to consume sufficient
quantities of this diet.
• Encourage small frequent meals or a snack rather than
three large meals a day.
• Serving meals around medications schedule, when
diarrhoea, mouth pain and intestinal spasm are
controlled.
• Prepared high protein, high calorie foods such as eggnog,
milkshakes, cream soup, puddings or custard.
• food that are known to alleviate condition are avoided.

19. • Family Support
• Attending to the emotional component of chronic disease
requires a thorough assessment of disease related stress fector.
• frequently the nurse can be instrumental in helping these
children adjust to problems problem of growth, retardation,
delayed sexual maturation, dietary, restriction, feeling of being
‘different’ or a ‘sickly’ inability to compete with peers, and
necessary absence from school during exacerbation of the
illness.
• If a permanent colectomy/ileotomy is required the nurse can
assist child and family in accepting and adjusting to the change
by teaching them, how to care for the ileotomy; by
emphasizing the positive aspect of surgery, particularly
accelerated growth and sexual development , permanent
recovery and eliminated risk of colonic cancer in UC and by
stressing the normality of life despite bowel diversion.

20. • Good mouth care before eating and the selection of bland food
helps relieve the discomfort of mouth sore
• Nurses have important role in preparing children and families
to administer NG feeding or TPN when indicated.
• The purpose and the expected outcomes of these therapies
should be carefully explained.
• the child's and family member’s anxiety should be
acknowledged and they should be given adequate time to
demonstrate the skill necessary to continue the therapy at
home if needed.
• The importance of continued drug therapy despite remission
of symptom must be stressed to the parents and child.
• Failure to adhere to the pharmacological regime can result in
exhibition of the disease process.