1. Caution to nurses
In acute ulcerative colitis no enema –(especially cathartics) - perforation may occur
If any preparation is necessary at all, give liquid diet for a few days and then a gentle tap water enema on the day of the investigation may be done

2. Management
Reduce inflammation
Modify inflammation - Suppress inappropriate immune responses
Provide rest to the diseased bowel
Nutritional therapy
Medical Therapy
Surgical therapy - resection of the colon and ileostomy

3. Nutritional therapy Oral fluids
Low residue, high -protein, high calorie diet
Vitamin supplements
Iron replacement
Correction of fluid and electrolyte imbalance by IV fluids
Avoid milk
Avoid cold foods and smoking
Total parental nutrition may be needed

4. Pharamacological Therapy
Sedatives
Antidiarrhoeals
Antiperistaltic drugs
Sulphonamides such as sulfasalazine, sulfisoxazole
Antibiotics for infection like abscesses, perforations, peritonitis
Parenteral adrenocorticotropic hormone (ACTH)
New topical and oral aminosalicylates (e.g.mesalamine, olsalazine are very effective in treatment.
Immunosuppressants used to reduce the dosage of corticoids and to prevent recurrences
Beware of complications.

5. Surgical Management Strictureplasty Resection and anastomosis
Segmental colectomy with anastomosis
Subtotal colectomy(nearly all of the colon removed) with ileorectal anastomosis
Total colectomy with lleoanal anastomosis(formation of pouch with the anal sphincter intact)
Total colectomy and ileostomy

6. Nursing Management of the patient requiring an ileostomy
Providing preoperative care
Providing postoperative care
Managing dietary and fluid needs
Managing skin and stoma care
Changing an ileostomy appliance
Irrigating a continent ileostomy
Preventing complications
Providing emotional support
Promoting home and ocommuunity-based care

7. Providing preoperative care
Intensive fluid, blood, and protein replacement
Antibiotics
If patient is taking corticosteroids continue
Low residue diet, frequent small feeds
Mark for stoma placement – usually in the right lower quadrant about 2cm below the waist crease, in an area away from previous scars, bony prominences, skin folds, or fistulae
Educate patient about ileostomy or colostomy with written materials, models, and discussion

8. Providing postoperative care
General surgery wound care
Stoma observed for colour change
Plastic bag with an adhesive facing is placed around the ileostomy withour allowing any leak.
The ileostomy is monitored for faecal discharge – about 72 hours after surgery. The patients may lose much fluid during the first few days and hence I/O chart and fluid and electrolyte balance have to be maintained.
Nasogastric suction for the first few days postoperatively. Later fluid diet can be started
Nausea and abdominal distension may indicate intestinal obstruction and are reported immediately.
Early ambulation.
Pain relief
After the perineal packing is removed daily irrigation 2 to 3 times a day until the wound heals completely

9. Providing Emotional Support
The patient thinks that everyone knows about his ileostomy or colostomy
Thinks the stoma is a mutilation
The patient often goes through the various phases of grieving, shock, disbelief, denial, rejection, anger, and restitution.
Patients doubts about normal activities and an anxiety about sex, childbearing, relationship with others, social movements
The nurse has to coordinate patient care through meetings attended by consultants such as the physician, psychologist, psychiatrist, social worker enterosomal therapist, and dietitian.
Team approach is important
The support of other ostomates is also helpful. Ostomy associations are dedicated to the rehabilitation of ostomates.

10. Managing Skin and Stoma Care
Ileostomy – liquid stools – discharged continuously- a pouch has to be worn at all times. Stomal size will vary initially; after 3 weeks oedema subsides – final size and type of appliance selected after 3 months.
Skin excoriation – allergic reaction to ostomy appliance or skin barrier or paste, chemical iritation from the effluent, mechanical injury from the removal of the appliance, and possible infection.
For irritation and yeast growth – nystatin powder (mycostatin) dusted lighty on the peristomal skin.

11. Changing an ileostomy Appliance
With traditional ileostomy the appliance is emptied every 4 to 6 hours, or at the same time as he empties the bladder. The pouch may have to be changed every 5 to 7 days. – variable. – most pouches are disposable and odor-proof.foods such as spinach and parsley act as deodorizers in the intestinal tract; foods that cause odors include cabbage onions and fish. Bismuth subcarbonate tablets tid or qud reduce odour. Lomotil may help in stool thickening and odour control

12. Irrigating a Continent ileostomy
Patient taught to drain the pouch.
A catheter is inserted into the reservoir to drain the fluid the length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irigated once a day . A pouch is not necessary; instead, most patients wear a small dressing over the opening. When faecal discharge is thick water can be injected through the catheter to loosen and soften it. Consistency affected by food. At first, drainage is only 60 to 80 ml, but as time goes on it will inccrease significantly. The internal Kock pouch will stretch, eventually accommodating 500 to 1000 ml. the patient uses the sensation of pressure in the pouch as a gauge to determine how often the pouch should be drained.

13. Managing Dietary and Fluid Needs
Low residue diet for 6 to 8 weeks
Strained fruits and vegetables given
Later fewer dietary restrictions, except for avoiding foods that are high in fibre or hard-to-digest kernels, such as celery, popcor, corn, poppy seeds, and coconut.
Foods are reintroduced one at a time. Tolerance assessed.
Chewing thoroughly is important.
If the effluent (raecal discharge) is too watery, fibrous foods (eg.whole grain cereals,,fresh fruit skins, beans,corns, and nuts) are restricted. If the effluent is excessively dry, salt, intake is increased. An increased intake of water or fluid will not increase the effluent because excess water is esdreted in the urine. .

14. Preventing Complications
Skin irritation – peristomal – due toleakage of effluent. An ill-fitting pouch is often the cause. The pouch is adjuxted by the nurse or an enterostomal therapist and skin bariers
Diarrhoea – fluid and electrolyte balance maintained and diarrhoea treated.
Stomal stenosis – caused by circular scar tissue that forms at the stoma site. – released surgically.
Urinary calculi – fluid intake is encouraged
Cholelithiasis – 3 times more common in people with ileostomy because of changes in the absorption of bile salts

15. Promoting Home and Community Based Care
Teaching patients self-care
Spouse and family should be familiar with the adjustment needed.
They need to know why it is necessary for the patient to occupy the bath room for 10 minutes or more at certain times of the day, and why certain equpment is needed.  reduction in the patient’s tension. A relaxed patient tends to have fewer problems. Visits from an enterostomal therapy nurse may be arranged. And ileostomy bag may have to be changed every 2 or 4 daysto allow for examination of the skin. To control odour.

16. Promoting Home and Community Based Care
The patient should know the commercial name of the pouch to be used so that he or she can obtain a ready supply and information about obtaining other supplies. The names of the local enterostomal therapy nurse and local self-help groups are often helpful.