Understanding Lower Bowel Disease

Knowing Inflammatory Bowel Disease Ulcerative Colitis Crohn’s Disease Similarities Cause unknown Geographic distribution Genetic component Chronic recurring inflammation of the intestinal tract Possible causes: Infectious agent because it produces changes similar to those of infectious diarrhea, but no specific organism identified. Autoimmune reaction from the presence of others such as lupus Food allergies Heredity Geography – occurs more in US and northern Europe, More prevalent in Jewish populations Genetic – familial

Inflammatory Bowel Disease Comparison Ulcerative Colitis Usual onset – young to middle age Affects mucosa and submucosa of the colon and rectum Common symptoms weight loss rectal bleeding diarrhea severe tenesmus Complications Perforation Megacolon Hemorrhage Crohn’s Disease Usual onset – young Can affect any portion of the GI tract and the entire thickness of the bowel wall Common symptoms diarrhea cramping fever malabsorption Complications Fistulas Strictures Abscesses Perforation Colitis Confined to rectum and sigmoid in most patients 15-35 with a second peak at 50-70 Diarrhea is the predominant symptom. Number of stools based on the severity of the disease, mild fewer than five, severe 6-10 or more bloody stools per day. Fecal urgency and tenesmus. Left lower quadrant cramping relieved by defecation Results anemia, hypovolemia, and malnutrition Tenesmus – spasmodic contraction of anal or bladder sphincter with pain and persistent desire to empty the bowel or bladder with involuntary ineffectual straining efforts Complications Toxic megacolon acute motor paralyis and dilation of the colon to greater than 6 cm May be triggered by electrolyte imbalances or narcotic administration Symptoms include fever, tachycardia, hypotension, dehydration, abdominal tenderness and cramping Perforation leading to peritonitis rare Risk for colon cancer increased Crohns – usually affects the terminal ileum and ascending colon Areas of involvement are usually discontinuous meaning lesions and then areas of normal bowel Begins with shallow ulcers cobblestone appearance Non bloody stools Symptoms vary by section of the colon involved. Obstruction is a common complication with distension, cramoing, pain and nausea and vomiting Fistulas may be asymptomatic but may develop abscess with chills, fever, tender abdominal mass, and leukocytosis Perforation uncommon. Increases rsik for cancer but not as much as colitis

Inflammatory Bowel Disease Cobblestoning Crohns Ulcerative Colitis

Collaborative Care Diagnostics Medications Nutrition Surgery Goals of Care Ulcerative Colitis Rest the bowel Control inflammation Combat infection Control malnutrition Alleviate stress Provide symptomatic relief Goals of Care Crohns Control inflammatory process Relieve symptoms Correct metabolic and nutritional problems and promote healing Diagnostics Small Bowel and Barium Enema Instruct the patient to follow a clear liquid diet for 24 hours, Withhold fluids for eight hours Administer laxatives, enemas, or suppositories as ordered Barium is inserted with lubricated tube experience a sense of fullness and feel need to defecate Expel barium following the procedure Stools may be white for next couple of days. Small Bowel series administration of barium , hold food for eight hours prior. Encourage fluids post procedure to facilitate passage of barium. Stools may be white for up to 72 hours. Sigmoidoscopy – consent, clear liquid, laxative or enema the night before Left side position, biopsy may be taken Report pain, fever, chills, or rectal bleeding Colonoscopy – consent, liquid diet, bowel prep, arrange for transportation may receive sedation Stool exams CBC with Hg and HCT Serum protein Folic acid Liver enzymes if sclerosing cholangitis is expected.

Medications Antimicrobials Corticosteroids Sedatives Antidiarrheals Hematinics and Vitamins Sulfonamide antibiotics antiinflammatory effect on intestsinal mucosa used in Crohns with large bowel involvement; Assess renal and liver function Contraindicated in pregnancy and or sensitivity to sulfa and or salicyclates Take oral preps after meals Drink at least 2 quarts of water to prevent kidney damage Causes sensitivity to the sun Notify doctor of skin rash, hives, sore throat, bleeding Mesalamine (Rowasa) and Olsalazine (Dipentum) cause fewer side effects available as suppositories, suspension or enema Corticosteroids - used for acute episodes antiinflammatory Sedatives to reduce anxiety Antidiarrheals such as Lomotil to decrease motility Hematinics to address anemia

Nutrition Individualized Goals Adequate nutrition without exacerbating symptoms Correct and prevent malnutrition Replace fluid and electrolytes losses Prevent weight loss Traditionally NPO during acute episodes. High calorie, high protein, low residue avoid raw fruits and vegetables, seeds, nuts May need parenteral feedings

Nursing Diagnosis Diarrhea related to irritated bowel and intestinal hyperactivity Anxiety related to possible social embarrassment, diagnostic tests, and treatments Imbalanced Nutrition: Less than Body Requirements related to decreased intake, decreased absorption, and increased nutrient loss through diarrhea Impaired Skin Integrity related to diarrhea and altered nutritional status Ineffective Coping related to chronic disease, lifestyle changes, stress and pain Ineffective Therapeutic Regimen Management related to lack of knowledge of disease course, lifestyle adjustments, nutritional and drug therapy

Colorectal Cancer Risk factors Age over 50 Polyps Family History Inflammatory Bowel Disease Exposure to Radiation High animal Fat and calorie intake Most are adenocarcinomas that began as polyps. No symptoms until advanced. Slow growing Early symptoms include change in bowel habits, pain , anorexia, weight loss. May have palpable mass.

Colon Polyps Sessile (villous) Pedunculated (tubular) Familial Polyp is a mass of tissue that arises from the bowel wall and protrudes into the lumen. May develop anywhere in the bowel but they occur most often in the sigmoid colon and rectum. Identified by their structure – the laRGER THE SIZE THE GREATER THE RISK Silent disease may bleed intermittently. Villous polyp – cauliflower like Pedunculated – stalk like stem Familial autosomal dominant genetic disorder usually develops after puberty risk of malignancy 100% by age 40 if not treated. Every six month screening Screening begins at age 50 and then every 5 years

Collaborative Care Screening Diagnostic tests Surgery Radiation Chemotherapy Screening digital rectal exam beginning at age 40 annual fecal occult blood testing at age 50 Diagnostic tests CBC Fecal occult blood CEA – tumor marker detected in patient s with cancer used to estimate prognois, monitor treatment and detect recurrence Sigmoidoscopy/colonoscopy CT scan Tissue biopsy Sigmoid colostomy is the most common permanent colostomy performed particularly for cancer of the colon

Surgical Interventions Performed when necessitated by complications or failure of conservative treatment measures Crohns: resection with end to end anastomosis Ulcerative colitis Total Colectomy Ostomy Permanent Temporary or loop Continent (Kock’s) ileostomy Bowel obstruction is the leading indication for surgery in Crohn’s disease Total colectomy (with ileal pouch anal anastomosis) procedure of choice for extensive ulcerative colitis usually perform temporary (2- 3 month) loop ileostomy at the same time to allow anal anastomosis to heal Ostomy is a surgically created opening between the intestine and the wall of the abdomen. Name based on location. Ileostomy usually remove colon, rectum, and anus. Temporary sometimes performed to allow healing of tissue. Kock’s ileostomy an intraabdominal reservoir is constructed with a nipple valve.

Ileostomy Facts Stool consistency is liquid to semi-liquid Fluid requirements may be increased No bowel regulation Use of pouch and skin barriers No irrigation Indications for surgery: ulcerative colitis, crohns, diseased or injured colon, birth defetcs, familial polypois, trauma, cancer

Nursing Diagnosis for Patients with a Colostomy/Ileostomy Risk for Impaired Skin Integrity – related to irritation from fecal drainage, irritation from appliance, and lack of knowledge Disturbed Body Image – related to presence of ostomy and odor Imbalanced Nutrition: Less than Body Requirements - related to lack of knowledge of appropriate foods and decreased appetite Ineffective Sexuality Patterns - related to perceived loss of sexual appeal and possibility of seepage of fecal material during sexual activity Risk for Deficient Fluid Volume - related to excess fluid loss from ileostomy or diarrhea with colostomy and decreased intake

Stoma Characteristics Color Rose to red Pale Blanching, dark red to purple Edema Mild to moderate Moderate to severe Bleeding Small amount Moderate to large Cause Viable stoma Anemia Inadequate blood supply Normal initial postop Trauma to stoma, medical cause Obstruction Allergic reaction Gastroenteritis Small amount normal Coag deficiency, varices, GI bleed

Colostomy Comparisons Ascending Stool consistency semiliquid Fluid requirement increased No bowel regulation Pouch ans skin barriers Irrigation no Indications: perforating diverticulitis, tumors Transverse: semiliquid to semiformed, irrigation no Sigmoid: formed stool , no change in fluids, bowel regulation possible, may need irrigation, cancer of the rectum or perforating diverticulum

Other Bowel Disorders Celiac Disease Hernias Intestinal Obstruction Diverticular Disease Irritable Bowel Lactase Deficiency Celiac – sprue flattening of mucosa with loss of villi sensitivity to gliadin fraction of gluten, a cereal protein cause unknown cause with malabsorption Manifestations are abdominal bloating, and cramps, diarrhea, steatorrhea, anemia and nutrient deficiencies Complications GI malignancies and intestinal lymphoma Testing stool fats, IgA IgG antibodies, protein, albumin, electrolytes, protime Treatment – vitamin replacements, may need Vit K, gluten free diet high in calories and protein, low in fat Hernias- defect in the abdominal wall that allows abdominal content to protrude out of the abdominal cavity. Classified by location – inguinal, umbilical, incisional Surgery usual treatment Obstruction – failure of bowel contents to move through bowel lumen. Small intestine usually affected. May be mechanical from scar tissue, hernias, tumors, IBD, or obstruction of lumen Functional peristalsis fails to move contents Manifestations vary based on location –SBO nausea, vomiting, distension, tenderness, hypovolemia, tachycardia, temp elevation, decrease in urine output Fluid and electrolyte changes LBO – colon dilation, constipation, colicky pain, vomiting RX decompression, surgery Diverticular disease - saclike projections of mucosa through the muscular layer of the colon, may occur anywhere in GI tract – usually asymptomatic, episodic pain usually left sided, constipation/diarrhea complications include hemorrhage an diverticulitis Diverticulitis – inflammation Complications – abscess and peritonitis, bowel obstruction, fistula formation, hemorrhage Diagnostic tests – WBC, hemoccult tets, Barium enema, abdominal x-ray, CT, sigmoid, colonoscopy Meds – Flagyl, Septra, Bacrim, mild – severe Mefoxin, Zosyn, Timentin Talwin or Demerol for pain Diet – high fiber avoid items with seeds May need Surgery Irritable Bowel – spastic colon increased reactivity in response to stimuli Hypersecretion of mucous abdominal pain and change in bowel habits Bulk forming laxatives, anticholinergics, antidepressants and increase in fiber Lactase Deficiency – genetic enzyme absence may have secondary causes results in lactose intolerance Lactose free diet elimination of milk and milk products