Surgical Therapy for Inflammatory Bowel Disease

Surgical Therapy for Inflammatory Bowel Disease (IBD)

• Ulcerative Colitis (UC): Surgery is indicated for complications outlined in a table (Table 47.19). Procedures include proctocolectomy with ileal pouch-anal anastomosis (IPAA) or proctocolectomy with permanent ileostomy. Proctocolectomy is curative as UC only affects the colon.

• Crohn's Disease: Surgery is often required for complications like obstructions or lack of response to other treatments (Table 47.19). The most common procedure is resecting diseased segments and reconnecting the healthy parts (reanastomosis). Recurrence at the anastomosis site is common. Repeated surgery can lead to short bowel syndrome (SBS).

• Short Bowel Syndrome (SBS): Occurs when too little small intestine remains due to surgery or disease, impairing nutrition and hydration. Lifetime fluid and/or parenteral nutrition (PN) may be needed.

• Strictureplasty: A procedure for Crohn's disease that opens narrowed areas obstructing the bowel, preserving the intestine and reducing short bowel syndrome risk. Recurrences are uncommon.

Nutrition Therapy for IBD

• Goals of Diet Management: Adequate nutrition without worsening symptoms, correction/prevention of malnutrition, replacement of fluid and electrolyte losses, and prevention of weight loss.

• Malnutrition in IBD: Common in IBD patients, making personalized diets crucial.

• Diet Considerations: Balanced, nutritious diet with adequate calories, protein, and other nutrients. Consult a registered dietitian for guidance.

• Causes of Nutrition Problems: Reduced oral intake, blood loss, and impaired absorption, influenced by disease location. Diarrhea and inflammatory mediators can also reduce appetite.

• Iron Deficiency Anemia: Frequent in IBD patients due to blood loss and malabsorption, potentially requiring oral or intravenous iron supplements.

• Zinc Deficiency: Possible with ostomies or diarrhea. Zinc supplements may be needed.

• Cobalamin and Bile Acid Deficiencies: Terminal ileum disease can impair absorption, leading to anemia (requiring cobalamin injections) and osmotic diarrhea (treated with cholestyramine).

• Drug-Induced Nutrition Problems: Medications like sulfasalazine or methotrexate may cause folate deficiency. Corticosteroids increase the risk of osteoporosis, requiring calcium and possibly potassium supplements.

• Enteral Nutrition (EN): Preferred over parenteral nutrition (PN) during acute exacerbations to support the GI tract. High in calories and nutrients, easily absorbed.

• Food Triggers: No universal triggers; food diaries help identify trigger foods. Patients are advised to avoid or limit problematic foods causing GI distress.

Nursing Management for IBD

• Assessment: Table 47.20 outlines subjective and objective data collection (including health history, medications, symptoms, and physical findings).

• Clinical Problems: Impaired bowel elimination, malnutrition, difficulty coping, and pain are common concerns.

• Goals: Reduced acute exacerbations, normal fluid/electrolyte balance, pain/discomfort relief, adherence to treatment, nutritional balance, and improved quality of life.

• Acute Care: Focus is on hemodynamic stability, pain control, fluid/electrolyte balance, and nutritional support. Monitor intake/output, stool characteristics, blood in stool/vomitus, and vital signs. Educate on position changes with orthostatic hypotension. Prioritize meticulous perianal skincare. Consult with nutritionists.

• Postoperative Care: Similar to general postoperative care for bowel surgeries (outlined in Chapter 20).

• Ambulatory Care: Importance of patient education about the chronic nature of IBD, including rest, diet, perianal care, drug action/side effects, symptom recognition, when to seek care, and stress reduction techniques. Resources like the Crohn's and Colitis Foundation are recommended. Build rapport, encourage self-care, and discuss smoking cessation in Crohn's patients. Help set realistic goals.

• Dealing with Disease Complications: Assess and address concerns related to fatigue, sleep disturbances, nutrition deficiencies, and anxiety. Recommend stress management techniques and support groups.

• Evaluation: Expected outcomes include reduced diarrhea, normal body weight, pain/discomfort relief, and effective coping mechanisms.

Geriatric Considerations for IBD

• Second Peak in Occurrence: Sixth decade of life. Clinical course and natural history similar to younger patients but proctitis/left-sided UC might be more common.

• Diagnostic Challenges: Can be confused with other conditions like colitis, diverticulitis, or Clostridium difficile infection (CDI) in older adults.

• Increased Risks: Drug therapy and surgery have higher risks for adverse events, hospitalization, and mortality. Immunomodulator and biologic therapies have increased risk of infection and cancer. IBD patients are at higher risk for anemia and malnutrition and fluid loss from diarrhea.

• Functional Limitations: May need assistance with managing fecal urgency and frequent trips to the bathroom.