INFLAMMATORY BOWEL DISEASE

CROHNS DISEASE
A. Case Scenario
Janine, a 22-year-old woman, comes to your office with a 6-week history of 5 loose, nonbloody stools
daily, right lower quadrant abdominal pain (especially after eating), 20-lb weight loss. Findings from the
physical examination show a definite and moderately tender 5-cm mass in the right lower quadrant of her
abdomen. Results from the stool studies are negative for enteric pathogens, and the results from her blood
work show mild anemia (hemoglobin, 11.2 g/dL), with a normal metabolic panel and normal thyroidstimulating hormone levels. Radiographic findings demonstrate a 10-cm narrowing in the terminal ileum
(string sign) with a separation of bowel loops around the terminal ileum.

B. Overview
Defined as chronic inflammatory condition of the bowel in which there are patchy areas of
inflammation anywhere in the entire GI tract; most common in the ileum or colon; referred to as
inflammatory bowel disease (IBD) and grouped with ulcerative colitis because symptoms are
similar
Incidence is higher among young adults and teenagers; occurs equally in both genders; more
often seen in clients of Jewish and Caucasian race
Develops slowly, with remissions and exacerbations; emotional factors related to family matters
or work aggravate the illness
Cause is unknown but thought to be multifactorial, probably involving an infectious process
(bacteria, viruses, mycobacteria), allergy or immune disorder, psychosomatic, dietary, hormonal,
and environmental factors

C. Clinical Manifestations
Inflammatory lesions may occur anywhere from the mouth to the anus; more often lesions
occur in the ascending colon, distal ileum, and anorectal areas
Primarily submucosal
-All layers of the bowel are involved, with the submucosal layer affected to the greatest
extent
Cobblestone appearance
-Resulting from the fissures and crevices that develop surrounded by areas of submucosal
edema
Skip lesions
-Characteristic feature of CD is the sharply demarcated, granulomatous lesions that are
surrounded by normal appearing mucosal tissue
-They are interspersed between what appear to be normal segments of the bowel
Scar tissue may interfere with movement of chime and perforation or obstruction may occur

D. Complications
Fistula formation
-Fistulas are tubelike passages that form connections between diff sites, including the
bladder, vagina, urethra, and skin.
-Perianal fistulas- that originate in the ileum are relatively common and may lead to
malabsorption, syndromes of bacterial overgrowth, and diarrhea
Abdominal Abscess formation
- Fistulas can also become infected and cause abscess formation
-The bowel becomes congested, thickened and may develop abscesses
Intestinal obstruction
-Scar tissue may interefere with movement of chime and perforation/obstruction may occur
Fluid and electrolyte imbalance
Deficiency in absorption of folic acid, calcium and vitamin D

E.

Signs/Symptoms
Intermittent diarrhea
Weight loss
Intermittent localized pain in the right lower quadrant (worsening as the disease progresses)
F/E imbalance
Dehydration
Elevated WBC
Iron deficiency anemia
Fever
Physical development and Growth retardation

F. Nursing Assessment
Nutritional and fluid status
Bowel pattern assessment
Daily weight
Activity tolerance
Visual examination of stool
History of risk factors/ stress level and emotional factors
Vital signs
Skin/nail color changes secondary to anemia

G.

Diagnostic Findings
CBC (elevated WBC, low RBC, Hgb, and Hct)
FE imbalance
Barium enema (reveals characteristic string sign or skip lesions)
Albumin level (low)
High erythrocyte sedimentation rate (ESR)

H. Diagnostic Tests
Proctosigmoidoscopy
Visualizes ulcerations, edema, hyperemia, and inflammation (result of secondary
infection of the mucosa and submucosa). Friability and hemorrhagic areas caused by
necrosis and ulceration occur in 85% of these patients.
Endoscopic examinations, e.g., sigmoidoscopy, esophagogastroduodenoscopy, or colonoscopy
Identifies adhesions, changes in luminal wall (narrowing/irregularity); rules out bowel
obstruction and allowed biopsy for features of Crohns disease or ulcerative colitis.
Stool specimens
(examinations are used in initial diagnosis and in following disease progression)
Mainly composed of mucus, blood, pus, and intestinal organisms, especially Entamoeba
histolytica (active stage). Fecal leukocytes and RBCs indicate inflammation of GI tract.
Stool positive for bacterial pathogens, ova and parasites or clostridium indicates
infections. Stool positive for fat indicates malabsorption
Abdominal magnetic resonance imaging (MRI)/computed tomography (CT) scan, ultrasound
Detects abscesses, masses, strictures, or fistulas.
Barium enema
May be performed after visual examination has been done, although rarely done during
acute, relapsing stage, because it can exacerbate condition.
CBC
May show hyperchromic anemia (active disease generally present because of blood loss
and iron deficiency); leukocytosis may occur, especially in fulminating or complicated
cases and in patients on steroid therapy.

I. PHARMACOLOGIC THERAPY
1. Aminosalicylates
The first aminosalicylate was sulfasalazine (Azuldifine), a combination drug that
was developed in the 1940s to treat rheumatoid arthritis
Sulfasalazine contains sulfapyridine and 5-aminosalicylic acid 5-ASA. The 5ASA accounts for its therapeutic benefits for IBD. Its exact mechanism of action
is unknown, but topical application to the intestinal mucosa suppresses
proinflammatory cytokines and other inflammatory mediators.

 When given orally, 5-ASA alone is absorbed before it reaches the lower GI tract
where it is needed. When combined with sulfapyridine, 5-ASA reaches the colon.
However, many people are unable to tolerate sulfapyridine. Newer preparations
have been developed to deliver 5-ASA to the terminal ileum and colon
olsalazine(Dipentum), mesalamine (Pentasa) and balsalazide (Colazal) These
drugs are as effective as sulfasalazine and are better tolerated when administered
orally
May cause yellowish orange discoloration of skin and urine
Avoid exposure to sunlight and UV light until photosensitivity is determined
2. Antimicrobials
Antimicrobials are used to treat CD, although no specific infectious agent has
been discovered. Metronidazole (Flagyl), ciprofloxacin (Cipro) and
clarithromycin(Biaxin) have been used successfully with CD, but have not been
shown to be as effective for UC.
3. Corticosteroids
Corticosteroids such as prednisone are used to achieve remission in IBD, they are
helpful for acute flare ups, but are given for the shortest possible time because of
side effects associated with long term use
4. Immunosuppressants
Two immunosuppressants, azathioprine(Imuran) and 6-mercaptopurine
(Purinethol), are given orally and take 3-6 months to exhibit full effectiveness.
They are most useful for patients with CD who do not respond to
aminosalicylates, corticosteroids, or antimicrobials. Methotrexate has also been
found effective for CD, but patients may suffer flu-like symptoms.
5. Biologic therapy
Infliximab (Remicade) is the first major biologic drug therapy
(immunomodulator) to be approved for the treatment of IBD. Infliximab is a
monoclonal antibody to the cytokine tumor necrosis factor. It is given IV to
induce and maintain remission in patients with active CD and in patients with
draining fistulas who do not respond to conventional drug therapy

J. SURGICAL MANAGEMENT
Total Proctocolectomy
-The colon and rectum are removed and the anus closed. The terminal ileum is brought out through
the abdominal wall and a permanent ileostomy formed.
Ileorectal Anastomosis
-The colon is resected, leaving a rectal stump. The terminal ileum is then anastomosed to this stump.
This is an early alternative to total proctocolectomy, however, it has several problems. The remaining

rectum is often still affected by the disease, and further treatment, even eventual resection, is often
required. There is also a significant incidence of rectal cancer among clients who had this surgery.
Ileal Pouch-Anal Anastomosis
-Also known as the J pouch; prevents the need for an ostomy and preserves the rectal sphincter
muscle. The rectal mucosa is excised and the colon is removed. An ileoanal reservoir is then created
in the anal canal, and a temporary loop ileostomy is formed. After healing has taken place, the
ileostomy is reversed and stool drains into the reservoir, which is created by suturing two loops of
bowel together.
Continental ileostomy or Kock Pouch
-A procedure in which a reservoir or pouch is constructed from a loop of ileum. This allows stool to
be stored intra-abdominally until it is drained through a nipple valve made from an intussucepted
portion of ileum. This has advantages because the client does not need to wear an external pouch, has
minimal skin problems, and usually has no leakage of stool or flatus. The client drains the pouch
several times a day using a catheter, usually when a feeling of fullness occurs.
K. Nursing Dx
1. Altered Nutrition: Less than Body Requirements r/t diarrhea and malabsorption
Weigh daily.
Encourage bedrest and limited activity during acute phase of illness.
Avoid or limit foods that might cause or exacerbate abdominal cramping,
flatulence (milk products, foods high in fiber or fat, alcohol, caffeinated
beverages, chocolate, peppermint, tomatoes, orange juice).
Promote patient participation in dietary planning as possible.
Resume or advance diet as indicated (clear liquids progressing to bland, low
residue; then high-protein, high-calorie, caffeine-free, nonspicy, and low-fiber as
indicated).
2. Acute Pain r/t inflamed mucosa
Encourage patient to report pain.
Assess reports of abdominal cramping or pain, noting location, duration, intensity
(010 scale). Investigate and report changes in pain characteristics
Note nonverbal cues (restlessness, reluctance to move, abdominal guarding,
withdrawal, and depression). Investigate discrepancies between verbal and
nonverbal cues.
Review factors that aggravate or alleviate pain.
Provide comfort measures (back rub, reposition) and diversional activities.
3. Risk for Ineffective Individual Coping r/t stress and exacerbations of the disease
Assess patients and SOs understanding and previous methods of dealing with
disease process.
Determine outside stressors (family, relationships, social or work environment).

 Provide emotional support:Active-Listen in a nonjudgmental manner;Maintain

nonjudgmental body language when caring for patient;Assign same staff as much
as possible.
Encourage use of stress management skills, (relaxation techniques, visualization,
guided imagery, deep-breathing exercises).
Refer to resources as indicated (local support group, social worker, psychiatric
clinical nurse specialist, spiritual advisor).
L. Nursing Management

1.
2.
3.
4.
5.

Control diarrhea/promote optimal bowel function.

Minimize/prevent complications.
Promote optimal nutrition.
Minimize mental/emotional stress.
Provide information about disease process, treatment
aspects/potential complications of recurrent disease.

needs,

and

long-term

6. Fluid replacement may be given to correct dehydration; monitor symptoms for dehydration; TPN
may be added if necessary to provide for nutritional needs while allowing GI tract to rest
M. Diet
Give low-residue, low-fat, high-protein, high-calorie diet

References
Book Sources:
Hogan, M. A., et.al. (2008). Pathophysiology: reviews & rationales. (2nd. ed.). New Jersey: Pearson
Education
McCance, K. L. & Huether, S. E. (2006). Pathophysiology: the biologic basis for disease in adults and
children. (5thed.). St. Louis, Missouri: Elsevier Mosby.
Porth, C.M. & Matfin, G. (2009). Pathophysiology: concepts of altered heath states. (8 thed.). Lippincott
Williams & Wilkins.
Internet Sources:
Inflammatory Bowel Disease (IBD). Retrieved from:
http://nurseslabs.com/7-inflammatory-bowel-disease-nursing-care-plans