References:
- Brunner (fill in)
- Lecturer (MJA)
Inflammatory bowel disease (IBD) is a group of chronic disorders: Crohn’s disease and ulcerative that result in inflammation or ulceration (or both) of the bowel. Both disorders have striking similarities but also several differences. In the 10% to 15% of cases where characteristics from both cannot be definitively differentiated, patients are classified as having “indeterminate colitis”.
- The cause is still unknown. Underlying factors include genetic predisposition, an altered immune response, and an altered response to gut microorganisms. Researchers theorize that environmental (e.g., air pollutants), food, tobacco, and viral triggers can result in inflammatory changes that characterize IBDs.
- Both disorders also feature extra-intestinal (systemic) manifestations. These include fever, arthralgia, malaise, and episodes of diaphoresis. Manifestations unique to each disorder are listed in Clinical Manifestations
Predisposing Factors
Family history predisposes people to IBD, particularly if a first-degree relative has the disease. Other risk factors include:
- Caucasian, Ashenkazi Jewish descent, living in a northern climate, and living in an urban area.
- Commonly diagnosed in 15 to 40 years, then at 55 to 65 years of age.
- Current smokers are at risk for Crohn’s disease, but those who are ex-smokers or nonsmokers are at risk for ulcerative colitis.
Crohn’s Disease (Regional Enteritis)
Crohn’s disease, also called regional enteritis, is characterized by a subacute and chronic inflammation of the GIT wall that extends through all layers (i.e., transmural lesion).
Pathophysiology
- The inflammatory process in Crohn’s disease begins with crypt inflammation and abscesses, which develop into small, focal ulcers.
- These initial lesions then deepen into longitudinal and transverse ulcers, separated by edematous patches, creating a characteristic cobblestone appearance in the affected bowel.
- Fistulas, fissures, and abscesses form as the inflammation extends into the peritoneum.
- Granulomas can occur in lymph nodes, the peritoneum, and through the layers of the bowel in about half of patients.
- Diseased bowel segments are sharply demarcated by adjoining areas of normal bowel tissue. These are called skip lesions, from which the label regional enteritis is derived.
- As the disease advances, the bowel wall thickens and becomes fibrotic, and the intestinal lumen narrows. Diseased bowel loops sometimes adhere to other loops surrounding them.
Clinical Manifestations
Summary Comparison of Crohn’s Disease and Ulcerative Colitis
| Crohn’s Disease | Ulcerative Colitis | |
|---|---|---|
| Course | Prolonged, variable | Exacerbations, remissions |
| Pathology | Early: Transmural thickening Late: Deep, penetrating granulomas | Early: Mucosal ulceration Late: Minute, mucosal ulcerations |
| Location | Ileum, ascending colon (usually) | Rectum, descending colon |
| Bleeding | Usually not, but mild if it occurs | Common and severe |
| Perianal involvement | Common | Rare and mild |
| Fistulas | Common | Rare |
| Diarrhea | Less severe | Severe |
| Abdominal mass | Common | Rare |
| Barium Studies | Regional, discontinuous skip lesions Thickening of bowel wall Mucosal edema Stenosis, fistulas | Diffuse involvement No narrowing of colon No mucosal edema Stenosis rare Shortening of colon |
| Sigmoidoscopy | May be unremarkable unless accompanied by perianal fistulas | Abnormal inflamed mucosa |
| Colonoscopy | Distinct ulceration separated by relatively normal mucosa in ascending colon | Friable mucosa with pseudopolyps or ulcers in descending colon |
| Therapeutic Management | Corticosteroids, aminosalicylates (sulfasalazine) Immunomodulators (e.g., azathioprine) or monoclonal antibodies (e.g., infliximab, adalimumab) may be tried if refractory to corticosteroids and aminosalicylates Antibiotics Parenteral nutrition Partial or complete colectomy, with ileostomy or anastomosis Rectum can be preserved in some patients Recurrence common | Corticosteroids, aminosalicylates (sulfasalazine) Immunomodulators (e.g., azathioprine) or monoclonal antibodies (e.g., infliximab, adalimumab) may be tried if refractory to corticosteroids and aminosalicylates Bulk hydrophilic agents Antibiotics Proctocolectomy, with ileostomy Rectum can be preserved in only a few patients “cured” by colectomy |
| Systemic Complications | Small bowel obstruction Right-sided hydronephrisis Nephrolithiasis Colon cancer Cholelithiasis Arthritis Uveitis Erythema nodosum | Toxic megacolon Perforation Hemorrhage Colon cancer Pyelonephritis Nephrolithiasis Cholangiocarcinoma Arthritis Uveitis Erythema nodosum |
Crohn’s Disease
An idiopathic inflammatory disease of the small intestine (~60%), large intestine (~20%) or both (~50%). The most commonly affected site is the terminal ileum (~33%).
- It may also be caused by Mycobacterium avium subspecies paratuberculosis (M. paratuberculosis)
- Related to genetic disposition from 1st degree relatives.
Pathology
- Deep fissures (enterocutaneous, enteroenteric) and ulceration develops from inflammation. This results in bowel fistulas, which cause diarrhea and malabsorption.
- Chronic pathologic changes include thickening of the bowel wall, which narrows the bowel lumen and causes strictures. This results in obstruction.
Assessment Findings
- Abdominal distention, masses, and visible peristalsis from obstruction.
- Diarrhea, commonly containing fat (steatorrhea) and sometimes containing blood (hematochezia, melena).
- Constant abdominal pain
- Low-grade fever
- Weight Loss seen in 80% of clients
Diagnostic Examination
- Autoimmune blood tests: positive Anti-DNA and ANA
Nursing Interventions
- Monitor for peritonitis, bowel obstruction, and nutritional and fluid imbalances
Ulcerative Colitis
Ulceration and inflammation of the colon or rectum. Its cause is unknown.
Assessment Findings
- Anorexia, weight loss
- Fever
- Severe diarrhea with rectal bleeding, dehydration, anemia
- Abdominal pain and cramping
Inflammatory Bowel Disease
| Differences | Crohn’s Disease | Ulcerative Colitis |
|---|---|---|
| Depth and Manifestation | Transmural, Patchy | Mucous Ulceration, Continuous |
| Region | Any part; Ileum | Rectum/Cecum |
| Causes | Unknown, Familial, Environmental | Unknown, Familial, Emotions |
| Age, Peak Incidence | 15 - 40 y.o. | 15 - 25 y.o., 55 - 65 y.o. |
| Bleeding | Minimal; stool contains pus and mucus | Severe; stool contains blood, pus, and mucus. |
| Fistulas | Common (d/t Transmural affectation) | Rare |
| Rectal Involvement | 20% | 100% |
| Diarrhea | 5 - 6 soft loose stools a day | 20-30 watery stools a day |
| Abdominal Pain | Present | Present |
| Weight Loss | Present | Present |
| Intervention | Total Parenteral Nutrition | Diet, Total Parenteral Nutrition |
| Medication | Steroids, Azulfidine (Sulfasalazine): antiinflammatory | Steroids, Azulfidine (Sulfasalazine) |
| Surgery | (Temporary) Ileostomy | Ileostomy, Proctocolectomy |
Nursing Interventions
- Maintain NPO during the active phase.
- Monitor for complications e.g. severe bleeding, dehydration, and electrolyte imbalances.
- Monitor bowel sounds
- Assist in stool and blood studies
- Restrict activities
- Administer IVF, Electrolytes, and TPN as ordered.
- Ileostomy: continuous watery drainage, with digestive enzymes (causes skin irritation)
- Irrigation (INC)
Diet Therapy
- Avoid gas-forming foods: whole grains, nuts, raw fruits and vegetables (spinach), pepper, alcohol, and caffeine.
- Avoid milk products
- Once off NPO, Clear Liquid Diet weaned into a low residue, high protein diet.
Medical Interventions
- Anti-inflammatory Drugs: Azulfidine (Sulfasalazine)
- Antibiotics
- Steroids (as anti-inflammatory)
- Bulk-Forming Agents (for diarrhea)
- Vitamin and Iron Supplementation (to compensate for malabsorption)