Inflammatory Bowel Disease (IBD)

IBS
irritable bowel syndrome
not considered an inflammatory disease
IBS is relapsing-remitting

Labs and diagnostics for IBS
CBC, WBC, RBC, hemoglobin, hematocrit
electrolytes
EST (erythrocyte sedimentation rate)
CRP (C-reactive protein)
Albumin and protein
fecal occult blood
abdominal X-ray
Barium swallow and barium enema
CT scan
Upper or lower endoscopy
MRI, US, WBC scan

Epidemiology of IBS
prevalence estimated at 10-20% of population
incidence approximately 1-2% per year
10-20% of people with IBS seek medical care per year

A diagnosis of IBS does not increase the risk for….
death, cancer, inflammatory bowel disease

Criteria for a person to be diagnosed IBS (Rome III Criteria)
Must include BOTH of the following –> abdominal discomfort or pain associated with 2 or more of the following 25% of the time:
1. improvement with defecation
2. onset is associated with a change in the frequency of stool
3. onset is associated with a change in form (appearance) of stool

AND…
No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains the patient’s symptoms

To be diagnosed IBS a person must have had symptoms for at least ____ days in the last ____ months
at least 3 days in the last 3 months

How is IBS managed?
patient education
diet modification (fiber, metamucil, remove problem foods, high sugar foods, lactose)
exercise
medication (antispasmodics, anti-diarrheal meds, fibre supplements, tri-cyclic antidepressants)
probiotics (manage symptoms, speeds transit through GI tract)
non-pharmacological treatments (relaxation therapy, biofeedback, psychotherapy, hypnotherapy)

Do people with IBS experience a benefit from modifying their diet?
YES – 15-71%

Symptoms may mimic IBS but actually could be…
lactose intolerance

Bowel irritants with IBS
lactose
cruciferous veggies (broccoli, beans) increase gas and bloating
insoluble fibres (increase stool bulk)
“friendly” microorganisms – breakdown cellulose

UC and CD labs and diagnostics
WBC, hematocrit, ESR and CRP ELEVATED, positive fecal occult blood
RBC, Hgb, albumin and protein DECREASED

Ulcerative colitis
inflammation of the mucosa of the large intestine
areas of inflammation are continuous

Treatment for ulcerative colitis
clear fluids
IV fluids to maintain hydration and replace electrolytes
activity as tolerated
analgesic for pain control
antiemetics for nausea
stool charting
strict monitoring of intake/output
sometimes, patients are put on TPN (due to side effects of UC such as dehydration or anemia)

Case study: Ulcerative colitis (Alison)
after hydration, Alison is still experiencing abdominal pain and nausea
no longer vomiting but the nausea makes her retch
although she is not eating, she still has the need to defecate 5-10 times a day but only passes small amounts of mucus and blood

Case study: Assessment of Alison
pale skin
fatigue
lethargy
SOB
hyperactive bowel sounds
VS – HR 126, BP 82/56, RR 32, T 37.9
Labwork – WBC High, RBC and Hgb Very Low, HCT Low

Case study: Possible causes of Alison’s UC
– hypovolemia due to blood loss, because there is nothing about a change in patient’s pain, and patient has been having rectal bleeding for a while
– peritonitis could cause the change in vital signs so this is also possible

Adrenal crisis
low cortisol and low aldosterone
low cortisol – liver issues –> decreased glucose output –> hypoglycaemia
low cortisol – stomach –> decreased digestive enzymes –> vomiting, cramps, diarrhea

low aldosterone – kidney –> losses of water and sodium (retention of potassium) –> hyperkalemia –> cardiac arrhythmias and decreased cardiac output –> hypotension

Case study: Treatment for Alison’s dehydration
transfusion of 3U of PRBCs
Post-transfusion bloodwork – Hgb is increased

Case study: Alison’s response to treatment
nausea is worse, confusion, lethargy, difficult to rouse, abdomen severely distended and tender to palpation
high temperature

Case study: What does Alison have????
TOXIC MEGACOLON

Toxic megacolon
Emergency surgery (insert an NG tube, surgical prep, administer Abx and pre-op medications)
Enterostomal therapist (ET Nurse) to mark the appropriate place for ostomy

WIll Alison have UC symptoms after her colectomy?
NO

Complications of Ulcerative Colitis
malnutrition
bowel perforation
toxic megacolon
GI bleed
complications outside of the GI tract (arthritis, inflammation of the eyes, pyelonephritis, kidney stones)

Crohn’s disease
any portion of the GI tract
terminal ileum is affected
non-continuous in the GI tract (patchy)
‘Cobblestone’ appearance

Types of crohn’s
stenosis
inflammation
fistula

Areas of the GI tract affected by crohn’s (%)
small intestine 5%
distal ileum 35%
colon alone 20%
other areas 40%`

Assessment of crohn’s disease patient’s
RLQ abdominal pain (colicky, moderate-severe pain)
nausea
malnourishment and ill
frequent, watery diarrhea
excoriation, painful anal region

Acronym for Crohn’s (CHRISTMAS)
C – cobblestones (Radiology appearance)
H – high temperature
R – reduced lumen
I – intestinal fistulae/Infliximab
S – skip lesions
T – transmural (all layers and may ulcerate)
M – malabsorption
A – abdominal pain
S – submucosal fibrosis

Treatment/Nursing care for Crohn’s Disease
Clear fluids
IV fluid to maintain hydration and replace electrolytes
activity as tolerated
analgesic for pain control
antiemetic for nausea
administer meds as ordered
stool charting
strict monitoring of intake/output

Medications for Crohn’s
5-ASA agent (Sulfasalazine or Asacol) –> sulpha only works with the large bowel, asocial will work in small intestine
Antibiotics –> metronidazole
Corticosteroids –> prednisone, budesonide, hydrocortisone
Immune modulator –> methotrexate

What is the drawback to the use of metronidazole in Crohn’s disease?
increased risk of pseudomembraneous colitis
when it is helpful in Crohn’s: perianal disease, fistulae, perioperatively

Complications of Crohn’s (in the GI tract)
malnutrition, bowel obstruction, fistula formation, anal fissures

Complications of Crohn’s (outside of the GI tract)
arthritis
inflammation of the eyes
gall stones
kidney stones, etc

Diet changes in Crohn’s disease
as inflammation resolves, pain and nausea settles down
Progression of diet:
clear fluids –> bland, low residue, low fat diet –> increased carbohydrates and protein –> increased Vitamin L and B12

If steatorrhea is present, the patient may need supplements of…
fat soluble vitamins (ADEK)

If the terminal ileum is involved in Crohn’s supplements of Vitamins __ and ___ may be needed
K and B12

Low residue diet
similar to a low-fibre diet
grain products –> white bread, buns, bagels, cereals, arrowroot cookies, soda crackers, white rice, pasta
fruits –> all juices except prune, applesauce, apricots, banana
veggies –> juices, potatoes, well cooked and tender veggies, AVOID cruciferous veggies (broccoli, cauliflower, cabbage, kale)
meat –> well cooked tender meat, fish and eggs, avoid beans and lentils
nuts –> avoid all nuts and seeds, popcorn
dairy –> as per HCP

GI issues treated with metronidazole:
infection
fistulas
perianal ulcers

GI issues treated with morphine and hyoscine butylbromide
pain

GI issues treated with imodium, octreotide and cholestyramine
severe diarrhea

GI issues treated with pantaloon, ranitidine, and prochlorperazine (antiemetic)
heartburn and nausea
vomiting

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