Lower GI Disorders

Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is defined as all disease processes that cause an inflammation within the bowel: however the term is more commonly used to identify two disease processes - Crohn’s disease and ulcerative colitis. Though subtle there are clinical differences between these two diseases:

  • Ulcerative colitis occurs in the colon and rectum and affects the mucosal layer
  • Crohn’s disease can occur anywhere from the mouth to the rectum, but most commonly in the small and/or large intestine. Crohn’s disease typically affects all layers of the bowel wall.
  • It is estimated that about one million Americans suffer from some form of inflammatory bowel disease.

About half of the people with inflammatory bowel disease have ulcerative colitis; about half have Crohn’s disease.

Crohn’s Disease

Epidemiology

  • First described by Crohn and associates in 1932
  • Prevalence estimated at 20 to 70 cases per 100,000 population
  • Most common among Western whites of European Anglo-Saxon descent
  • Three to five times more common among European or North American Jews than among non Jews
  • Onset most often occurs during adolescents or young adulthood
  • Most common age at onset is 15 to 30
  • Familial tendency toward development
  • Men and women affected about equally
  • Exact cause remains unknown

Ulcerative Colitis

Epidemiolgy

  • Annual incidence in the United States is about six to eight cases per 100,00 people
  • Groups commonly affected are the same as those affected by Crohn’s disease
  • European and American Jews are affected more commonly than non-Jews or Jews living in Israel., and whites are affected more commonly than non whites
  • There is some familial tendency
  • The incidence of disease onset peaks in the third and fifth decade of life
  • Men and women are affected equally
  • Exact cause remains unknown

The Pathophysiology of Crohn’s Disease

Can affect any portion of the alimentary canal, however 90% of patients have involvement of the terminal ileum, the segment most commonly affected. Perianal disease is common and can occur without any colon involvement. Perianal disease is characterized by abscesses, fissures, fistulas, and ulceration’s of the perianal skin.

Under the microscope, Crohn’s disease involves transmural, granulomatous inflammation; the entire bowel wall is edematous and infiltrated with inflammatory cells. “Skip” lesions are common, with normal bowel seen between diseased segments. The regional lymph nodes are always involved.

Apthous ulcers are usually the earliest pathologic finding. These ulcers are surrounded by normal or mildly edematous mucosa. As the disease becomes more invasive, fissures form that may extend into the submucosal layer; these are known as rake ulcers. The combination of deep ulcers and edematous tissue creates the classic “cobblestoned” appearance of the mucosa. With advanced disease, these fissures can penetrate the bowel wall to create fistulas or abscesses.

As the disease progresses, the bowel wall becomes fibrotic and stenotic, with narrowing of the lumen. The mesentery may also become shortened, resulting in fixation of the bowel.

Because early symptoms of Crohn’s disease are vague and episodic, the disease often goes unrecognized for many years. Initial symptoms include general malaise, anorexia, fever, mild abdominal discomfort, and diarrhea. Children and adolescents may also experience growth retardation or failure to mature sexually. As the disease progresses, the symptoms become more severe. The most consistent symptoms are abdominal pain and diarrhea. Abdominal pain resulting from partial obstruction is intermittent and crampy, while pain with an acute exacerbation is more persistent and frequently associated with abdominal tenderness and the formation of abscesses or fistulas.

Complications of Crohn’s Disease

• Fistulas • Abscess formation
• Intestinal obstruction • Perianal disease
• Malnutrition • Growth retardation
• Bowel perforation • Massive hemorrhage
• Toxic megacolon (rare)


Crohn’s Disease - Patient Teaching

  1. Explain that the cause of Crohn’s disease is not known; stress that it is not a psychosomatic disease or a result of dietary indiscretion.
  2. Explain that the disease is chronic and recurrent, but emphasize the probability of long periods of remission.
  3. Explain the importance of a healthy diet; explain that dietary restrictions are based on individual tolerance, and to teach the patient to monitor his response to various foods. Encourage the patient to eat a variety of healthful, enjoyable foods within his limits of toleration.
  4. Explain that high levels of stress may cause exacerbations, and help the patient plan effective ways of dealing with stress such as routine exercise or relaxation therapy.
  5. Emphasize the importance of both routine medical follow-up and prompt reporting of any symptoms of an exacerbation, such as abdominal pain, fever, increased diarrhea, malaise, anorexia.
  6. Provide instructions about all prescribed medications.
  7. Teach the patient signs and symptoms of complications that should be reported immediately: flatus or stool from the urethra or vagina; increasing abdominal distention associated with cramping pain; and increasing abdominal tenderness associated with fever.
  8. Provide information or support services and counseling centers in area ( Crohn’s and Colitis Foundation of America.

The Pathophysiology of Ulcerative Colitis

Ulcerative colitis is a disease that primarily affects the mucosa of the rectum and colon, sparing the small bowel. It usually begins in the rectum and progresses proximally to the colon and ends at the ileocecal valve. On colonoscopy the mucosa appears diffusely red, friable, and edematous with bleeding occurring on contact. Pseudopolyps are common and are non-cancerous.

Clinical symptoms of ulcerative colitis include diarrhea, rectal bleeding, weight loss, and crampy abdominal pain.

Extraintestinal manifestations have been associated with ulcerative colitis and Crohn’s disease: peripheral ateritis, ankylosing spondylitis, sacroilitis, finger clubbing, conjunctivitis, iritis, uveitis, erythema nodosum, pyoderma gangreosum, and thromboembolic disease. Correlation of these manifestations to a bowel disturbance can aid in the diagnosis of IBD.

Major Complications of Ulcerative Colitis

• Massive bleeding • Hypovolemia secondary to diarrhea
• Toxic megacolon • Perforation
• Adenocarcinoma of the colon • Extracolonic manifestations - skin and eye lesions, joint abnormalities, and liver disease

Nursing Diagnosis

Crohn’s Disease

Ulcerative Colitis

Diarrhea related to intestinal inflammatory process Diarrhea related to intestinal inflammatory process
Altered nutrition: less than body requirements related to decreased intake, nausea, abdominal pain and cramping Altered nutrition: less than body requirements related to decreased intake, nausea, abdominal pain and cramping, food intolerance, and diarrhea
Risk for ineffective family coping related to the nature of the disease symptoms and the chronicity of the disease and the effect on sexuality Risk for ineffective family coping related to the nature of the disease symptoms and the chronicity of the disease and the effect on sexuality
Pain related to intestinal inflammation Pain related to intestinal inflammation
Risk for impaired skin integrity, related to diarrhea, incontinence, and perianal disease Risk for impaired skin integrity related to diarrhea, incontinence, and perianal disease

Differentiating Crohn’s Disease from Ulcerative Colitis

Crohn’s Disease

Ulcerative Colitis

Diarrhea, abdominal pain, weight loss, growth failure. Diarrhea may occur months after presence of abdominal pain Diarrhea usually bloody, is early symptom, may become progressively worse. Tenesmus may interfere with sleep at night
Rectal bleeding may be present Rectal bleeding predominant symptom
Abdominal pain is early symptom, usually right side or in area of navel Abdominal cramping usually relieved by moving the bowels
Malnutrition, weight loss Malnutrition, weight loss not as common, but can occur secondary to decreased intake
Inflammation of full thickness of the colon, may be continuous or interspersed between normal tissue “skip lesions” Apthous ulcers Inflammation of the mucosa, friable and edematous, pseudopolyps may be present
May involve any part of the digestive tract. Most common site is the terminal ileum Involves only the rectum or the colon with no skip areas of normal tissue
Perianal disease is common, skin tags, fissures, fistulas Perianal disease is uncommon
Growth retardation Skin lesions
Low grade fever, fatigue Low-grade fever, fatigue, usually present with colon involvement
Familial trait Familial trait
Extraintestinal manisfestations Extraintestinal manifestations
Possible mild increase in risk of cancer Increased risk of cancer
Indicated to remove diseased areas that don’t respond to aggressive medical therapy. Surgery does not cure the disease Removal of the colon cures the intestinal disease, but not the extraintestinal symptoms, such as inflammation of the joints and liver disease

Resource Groups

Crohn’s and Colitis Foundation of America (CCFA)
444 Park Avenue South
New York, New York 10016-7374
212-685-3440
800-343-3637
www.ccfa.org

New Jersey Chapter of the Crohn’s and Colitis Foundation of America
45 Wilson Avenue
Manalapan, NJ 07726
732-786-9960
Fax: 732-786-9964
E-mail newjersey@ccfa.org
www.ccfa.org
Marion Torrone, Chapter Development manager

United Ostomy Association (UOA)
36 Executive Park, Suite 120
Irvine, CA 92714-6744
714-660-8624
800-826-0826

Help for Incontinent People
PO Box 544
Union, SC 29379
803-579-7900

Wound Ostomy and Continence Nurses Society
2755 Bristol St. Ste. # 110
Costa Mesa, CA 92626
712-476-0268

Living with Ulcerative Colitis
Proctor and Gamble
1-800-663-6698
www.asacol.com

Patient Teaching - Ulcerative Colitis

  1. Explain that the cause of ulcerative colitis is not known; stress that it is not a psychomatic disease.
  2. Explain that the disease is chronic and recurrent; tell the patient that the disease usually can be controlled with drugs, with long periods of remission.
  3. Explain that the disease can be cured by surgery, although most patients never require surgery.