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Inflammatory bowel disease (IBD) - chronic inflammation of the bowel - ulcerative colitis and Crohn's disease Ulcerative colitis - chronic inflammatory bowel disorder - affects the mucosa and submucosa of the colon and rectum Chronic intermittent colitis - most common form - insidious onset - attacks lasting to 1-3 mths with intervals of mths to years - affect distal colon with few systemic manifestations Fulminant colitis - acute form of ulcerative colitis - involves the entire colon - severe bloody diarrhea, acute abd pain and fever - high risk for complications Crohn's Disease - chronic, relapsing inflammatory disorder affects the GI tract - aka regional enteritis: affect any portion of GI Tract from mouth to anus, but usually the terminal ileum and ascending colon General manifestations of ulcerative colitis - diarrhea - stools contain blood and muscus - nocturnal diarrhea possible Manifestations of mild ulcerative colitis - fewer than 5 stools per day - intermittent rectal bleeding and mucus - few systemic manifestations Manifestations of severe ulcerative colitis - more than 6 - 10 bloody stools per day - extensive colon involvement - anemia, hypovolemia, malnutrition - rectal inflammation => fecal urgency and tenesmus => LLQ cramps relieved by defecation - fatigue, anorexia and weakness Tenesmus - painful but ineffective urge to defecate Systemic manifestation - shown in severe form of inflammatory bowel disease (IBD) - arthritis, skin and mucous membrane lesions, uveitis - thromboemboli - sclerosing cholangitis (more common in men , 30-50 yrs Uveitis - inflammation of the uvea, the vascular layer of the eye Sclerosing cholangitis - inflammation and scarring of the bile ducts Complications of ulcerative colitis a. Acute - hemorrhage - toxic megacolon: acute motor paralysis and dilation of colon to > 6 cm, may be triggered by the use of laxatives, narcotics, anticholinergic drugs and hypokalemia => fever, tachycardia, hypotension,dehydration abd tenderness and crampings, changes in number of stools per day - Perforation => peritonitis b. Long-term - Colorectal cancer Manifestations of Crohn's disease - involvement with the whole GI => diverse manifestations - persistent diarrhea: liquid or semiformed and not bloody - Abd pain (RLQ, relieved by defecation) and tenderness - palpable RLQ mass - systemic: fever, fatigue, malaise, wt loss, anemia - anorectal lesions: fissures, ulcers, fistulas and abscesses - nausea and vomiting if stomach and duodenum involved Complications of Crohn's disease a. Acute - Intestinal obstruction: repeated inflammation and scarring - Abscess, malabsorption - Fistula: maybe asymptomatic, when abscess, chills, fever, tender abd mass => leukocytosis. Fistula between small bowel and colon => exacerbate diarrhea, wt loss and malnutrition. Fistula between bowel and bladder => UTI - Perforation (uncommon) => generalized peritonitis b. Long-term - colon cancer Sulfasalazine (Azulfidine) - 5-aminosalicylic acid: anti-inflammatory drug for intestinal mucosa in IBD: inhibits prostaglandin production - Contradict in pregnancy, hypersensitive to sulfonamides or salicylates - After meals => decrease gastric distress; use sunscreen => prevent burns; do not take extra aspirin and vitamin C without consulting physician => use alternative contraceptive to oral form - Notify physician when: skin rash or hives, sore throat or mouth, bleeding gums, joint pain, easy bruising and fever Olsalazine and mesalamine - also contain 5-aminosalicylic acid (anti-inflammatory drug for intestinal mucosa in IBD: inhibits prostaglandin production) with less adverse effects - Contradict in pregnancy, hypersensitive to aspirin - more than 1 dose => space evenly in 24 hrs - adverse effects: nausea, diarrhea, abd cramps or flatulence; CNS: headache, dizziness, insomnia, weakness and fatigue; rash or itching; flulike symptoms, malaise - mesalamine: oral or rectal (topical anti-inflammatory for ulcerative colitis) Methylprednisolone (Medrol, Solu-Medrol), Prednisolone (Delta-Cortef), Prednisone - Glucocorticoids => potent anti-inflammatory effects => acute episodes of IBD => multiple side effects => not maintain remission Monoclonal antibody infliximab (Remicade) - immune response modifiers (newer treatments for IBD) - supress tumor necrosis factor (TNF) - for clients who have not responded to standard therapies metronidazole (Flagyl) - antibiotic with anti-inflammatory effects - help prevent remission after ileal resection in Crohn's disease ciprofloxacin (Cipro) - alternative to metronidazole (Flagyl) loperamide and diphenoxylate - antidiarrheal agents - slow GI motility and reduce diarrhea - safe for mild and chronic manifestations but not acute attacks => may precipitate toxic dilation of the colon Food helps reduce foul-smelling in stools - buttermilk and spinach (but spinach produces gas) - avoid eggs and cucumber (produce gas) Clinical Characteristics of Ulcerative Colitis Gender: equal opportunity Age at onset: 15-35 secondary peak between 50-70 Course of disease: chronic and intermittent Diarrhea: 5-30 stools/day with blood and mucus Abd pain: cramping in LLQ, relieved by defecation Nutritional deficit: common, anemia, hypoalbuminia & weight loss Constitutional manifestations of ulcerative colitis - fever rare - may have associated arthritic - erythema nodosum or uveitis Clinical Characteristics of Crohn's disease Gender: equal opportunity Age at onset: 10-30 Course of disease: slowly progressive, relapsing Diarrhea: common, less than ulcerative colitis, with no obvious blood or mucus in stool Abd pain: cramping or steady pain in RLQ or periumbilical area, tenderness and mass noted in RLQ Nutritional deficit: common and significant => anemia, weight loss, multiple vitamin & mineral deficits Constitutional manifestations of Crohn's disease - fever, malaise, fatigue - urinary complications possible Appearance of mucosa in ulcerative colitis - granular, dull, hyperemic, friable - disease uniform in affected bowel - pseudopolyps may be seen Appearance of mucosa in Crohn's disease - cobblestone appearance - areas of normal tissue surrounded by ulceration and fissures Diet for ileostomy - low-residue diet recommended - avoid food that causes excessive odor or gas - limit high-fiber foods - avoid foods that cause blockage: popcorn, corn, nuts, strawberries, caraway seeds, etc.