Gastrointestinal Inflammatory Disorders PDF

GASTROINTESTINAL INFLAMMATORY DISORDERS  COMPARISON 4 CROHN’S DISEASE ULCERATIVE COLITIS Chronic inflammation that Recurrent ulcerative and long can occur anywhere in the lasting inflammation of...

GASTROINTESTINAL INFLAMMATORY DISORDERS  COMPARISON 4 CROHN’S DISEASE ULCERATIVE COLITIS Chronic inflammation that Recurrent ulcerative and long can occur anywhere in the lasting inflammation of the gastrointestinal tract but inner most lining of the colon most common in the and rectum that commonly terminal ileum and begins in the rectum and ascending colon leads to spreads upward toward the thickening and scarring cecum. through all layers.  CROHN’S DISEAS ULCERATIVE COLITIS Risk Factors : -Genetic predisposition - familial tendencies more in female -Environmental factors -Infection, Smoking (crohn’s disease more prone in smokers than ulcerative colitis), -use of nonsteroidal anti-inflammatory medications, diet high in fat or refined foods and food allergies, and stress. -Dysregulated immune system- occurs when the body can't control or restrain an immune response. The body either: Underreacts to foreign invaders. This can cause infections to spread quickly.  CLINICAL MANIFESTATIONS: 6 CROHN’S DISEASE: ULCERATIVE COLITIS : Prominent right Prominent left lower quadrant abdominal pain lower quadrant Marked increase in crampy abdominal diarrhea with bloody pain mucus and intermittent Slightly increase tenesmus. (the frequent diarrhea with and urgent feeling that you need to pass stool, even if Steatorrhea your bowels are already Fever, vomiting and empty. dehydration Mild to severe rectal Anorexia, fatigue bleeding and weight loss Vomiting, dehydration but rarely fever CROHN’S DISEASE Steatorrhea - (Fatty Stool) Frequent greasy, loose stools Stools that float and are difficult to flush down the toilet Foul-smelling stools CROHN’S PATHOPHYSIOLOGY The disease process begins with edema and thickening of the mucosal, sub-mucosal and muscular layer and ulcers begin to appear. These lesions are not in continuous but rather separated by a normal tissue. Patches of inflammation occur next to healthy bowel tissue hence; these clusters of ulcers tend to take on a classic “cobblestone” appearance. Fistulas, fissures, and abscesses form as the inflammation extends into the peritoneum and the intestinal lumen narrows. Fistulas develop between loops of bowel (enteroenteric fistulas); bowel and bladder (enterovesical fistulas); bowel and skin (enterocutaneous fistulas “COBBLESTONE” APPEARANCE. ULCERATIVE COLITIS PATHOPHYSIOLOGY The disease process usually begins in the rectum and spreads proximally to involve the entire colon. The superficial mucosa of the colon becomes edematous. The desquamation or shedding of the colonic epithelium causes multiple ulcerations resulting to abscess and bleeding. The lesions are continuous, eventually, the bowel narrows, shortens, and thickens because of muscular hypertrophy and fat deposits. ULCERATIVE COLITIS Left sided colitis is called when the inflammation is at the left side of he rectum. Proctitis is limited only to the rectum. Pancolitis when the inflammation covers the entire colon.  COMPLICATIONS: 14 CROHN’S DISEASE: ULCERATIVE COLITIS : Intestinal Complications Intestinal Complications Stenosis, Abscesses and Strictures are Toxic megacolon and colorectal cancer more common Vascular engorgement and highly vascular Perforation leading to intra-abdominal granulation tissue. and perianal abscess and disease Perforation and bleeding Increased risk for colon cancer from Extraintestinal Complications fistula and abscess formation Fluid and electrolyte imbalances Extraintestinal Complications malnutrition from malabsorption, Fluid and electrolyte imbalances secondary anemia, risk of malnutrition from malabsorption, osteoporosis, skin problem and eye secondary anemia, risk of problem. osteoporosis, skin problem and Eye problem.  GASTROINTESTINAL FISTULA A gastrointestinal fistula is an abnormal opening in the stomach or intestines that allows the contents to leak to another part of the body. Leaks that go through to a part of the intestines are called entero-enteral fistulas. Leaks that go through to the skin are called enterocutaneous fistulas. Other organs can be involved, such as the bladder, vagina, anus, and colon. Fistulas develop between loops of bowel (enteroenteric fistulas); bowel and bladder (enterovesical fistulas); bowel and skin (enterocutaneous fistulas Fistulae may form in the perianal area between loops of intestine or extend into the bladder. Stricture may develop promoting obstruction. Smoking increases the risk of developing severe disease.  DIAGNOSTIC CROHN’S DISEASE ULCERATIVE COLITIS EVALUATION Stool examination positive for occult blood positive for blood, mucus & steatorrhea and pus Proctosigmoidoscopy Inflamed rectosigmoid Inflamed rectum and Examination rectosigmoid colon Barium study of the Shows classic “string sign” show mucosal irregularities, lower GI tract terminal ileum, indicating focal strictures or fistulas, segment constriction and shortening of the colon, and ulceration with cobblestone dilation of bowel loops. appearance Computed Tomography Bowel wall thickening, abscesses and perirectal Scan/MRI, Ultrasound strictures and fistula tracts ulceration, lead pipe sign  DIAGNOSTIC CROHN’S ULCERATIVE EVALUATION DISEASE COLITIS 19 Laboratory : Decrease hematocrit & Decrease hematocrit & Complete blood count hemoglobin levels hemoglobin levels White blood cell count Increase Increase Sedimentation rate Increase Increase Albumin and protein Decrease Decrease level  MEDICAL MANAGEMENT: CROHN’S DISEASE 1.Immune system suppressors include: These are the most widely used immunosuppressants for treatment of inflammatory bowel disease. These drugs also reduce inflammation, but they target your immune system, which produces the substances that cause inflammation. Examples: Azathioprine (Azasan, Imuran) mercaptopurine (Purinethol, Purixan) 2. Ustekinumab (Stelara). This was recently approved to treat Crohn's disease by interfering with the action of an interleukin, which is a protein involved in inflammation. Risankizumab (Skyrizi). This medication acts against a molecule known as interleukin- 23 and was recently approved for treatment of Crohn's disease.  QUICK FACTS: RISANKIZUMAB (SKYRIZI) The approved dose to treat adults with moderately to severely active Crohn's disease is 600 mg administered by intravenous infusion over at least one hour at week 0, week 4, and week 8, followed by 360 mg administered by subcutaneous injection at week 12, and every 8 weeks thereafter.  MEDICAL MANAGEMENT: 22 ULCERATIVE COLITIS Immunomodulators- Include 6-mercaptopurine (Purixan®, Purinethol®), azathioprine (Azasan® and Imuran®), or methotrexate (Trexall®). These medications help calm the overactive immune system. Biologics: Biologics treat moderate to severe ulcerative colitis by targeting parts of the immune system to quiet it down. Medications like infliximab (Remicade®), adalimumab (Humira and ustekinumab (Stelara®) are biologics.  SURGICAL MANAGEMENT 23 Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA) This is the most commonly performed surgery in ulcerative colitis patients. Many healthcare providers and patients prefer this surgical option because it restores bowel function, allowing stool to pass through the anus. This procedure is commonly referred to as J- pouch surgery. Presentation title 24  Total Proctocolectomy with End Ileostomy: 25 This proctocolectomy surgical procedure removes the colon, rectum, and anus, and creates an end ileostomy so that waste can exit your body into an ostomy bag. This procedure is similar to the temporary ileostomy in the IPAA surgery, except the ileostomy will be permanent. The stoma, or small hole created in the abdomen for the ileum, is about the size of a quarter, pinkish in color, and will appear moist and shiny. The stoma will protrude slightly outside of the abdomen. After this surgery, you will wear an external ostomy pouch at all times to collect waste. The pouch must be emptied several times a day. The ileostomy is usually placed in your lower abdomen to the right of your navel, just below the belt line. Presentation title  APPENDICITIS Appendicitis is an inflammation of the vermiform appendix, a small fingerlike appendage about 10 cm (4 in) long that is attached to the cecum just below the ileocecal valve of the large intestine into which the small intestine empties its contents.  RISK FACTORS: 28 It can occur at any age, but most frequently between the ages of 10 and 30 years Recent infection- cause by bacteria, viruses occurs in the gastrointestinal system Trauma to the appendix Low fiber diet - increases risk for constipation causes some fecal to lodged to the appendix and become inflamed Presentation title 29 30  OTHER CLINICAL SIGNS OF APPENDICITIS Rovsing’s Signs- Palpation on the left lower quadrant causes right lower quadrant pain when patient is supine.  32 Obturator Sign- increasing right lower quadrant pain during internal rotation of a passively flexed right hip and knee when patient is supine.  33 Psoas Sign - increasing right lower quadrant pain during extension of the right hip when lying on left lateral decubitus position.  Constipation can also occur with appendicitis. Laxatives administered in this instance may result in perforation of the inflamed appendix. Sudden relief of pain may indicate rupture of appendix.  COMPLICATIONS: 1.Perforation of the appendix which can lead to peritonitis. 2.Abscess formation 3.Portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestine.  DIAGNOSTIC EVALUATION : Abdominal x-ray films -Free gas, and may show an appendicolith Ultrasound studies -Noncompressible, blind-ended, a peristaltic tubular structure in right lower quadrant arising from the base of cecum -Lumen distended with anechoic and hypoechoic material -Appendicolith CT scan abdomen /MRI -Reveal a right lower quadrant density or localized distention of the bowel. Complete blood cell count -Elevated white blood cell count  TREATMENT Surgery is indicated for appendicitis via Laparoscopy or Laparotomy APPENDECTOMY - surgical removal of the appendix. Laparoscopic appendectomy That means it's done without a large incision. Instead, from 1 to 3 tiny cuts are made. A long, thin tube called a laparoscope is put into one of the incisions. It has a tiny video camera and surgical tools. The surgeon looks at a TV monitor to see inside your abdomen and guide the tools. Open Appendectomy- ruptured appendix  MEDICAL MANAGEMENT: 41 APPENDICITIS Potential oral regimens (either for initial therapy or as step- down therapy after an initial intravenous regimen) include a fluoroquinolone (eg, ciprofloxacin or levofloxacin) in combination with metronidazole, a third-generation cephalosporin (eg, cefdinir) in combination with metronidazole, or amoxicillin-clavulanate NURSING MANAGEMENT Goals include 1. Relieving pain 2. Preventing fluid volume deficit 3. Reducing anxiety 4. Eliminating infection from the potential or actual disruption of the GI tract 5. Maintaining skin integrity 6. Attaining optimal nutrition 7. Discharge teaching for the patient and family PERITONITIS ▪ Peritonitis is define as an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. ▪ The inflammation is usually cause by an infection of the peritoneum that can happen for a variety of reasons. ▪ Patient with peritonitis requires prompt medical attention as it could be life threatening.  SPONTANEOUS SECONDARY PERITONITIS- NATURAL PERITONITIS can occur in patients with severe liver disease, Peritonitis can result heart disease or from rupture kidney disease (perforation) in your Ascites- the abdomen accumulation of fluid Perforated bowel within the abdominal Ruptured appendix cavity. Dialysis The presence of ascites, together with the Stab wound – bacteria person’s weakened from a knife or other defenses against sharp object enters the infection, often leads to abdominal cavity bacterial infection. 45  Nausea and vomiting Physical 46 Loss of appetite examination: the abdomen is hard Diarrhea and + pain Low urine output There are no bowel Thirst movements or Inability to pass stool sounds. /Diminished Signs of shock : peristalsis including low blood pressure, Abnormal Fatigue pulse rate and pale Confusion skin.  Due to etiological factor (Inflammation, infection, ischemia, trauma, or tumor perforation) PATHOPHYSIOLOGY Inflammation of peritoneal cavity (Edema of the tissues results, and exudation of fluid develops in a short time. Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, WBC, cellular debris, and blood). Abscess of infection- due to inflammation ( The immediate response of the intestinal tract is hyper motility, followed by paralytic ileus with an accumulation of air and fluid in the bowel). Spread of infection throughout the body  PATHOPHYSIOLOGY LEAKAGE. Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity. PROLIFERATION. Bacterial proliferation occurs. EDEMA. Edema of the tissues occurs, and exudation of fluid develops in a short time. INVASION. Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells, cellular debris and blood. RESPONSE. The immediate response of the intestinal tract is hyper motility, soon followed by paralytic ileus with an accumulation of air and fluid in the bowel. -SAMSON Abdominal x-ray Shows air, fluid levels and distended bowel loops Ultrasonography Shows abscesses and fluid collections CT scan of the Shows intra abdominal abdomen abscess formation Laboratory Complete -Increase white blood cells Blood Count count ( Leukocytosis) Hemoglobin and -Low Hematocrit -Altered levels of potassium, Serum electrolyte sodium, and chloride. studies COMPLICATIONS: Sepsis- Major cause of death from peritonitis Shock- -Result from septicemia or hypovolemia Intestinal obstruction and Bowel Adhesion  MEDICAL MANAGEMENT For spontaneous bacterial peritonitis (SBP), a 10- to 14-day course of antibiotics is recommended: Cefotaxime (2 g IV q8h) ,a combination of metronidazole with either levofloxacin or an oral cephalosporin, or amoxicillin-clavulanate.  SURGICAL TREATMENT Explore Laparotomy- peritoneal washing/ cleaning/drain the fluids. Important Discharge Instructions: No heavy lifting for 4-6 weeks Keep the incision clean and dry Be aware of signs of infection. This includes fever, or redness or yellow drainage from the incision. Peritoneal Lavage: washing out peritoneal cavity with copious amounts of warm isotonic fluid during surgery to dilute residual bacterial and remove gross contaminants PANCREATITIS is the redness and swelling (inflammation) of the pancreas. This happens when digestive juices or enzymes attack the pancreas. The pancreas lies behind your stomach on the left side of your belly. It is close to the first part of your small intestine (the duodenum).  54 TYPES OF PANCREATITIS ACUTE PANCREATITIS CHRONIC PANCREATITIS It is an inflammatory disorder Chronic pancreatitis is that involves self-destruction characterized by gradual of the pancreas by its own destruction of functional pancreatic tissue. enzymes through autodigestion. Inflammation of the pancreas that does not heal or improve—it gets worse over time and leads to permanent damage.  The most common causes of both acute and chronic pancreatitis 55 are gallstones heavy alcohol use genetic disorders of your pancreas some medicines Other causes include infections, such as viruses or parasites injury to your abdomen pancreatic cancer  diarrhea nausea greasy, foul- smelling stools vomiting weight loss jaundice Cullen’s sign and Grey Turner’s signs, described as ecchymosis in the periumbilical area and in one or both flanks respectively, represent the extravasation of hemorrhagic pancreatic exudate to these areas. SIGNS OF ABDOMINAL WALL HEMORRHAGE DIAGNOSTIC EVALUATION Lipase is the preferred laboratory test for diagnosing acute pancreatitis, as it is the most sensitive and specific marker for pancreatic cell damage. If lipase is >3x the upper limit of normal, it is highly likely that the patient has acute pancreatitis. Additional laboratory testing, such as complete blood count (CBC) and lactate dehydrogenase (LDH) tests, are useful to obtain prognostic information.  The normal range for adults younger than 60 is 10 to 140 U/L. Normal results for adults ages 60 and older is 24 to 151 U/L. Higher than normal levels of lipase mean that you have a problem with your pancreas. If your blood has 3 to 10 times the normal level of lipase, then it's likely that you have acute pancreatitis. Complete Blood Count- increased WBC ( Leukocytosis)  MEDICAL MANAGEMENT 60 The best option for the treatment is Imipenem 3 × 500 mg/day i.v. for 14 days. Alternatively, Ciprofloxacin 2 × 400 mg/day i.v. associated with Metronidazole 3 × 500 mg for 14 days can also be considered as an option. Medical Management Medications The treatment of Acute pancreatitis  Narcotic analgesics such as morphine sulfate are used to control pain. Antibiotics often are prescribed to prevent or treat infection. Treatment for Chronic pancreatitis  Require analgesics, but are closely monitored to prevent drug dependence.  Narcotics are avoided when possible.  Pancreatic enzyme supplements are given to reduce steatorrhea  H2 blockers such as cimetidine (Tagamet) and ranitidine (Zantac)  Proton-pump inhibitors such as omeprazole (Prilosec) may be given to neutralize or decrease gastric secretions.  Octreotide (Sandostatin), a synthetic hormone, suppresses pancreatic enzyme secretion and may be used to relieve pain in chronic pancreatitis. CHOLECYSTITIS or inflammation of your gallbladder, occurs when a gallstone blocks bile from exiting the organ.  Cholecystitis can either be acute or chronic. Acute Cholecystitis is the sudden inflammation of the gallbladder. Chronic Cholecystitis is the inflammation that last for a longer period of time. Damaged to the gallbladder can lead to a scarred and thickened gallbladder. YOU ARE AT GREATER RISK OF 65 DEVELOPING CHOLECYSTITIS IF YOU: Have a family history of gallstones Anyone older than age 60 Eat a diet high in fat and cholesterol. overweight/obesity. Diabetes Takes estrogen replacement therapy or birth control pills. PATHOPHYSIOLOGY When there is a blockage or obstruction that occur in the gallbladder, most commonly is gallstone. The gallbladder becomes distended, blood flow and lymphatic drainage are compromised leading to ischemia and necrosis.  Cause of Cholecystitis Gallstones- it can block the cystic duct — the tube through which bile flows when it leaves the gallbladder — causing bile to build up and resulting in inflammation. Tumor. A tumor may prevent bile from draining out of your gallbladder properly, causing bile buildup that can lead to cholecystitis. Bile duct blockage. Kinking or scarring of the bile ducts can cause blockages that lead to cholecystitis.  COMPLICATIONS Empyema. An empyema of the bladder develops if the gallbladder becomes filled with purulent fluid. Gangrene. Gangrene develops because the tissues do not receive enough oxygen and nourishment at all. Cholangitis. The infection progresses as it reaches the bile duct.  DIAGNOSTIC EVALUATION: 70 Magnetic Resonance Cholangiopancreatography (MRCP): This type of MRI shows details of your liver, gallbladder, bile ducts, structures and ducts of the pancreas as well. It can show gallstones, inflammation or blockage of the bile ducts and gallbladder and if there is any inflammation of the pancreas. Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct through the duodenum.  DIAGNOSTIC EVALUATION: 71 Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between gallbladder disease and cancer of the pancreas (when jaundice is present); supports the diagnosis of obstructive jaundice and reveals calculi in ducts. Abdominal Computed Tomography (CT Scan): This X-ray test shows details of your liver, gallbladder and bile ducts. It shows inflammation of the gallbladder.  PREPARATION 73 PATIENT SHOULD BE PLACED ON NPO STATUS AT LEAST 4- 8 HOURS PRIOR THE PROCEDURE. REMOVE ALL JEWELRIES, HAIR PINS, removable dental devices, pens, glasses, cell phones or similar items outside the scanning area. The patient will receive the substance through an intravenous (IV) line (a soft tube placed in a vein) or orally (by mouth). The oral dye may have an unpleasant taste and make the stomach feel full. How can cholecystitis be prevented? 74 You can reduce your risk of developing cholecystitis by: Eating a healthy diet: Choose to eat a healthy diet – one high in fruits, vegetables whole grains and healthy fats – such as the Mediterranean diet. Stay away from foods high in fat and cholesterol. LOW FAT DIET Exercising: Exercise reduces cholesterol, and to lower the cholesterol level and lower the chance of getting gallstones. Losing weight slowly: If you are making efforts to lose weight, don’t lose more than one to two pounds a week. Rapid weight loss increases your risk for developing gallstones. Therapeutic Management Antibiotic therapy. Levofloxacin and Metronidazole for prophylactic antibiotic coverage against the most common organisms. Promethazine or Prochlorperazine may control nausea and prevent fluid and electrolyte disorders. Oxycodone or Acetaminophen may control inflammatory signs and symptoms and reduce pain  What is the first line treatment for cholecystitis? In most patient populations, laparoscopic cholecystectomy, performed within 3 days of diagnosis, is the first-line therapy for acute cholecystitis.  SURGICAL MANAGEMENT CHOLECYSTECTOMY- REMOVAL OF GALLBLADDER ( STONES) There are 2 types of surgery to remove the gallbladder: 1. Open (traditional) method. In this method, 1 cut (incision) about 4 to 6 inches long is made in the upper right-hand side of your belly. The surgeon finds the gallbladder and takes it out through the incision.  78 When is an open cholecystectomy needed? Extensive inflammation, adhesions, anatomical variances, bile duct injury, retained bile duct stones, and uncontrolled bleeding are all indications to convert to an open procedure. 2. Laparoscopic method. This method uses 3 to 4 very small 79 incisions. It uses a long, thin tube called a laparoscope. The tube has a tiny video camera and surgical tools. The tube, camera and tools are put in through the incisions. The surgeon does the surgery while looking at a TV monitor. The gallbladder is removed through 1 of the incisions. Advantages: minimally invasive surgery to remove the gallbladder The surgery involves a few small incisions, and most people go home the same day and soon return to normal activities. Less pain. Lower risk of complications. POST-OP DISCHARGE INSTRUCTIONS: 80 Avoid lifting heavy things Drink plenty of water Eat foods high in fiber to help bowel movements (pooping) Slowly increase activity Walk a little bit every day to prevent blood clots