Adult Medical Surgical Nursing Gastro-intestinal Module: Conditions of Malabsorption Inflammatory Bowel Disorder: Crohn’s Disease; Ulcerative Colitis

Conditions of Malabsorption Malabsorption is the inability of the intestinal mucosa to absorb one or more of the major nutrients

Conditions of Malabsorption Infection: gastro-enteritis, amoeba, giardia Post-intestinal surgery (resection) Specific nutrient disorders: lactose intolerance, cystic fibrosis, coeliac Maldigestion of fats (also fat-soluble vitamins ADEK): related to obstruction of bile flow into the intestine Inflammatory bowel disorder: Crohn’s Disease and Ulcerative Colitis

Conditions of Malabsorption: Clinical Manifestations Diarrhoea, watery or with blood, mucus and/ or pus Frequent loose bulky offensive stools Pale, grey fatty stools Abdominal distension/ flatulence Weakness, muscle-wasting, weight loss Malnutrition and loss of well-being, dehydration Vitamin deficiency, anaemia, bruising tendency, osteoporosis, osteomalacia

Conditions of Malabsorption: Diagnostic Tests History and physical examination Blood: CBC, ESR, CRP, Urea, Electrolytes, LFTs, Plasma proteins Stool: analysis, culture, parasites, 24-hour fat content, Guaic occult blood Endoscopy Colonoscopy Barium or Gastrografin studies

Inflammatory Bowel Disorder A chronic inflammatory condition which may relate to auto-immune disorder There are two major conditions: Crohn’s Disease (regional enteritis) Ulcerative Colitis Both conditions hold a risk for development of colon cancer

Crohn’s Disease

Crohn’s Disease: Pathophysiology Sub-acute/ chronic inflammation of the distal ileum and ascending colon mainly Mucosal ulceration in patches, separated by normal tissue Ulceration may extend through all layers Can cause perforation to the peritoneum Inflammatory process leads to fibrosis, thickening the bowel wall and narrowing the lumen

Crohn’s Disease: Clinical Manifestations Abdominal mild colicky pain (cramps from semi-obstruction) Chronic diarrhoea (containing blood, mucus, pus): oedematous inflamed intestine with weeping irritating discharge Weight loss, malnutrition, anaemia (chronic malabsorption), emaciation, dehydration Fever and pain if abscesses Acute severe pain/ shock if perforation Remission and exacerbation

Crohn’s Disease: Diagnosis Blood: ↑ WCC, ESR, CRP (inflammation) ↓ Hb, ↓ plasma proteins (albumen) Electrolyte imbalance Stool: blood, mucus, pus Endoscopy/ colonoscopy: typical ulcerated patches seen Barium or gastrografin studies: “string” sign, stricture/narrowing of intestinal lumen

Ulcerative Colitis

Ulcerative Colitis: Pathophysiology Chronic inflammatory disease of the mucosa of the colon and rectum (10-15% will develop colon cancer) Ulceration, desquamation and shedding of mucosa, bleeding, pus (severe protein loss) Begins in rectum. May affect whole colon Recurrent lesions, one after the other Strictures and muscular hypertrophy

Ulcerative Colitis: Clinical Manifestations Abdominal cramp-like pain (rebound tenderness right lower quadrant) Diarrhoea (10-20 liquid stools daily with blood, mucus and pus in stool) Rectal bleeding and urge to defaecate Anorexia, severe weight loss, emaciation, muscle wasting, malnutrition, dehydration, anaemia, hypocalcaemia Erythema, uveitis, arthritis (auto-immune)

Ulcerative Colitis: Diagnosis Blood: ↑ WCC, ESR, CRP (inflammation) ↓ Hb, ↓ plasma proteins (serum albumen) Electrolyte imbalance Stool: frequent diarrhoea with pus, blood, mucus Sigmoidoscopy: severe mucosal ulceration and shedding Barium/ Gastrografin: shows shortening and dilatation of bowel (may perforate)

Inflammatory Bowel Disorder: (Crohn’s Disease and Ulcerative Colitis) Management

Inflammatory Bowel Disorder: Medical Treatment Rest for the patient and for the bowel (to reduce inflammation and inappropriate immune response) Nutrition and fluid replacement: Encourage oral fluids Intravenous infusion if electrolyte imbalance Low-residue, high protein, high calorie diet as tolerated, with vitamin, minerals Total Parenteral Nutrition (TPN)

Inflammatory Bowel Disorder: Medications Sedatives and antispasmodics to control bowel motility and pain: Diazepam, Codeine Phosphate, Imodium, Buscopan Antibiotics (Sulphonamides) to control secondary infection/ abscesses Corticosteroids (oral and by enema): anti-inflammatory; immunomodulators if severe- lower immune response (Imuran)

Inflammatory Bowel Disorder: Surgery Where conservative treatment fails or complications occur Resection of the affected part of the intestine and ileostomy is performed above as a faecal diversion May be temporary or permanent stoma* May involve pouch of ileum (Kock pouch) Contents of ileostomy drainage are fluid, contain proteolytic enzymes and are irritant to the skin (extreme care needed)

Post-Surgery Complications Diarrhoea leading to dehydration and electrolyte imbalance: excessive fluid loss through stoma Stomal stenosis/ retraction Peri-stomal irritation/ excoriation (poorly-fitting pouch; proteolytic enzymes in fluid) Psychological/ social implications Renal calculi (dehydration) Gall-stones (change in absorption of bile acids)

Inflammatory Bowel Disorder: Nursing Considerations Emotional support (patient is often depressed) Teaching about fluids, diet, medications, rest Monitoring progress, stool frequency, fluid balance, electrolytes, weight, skin turgor Post-surgery stoma care: check that stoma is pink and moist, no stenosis Skin care: anti-fungal powder or barrier cream Accurate fitting (and avoid frequent changing) of stomahesive patches (proteolytic enzymes)