Inflammatory Bowel Disease

1. Disease Characteristics
   1. Rectum to Cecum (Continuous)
   2. Mucousal & Submucousal Layer
   3. Pseudopolyps

      Annotations:

      • Tongue Like Projections into the Bowel Lumen
   4. Onset Teens to Mid 30's
   5. Fibrosis
      1. Rigid pipe like (Surgery becomes Necessary)
   6. Diagnostic Test: Colonoscopy/ Sigmoidoscopy (Biopsy)/ Double Contrast Barium Enema,
      1. GOlYTELY
         1. Contraindicated for Patients w/ Bowel obstruction, Perforation, Toxic Megacolon!! (Caution w/ severe colitis) Adverse Reactions (Abdominal Fullness & bloating)
         2. 8oz glass q 10min until 1 gallon is ingested
2. Signs & Symptoms
   1. Protein Loss through Stool
   2. Bloody Diarrhea
      1. Fluid & Electrolyte Loss

         Annotations:

         • Water & Electrolytes cannot be absorbed through inflammed Mucosa
      2. Severe (Tachycardia/anemia/dehydration) 10-20 stools
   3. Abdominal pain
   4. Toxic Megacolon "Preforation" (More common in Ulcerative Colitis)
      1. Emergency Colorectomy
      2. Dilation & Paralysis of the Colon
   5. Tenemus

      Annotations:

      • Cramping Rectal pain
   6. Fever (Acute Attacks)
   7. Stricutures (Occassional)

1. Disease Characteristics
   1. Can Effect ANY part of the GI tract from the mouth to the Anus
   2. Most often terminal Ileum & Colon
   3. Transmural

      Annotations:

      • Effects All layers of the Bowel 
   4. Skip Lesions
   5. Cobblestoning Mucosa

      Annotations:

      • The appearance ot the intestines/Colon will look Cobblestone. 
   6. Onset Teens- Mid 30s
   7. Diagnostic Test: Capsule Endoscopy, Small Bowel Series (Barium) "Biopsy cannot be obtained
2. Signs & Symptoms
   1. Weight Loss (Small Intestine Involved)

      Annotations:

      • Small intestine impairs Nutrient absorption. 
   2. Diarrhea
   3. Colicky Abdominal Pain
   4. Bowel Obstruction
      1. Strictures
   5. Peritonitis

      Annotations:

      • Microscopic Leaks can allow content from bowel enter the peritoneal cavity & produce abscess/ or Peritonitis. 
      1. Preforation
   6. Fistulas

      Annotations:

      • Can occur between adjacent areas of bowel. *Bowel & Bladder  *Bowel & Vagina * Skin to Outside the Body
      1. UTI
      2. Feces in Urine? Feces on Skin?
   7. Anal Abscess
   8. Fever (Intermittent)
3. Diagnostics

1. Surgical

   Annotations:

   • Treatment has failed & Diarrhea is intractable 
   1. Colon Removed (Ileostomy or Ileoanal Resovoire formed
   2. Stricturplasty in crohn's to widen narrow bowel
2. Medications
   1. 5ASA

      Annotations:

      • Decrease Bowel Inflammation through direct contact of Bowel Mucosa. 
      1. Suppositories, Enema & Foam
      2. Yellow/orange Urine/skin (Not harmful)
      3. Photosensitivity
      4. Sulfasalazine w/ Sulfapyridine (Orally)
      5. Alternative: Mesalamine, Osalazine, Balsalazide,
      6. Folic Acid

         Annotations:

         • Medication effects this, the patient will need a folic acid supplement!!!!
   2. Antimicrobials
      1. Metronidazole, Ciproflaxacin
   3. Immunosuppressants
      1. NOT for Acute Flare ups (Delayed onset)
      2. azathiopine, 6-MP, Methotrexate, Cyclosporine
      3. Monitor CBC
      4. Methotrexate (shown to be effective)
         1. NOT FOR PREGNANT WOMEN
   4. Corticosteroids
      1. Prednisolone
      2. Budesonide
      3. Shortest Time Possible, Taper off when Surgery is planned!
      4. Will need Ca+ Supplement
      5. Potassium!

         Annotations:

         • Leads to Sodium Retention, and loss of Potassium!!!
   5. Biologic & Target Therapy (Immunodulators)

      Annotations:

      • Need to be tested for TB! & cannot have live virus vaccines. Need to be taught signs of infection.
      1. TNF (-mab)

         Annotations:

         • Infliximab (IV) , adalimumab (Self Administered SC 1-2w), certolizumab by a HCP q 4w, golimumab x2 first month & then q 4w) 
      2. natalizumab

         Annotations:

         • Prevent Migration of Leukocyte from bloodstream to inflammed Tissue. IV q 28days *Special Monitoring Program
   6. Antidiarrheals
   7. Anticholinergics/sedative

      Annotations:

      • Cholinergic effect PNS (Rest & Digest) The bowel are hypermobile so this Decreases this response.
   8. Anemia
      1. Oral (Iron Gluconate/Ferrous Sulfate) if cannot tolerate give parental
      2. Severe iV/IM (iron Dexteran)

1. Nutrition
   1. Fat Malbapsorption & Anemia
      1. Cobalamin (Vitamin B12) in injection form monthly, oral or nasal daily
      2. Cholestyramine (Ion exchange Resin)

         Annotations:

         • Binds to unabsorbed Bile fats. This helps control diarrhea.  
      3. Zinc

         Annotations:

         • Zinc Deficiency: May contribute to diarrhea
   2. Liquid Enteral Feeding Preferred over Parental
   3. High calories, high vitamin, high protein, Low Residue, lactose free Diet
   4. Small Frequent meals & Avoid Spicy food
2. Screen for Cancer
3. Teach Smoking Cessation! (increase bowel motility)
4. Hospital Care
   1. Monitor # of stools
   2. Monitor I&O
   3. Dibucaine, witch hazel , sitz bath for perianal care
5. Exacerbation?
   1. IV F&E replacement
   2. REST BOWELS
   3. TPN
      1. Good for 24hrs
      2. Capillary Glucose (Monitor)
         1. Insulin

            Annotations:

            • Sliding Scale
      3. Large Guage (PICC/CVAD)
      4. start low & go slow

Annotations:

• Periods of Remission Interspersed with Exacerbation. 

1. Severe Abdominal Pain
2. Rebound Tenderness
3. Abdominal Distention
4. Decrased Bowel Sounds
   1. Paralytic Ileus, N&V
5. Fever

1. CBC (Blood Loss?)
2. WBC (Preforation? Megacolon?)
3. Fluid & Electrolyte Loss Na+, K+, Cl-, Bicarbonate, Mg2+,
4. Hypoalbuminemia (protein Loss)

   Annotations:

   • Poor Nutrition or Protein Loss
5. Elevated Erythrocyte Sedimentation rate, C-Reactive Protein, WBC (Inflammation?)
6. Stool Occult

   Annotations:

   • Examined for Blood, Pus & Mucous in stool.