Inflammatory Bowel Disease

- is an umbrella term used to describe conditions that are characterized by bowel

inflammation
- commonly it tends to infect the lower portion of the small intestine particularly the
ileum
- wall of the intestine is composed of 4 layers.
-tunica serosa,tunica muscularis, tunica submucosa, tunica mucosa(inner layer)

Crohn’s Disease
- An inflammation which can happen anywhere in the digestive tract.
- Inflammation involves the entire thickness of the intestinal wall but
most commonly the submucosa.
- The inflammation may extend through every layer of the affected
bowel tissue.
- Inflammatory process occurs in patchy segments, separated by
normal tissue
- Most commonly affects the small bowel, especially in the area of the
terminal ileum.
- Lesions may also arise in the cecum and ascending colon.
- Edema, inflammation and fibrosis occur involving all layers of the
bowel wall.
- Client may experience periods of complete remission that alternate
with exacerbations.
Etiology and Epidemiology
- Mortality rate is not high
- Both sexes are affected equally
- Common in whites and among Jewish people
- Occurs at all ages but more often between 20-40 years
- Cause is still unknown although several theories exist
- Recurrences and complications can result in disability.
- The most popular theory is autoimmune - some scientist think that the
protein produced by the immune system called anti TNF may be a possible
cause for the inflammation
Pathophysiology
Presence of food, bacteria and other substances

Immune system reacts abnormally

WBC accumulates the lining of intestines

Chronic inflammation
NOTE: anti-Tumor Necrosis Factor (TNF) may be a possible cause for the
inflammation

Diagnostics:
1. Stool analysis to rule out bacterial or parasitic infection.
2. Colonoscopy
3. Barium enema - X-ray examination of the colon in which barium is used as a
contrast medium, barium is administered rectally.
 laxatives and cleansing enemas are administered the evening before the
test; cleansing enemas may be given also in the morning.
-For cleansing enemas: position the patient to Left side in sim’s position.
-Lubricate the tip of the tubing with water-soluble lubricant.
-Gently insert tubing into client’s rectum and raise the container no more
than 12-18 inches above the client.

Complications
1. Fistulas and abscesses
2. Perforation leading to Peritonitis
3. Nutritional deficiencies, especially of fat soluble vitamins.
Treatment:
1. Dietary modifications: Increase calories and protein (facilitate healing)and
decreased fats and residue(since client is having diarrhea).
2. Encourage client to eat small servings several times a day.
3. Medications:
- Cortecosteroids – to reduce inflammation
- Sulfasalazine – an antimicrobial agent used to control inflammation also.
- Immunosuppressive agents in long term management of chronic problems.
- Antidiarrheal agents
- Anticholinergics.
- Metronidazole (Flagyl)
4. Surgical intervention is indicated if fistulas, perforation, bleeding and
intestinal obstruction occur.
Nursing Intervention:
Goal: To decrease inflammatory response and promote healing.
1. Evaluate and maintain adequate hydration status.
2. NPO – to decrease bowel activity; fluids are introduced gradually.
3. IV fluids
4. Evaluate electrolyte status.
5. Good skin hygiene around anal area to prevent excoriation caused by
diarrhea.
6. Antidiarrheal agents.
7. If fistulas form, the client is most often malnourished; may requires total
parenteral nutrition.
8. Assess characteristics in patterns of stool.
ULCERATIVE COLITIS
- A chronic inflammatory disease that causes ulceration of the mucosa usually
in the rectum and sigmoid colon and spreads upward beyond to involve most
of the descending colon.
- Is more common
- Occurs at all ages. Peaks at ages 15-25 and 55-65 years.
- Cause is unknown but infection, genetic and immunologic factors play a role
- The most significant theory is the immunologic factor – The presence of T
lymphocytes may have cytotoxic effects in the epithelial cells of the colon
- Area of inflammation is diffuse, involving mucosa and submucosa of the
intestinal wall; inflammatory process progress to scar formation
- Problem frequently begins in the rectum and spreads in a continuous manner
up the colon; seldom is the small intestine involved.
- Mucosa develops ulcerated areas that can precipitate hemorrhage.
 - Condition has periods of exacerbations and emissions; is frequently
associated with psychological factors and stress.
Diagnostics:
- Stool is positive for blood
- Laboratory results: Low Hct and Hgb conc. elevated WBC, low albumin levels
- Abdominal x-ray
- Sigmoidoscopy
- Colonoscopy
- Barium enema
- CT scan, MRI and UTZ
 Characteristic Crohn’s Disease Ulcerative Colitis
Etiology Unknown Unknown
Genetic or Hereditary Genetic predisposition
Autoimmune Secondary to viral or
bacterial infection
Onset Young Adult Young to Middle age
Race Jewish people Jewish people
Pathology and anatomy
>Depth of involvement: Transmural Mucosa and submucosa
>Rectal involvement: Seldom Often
>Colon involvement: Ascending and Transverse Rectum and Sigmoid colon
colon
>Small intestine
involvement: Ileum Usually normal
>Distribution of disease: Segmental Continuous
>Inflammatory mass: Chronic and extensive Rare (crypt abscess)
>Cobblestone-like Present Absent
mucosa and granuloma: Absent
>Lymph involvement: Present Cancer of the colon
>Malignancy results: Rare Absent
>Fibrous Stricture: Common

Clinical Characteristics
>Course of Disease: Slowly progressive Remission and relapse
>Abdominal pain: Intermittent and present at Cramping abdominal pain
the RLQ
>Rectal bleeding: Occasional Common
>Hematochezia: Unusual or absent Almost always present
>Diarrhea: Nonbloody diarrhea Bloody diarrhea
>Vomiting: Present Present
>Weight loss: Present Present
>Fever: Present Present
>Nutritional Deficit: Present Present
Present
Complications:
- Obstruction, perforation and abscess
- Increased incidence for development of colon cancer.
Treatment:
The main objectives:
>Reduce inflammation
>Suppress inappropriate immune responses
>Provide rest
>Improve quality of life
>Prevent or minimize complications
 Provide rest periods
 Diet: Oral fluids and Low-residue, high protein, high calorie with supplemental
vitamin therapy
 Avoid foods that can exacerbate diarrhea
 Avoid cold foods and smoking
 Monitor I and O
 Parenteral nutrition may be indicated
 monitor blood glucose q6hrs
A. Mild to Moderate disease
- Sulfasalazine to help control inflammation
- Corticosteroids
- Medication for pain, antidiarrheal agents and immunosuppressive agents.
B. Acute or Active disease
- Corticosteroids: administered Intravenously, if oral administration is ineffective
- NPO status to rest bowel
- Retention enemas and rectal foams to ease inflammation.
- Immunosuppressive drugs in combination with steroids
C. Surgical Intervention: resection of the diseased portion of the bowel.
1. Ileostomy – opening of the ileum through the abdominal wall; stool drainage is
liquid and excoriating; drainage is frequently continuous; therefore it is difficult to
establish bowel control. Fluid and electrolyte imbalances are common
complications.
2. Colostomy – opeing of the colon through the abdominal wall; stool is generally
semisoft and bowel control maybe achieved
Note: The difference between colostomy and ileostomy.
Preoperative care:
a. Client is frequently on a low residue diet before surgery to decrease intestinal
contents.
 b. Placement of stoma is evaluated and site is selected with client standing.
Avoid skin creases and folds; select site that does not interfere with clothing.
Postoperative Nursing implications:
a. Measure the stoma and select appropriately sized appliance. Stoma will
shrink after surgery, which necessitates changes in size of the appliance.
b. Appliance should fit easily around the stoma and protect the skin. Especially
for ileostomy because some of the intestinal juices which may leak into the
stoma and may excoriates the skin.
Key points: Irrigation
a. Do not irrigate ileostomy or maintain regular irrigations in child with
colostomy
b. Irrigate colostomy at same time each day to assist in establishing a normal
pattern of elimination.
c. Involve client in care as early as possible.
d. In adults, irrigate with 500-1000ml of warm tap water.
Nursing Priority:
a. Do not force catheter into the stoma.
b. Insert the catheter more than 4 inches
c. Use more than 1000ml of irrigation fluid
d. Irrigate more than once a day
e. Irrigate in the presence of diarrhea.
f. Place client in a sitting position for irrigation, preferably in the bathroom.
Encourage client to change position and relax while irrigating.
g. Elevate solution container approximately 12-18 inches and allow solution to
flow in gently. If cramping occurs, lower fluid or clamp the tubing.
h. Allow 25-45 minutes for return flow.
i. Assist the client to control odors: diet and odor control tablets may be given

DIVERTICULA

- Diverticulum are small outpouchings or herniations of the mucosal lining of

the colon
- Diverticulosis exists when multiple diverticula are present without
inflammation.
- Diveticulitis is the inflammation of the diverticulum.
- 30% of individuals older than 50 years of age are estimated to have
diverticula, and the incidence increases to about 70% in persons over 70
years of age.
- Many regard this as part of the aging process
- Develop primarily in the left colon and sigmoid colon because the lumen is
narrowest and pressure is highest, but they can occur throughout the colon.
ETIOLOGY:
- Low fiber diet - have been implicated in the development of diverticula,
because this diets decrease bulk in the stools and predispose to constipation
- Atrophy or weakness of the bowel muscle - Muscle contraction in the sigmoid
increase the thickness of the muscle and cause the weaker connective tissue
to herniate between the circular bands and form the diverticula.
- Diverticulitis develops when undigested food blocks the diverticulum , leading
to a decrease in the blood supply to the area
 - Fecaliths drain in the diverticulum they may become trapped and cause
irritation and inflammation
Manifestations: The vast majority of diverticula are never formally diagnosed, and
the person remains completley asymptomatic. Patients seek medical treatment only
if diverticulitis occurs.
 Left quadrant pain
 Constipation and Diarrhea
 Anorexia
 Low-grade fever
 May palpate a tender mass
 Rectal bleeding occurs in about 15% of clients.
Diagnostic:
 Ct scan
 Barium enema - can clearly reveal the classic diverticular pouches and
thickened muscle layers but is usually not performed until after inflammation
subsides.
 Proctosigmoidoscopy - to rule out other serious colon diseases.
Nursing intervention
- Modification of the diet - Asymptomatic diverticular disease requires no
specific therapy other than modification of the diet. Adherence to a high fiber
diet and prevention of constipation with bran and bulk lazatives
 NPO – diverticulitis
 have NG tube until pain subside
 May be given oral liquids and gradually increase
 Advise client to avoid activites that increase intraabdominal pressure - such
as: Bending, stooping, coughing and vomiting
 Encourage Fluid intake
 Administer Antibiotic as prescribed by the physician
Surgical Management:
>ligation or removal of the sac or resection of involved bowel

HEMORRHOIDS
- Internal hemorrhoids are varicosities of the superior hemorrhoidal plexus
occurring above the mucocutaneous border (pectinate line)
- External hemorrhoids are dilations of the inferior hemorrhoidal plexus that lie
below the mucocutaneous
- Are dilated blood vessels in the lining of anal canal.
- May be internal or external
- Common disorder, affecting both men and women of any age
- The incidence is increased in people between 20-50 years old.
- Cause: the exact cause of hemorrhoids remains unclear but pregnancy is a
common initiating condition.
- Other condition associated with hemorrhoids: Obesity,Chronic liver disease,
Portal hypertension, sedentary occupations that involve long periods of
standing and sitting, chronic constipation
Increased intraabdominal pressure and hemorrhoidal venous pressure

Overdistention of the veins

Manifestations:
- Enlarged mass at the anus-Ext. hemorrhoids
- Bleeding and prolapse-Int. hemorrhoids
- Rectal itching
- Constipation
- Pain
- Major manifestation of external hemorrhoids - Blood is bright red and maybe
seen in the stool or on the toilet tissue. Hemorrhoids may prolapse during
defecation and spontaneously return

Diagnostics:
 Visual examination - External Hemorrhoids are diagnosed by visual
examination
Internal hemorrhoids: are diagnosed through:

 History
 Digital palpation
 Proctoscopy - used to confirm diagnosis
Management:
 Diet: High fiber diet
 Encourage increase fluid intake
 Laxatives or other stool softener to relieve constipation
 Warm sitz baths - An initial application of cold packs, followed by warm sitz
baths 3-4 times a day.
 Application of topical anesthetic or steroid creams
Surgical Management:
 Rubber band ligation
 Sclerotherapy
 Cryosurgery and Photocoagulation
 Hemorrhoidectomy