Gastrointestinal Disorders: Crohn's and Colitis

• Inflammatory bowel disease (IBD) can affect structures or segments along the gastrointestinal tract.
• The term IBD includes both acute and chronic disorders.
• Acute and chronic IBD can result in nutritional deficits, altered bowel elimination, infection, pain, and fluid or electrolyte imbalances.

Acute Inflammatory Bowel Disease

• Appendicitis is an example of acute inflammatory bowel disease.
• Gastroenteritis is another example of acute inflammatory bowel disease.

Appendicitis

• Appendicitis is the inflammation of the vermiform appendix.
• Appendicitis is caused by an obstruction of the lumen or opening of the appendix and fecaliths.
• Adolescents and young adults are at increased risk of contracting appendicitis.

Peritonitis

• Peritonitis is inflammation of the peritoneum.
• Peritonitis results from infection of the peritoneum due to puncture (surgery or trauma), rupture of part of the gastrointestinal tract (diverticulitis, peptic ulcer disease, appendicitis, bowel obstruction), or infection from continuous ambulatory peritoneal dialysis.

Gastroenteritis

• Gastroenteritis is inflammation of the stomach and small intestine.
• Gastroenteritis is triggered by infection (either bacterial or viral).
• Vomiting and frequent, watery stools associated with gastroenteritis place the client at increased risk for fluid and electrolyte imbalance and impaired nutrition.

Chronic Inflammatory Bowel Disease

• Ulcerative colitis, Crohn’s disease, and diverticulitis are examples of chronic inflammatory bowel disease.
• Ulcerative colitis and Crohn’s disease are characterized by frequent stools, cramping abdominal pain, exacerbations, and remissions.

Ulcerative Colitis

• Ulcerative colitis involves edema and inflammation primarily in the rectum and rectosigmoid colon.
• In severe cases, ulcerative colitis can involve the entire length of the colon.
• Edema and thickened bowel mucosa can cause partial bowel obstruction.
• Intestinal mucosal cell changes can lead to colon cancer.
• The mucosa, submucosa, and the colon will become edematous and reddened and can bleed easily.

Crohn’s Disease

• Crohn’s disease is inflammation and ulceration of the gastrointestinal tract, often at the distal ileum.
• All bowel layers can become involved; lesions are sporadic.
• Fistulas and abscesses are common in Crohn's disease.
• Crohn’s disease can involve the entire GI tract from the mouth to the anus.
• Malabsorption and malnutrition can develop when the jejunum and ileum become involved, requiring supplemental vitamins and minerals, possibly including vitamin B12 injections.

Diverticulitis

• Diverticulitis is inflammation and infection of the bowel mucosa caused by bacteria, food, or fecal matter trapped in one or more diverticula (pouch-like herniations in the intestinal wall).
• Diverticulitis is not to be confused with diverticulosis, which is the presence of many small diverticula in the colon without inflammation.
• Not all clients who have diverticulosis develop diverticulitis.
• Diverticula can perforate and cause peritonitis and/or severe bleeding.

Etiology and Risk Factors

• Etiology of ulcerative colitis and Crohn’s disease is unknown but possibly due to a combination of genetic, environmental, and immunological causes.
• Risk factors for ulcerative colitis and Crohn’s disease include genetics and culture.
• Risk factors for diverticular disease include being African American.
• Risk factors for Crohn’s disease include tobacco use.

Expected Findings for Ulcerative Colitis

• Abdominal pain/cramping often presents as left-lower quadrant pain relieved with defecation.
• Patients often experience anorexia and weight loss.
• Fever.
• Diarrhea: up to 15 to 30 liquid stools/day.
• Stools containing mucus or blood.
• Abdominal distention, tenderness, and/or firmness upon palpation.
• Rectal bleeding.

Expected Findings for Crohn's Disease

• Abdominal pain/cramping often presents as right-lower quadrant pain that is relieved by defecation.
• Patients often experience anorexia and weight loss.
• Fever.
• Diarrhea: approximately five loose stools/day.
• Abdominal distention, tenderness and/or firmness upon palpation.
• Anemia and malaise.

Expected Findings for Diverticulitis

• Acute onset of abdominal pain often in left-lower quadrant.
• Nausea and vomiting.
• Fever.
• Diarrhea or constipation.
• Abdominal distention.

Laboratory Tests for IBD (Ulcerative Colitis and Chron's)

• Decreased hematocrit and hemoglobin.
• Increased erythrocyte sedimentation rate (ESR).
• Increased WBC.
• Decreased albumin.
• Increased C-reactive protein.
• Stool for occult blood can be positive.
• Decreased electrolytes.

Diagnostic Procedures for IBD

Magnetic Resonance Enterography

• Used with all IBD
• Maintain NPO for 4 to 6 hr prior to the exam.
• You might be asked to drink a contrast medium prior to the test.

Ulcerative Colitis

• Sigmoidoscopy or colonoscopy: Intestinal tissue specimens can be collected to differentiate IBD.
• Barium enema: Helpful to distinguish ulcerative colitis from other disease processes
• CT scan or MRI: Can identify the presence of abscesses
• Stool examination: For the presence of parasites or microbes, blood and mucus

Crohn’s Disease

• Endoscopy.
• Newer diagnostic tools used, such as video capsule endoscopy.
• Proctosigmoidoscopy: Performed to identify inflamed tissue.
• Colonoscopy and sigmoidoscopy: A lighted, flexible scope inserted into the rectum to visualize the rectum and large intestine and to collect intestinal tissue specimens.
• Abdominal ultrasound, x-ray, and CT scan: CT scans can show bowel thickening.
• Barium enema: A barium enema can show the presence of diverticulosis and is contraindicated in the presence of diverticulitis due to the risk of perforation.

Nursing Actions for Diagnostic Procedures

• Reinforce teachings about the procedure.
• Assist with preparing the bowels prior to the procedure.

Findings in Diagnostic Procedures

• Small intestine ulcerations and narrowing is consistent with Crohn’s disease.
• Ulcerations and inflammation of the sigmoid colon and rectum is significant for ulcerative colitis.

Client Education for Diagnostic Procedures

• Remain NPO as required, and perform bowel preparation.
• There can be possible abdominal discomfort and cramping during the barium enema.
• Stools will be white in color after the procedure and return to normal after all of the barium is expelled.

Nursing Care for Ulcerative Colitis and Crohn’s Disease

• Supportive care includes promoting rest, decreasing stressors, providing nutritional support and treating symptoms.
• Instructions regarding the usual course of the disease process should be provided.
• Instructions regarding medication therapy and vitamin supplements should be provided.
• Monitor by colonoscopy due to the increased risk of colon cancer.
• Assist the client in identifying foods that trigger manifestations.
• Monitor for electrolyte imbalance, especially potassium. Diarrhea can cause a loss of fluids and electrolytes.
• Monitor I&O, and check for dehydration.

Client Education for Ulcerative Colitis and Crohn’s Disease

• Seek emergency care for indications of bowel obstruction or perforation (fever, severe abdominal pain, vomiting).
• For extreme or long exacerbations, NPO status and administration of total parenteral nutrition promotes bowel rest while providing adequate nutrition.
• Avoid caffeine, alcohol, and lactose.
• Eat high-protein, high-calorie, low-fiber foods.
• Small, frequent meals can reduce the occurrence of manifestations.
• Dietary supplements that are high in protein and low in fiber (elemental and semi-elemental products, canned nutrition beverages) can be used.
• Weigh 1 or 2 times weekly.
• Use vitamin supplements and B12 injections, if needed.

Nursing Care for Diverticulitis

• For severe manifestations (severe pain, high fever), the client is hospitalized, kept NPO, and receives nasogastric suctioning, IV fluids, IV antibiotics, and IV opioid analgesics for pain.
• Instruct the client who has mild diverticulitis about self-care at home, including medications as prescribed (antibiotics, analgesics, antispasmodics) and getting adequate rest.
• Reinforce instructions to promote normal bowel function and consistency, avoiding laxatives and enemas, and drinking adequate fluids.

Client Education for Diverticulitis

• Consume a clear liquid diet until manifestations subside.
• Progress to a low-fiber diet once solid foods are tolerated without other manifestations.
• Slowly advance to a high-fiber diet as tolerated when inflammation resolves.
• Avoid seeds or indigestible material (nuts, popcorn, seeds), which can block diverticulum.
• Avoid foods or drinks that can irritate the bowel, like alcohol, and limit fat to 30% of daily calorie intake.

Medications for Ulcerative Colitis and Crohn’s Disease

5-aminosalicylic Acid

• Anti-inflammatory Reduces inflammation of the intestinal mucosa and inhibits prostaglandins.
• Contraindicated if the client has a sulfa or salicylate allergy.
• Adverse effects include nausea, fever, and rash.
• Monitor CBC, and kidney and hepatic function.
• Monitor for the development of agranulocytosis, hemolytic anemia, and macrocytic anemia.
• Take the medication with a full glass of water after meals.
• Avoid sun exposure.
• Increase fluid intake to 2 L/day.
• This medication can cause urine, skin, and contact lenses to have a yellow-orange color.
• Notify the provider if nausea, vomiting, anorexia, sore throat, rash, bruising, or fever occur.
• Take medication as directed.
• The usual maintenance dose of sulfasalazine is 2 to 4 g/day.

Sulfonamides: Sulfasalazine

Nonsulfonamides

• Mesalamine and Balsalazide
• The adverse effects are not as serious as sulfasalazine.
• These medications can be contraindicated if the client has a salicylate or sulfa allergy.
• Monitor for kidney toxicity.
• Report headache or gastrointestinal problems (abdominal discomfort, diarrhea).

Corticosteroids

• Reduces inflammation and pain
• For rectal inflammation, topical steroids can be administered by a retention enema.
• Used to induce remission.
• Not for long-term use due to adverse effects.
• Prolonged use can lead to adrenal suppression, osteoporosis, risk of infection, and cushingoid syndrome. Use corticosteroids in low doses to minimize adverse effects.
• Can slow healing.
• Medications include Prednisone, Prednisolone, Hydrocortisone, and Budesonide.
• Monitor blood pressure, electrolytes and glucose.
• Reduce systemic dose slowly.
• Take the oral dose with food.
• Avoid discontinuing dose suddenly.
• Report unexpected increase in weight or other indications of fluid retention.
• Avoid crowds and other exposures to infectious diseases.
• Report evidence of infection (Crohn’s disease can mask infection).

Immunosuppressants

• Mechanism of action in treatment of IBD is unknown.
• Medications include Cyclosporine, Methotrexate, Azathioprine, and Mercaptopurine.
• Monitor for pancreatitis and neutropenia.
• Can take up to 6 months to see therapeutic effects.
• Not used as monotherapy.
• Reserved for refractory disease due to toxicity.
• Avoid crowds and other chances of exposures to infectious diseases, and report evidence of infection.
• Monitor for indications of bleeding, bruising, or infection.

Immunomodulators

• Suppresses the immune response
• Inhibits tumor necrosis factor, an antibody found in Crohn’s disease
• Medications include Infliximab, Adalimumab (self-administered by subcutaneous injection), Natalizumab (can cause progressive multi-focal leukoencephalopathy, a deadly brain infection), and Certolizumab.
• Many adverse effects are possible, including chills, fever, hypotension/hypertension, dysrhythmias, and blood dyscrasias.
• Monitor liver enzymes, coagulation studies, and CBC.
• Avoid crowds and other exposures to infectious diseases, and report evidence of infection.
• There is a risk for development or reactivation of tuberculosis.
• Monitor and report evidence of bleeding, bruising, or infection, and transfusion or allergic reaction.

Antidiarrheals

• Suppress the number of stools
• Used to decrease risk of fluid volume deficit and electrolyte imbalance, and to reduce discomfort.
• Use of antidiarrheals can lead to toxic megacolon (massive dilation of the colon with a risk of the development of gangrene and peritonitis), and should be used cautiously.
• Medications include Diphenoxylate and atropine and Loperamide.
• Observe for manifestations of toxic megacolon that can result in gangrene and peritonitis (hypotension, fever, abdominal distention, decrease or absence of bowel sounds).
• Observe for indications of respiratory depression, especially in older adult clients.
• Due to the central nervous system effects, avoid hazardous activities until the response to the medication is established.

Medications for Diverticulitis

Antimicrobials

• Treat infection and decrease inflammation in Crohn’s disease.
• Used to treat abscesses or fistulas.
• Discontinue ciprofloxacin for tendon pain, as it can cause tendon rupture.
• Decreased dose should be used for clients who have impaired kidney function.
• Medications include Ciprofloxacin, Metronidazole, and Sulfamethoxazole-trimethoprim.
• Monitor kidney and hepatic studies.
• Can cause a superinfection; observe for manifestations of thrush or vaginal yeast infection.
• Urine can darken (expected, harmless effect).
• Monitor for manifestations of CNS effects (numbness of extremities, ataxia, and seizures), and notify the provider immediately.

Therapeutic Procedures

• Clients who do not have success with medical treatment or who have complications (bowel perforation, colon cancer) are candidates for surgery.
• For ulcerative colitis, a colectomy/proctocolectomy with or without ileostomy may be performed.
• For crohn's disease, a laparoscopic stricturoplasty to increase the diameter of the bowel for bowel strictures or surgical repair of fistulas may be performed.
• For cases of diverticulitis, surgery may be required for rupture of the diverticulum that results in peritonitis, bowel obstruction, uncontrolled bleeding, or abscess, and colon resection with or without colostomy may be performed.

Preoperative Care

• Preoperative care is similar to other abdominal surgeries.
• If the creation of a stoma is planned, collaborate with an enterostomal therapy nurse regarding care related to the stoma.
• Administer antibiotic bowel prep, if prescribed.
• Administer cleansing enema or laxative, if prescribed.

Postoperative Care

• Postoperative care is similar to care for clients who have other types of abdominal surgery.
• The client should be NPO and have a nasogastric tube to suction, unless the surgery was performed laparoscopically.
• Monitor bowel sounds and check for abdominal distension.
• Observe color, amount, odor of surgical drains or drainage.
• An ileostomy can drain as much as 1,000 mL/day. Prevent fluid volume deficit and replace fluid loss with IV fluids if the client is NPO. Oral hydration is slowly introduced in 1 to 2 days.
• Care after discharge: Refer the client who has an ostomy to an enterostomal therapist and an ostomy support group.

Interprofessional Care

• Assist with obtaining a referral for nutritional counseling.
• The client might benefit from complementary therapy (biofeedback, massage, yoga).
• Recommend community support groups or a mental health referral for assistance with coping.

Complications of Ulcerative Colitis, Crohn’s Disease, and Diverticulitis

• Bleeding and fluid and electrolyte imbalance.
• Peritonitis can occur due to perforation of the bowel.
• Abscess formation can occur as a complication of diverticular disease and Crohn’s disease.

Peritonitis

• A life-threatening inflammation of the peritoneum and lining of the abdominal cavity
• Often caused by bacteria in the peritoneal cavity
• Rigid, board-like abdomen (hallmark indication).
• Abdominal distention.
• Nausea, vomiting.
• Rebound tenderness.
• Tachycardia.
• Fever.
• Early manifestation in older adult clients: decreased mental status, confusion
• Place the client in Fowler’s or semi-Fowler’s position to promote drainage of peritoneal fluid and improve lung expansion.
• Monitor respiratory status and administer oxygen as prescribed. Turn, cough, and deep breathe. Mechanical ventilation can be required.
• Maintain and monitor nasogastric suction.
• Keep the client NPO.
• Monitor fluid and electrolyte status and for hypovolemia.
• Administer analgesics as prescribed.
• Monitor bowel sounds.
• Monitor for reports of passing flatus.
• Monitor for manifestations of paralytic ileus which includes slowing or absence of bowel sounds.
• Assist with the administration of hypertonic IV fluids and broad-spectrum antibiotics as prescribed.
• Collaborate with case management to determine home care and wound management needs.
• If surgery is performed, closely monitor postoperative vital signs, I&O every hour immediately after surgery, and surgical dressing for bleeding.
• If the client requires wound irrigation postoperatively, use sterile technique, and monitor irrigation intake and output to prevent fluid retention.
• Maintain adequate rest and resume home activity slowly, as tolerated. No heavy lifting for at least 6 weeks.
• Monitor for evidence of return infection, and notify the provider immediately.

Bleeding Due to Deterioration of the Bowel

• Observe for indications of rectal bleeding (black, tarry stools; bright red blood).
• Monitor vital signs and check laboratory values, especially hematocrit, hemoglobin, and coagulation factors.
• Report rectal bleeding and understand the importance of bed rest.

Fluid and Electrolyte Imbalance

• This occurs due to loss of fluid through diarrhea, vomiting, and nasogastric suctioning.
• Monitor laboratory values, and provide replacement therapy.
• Monitor weight and for indications of fluid volume deficit (loss or absence of skin turgor).
• Record and report the number of loose stools.
• Maintain adequate fluid intake and follow the prescribed diet.

Abscess and Fistula Formation

• Occurs due to the destruction of the bowel wall, leading to an infection.
• Monitor fluid and electrolytes.
• Observe for manifestations of dehydration (decreased urine output, fever, hypotension, tachycardia, dizziness).
• Provide a diet high in protein and calories (at least 3,000 calories/day) and low in fiber.
• Administer a vitamin supplement.
• Consult with an enterostomal therapist to develop a plan to prevent skin breakdown and promote wound healing.
• Monitor for evidence of infection, which can indicate abdominal abscesses or sepsis.
• Ensure the function of drainage devices if used.

Toxic Megacolon

• Occurs due to inactivity of the colon.
• Massive dilation of the colon occurs, and the client is at risk for perforation.
• Maintain nasogastric suction.
• Assist with the administration of IV fluids and electrolytes.
• Administer prescribed medications (antibiotics, corticosteroids).
• Prepare the client for surgery (usually an ileostomy) if the client does not begin to show improvement within 72 hr.

Explore Crohn's disease, ulcerative colitis, appendicitis, and gastroenteritis. Understand their causes, manifestations, and complications. Learn about differentiating characteristics and potential long-term risks.