Please enable JavaScript.
Coggle requires JavaScript to display documents.
Inflammatory Bowel Disease (IBD) (Medical Management (Ulcerative Colitis),…
Inflammatory Bowel Disease (IBD)
Inflammatory Bowel Disease:
GI tract disorders characterized by inflammation & ulceration
Varied clinical manifestations
Unpredictable periods of remission & exacerbation
Can be debilitating
about 10,000 cases diagnosed annually in Canada
Two Disorders: ulcerative colitis and crohn's disease
Etiology unclear
Potential causes: infectious agents, autoimmune response, environmental influences or allergies, genetics
Cause is likely multifactorial
Ulcerative Colitis vs. Crohn's Disease
Ulcerative colitis:
Inflammation & ulceration of the colon & rectum
Diffuse inflammation of the mucosa & submucosa
Crohn’s Disease:
Inflammation can also occur in the small intestine, mouth, esophagus & stomach
Inflammation occurs deeper in the intestinal wall
Ulcerative Colitis
Onset:
May occur at any age
Usually begins between 15-25 years of age
Affects both sexes equally
Appears to run in families
Clinical Manifestations:
most common symptoms are abdominal pain and bloody diarrhea
appearance of colon: mucosa edematous and red; superficial ulcers with mucous exudate (mildly active); mucosa very red ad inflamed; mucosa is very edematous with bleeding occurring (active)
Severity:
Mild: up to 4 loose stools per day, stools may be bloody, mild abdominal pain
Moderate: 4-6 stools/day, stools may be bloody, moderate abdominal pain, anemia
Severe: more than 6 bloody loose stools per day, fever, anemia & tachycardia
Very severe (fulminant): more than 10 loose stools/day, constant blood in stools, abdominal tenderness/distension, may require transfusion, potentially fatal
Complications
:
About half of patients have complications
Intestinal: abscesses, pseudopolyps, hemorrhage, perforation, toxic megacolon, & colonic dilatio
Extraintestinal: can involve the joints, skin, mouth, eyes, & hematological system
No one knows for sure why problems occur outside the colon
A client who has had ulcerative colitis for more than 10 years is at greater risk of colorectal cancer
Client should be regularly screened with colonoscopy
higher risk for osteoporosis and related fractures
Diabetes mellitus is one of the most frequent co-morbidities seen in individuals with ulcerative colitis (suggests genetic component; corticosteroids used to treat UC may be associated with onset of glucose intolerance and diabetes, and with difficult control of glucose levels)
Diagnosis of Ulcerative Colitis:
History & physical
Colonoscopy or sigmoidoscopy
Barium enema
Blood tests
complete blood cell count (iron deficiency anemia from blood loss; elevated leukocytes may indicate toxin)
electrocytes (decrease due to fluid and electrolyte losses)
serum protein levels (hypoalbuminemia is severe cases)
Stool tests (including c-diff)
Sigmoidoscopy: view the rectum, sigmoid colon & descending colon
Colonoscopy: view the entire large intestine
Endoscope is inserted into the anus to see the inside of the colon and rectum
Inflammation, bleeding, or ulcers will be visible on the colon wall
Tissue biopsy may be taken
Medical Management (Ulcerative Colitis)
Goal of therapy is to induce and maintain remission, and to improve the quality of life for people with ulcerative colitis
Drug therapy is an extremely important aspect of treatment
Several types of drugs are available
Goals of Treatment: rest the bowel; control the inflammation; manage fluids and nutrition; manage client stress; provide education on the disease & treatment; provide symptomatic relief)
Aminosalicylates:
Contain 5-aminosalicyclic acid (5-ASA)
Help control inflammation
Used for mild to moderate disease
May be given orally, or rectally (enema or suppository)
Sulfasalazine:
Principal drug used to achieve and maintain clinical remission
Combination of sulfapyridine and 5-ASA
Both antiinflammatory and antibacterial properties
Sulfapyridine component carries the anti-inflammatory 5-ASA to the intestine
May lead to side effects such as nausea, vomiting, heartburn, diarrhea, and headache.
Sulfasalazine:
Effective in treatment of mild to moderately severe disease episodes
After remission is obtained, therapy is continued with a gradual reduction over several months
Maintenance dose is usually continued 1 year
Other 5-ASA Agents:
Other 5-ASA agents have a different carrier, offer fewer side effects, and may be used by people who cannot take sulfasalazine
Oral/systemic agents: Olsalazine (Dipentum); Mesalazine (Asacol); Balsalazide
Suppositories: Mesalazine (Salofalk)
Other Medications:
antibiotics
Anti-diarrheal medications e.g. Imodium (used with caution, may increase risk of toxic megacolon)
Pain relievers (acetaminophen for mild pain; NOT NSAIDS)
Iron supplements
Corticosteroids:
Oral prednisone: mild to moderate disease
IV methylprednisone or hydrocortisone: moderate to severe disease or 5-ASA ineffective
Common side effects: weight gain, acne, facial hair, hypertension, diabetes, mood swings & increased risk of infection
Not recommended for long-term use
Immunosuppressants/Immunomodulators:
Reduce inflammation by suppressing the immune response
Used for patients who have not responded to 5-ASAs or corticosteroids or who are dependent on corticosteroids
Oral medications, slow-acting and may take up to 6 months before full benefit is seen
Azathioprine (Imuran)
Cyclosporine (Neoral)
Biologics:
Target specific proteins involved in the inflammatory process
TNF(tumour necrosis factor)-alpha inhibitors: Infliximab (Remicade); Adalimumab (Humira); Golimumab (Simponi)
Integrin receptor antagonist: Vedolizumab (Entyvio)
Risk of infection and certain cancers
Diet: (no special diet but may...
High calorie, high protein, low residue diet may be prescribed
This diet eliminates foods that are indigestible or stimulating to the intestinal tract to reduce the amount of residue in the colon
Hot & cold foods should be eaten slowly
Six small meals per day are tolerated better
Milk products are limited to 2 cups daily. More restricted-residue diet, milk should be eliminated
Low Residue Diet:
Excludes alcohol & fruit juices with pulp
Excludes whole grain breads & cereals
Excludes fried, smoked, pickled or cured meats
Excludes fried or uncooked eggs
Excludes most cheeses & fruit yogurt
Excludes raw & unstrained vegetables
Excludes raw fruits, skins, seeds, nuts
If symptoms become severe:
Nutritional supplements: to restore the balance of nutrients, help prevent weight loss, and possibly relieve pain
NPO: to allow the bowel to rest
Parenteral nutrition: administration of nutrients by a route other than the GI tract
Total Parenteral Nutrition (TPN): delivery of a nutritionally adequate solution consisting of glucose, protein, mineral
TPN Solutions:
May be standardized or customized
Calories supplied by carbohydrates in the form of dextrose
Peripheral: 10-12.5% dextrose supplies 340-425Kcal/L
Central: 20-50% dextrose supplies 680-1700Kcal/L
Fat in the form of fat emulsions (10, 20 & 30 % fat emulsions solutions approved)
Maximum fat emulsion amount should not exceed a dose of 2.5 g/kg per day & administered slowly over 12 -24 hrs
Protein in the form of amino acids (1.5 to 2 g/kg per day for most clients with moderate – severe stress)
Electrolytes (assessment of individual requirements takes place daily at beginning of therapy & then several times a week as treatment progresses)
Trace elements, vitamins
Difference between central and peripheral parenteral nutrition:
Differ in tonicity which is measured in milliosmoles (mOsm)-
Standard IV solutions of D5W are essentially close to isotonic (280 mOsm)
Central TPN are hypertonic – at least 1600 mOsm – must be infused in a central vein
PPN is hypertonic but less so (D10W) – can be administered through a large peripheral vein
Surgical Management
25-40% of ulcerative colitis patients require surgery to remove their colon
Recommended when medical treatment fails or due to side effects of corticosteroids
Complications requiring emerg surgical intervention:
Perforation of the colon
Massive bleeding in the colon
Sudden, severe ulcerative colitis
Toxic megacolon (muscle wall of the colon dilates and bacteria and gases build up inside the colon)
standard surgical procedure for ulcerative colitis is proctocolectomy (removal of the colon and rectum)
Unlike Crohn's disease, which can recur after surgery, ulcerative colitis is "cured" once the colon is removed
Total Proctocolectomy with permanent ileostomy:
1-stage surgery: removal of colon, rectum & anus; end of terminal ileum forms a stoma in RLQ
Total Colectomy with ileoanal reservoir:
Patient must be highly motivated
Must be free of Crohn’s & colorectal CA
Must have competent anorectal sphincter
1-3 stages performed ~ 12 weeks apart:
temporary ileostomy
formation of ileal reservoir with temporary diverting loop ileostomy (protects reservoir during healing)
takedown of loop ileostomy to functionalize reservoir