Inflammatory bowel disease

Ulcerative colitis
- Type of inflammatory bowel disease that causes
inflammation and ulcers in the inner lining of the colon and
rectum
- Destroys cells of the lining, forms ulcers which bleed and
release pus or mucus
- Colon has difficulty absorbing water and minerals
(dehydration, decreased appetite and weight)
- Inflammation causes urgent and frequent emptying
- Causes:
o Environmental source:
§ Diet (high in fat)
§ Allergy to dairy
§ Stress
§ Illness
§ NSAIDs
o Genetic factor
- Types:
o Ulcerative proctitis – affects rectum
o Proctosigmoiditis – affects rectum and sigmoid
o L-sided colitis – affects rectum, sigmoid, and descending
o Pancolitis – affects all the colon and rectum
- Signs and symptoms:
o Urgent BMs
o Low RBCs (anemia, loss of weight
o Cramps in abdomen
o Electrolyte imbalances, elevated
o Rectal bleeding
o Severe diarrhea with blood, pus, and mucus
o Fever
- Complications:
o Flare-ups and remission
o Ulcerative sites will heal but the lining will be damaged
o Polyps will form (psuedopolyps)
o Scar tissue
§ Leads to bowel narrowing and shortening.
o Will no longer have small pouches (haustra) present
§ Helps food churning throughout large intestine
- Complications in severe cases:
o Rupture of the bowel
§ Holes form in the bowel from repeated ulceration
§ Leads to peritonitis (leaking of intestinal contents into the abdominal
cavity)
• S+S = distention, increased HR, tachypnea, pain
 o Toxic megacolon
§ The large intestine dilates due to inflammation = toxic
§ Large intestine is unable to function properly and becomes paralyzed,
eventually rupturing
§ S+S = tachycardia, dehydration, abdo distention, pain, hypoactive bowel
sounds, diarrhea, fever
- Diagnostic tests:
o Colonoscopy
§ Small camera used to examine the whole colon
o Barium enema
§ X-ray used to assess the colon
§ Enema of contrast is given through the rectum to help line the colon and
rectum for x-ray pictures
- Nursing interventions:
o Monitor VS, bowel movements
o Keep pt. hydrated
o Monitor daily weights
o Focus on GI assessment
o TPN
o May be NPO with IV hydration
- Nutrition education:
o Food to avoid during flare-up:
§ High fiber
§ Nuts, raw vegetables, fruits
§ Allergen type foods: dairy, wheat, fish
§ Spicy
§ High fat
§ Gluten
§ Gas causing (beans, onions)
o Food to eat during flare-up:
§ Low fiber (white bread, white rice…)
§ High protein
§ Stay hydrated
- Drug regimen
o Control flare-ups and maintain remission
o Anti-inflammatory:
§ 5-aminosalicylates (5-ASA)
• First line for mild-moderate
• Helps maintain remission
• Prevents flare-ups
§ Corticosteroids
• Used when ASAs aren’t working
• Not used long term
 o Prednisone
§ Side effects:
• Increased blood sugar
• Weight gain – increased appetite
• Keeps you awake (take in the morning)
• Thinning skin
• Easy bruising
• Osteoporosis
o Immuno-suppressors/modulators:
§ Used when other meds haven’t worked or need to be off steroids
§ Work by decreasing response of the immune system
§ Immunosuppressors:
• Azathioprine/Imuran
o Risk for infection and cancer
o No live vaccines
§ Immunomodulators:
• Adalimumab/Humira
o Tumor necrosis factor blocker
o Antibiotics:
§ Treat or prevent infections during flare-ups
o Antidiarrheal meds:
§ Imodium use sparing
§ Watch for toxic megacolon risk
o Pain:
§ No NSAIDs
§ Can cause flare-ups
- Surgery
o Proctocolectomy
§ Complete removal of the colon and rectum
§ Patient will have a permanent ileostomy
o Ileoanal anastomosis (J-pouch)
§ Colon and rectum removed, and a pouch is created that is attached to the
ileum to allow stool to pass from the small intestine to the anus
§ No ostomy created
Crohn’s disease
- Can be found throughout both the large and small intestine
- Affects the whole bowel wall – causes ulcer formation that extends all the way through
the serosa
- Presents in patches throughout GI tract
- Can have healthy patched of lining next to diseased parts which gives
it a cobblestone appearance when the patient is scoped
- Cause:
o Faulty immune system that may be triggered by:
§ Environmental source:
• Allergens to foods
• Stress
• Illness
• Virus/bacteria from GI illnesses as with
gastroenteritis
• Smoking
• Medications like NSAID usage
§ Genetic factors:
• Run in families
- Cycle of disease
o Periods of flare-ups and remission which leads to the chronic cycle of healing vs
lining damage, hence the development of scar tissue
o No cure
o Bowel resection surgery can help improve the patient’s symptoms which is where
the diseased part of the bowel is removed
- Symptoms
o Abdominal tenderness
o Loss of appetite
o Weight loss
o Fever
o Fatigue
o Rectal bleeding
o Anal skin tags and ulcers
o Diarrhea
o Abdominal cramps
o Blood in stool
o Perianal fistula
o Inflammation of your joint or skin
o Anemia and related shortness of breath
- Complications
o Fistulas
o Ulcers
o Anal fissure
o Malnutrition
o Colon cancer
o Strictures
- Medication risks
o Lower immune system function and may increase risk of cancer and infections
o Corticosteroids are also associated with increased risk of glaucoma, cataracts,
diabetes, high BP, bone fractures, and osteoporosis
- Nursing interventions
o Help patients understand the disease
o Medication treatment
o Diet
o Surgery to correct strictures, fistulas, abscesses, or bowel restrictions to remove
diseased parts of the bowel
o Smoking cessation
o Administering TPN in severe cases
o Calculating precise in and out
o Monitoring GI system (BMs, pain/bloating, vomiting…)
- Foods to avoid
o Alcohol and caffeine
o Carbonated drinks
o Refined sugars
o Dairy products
o Raw vegetables
o Fruits with pulp or seeds
o Spicy foods
o Nuts and seeds
o Gluten and whole grains
o Popcorn
- Medications (same as UC)
o Control flare-ups and maintain remission
o Anti-inflammatory:
§ 5-aminosalicylates (5-ASA)
• First line for mild-moderate
• Helps maintain remission
• Prevents flare-ups
§ Corticosteroids
• Used when ASAs aren’t working
• Not used long term
o Immuno-suppressors/modulators:
§ Used when other meds haven’t worked or need to be off steroids
§ Work by decreasing response of the immune system
§ Immunosuppressors:
• Azathioprine/Imuran
o Risk for infection and cancer
o No live vaccines
§ Immunomodulators:
• Adalimumab/Humira
o Tumor necrosis factor blocker
 o Antibiotics:
§ Treat or prevent infections during flare-ups
o Antidiarrheal meds:
§ Imodium use sparing
§ Watch for toxic megacolon risk
o Pain:
§ No NSAIDs
§ Can cause flare-ups
- Diagnostic tests
o Barium swallow
§ X-ray used to assess the pharynx and esophagus
§ Enema of contrast is given through the mouth to help line the GI tract for
x-ray pictures
o Esophagogastroduodenoscopy gastroscopy (G-scope)
§ To visualize and assess the esophagus, stomach, and upper portion of the
duodenum to assist in diagnosis of bleeding, ulcers, inflammation, tumors,
and cancer
§ Reasons for upper endoscopy:
• Unexplained discomfort
• GERD
• Persistent nausea and vomiting
• Upper GI bleeding
• Iron deficiency anemia
• Difficulty swallowing
• Removal of foreign body
• To check healing or progress on previously found polyps, tumors,
or ulcers
§ Complications:
• Aspiration of food or fluids into lungs
• Reactions to the sedative meds
• Bleeding can occur from biopsies
• Endoscope can cause a tear or hole in the area being examined
(rare)
§ Instruct the patient to fast and restrict fluids for 6-8 hrs prior to the
procedure to reduce the risk of aspiration related to nausea and vomiting
§ The patient may be required to be NPO after midnight
§ Risk of bleeding: the patient should be instructed to avoid taking natural
products and medications with known anticoagulant, antiplatelet, or
thrombolytic properties or to reduce dosage, as ordered, prior to the
procedure
§ Normal findings:
• Esophageal mucosa is normally yellow-pink
• Gastric mucosa is orange-red and contains rugae
• No abnormal structures or functions are observed in the esophagus,
stomach, or duodenum
o Colonoscopy (C-scope)
§ To visualize and assess the lower colon for tumors,
cancer, and infection
§ Prior to C-scope:
• Informed consent
• Medical history
• Check for allergies, bleeding history,
medications…
• Provide info about the procedure (permits
examination of the large intestine’s lining,
describe procedure)
• Ensure the patient has complied with the
bowel preparation (clear-liquid diet for 24-
48 hrs before, NPO midnight, laxative 1
gallon of GoLYTELY solution in the evening
• Establish IV for sedatives
• Provide reassurance
• Air introduced through colonoscope (to distend intestinal wall and
facilitate viewing the lining and advancing the instrument)
• Instruct to empty bladder before test
• Remove all jewellery
§ Monitor VS and neuro status every 15 mins for 1 hr, then every 2 hrs
§ It is normal to have mild abdominal cramping and passing of gas after the
test
§ Need to stay in clinic for 1-2 hrs after
§ Encourage increased fluid intake
§ If sedated = no driving for 24 hrs
§ Risk of bleeding
• The patient should be instructed to avoid taking natural products
and medications with known anticoagulant, antiplatelet, or
thrombolytic properties or to reduce dosage prior to procedure
§ Normal intestinal mucosa with no abnormalities of structure, function, or
mucosal surface in the colon or terminal ileum
Pancreatitis
- Acute pancreatitis refers to the sudden inflammation and destruction of the pancreas
- Digestive enzymes gets activated while still in pancreas
- Degree of inflammation varies from mild edema to severe hemorrhagic necrosis
- Most common causes are alcohol abuse and gallstones in gallbladder
- Pancrease is destroyed by its own digestive enzymes – triggers infammatory response
o Can cause blood vessels to become leaky, causing fluis to collect around pancreas
o Leads to parenchymal edema
o The edema causes capsule of the pancreas to swell and digestive anzymes digest
and destroy the peripancreatic fat
o Blood vessels may rupture – hemorrhage
o Can ultimately liquify the pancreatic tissue – called liquefactive hemorrhagic
necrosis
- Can result from:
o Cholelithiasis (gallstones): one of the most common causes of acute pancreatitis
o Ethanol: heavy alcohol use also common, may account for 30%
o Large quantities of steroids: can induce pancreatitis through an unknwon
mechanism within 2 week of exposure
o Endoscopic retrograde cholangiopancreatography (ERCP): diagnose conditions
of the biliary or pancreatic ducts
o Pancreatic duct obstruction: which can be caused by gallstones, tumours,
parasites
o Genetic diseases: cystic fibrosis, acinar cell injury caused by alcohol
o Viral infections: like paramyxovirus
o Autoimmune diseases: like lupus
o Ischemia: abdominal trauma
- Causes from med side-effects:
o Immunosuppressants: azathioprine, mercaptopurine, leflunomide
o Chemotherapy: asparaginase
o Antimicrobials: pentamidine, didanosine, tetracyclines, dapsone, isoniazid,
metronidazole, sulfonamides
o Anticonvulsants: valproic acid
o Hormone therapy: estrogen, tamoxifen
o NSAIDs: mesalamine, celecoxib, sulindac
o BP meds: thiazides, enalapril, methyldopa
o Antilipidemic: simvaststin, fenofibrate
o Antiarrhythmic: procainamide
o Antidiabetic: sitagliptin, exenatide
- Complications:
o Pancreatic tissue destruction, which triggers an inflammatory response
§ Can cause blood vessles to become leaky, causing fluid to collect around
the pancreas, which leads to parenchymal edema
§ The edema causes the capsule of the pancreas to swell, and digestive
enzymes digest and destroy the peripancreatic fat
 o Blood vessels may rupture, causing hemorrhage
§ All of the tissue digestion and hemorrhage can liquify the pancreatic
tissue, a process called liquefactive hemorrhagic necrosis
o Formation of pancreatic pseudocyst (when fibrous tissue develops around the
liquefactive necrotic tissue of the pancreas)
§ Pancreatic pseudocysts have the potential to rupture, causing severe
hemorrhage and the release of pancreatic juice full of digestive enzymes
into the abdominal cavity, which can lead to a massive inflammatory
reaction that may develop into peritonitis
§ A pseudocyst can also get infection, most often by bacteria like
Escherichia choli – will become a pancreatic abscess
o Serious internal hemorrhage from damaged blood vessels, which can develop into
hypovolemic shock, the systemic activation of blood coagulation factors or
disseminated intravascular coagulation (DIC)
o Ultimately, clients may develop multi-organ failure, involving the heart kidneys,
lungs, which can lead to ARDS, which is the leading cause of death among clients
with acute pancreatitis
- Manifestations:
o Abdominal tenderness and pain in LUQ or epigastric region, which radiates to
back, and tends to worsen after eating
o Abdominal distention
o N&V
o Diarrhea
o Pyrexia
o Tachycardia
o Bluish discoloration around belly button (Cullen’s sign) or flank area (Grey
Turner’s sign) – if necrosis induced hemorrhage spreads
o Hypocalcemia (can lead to tetany) – if fatty acids bind and deplete calcium to
form soap, which is called saponification
o Fox’s sign:
§ Bruising around inguinal ligament
§ Occurs with retroperitoneal bleeding (acute hemorrhagic pancreatitis)
- Diagnostics:
o Based on clinical findings, lab tests, and imaging
o Labs: increase in blood amylase and lipase
o CBC: increase WBC or an elevated Hct due to dehydration or acute hemorrhaging
o C-reactive protein and lactate dehydrogenase
o Glucose: often high
o Calcium may be low
o Abdominal ultrasound: enlarged pancreas
o Abdominal CT: may show inflammation, necrosis, and formation of pseudocysts
o ERCP
o MCRP (magnetic resonance cholangiopancreatography
 - Collaborative care:
o Pain management
o Adequate hydration
o Prevention/alleviation of shock – may result from hemorrhage in pancreas
o Reduction of pancreatic secretions
o Control electrolyte imbalance
o Avoid food until indicated (may have IV)
o Encourage diet high in CHO content

Diverticulitis
- Formation of diverticula, which are small pouch-like protrusions that form along the
walls of a hollow structure, most commonly found in the sigmoid colon of the large
intestine
- Having multiple diverticula in the colon is called diverticulosis
- If the diverticula become inflamed its called diverticulitis
- Increase in pressure inside the colon, which pushes on the mucosa and submucosa until
they bubble out through weak spots along the wall, like where a blood vessel penetrates
the muscle layer of the intestine
- These blood vessels can get weaker and rupture, leading to GI bleeding
- Bacteria and undigested food may get stuck inside these protrusions, and cause infection
within the intestinal wall
- Risk factors:
o Age over 40
o Diet low in fiber and high in fatty
foods or red meat
o Obesity
o Sedentary lifestyle smoking
o Alcohol use
o Certain meds (NSAIDs)
- Signs and symptoms:
o Change in bowel pattern (sudden
constipation/diarrhea)
o Abdominal bleeding
- Complications:
o Walls of intestine become very thin and the arteries become very superficial
within the diverticulum wall
o The artery wall can become weak overtime and eventually lose integrity which
leads to GI bleeding or the diverticulum ruptures
o Many patients will experience painless bleeding and bright blood in stool/rectum
o Narrowing of bowel wall that leads to bowel obstruction
§ Can be due to chronic episodes of diverticulitis or the presence of acute
inflammation. Fecal matter or food can get stuck in this narrowing which
causes obstruction
 o Intestinal wall weakens so much that it creates an opening that acts as a. channel
or passage to other organs, such as another intestine or another organ. Most
common type of fistula with diverticulitis is colovesicular (fistula from intestine
to bladder)
- Manifestations:
o Abdominal pain LLQ – relieved with passing flatus or BM
o Fever/chills
o N&V
o Change in bowel habits
o Alternating constipation and diarrhea
o Painless hematochezia (blood from rectum)
o Elevated WBC
- Assessment:
o Auscultate BS
o Palpate abdomen
o Report if signs of peritonitis, including diminished or absent BS,
distention, rebound tenderness
o Prepare pt for emergent surgical intervention
- Diagnostics:
o Colonoscopy
o CT
o CBC
o Urinalysis
o Elevated inflammatory markers like CRP
o FOBT
- Collaborative care:
o Improve GI function, monitor complications, provide supportive care
o Place pt on bed rest
o NPO status
o Administer ordered IV fluids, antibiotics, analgesics
o If N&V insert NGT
o Review most recent lab test results
o Assess VS
o Report signs of severe diverticular bleeding
o Diet teaching