Crohn's Disease & Ulcerative Colitis: A Presentation PDF

CROHN’S DISEASE/ULCERATIVE COLITIS INFLAMMATORY BOWEL DISEASE Dr.Sibi Peter,PhD,RN,CCRN CROHN’S DISEASE: WHAT’S GOING ON? Peak age of onset is teens to mid 30’s, 2nd peak after 60, both sexes equally affected. More common in White’s Particularly those of Jewish and Middle Europ...

CROHN’S DISEASE/ULCERATIVE COLITIS INFLAMMATORY BOWEL DISEASE Dr.Sibi Peter,PhD,RN,CCRN CROHN’S DISEASE: WHAT’S GOING ON? Peak age of onset is teens to mid 30’s, 2nd peak after 60, both sexes equally affected. More common in White’s Particularly those of Jewish and Middle European decent Autoimmune disease A non-continuous inflammatory disease that can affect any point from the mouth to the anus. Characterized by skip lesions Periods of attacks or exacerbations and remission. No known cause, but a genetic predispositions has been confirmed. No known cure. Treatments tend to be more focused on treating inflammation. Surgery for severe cases of disease. CROHN’S DISEASE: DESCRIPTION Pathologic Characteristics  Can occur anywhere along the GI tract from mouth to anus  Most frequent site is at the terminal ileum  Noted by its skip lesions  Entire thickness of bowel wall affected  Cobblestone appearance of colonic mucosa  Granulomas and small bowel involvement is common  CROHN’S DISEASE: ETIOLOGY AND PATHOPHYSIOLOG Y Ulcerations penetrate between islands of inflamed Narrowing of the Ulcerations are edematous lumen with deep and mucosa, causing stricture longitudinal. the classic development cobblestone appearance. May cause bowel obstruction Microscopic leaks can allow bowel contents to spill into peritoneal cavity. Peritonitis may develop. Abscesses or fistulous tracts that communicate with other loops of bowel, skin, bladder, rectum, or vagina may occur. CROHN’S DISEASE: ETIOLOGY AND PATHOPHYSIOLOGY CROHN’S DISEASE: CLINICAL MANIFESTATIONS Chronic disorder with mild to severe exacerbations that occur at unpredictable intervals over many years. Diarrhea and cramp-like abdominal pain is the most common complaint Rectal Bloody stool Fever Fatigue Weight loss bleeding may occur CROHN’S DISEASE: COMPLICATIONS Extra-intestinal (systemic) Intestinal (Localized Thromboembolism to GI tract) Arthritis Fistulas Strictures Ankylosing spondylitis Anal Eye inflammation abscesses Perforation Kidney stones Carcinoma Recurrence Gallstones after surgery, Skin lesions common at of anastomosis CROHN’S Nutritional problems are very commonly seen in DISEASE: patients with Crohn’s disease. COMPLIC ATIONS Small intestine Fat malabsorpti on involvement of Anemia the disease can Electrolyte disturbances result in: Dehydration CROHN’S DISEASE: DIAGNOSTIC STUDIES History and physical examination Blood studies  CBC  Serum electrolyte levels  Serum protein levels Stool cultures  Pus  Blood  Mucus CROHN’S DISEASE: DIAGNOSTIC STUDIES CT with contrast  CT scan shows abscess formation and thickening of bowel wall due to inflammation Barium Studies  Will show “apple core” in area of stricture formation, narrowing due to inflammation, and fistula formation. Not performed if bowel perforation is a concern. MRI Small Bowel Series Capsule Endoscopy-Very high sensitivity Double Balloon Enteroscopy, Colonoscopy  Biopsy specimens  Drug Therapy  Step-Up approach uses less toxic medications first  Aminosalicylates-Work by inhibiting substances that produce inflammation  Antimicrobials  Step-Down approach uses biologic and targeted therapies first  Corticosteroids-Solumedrol, Solucortef, Decadron, Prednisone  Immunosuppressants-6- CROHN’S DISEASE: mercaptopurine (6-MP) and azathioprine (AZA)  Biologic and targeted therapies COLLABORATIVE CARE CROHN’S DISEASE: COLLABORATIVE CARE Drug therapy  Sulfasalazine (Azulfidine)  Sulfapyridine and 5-ASA  Decreases GI inflammation  Effective in achieving and maintaining remission  Mild to moderately severe attacks  Drug therapy (cont’d)  Antimicrobials  Metronidazole (Flagyl)  Ciprofloxacin (Cipro)  Corticosteroids Decrease inflammation Methylprednisone Budesonide (Entocort) CROHN’S DISEASE: COLLABORATIVE CARE CROHN’S DISEASE: COLLABORATIVE CARE Drug therapy (cont’d)  Immuno suppressants Require regular CBC monitoring  Methotrexate (very effective in Crohn’s)  Biologic therapies Anti-TNF agents CROHN’S DISEASE: COLLABORATIVE CARE Surgical Interventions Usually preformed for complications Strictureplasty- To widen areas of narrowed bowel Complete Bowel Resection  Nutritional therapy  Dietary consultant  Correct and prevent malnutrition  Replace fluid and electrolyte losses  Prevent weight loss  High-calorie  High-protein  Low-residue diet  Vitamin and iron supplements CROHN’S DISEASE:  Elemental diet COLLABORATIVE CARE CROHN’S DISEASE: NURSING MANAGEMENT Nursing Assessment Pain or discomfort  Autoimmune disorders, infection  Fluid/electrolyte balance  Diarrhea (presence of blood)  Weight loss  Anxiety, depression  Use of prescribed and OTC medicines  Family history  Coping strategies CROHN’S DISEASE: NURSING MANAGEMENT Teaching  Importance of rest and diet management  Perianal care  Action and side effects of drugs  Symptoms of recurrence  When to seek medical care  Use of diversional activities to reduce stress ULCERATIVE COLITIS An inflammatory disease of the large intestine that affects the mucosal layer beginning in the rectum and colon and spreading into the adjacent tissue. Ulcerations ,fistulas, and abscess formation occur. Bloody diarrhea with mucous is the primary symptom. Areas of inflammation form pseudo polyps.  ULCERATIVE COLITIS- CLINICAL MANIFESTATIONS Chronic disease with mild to severe exacerbations that occur at unpredictable intervals. Bloody diarrhea and abdominal pain are the most common complaints. Systemic symptoms that may occur include: Fever Weight loss Tenesmus Pain may vary from mild to severe pain associated with perforation Diarrhea may vary depending on disease Mild > no more than 4 semi formed stools per day with small amount of blood Moderate > up to 10 stools per day with increase bleeding and systemic symptoms (fever, malaise, mild anemia) Severe > 10 to 20 stools per day, diarrhea is bloody with mucus, fever, weight loss, anemia, tachycardia, dehydration  Intestinal (Localized to GI Tract) Strictures UC- Perforations COMPLIC Hemorrhage ATIONS Toxic megacolon Carcinoma Clostridium difficile infection UC- COMPLICATIO NS Extra-testinal (systemic) Thromboembolism Arthritis Ankylosing spondylitis Eye inflammation Kidney stones Gallstones Skin lesions UC- SURGERY Surgical therapy: Procedures for chronic ulcerative colitis 1. Total colectomy with rectal mucosal stripping and ileoanal reservoir 2. Total protocolectomy with continent ileostomy (Kock pouch) 3.Total protocolectomy with permanent ileostomy  Total colectomy with rectal mucosal stripping and ileoanal reservoir Combination of two procedures 8 to 12 weeks apart Adaptation over 3 to 6 months Able to control defecation at anal sphincter UC- SURGERY UC- SURGERY Total protocolectomy with continent ileostomy (Kock pouch) Rarely used today Pouch is a reservoir and is drained at regular intervals. Problems include Valve failure Leakage Pouchitis  Total protocolectomy with permanent ileostomy One-stage operation Removal of colon, rectum, and anus with closure Continence is not possible. UC- SURGERY  POSTOPERATIVE CARE- ILEOSTOMY Monitoring of stoma viability Initial drainage will be liquid. Transient incontinence of mucus from manipulation of anal canal Mucocutaneous juncture Peristomal skin integrity Enterostomal therapy nurse should help with problems. Output may be as high as 1500 to 2000 mL per 24 hours. Observe for hemorrhage, abdominal abscess, small bowel obstruction, dehydration Kegel exercises Self-care instructions given and reviewed before discharge STUDENT RESPONSE QUESTION A client who recently underwent surgery and now has a colostomy is correctly instructed by the nurse that for the next few weeks the client's diet will include foods such as: 1. Vegetables 2. Fresh fruit 3. Whole grain breads 4. Poached eggs and rice  STUDENT RESPONSE QUESTION Patients with Crohn’s Disease have no True or risk of False disease exacerba tion after having surgery. STUDENT RESPONSE QUESTION Which of the following comments made by the patient indicates that additional instruction about the care of a new ileostomy is needed? 1. “I should change the appliance daily to prevent odors.” 2. “When I change the appliance, I should check the skin for irritation.” 3. “I should clean around the stoma with mild soap and water and pat dry.” 4. “I’ll need to alter the appliance opening when the stoma becomes smaller as the area heals.”  After teaching the patient with inflammatory bowel disease about dietary modifications, the nurse determines that teaching was effective when the patient chooses which of the following menus? 1. Baked cod, baked sweet potato, and canned pears 2. Barbecued brisket, coleslaw, baked beans, and angel food cake 3. Fried shrimp with cocktail STUDENT sauce, corn on the cob, and a fruit roll-up RESPONSE 4. Turkey burger with cheese on a whole wheat bun, french QUESTION fries, and an orange