RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Gastrointestinal Conditions & Ostomy Surgeries

Type of Gastrointestinal conditions Irritable Bowel Syndrome (IBS) Diverticulosis/Diverticulitis Inflammatory Bowel Diseases Ulcerative Colitis Crohn’s Disease

Irritable Bowel Syndrome (IBS) Irritable bowel syndrome is a disorder characterized most commonly by cramping, abdominal pain, bloating, constipation, and diarrhea. IBS causes a great deal of discomfort and distress, but it does not permanently harm the intestines and does not lead to a serious disease, such as cancer. Most people can control their symptoms with diet, stress management, and prescribed medications. For some people, however, IBS can be disabling. They may be unable to work, attend social events, or even travel short distances.

IBS As many as 20 percent of the adult population, or one in five Americans, has symptoms of IBS, making it one of the most common disorders diagnosed by doctors. It occurs more often in women than in men, and it begins before the age of 35 in about 50 percent of people.

Causes of IBS Researchers have yet to discover any specific cause for IBS. One theory is that people who suffer from IBS have a colon (large bowel) that is particularly sensitive and reactive to certain foods and stress. The immune system, which fights infection, may also be involved Some implication of Serotonin

What makes the symptoms of IBS worse? large meals bloating from gas in the colon Medicines wheat, rye, barley, chocolate, milk products, or alcohol drinks with caffeine, such as coffee, tea, or colas stress, conflict, or emotional upsets

Diagnosis of IBS There is no specific test for IBS, although diagnostic tests may be performed to rule out other diseases. These tests may include stool sample testing, blood tests, and x rays. Typically, a doctor will perform a sigmoidoscopy, or colonoscopy.

Treatment for IBS No cure for IBS – MDs treat symptoms For Constipations – use of laxatives Antispasmotic to control colon spasms Antidepressants (Antispasmotics & antidepressants can cause constipation) Muscle relaxants for bladder & intestines

Stress & IBS Stress can stimulate colon spasms in people with IBS Colon is partially controlled by autonomic nervous system Stress management strategies may help reduce colon spasms

Diet & IBS For many people careful eating reduces IBS symptoms Keep a journal on what foods make symptoms worse Increasing dietary fiber may improve symptoms Drink 6-8 glasses of water per day

IBS Summary IBS is a disorder that interferes with the normal functions of the colon. The symptoms are crampy abdominal pain, bloating, constipation, and diarrhea. IBS is a common disorder found more often in women than men. People with IBS have colons that are more sensitive and reactive to things that might not bother other people, such as stress, large meals, gas, medicines, certain foods, caffeine, or alcohol. IBS is diagnosed by its signs and symptoms and by the absence of other diseases. Most people can control their symptoms by taking medicines (laxatives, antidiarrhea medicines, antispasmodics, or antidepressants), reducing stress, and changing their diet. IBS does not harm the intestines and does not lead to cancer. It is not related to Crohn’s disease or ulcerative colitis.

Diverticulosis/Diverticulitis Many people have small pouches in their colons that bulge outward through weak spots, like an inner tube that pokes through weak places in a tire. Each pouch is called a diverticulum (pl. diverticula). The condition of having diverticula is called diverticulosis. About 10 percent of Americans over the age of 40 have diverticulosis. The condition becomes more common as people age. About half of all people over the age of 60 have diverticulosis.

Diverticulitis When the pouches become infected or inflamed, the condition is called diverticulitis. This happens in 10 to 25 percent of people with diverticulosis. Diverticulosis and diverticulitis are also called diverticular disease.

Complications Bleeding Abscess, Perforation & Peritonitis When diverticula bleed, blood may appear in the toilet or in your stool. Bleeding can be severe, but it may stop by itself and not require treatment Abscess, Perforation & Peritonitis The infection causing diverticulitis often clears up after a few days of treatment with antibiotics. If the condition gets worse, an abscess may form in the colon. A large abscess can become a serious problem if the infection leaks out and contaminates areas outside the colon. Infection that spreads into the abdominal cavity is called peritonitis.

Complications Fistula Intestinal obstruction A fistula is an abnormal connection of tissue between two organs or between an organ and the skin. When diverticulitis-related infection spreads outside the colon, the colon's tissue may stick to nearby tissues. The organs usually involved are the bladder, small intestine, and skin. Intestinal obstruction The scarring caused by infection may cause partial or total blockage of the large intestine. When this happens, the colon is unable to move bowel contents normally. When the obstruction totally blocks the intestine, emergency surgery is necessary. Partial blockage is not an emergency, so the surgery to correct it can be planned.

Causes of Diverticular Disease The dominant theory is that a low-fiber diet is the main cause of diverticular disease. Diverticular disease is common in developed or industrialized countries—particularly the United States, England, and Australia—where low-fiber diets are common. The disease is rare in countries of Asia and Africa, where people eat high-fiber vegetable diets Diverticulitis occurs when diverticula become infected or inflamed. It is not certain what causes the infection. It may begin when stool or bacteria are caught in the diverticula. An attack of diverticulitis can develop suddenly and without warning

Diagnosis of Diverticular Disease Medical History Physical/digital exam of the rectum X-rays

Treatment of Diverticular Disease Diverticulosis High Fiber Diet Mild pain medications Serious attack can lead to hospitalization and surgery Diverticulitis Tx is focused on clearing up infection Antibiotics (oral) Hospitalization Liquid diet IV antibiotics Surgery

Points to Remember Diverticulosis occurs when small pouches, called diverticula, bulge outward through weak spots in the colon (large intestine). The pouches form when pressure inside the colon builds, usually because of constipation. Most people with diverticulosis never have any discomfort or symptoms. The most likely cause of diverticulosis is a low-fiber diet because it increases constipation and pressure inside the colon. For most people with diverticulosis, eating a high-fiber diet is the only treatment needed. You can increase your fiber intake by eating these foods: whole grain breads and cereals; fruit like apples and peaches; vegetables like broccoli, cabbage, spinach, carrots, asparagus, and squash; and starchy vegetables like kidney beans and lima beans. Diverticulitis occurs when the pouches become infected or inflamed and cause pain and tenderness around the left side of the lower abdomen

Ulcerative Colitis Ulcerative colitis is a disease that causes inflammation and sores, called ulcers, in the lining of the rectum and colon. Ulcers form where inflammation has killed the cells that usually line the colon, then bleed and produce pus. Inflammation in the colon also causes the colon to empty frequently, causing diarrhea.

Ulcerative Colitis Ulcerative colitis can occur in people of any age, but it usually starts between the ages of 15 and 30, and less frequently between 50 and 70 years of age. It affects men and women equally and appears to run in families, with reports of up to 20 percent of people with ulcerative colitis having a family member or relative with ulcerative colitis or Crohn’s disease. A higher incidence of ulcerative colitis is seen in Whites and people of Jewish descent

Symptoms of Ulcerative Colitis anemia fatigue weight loss loss of appetite rectal bleeding loss of body fluids and nutrients skin lesions joint pain growth failure (specifically in children)

Causes of Ulcerative Colitis People with ulcerative colitis have abnormalities of the immune system, but doctors do not know whether these abnormalities are a cause or a result of the disease. The body’s immune system is believed to react abnormally to the bacteria in the digestive tract. Ulcerative colitis is not caused by emotional distress or sensitivity to certain foods or food products, but these factors may trigger symptoms in some people. The stress of living with ulcerative colitis may also contribute to a worsening of symptoms.

Diagnosis of UC Physical Exam/Medical History Blood tests for anemia or high white blood cell count Stool sample Colonoscopy or sigmoidoscopy are most accurate X-rays with barium enema

Treatment of UC Antibiotics (Aminosalicylates) given orally, suppository or by enema Coritcosteriods – strong anti-inflammatory medication Immunomodulators (for individuals who do not respond to antibiotics or steroids). Increases immune system. Hospitalization Attempts to stop diarrhea and replenish fluids/electolytes Surgery (Ostomies) About 5% of people with UC develop colon cancer

Crohn’s Disease Crohn’s disease is an ongoing disorder that causes inflammation in any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine, called the ileum.

Causes of Crohn’s Disease Several theories exist about what causes Crohn’s disease, but none have been proven Research shows that the inflammation seen in the GI tract of people with Crohn’s disease involves several factors: the genes the patient has inherited, the immune system itself, and the environment.

Symptoms of Crohn’s Disease The most common symptoms of Crohn’s disease are abdominal pain, often in the lower right area, and diarrhea. Rectal bleeding, weight loss, arthritis, skin problems, and fever may also occur. Bleeding may be serious and persistent, leading to anemia. Children with Crohn’s disease may suffer delayed development and stunted growth. The range and severity of symptoms varies.

Diagnosis of Crohn’s Disease Similar tests as Ulcerative Colitis Physical exam Lab tests Colonoscopy X-rays Biopsy

Complications of Crohn’s Disease Intestinal Blockage due to scarring and thickening of intestinal wall Can also effect surrounding tissues such as bladder, vagina, or skin (fistulas) Deficiencies in proteins, calories, & vitamins Other conditions: arthritis, gall and or kidney stones, skin disease, inflammation in mouth or eyes

Drug treatment Anti-Inflammation Drugs Cortisone/Steroids Immune System Supressors Medication to block body’s inflammation response (Infliximab or Remicade) Antibiotics Anti-Diarrheal and Fluid Replacements

Other treatments Nutritional supplementation Surgery Needed particularly for children with Crohn’s disease for proper growth Surgery 2/3 to 3./4 of all people with Crohn’s disease will require surgery at some point in their lives Surgery can help, but it is not a cure (see ostomy part of lecture)

Ostomy Surgeries Numerous medical conditions, including congenital defects, trauma, inflammatory bowel disease (IBD),and bowel and bladder cancer, can be treated by ostomy surgeries These surgeries close the normal route of elimination of bodily wastes and create a new opening (stoma)

Ostomy Surgeries GI Stomas Jejunostomy Ileostomy Cecostomy Colostomy

Colostomy Colostomy: A surgically created opening in the abdominal wall through which digested food passes. Temporary colostomy Permanent colostomy Reasons for surgery: Cancer, diverticultis trauma, imperforate anus Vocational impact – restrict heavy lifting

Ileostomy A surgically created opening in the abdominal wall through which digested food passes. The Ileum (the lowest part of the small intestine) is brought through the abdominal wall to form a stoma. A Ileostomy is performed when a disease or injured colon cannot be treated successfully. Vocational implication – restrict heavy lifting.

Jejunostomy Can be used for either feeding or removal of stool, depending on if the stoma is at the beginning or end of the Jejunum. Feeding: A tube is placed into the jejunum versus the stomach (gastrostomy). People with a jejunostomy can eat and drink by mouth. The device is an “insurance” mechanism for nutrition. It can be temporary or permanent. Stool removal: in certain instances a jejunostomy is conducted similarly to the Ileostomy. Again, this usually temporary.

Cecostomy A tube that goes through the skin into the beginning of the large intestine to help remove gas or feces by injecting a solution (antegrade enema) that flushes the gas and stool out of the rectum. Can be temporary or permanent.

Urinary Stomas When a urinary stoma is created, the urine does not go to the bladder. The urine is rerouted through an opening on the abdomen (stoma) created by a surgeon. Vesicostomy: An opening in the bladder created to connect the bladder to an opening on the lower abdomen. Ureterostomy: The ureter (or ureters) is attached to the skin’s surface through a small opening in the abdomen. Ileal conduit: A small section of the ileum (small intestine) is used to create a passage for the urine to exit the body. This section of the small intestine, called a conduit, is attached to the abdominal wall to create a stoma. The urine flows from the kidneys, through the ureters, and out the stoma

Psychosocial/Vocational implications Ostomy surgery itself does not present obstacles to most vocational functioning – underlying disease process may influence RTW Changes in body image Economic costs of living with an ostomy can be considerable when complications from the stoma or disease process develop Provide information and education to the person in a manner that relays a message of acceptance

Additional Resources and Information from the Web United Ostomy Association (www.uoa.org) International Ostomy Association (www.ostomyinternational.org) World Ostomy Resource (www.powerup.com.au/~takkenb/OstomySites.htm) Crohn’s Colitis Foundation of America (www.ccfa.org) Oley Foundation (www.oley.org)