Inflammatory Bowel Disease

Inflammatory Bowel Disease •

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Immunologically-related disorder Characterized by chronic recurrent inflammation of the GI tract Cause unknown but theories exist: infection (bacteria or virus), food allergies, autoimmune reaction, heredity Ulcerative Colitis

Pathologic Characteristics

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Inflammation of colon and rectum Involves mucosa and submucosal layers

Age/Sex

Clinical Manifestations

Common to Both •

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Inflammation of segments of the GI tract- can occur anywhere in the GI tract Skip Lesions Cobblestone appearance Entire thickness of GI tract

Upper middle class urban: Jewish 15-30 years old Bloody diarrhea (Metabolic acidosis = loss bicarbonate in stools)

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Complications

INTESTINAL •

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Diagnostics

Inflammation of the GI tract

Crohn’s Disease

Hemorrhage Increase risk of colon cancer if ulcerative colitis >10 years Strictures/perforation (less common than with Crohn’s) Toxic Megacolon Perforation d/t colon losses its mobility. Dilation and paralysis of colon ends with perforation and peritonitis. Eventually colon becomes necrotic and gangrenous

CBC

Abdominal pain Cramping, constant or intermittent Elevated temperature Weight loss Dehydration Elevated heart rate Fatigue Abdominal distention

Non bloody diarrhea

EXTRAINTESTINAL • • • • • • • •

Associated with active inflammation Joint = arthritis Fingers = clubbing Skin= erythema Malabsorption Eyes = conjunctivitis Gallstones Kidney stones

INTESTINAL

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Electrolytes Stool C&S Endoscopy – best diagnostic to visualize scar tissues Barium xray (lower GI = enema, upper GI =

Strictures and obstruction = scar tissue from inflammation and narrow lumen Fistulas develop between sections of GI tract and organs (bowel –vaginal and bowel – bladder). Patient at risk for UTI and urinary stools in Foley Perforation d/t inflammation in ALL layers = peritonitis and abscess Decreased absorption, esp. fat = decrease in fat soluble ADEK

WBC

barium swallow) Treatment: Medication Goals: • Rest bowel • Control inflammation • Prevent infection • Correct malnutrition • Decrease stress • Symptomatic relief

Surgery

Azulfidine (Sulfa-salazine) • Anti-inflammatory • 5 amino salicyclic acid • People allergic to sulfonamides or salicylates (e.g., ASA) should not take this drug. • Adequate fluid intake must be maintained in order to prevent crystal and stone formation.

Me-salamine (Rowasa, Pentasa, Asacol) • • •

Anti-inflammatory 5 amino salicyclic acid May produce an orangeyellow color of the urine

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Total Proctocolectomy with Permanent Ileostomy: removal of colon, rectum, cecum, anus Liquid stools

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Total Proctocolectomy with continent Ileostomy (Kock Pouch): removal of colon, rectum and anus. Anus is closed. Internal pouch created with one way valve to prevent continuous leakage of fluid. No external pouch. Self-catheterize. Complication: Valve failure

Corticosteriods (Prednisone) • Induced remission • Anti-inflammatory effect • Not used as long term Immunosuppressives 1. 6MP (Mercaptopurine) 2. Cyclosporine 3. Imuran • •

Risk for infections d/t bone marrow suppression Taken 3-6 months

Infliximab (Remicade) • Indication: Patient with IBD with inadequate responses to other therapies. A monoclonal antibody that interferes with the inflammatory process/immune system. 2 hr IV infusion: initial, then wks 2 & 6; then q 8 weeks. Side effects: Infection (high incidence of TB: pretreatment screening and ongoing monitoring)

Azulfidine (Sulfa-salazine) • Effective if Crohn’s located in large intestine, but not as effective if Crohn’s located in small intestine Flagyl useful when Crohn’s is in perianal area Adalimumab (Humira) • Crohn’s disease • Monoclonal antibody (type of biologic response modifier) • Usually prescribed after other pharmacologic treatments fail. • Goal: induce and maintain remissions • SubQ (self injection) 1 q other week. • Side effects: TB, lymphoma, injection site reactions, nausea, URI

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NO surgical can treat Crohn’s disease Balloon dilatation

and Pouchitis. Can be treated with Flagyl.

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Treatment: Nutrition Goals

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Total Colectomy and Ileal Reservoir: Two surgeries. 1) Colectomy, reservoir construction, temporary ileostomy 2) Ileostomy closure – as this functions as internal pouch; must have competent anal sphincter; over 3-6 months, patients learn to control BMs; Post op Kegel exercise to increase strength of pelvic floor muscles. Vitamin and iron supplements Long term Azulfidine – can cause Folic acid deficiency Malabsorption

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TPN with severe disease Elemental diets: high calorie and nutrient, lactose-free, absorbed in the proximal small intestine which allows the more distal bowel to rest Initially NPO Hi calorie – Hi protein-Lo residue/fiber Avoid smoking (increase GI motility) Zinc deficiency may result from chronic diarrhea Provide rest Assist with coping strategies Frequent BMs – rectal discomfort, anxiety and depression Monitor for hypovolemia Monitor nutritional status

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Low fat No milk products – lactose not adequately absorbed because of damage mucosa Malabsorption – decreased absorption of B12 by terminal ileum (if affected)

Probiotics • Good bacteria • Restores balance to gut flora • Decrease in flares • Lactobacillus (Culturelle) • Pourable yogurt and yogurt with “live cultures’