Inflammatory Bowel Disease (IBD)
Prof: Panicker
Health Alterations I
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Inflammatory Bowel Disease
 Characterized by chronic, recurrent
inflammation of intestinal tract
 Periods of remission are interspersed with
periods of exacerbation
 Exact cause is unknown
 There is no cure
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Inflammatory Bowel Disease
Classification
 On the basis of clinical manifestations,
IBD is classified as either
 Ulcerative colitis
 Inflammation and ulceration of colon and
rectum
 Crohn’s disease
 Inflammation of any segment of GI tract from
mouth to anus
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Inflammatory Bowel Disease
Description
 May occur at any age
 Commonly occur during teenage years
and early adulthood
 Second peak in sixth decade
 Occur more commonly in people of
white and Ashkenazic Jewish origin
 Many have a family member with
disorder
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Inflammatory Bowel Disease
Etiology and Pathophysiology
 An autoimmune disease
 Involves an immune reaction to a person’s
own intestinal tract
 Some agent or combination of agents
triggers an overactive, inappropriate,
sustained immune response
 Results in widespread inflammation and
tissue destruction
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Inflammatory Bowel Disease
Etiology and Pathophysiology
 Involves a combination of factors
 Environmental factors
 Genetic predisposition
 Alterations in immune function
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Inflammatory Bowel Disease
Etiology and Pathophysiology
 Environmental factors
 Diet
 Exposure to air pollution
 Stress
 Smoking
 More prevalent in industrialized
countries
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Inflammatory Bowel Disease
Etiology and Pathophysiology
 Crohn’s disease
 High fiber and fruit intake associated with
↓ risk
 Oral contraceptives and NSAIDS
exacerbate symptoms
 Ulcerative colitis
 High vegetable intake associated with ↓
risk
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Inflammatory Bowel Disease
Etiology and Pathophysiology
 Numerous genome-wise association
studies have confirmed a genetic
predisposition
 IBD occurs more frequently in family
members of persons with IBD
 Especially monozygotic twins
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Inflammatory Bowel Disease
Pattern of Inflammation
Comparison of distribution patterns of Crohn’s disease
and ulcerative colitis.
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Inflammatory Bowel Disease
Pattern of Inflammation
 Inflammation patterns differ between
Crohn’s disease and ulcerative colitis
 Chronic disorders
 Patients suffer mild to severe acute
exacerbations that occur at unpredictable
intervals over many years
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Inflammatory Bowel Disease
Clinical Manifestations
 Diarrhea
 Weight loss
 Abdominal pain
 Fever
 Fatigue
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Inflammatory Bowel Disease
Complications
 GI tract (local) complications (KNOW)
 Hemorrhage
 Strictures
 Perforation (with possible peritonitis)
 Abscesses
 Fistulas
 CDI (C. Diff)
 Colonic dilation (toxic megacolon)
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Inflammatory Bowel Disease
Complications
 High risk for colorectal cancer
 Systemic complications
 Joint, eye, mouth, kidney, bone, vascular,
and skin problems
 Circulating cytokines trigger
inflammation
 Liver failure
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Diagnostic Studies
 History and physical examination
 Blood studies
 CBC (Iron Deficiency Anemia from Blood
Loss)
 Serum electrolyte levels
 Serum protein levels
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Diagnostic Studies
 Stool examination
 Pus
 Blood
 Mucus
 Stool cultures (If Infection is Present)
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Diagnostic Studies
 Imaging studies
 Double-contrast barium enema study
(Know Kidney Levels-BUN/Creatinine)
 Small bowel series
 Transabdominal ultrasonography (inside)
 CT
 MRI
 Colonoscopy
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Interprofessional Care
 Goals of treatment of IBD
 Rest the bowel
 Control inflammation
 Combat infection
 Correct malnutrition
 Alleviate stress
 Relieve symptoms
 Improve quality of life
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Interprofessional Care
Drug Therapy
 Goals of drug treatment are to induce
and maintain remission
 Aminosalicylates
 Antimicrobials
 Corticosteroids
 Immunosuppressants
 Biologic and targeted therapy
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Interprofessional Care
Drug Therapy
 Drug selection depends on severity
and location of inflammation
 Step-up approach
 Uses less toxic therapies first
 More toxic medications are started when
initial therapies do not work
 Step-down approach
 Uses biologic and targeted therapy first
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Interprofessional Care
Drug Therapy
 Medications containing 5-ASA
(5- aminosalicylic acid)
 Mainstay in achieving and maintaining
remission and preventing flare-ups of IBD
 Sulfasalazine (Azulfidine) (KNOW)
 New generation of sulfa-free drugs
 Olsalazine (Dipentum)
 Mesalamine (Pentasal)
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Interprofessional Care
Drug Therapy
 Corticosteroids
 Decrease inflammation
 Used to achieve remission
 Helpful for acute flare-ups
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Interprofessional Care
Drug Therapy
 Immunosuppressants
 Suppress immune response
 Maintain remission after corticosteroid
induction therapy
 Require regular CBC monitoring (can
suppress bone marrow and lead to
infection and bleeding) (WBC) (Kidney:
RBC)
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Interprofessional Care
Drug Therapy
 Biologic and targeted therapies
 TNF (antitumor necrosis factor) agents
 Infliximab (Remicade)
 Adalimumab (Humira)
 Certolizumab pegol (Cimzia)
 Golimumab (Simponi)
 Integrin receptor antagonists
 Natalizumab (Tysabri)
 Vedolizumab (Entyvio)
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Interprofessional Care
Drug Therapy
 Biologic and targeted agents do not
work for everyone
 Costly
 May produce allergic reactions
 Immunogenic (make antibodies)
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Interprofessional Care
Nutritional Therapy
 Dietary consultant
 Goals of diet management
1.
2.
3.
4.
Provide adequate nutrition without
exacerbating symptoms
Correct and prevent malnutrition
Replace fluid and electrolyte losses
Prevent weight loss
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Interprofessional Care
Nutritional Therapy
 Nutritional deficiencies are due to
 Decreased oral intake
 Blood loss
 Malabsorption of nutrients
 Depends on location of inflammation
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Interprofessional Care
Nutritional Therapy
 Medications can contribute to
nutritional problems
 Sulfasalazine
 Daily folic acid supplements
 Corticosteroids
 Calcium supplements to prevent osteoporosis
 Potassium supplements
 Vitamin D deficiency is common
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Interprofessional Care
Nutritional Therapy
 During acute exacerbations
 Regular diet may not be tolerated
 Liquid enteral feedings are preferred
 High in calories and nutrients
 Lactose free
 Easily absorbed
 Regular foods are reintroduced gradually
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Interprofessional Care
Nutritional Therapy
 Foods that trigger exacerbations vary
 Food diary helps identify problems for
individuals
 Lactose intolerance
 High-fat foods
 Cold foods
 High-fiber foods
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Case Study
Audience Response Question
(©iStockphoto/Thinkstock)
After teaching D.B. about dietary modifications, you
determine that teaching was effective when he chooses
which menu?
a. Baked cod, baked sweet potato, and canned pears
b. Barbecued brisket, coleslaw, baked beans, and angel food
cake
c. Fried shrimp with cocktail sauce, corn on the cob, and a
fruit roll-up
d. Turkey burger with cheese on a whole wheat bun, french
fries, and an orange
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Interprofessional Care
Surgical Therapy
 Exacerbations are debilitating and
frequent
 Massive bleeding
 Perforation
 Strictures and/or obstruction
 Tissues changes indicating dysplasia or
carcinoma
 Surgery is indicated if treatment fails
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Chronic Ulcerative Colitis
Surgical Therapy
 Procedures for chronic ulcerative
colitis
 Total protocolectomy with ileal
pouch/anal anastomosis (Curative)
 Total protocolectomy with permanent
ileostomy
 Can be performed laparoscopically
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Chronic Ulcerative Colitis
Surgical Therapy
 Total proctocolectomy with ileal
pouch/anal anastomosis (IPAA)
 Most commonly used surgical procedure
for ulcerative colitis
 A diverting ileostomy is performed
 An ileal pouch is created and
anastomosed directly to anus
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Ileoanal Pouch
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Chronic Ulcerative Colitis
Surgical Therapy
 IPAA
 Combination of two procedures
 Performed 8–12 weeks apart
 Patient able to resume control of
defecation at the anal sphincter
 Major complication: acute or chronic
Pouchitis
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Chronic Ulcerative Colitis
Surgical Therapy
 Total protocolectomy with permanent
ileostomy
 One-stage surgery
 Removal of colon, rectum, and anus with
closure
 Continence is not possible
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Crohn’s Disease
Surgical Therapy
 Commonly performed for complications
 Strictures
 Obstructions
 Bleeding
 Fistula
 Most patients eventually require surgery
 Disease often recurs at anastomosis site
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Crohn’s Disease
Surgical Therapy
 Short bowel syndrome
 Too little small intestine surface area to
maintain normal nutrition and hydration
from disease or surgery
 Lifetime fluid boluses and parenteral
nutrition may be needed
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Crohn’s Disease
Surgical Therapy
 Strictureplasty (repair)
 Opens up narrowed areas obstructing
bowel
 Reduces risk of developing shortbowel syndrome and associated
complications because intestine
remains intact
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Case Study
Audience Response Question
(©iStockphoto/Thinkstock)
D.B. must undergo surgical intervention. Which comment
indicates that additional instruction about the care of his
new ileostomy is needed?
a. “I should change the appliance daily to prevent odors.”
b. “When I change the appliance, I should check the skin for
irritation.”
c. “I should clean around the stoma with mild soap and
water and pat dry.”
d. “I’ll need to alter the appliance opening when the stoma
becomes smaller as the area heals.”
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Interprofessional Care
Surgical Therapy
 Postoperative care
 Ileostomy
 Monitoring of
 Stoma viability
 Mucocutaneous juncture
 Peristomal skin integrity
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Interprofessional Care
Surgical Therapy
 Postoperative care
 Ileostomy
 Output may be as high as 1500–1800 mL per
24 hours
 Observe for
 Fluid and electrolyte imbalance
 Hemorrhage
 Abdominal abscess
 Small bowel obstruction
 Dehydration
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Interprofessional Care
Surgical Therapy
 Postoperative care
 Ileostomy
 Initial drainage will be liquid
 Transient incontinence of mucus from
manipulation of anal canal
 Kegel exercises
 Perianal skin care
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Nursing Management
 Nursing Assessment
 Autoimmune disorders, infection
 Use of prescribed and OTC medicines
 Family history
 Diarrhea (presence of blood)
 Weight loss
 Anxiety, depression
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Nursing Management
 Nursing Diagnoses
 Diarrhea
 Imbalanced nutrition: less than body
requirements
 Ineffective coping
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Nursing Management
 Planning: Overall Goals
1. Decreased number and severity of acute
exacerbations
2. Normal fluid/electrolyte balance
3. Freedom from pain or discomfort
4. Compliance with medical regimen
5. Nutritional balance
6. Improved quality of life
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Nursing Management
 During acute phases, implement
strategies that focus on
 Hemodynamic stability
 Pain control
 Fluid and electrolyte imbalance
 Nutritional support
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Nursing Management
 Manage hygiene until diarrhea is
controlled
 Tend to odor control
 Prevent skin breakdown
 Monitor I and O
 Weigh daily
 Assess bowel sounds
 Consult with dietitian
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Nursing Management
 Teaching includes
 How to manage this chronic illness
 Importance of rest and diet management
 Perianal care
 Drug action and side effects
 Symptoms of recurrence of disease
 When to seek medical care
 Ways to reduce stress
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Nursing Management
 Establish rapport
 Encourage discussion of self-care
strategies
 Fully explain all procedures and
treatments
 Helps build trust
 Decreases apprehension
 Increases self-control
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Nursing Management
 Assist in setting realistic goals
 Consider need for increased rest
 Schedule activities around rest periods
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Nursing Management
 Emotional support
 Intermittent exacerbations and remission
of symptoms can be common
 Frustration, depression, anxiety need
managed
 Therapy
 Stress management
 Support groups
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Nursing Management
Evaluation
 Expected Outcomes
 Decreased number of diarrhea stools
 Body weight maintained within normal
range
 Freedom from pain and discomfort
 Use of effective coping strategies
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Inflammatory Bowel Disease
Gerontologic Considerations
 Second peak in occurrence of IBD is in
the 6th decade
 Proctitis and left-sided ulcerative colitis
are more common
 Diagnosis can be difficult and confused
with
 CDI
 Colitis is associated with diverticulosis or
NSAID ingestion
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Inflammatory Bowel Disease
Gerontologic Considerations
 Greater risk of complications in frail
older patients with IBD
 Adverse events from corticosteroids
 Increased infection and malignancy
associated with drug therapy
 Volume depletion and electrolyte
imbalance from diarrhea
 Physical limitations that impact self care
 Colitis
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