Caring for a patient with

inflammatory

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bowel disease
Collectively known as inflammatory bowel
disease (IBD), Crohn disease and ulcer-
ative colitis affect 1.5 million Americans,
according to the Crohns and Colitis
Foundation of America. We show you how
to distinguish between these two chronic
disorders and develop a care plan for your
patients.
By Richard L. Pullen, Jr., EdD, RN
Professor of Nursing and Assistant Director of ADN Program
Amarillo College Department of Nursing Amarillo, Tex.
Editorial Advisory Board Member Nursing made Incredibly Easy!
Marcia K. Julian, MSN, RN
Instructor of Nursing Amarillo College Department of Nursing
Amarillo, Tex.
IBD is a disorder that produces chronic,
uncontrolled inflammation of the intestinal
mucosa, which can affect any part of the
gastrointestinal (GI) tract, causing edema,
ulceration, bleeding, and profound fluid
and electrolyte losses. Crohn disease and
ulcerative colitis are collectively known as
IBD. Managing fluid and electrolyte imbal-
ances, nutritional deficiencies, infections,
chronic pain, and body image disturbances
are just some of the goals for the interpro-
fessional healthcare team.
In this article, well help you understand
David Gifford/Photo Researchers, Inc.
the differences between Crohn disease and
ulcerative colitis and care for your patients
with these chronic inflammatory conditions.
Inflammation ahead
The underlying cause of IBD isnt clearly
understood. However, the research evi-
dence suggests that bacteria and viruses
or proteins (antibodies) cause the immune
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2.0
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system to overreact and produce
inflammation in the GI tract. Two
known antibodies that are sometimes
found in the serum of patients with
IBD are antineutrophil cytoplasmic
antibodies (ANCA) and antisaccharo-
myces cerevisiae antibodies (ASCA).
In fact, ASCA are a diagnostic marker
for Crohn disease, whereas ANCA
are more likely to be identified in the
serum of patients with ulcerative coli-
tis. Other antibodies have been associ-
ated with IBD, including Escherichia
coli antibodies, Pseudomonas fluorescens
antibodies, and Clostridium species
antibodies.
Environmental agents may be a
trigger for the development of IBD,
according to the CDC. IBD is more
common in developed countries, and theres
a noted north-to-south variation and a high-
er frequency in urban communities com-
pared with rural areas. These observations
suggest that urbanization is a potential con-
tributing factor. Its postulated that this is
the result of westernization of lifestyle, such
as changes in diet and smoking and varianc-
es in exposure to sunlight, pollution, and
industrial chemicals. According to evidence-
based research, smoking is a risk factor for
the development of Crohn disease.
Genetics and ethnicity are strong predic-
tive factors in developing IBD. If a person has
a relative with IBD, that person is 10 times
more likely to have IBD and 30 times more
likely if the relative is a sibling. Research
studies have linked chromosome 16, or the
IBD-1 gene, to IBD. The incidence of IBD
is two to four times greater in people of
Caucasian and Ashkenazic Jewish origin
than in individuals from other ethnic groups.
 The peak onset of IBD is between ages 15
and 30, but it can occur at any age. The inci-
dence of ulcerative colitis is more frequent
in men, whereas Crohn disease is more fre-
quent in women.
Crohn disease and ulcerative colitis have
similar characteristics and both are marked
by periods of remission and flares (see Crohn
disease versus ulcerative colitis). Lets take a
closer look at the unique features of each
disorder.
A closer look at Crohn disease
Primarily seen in adolescents, young adults,
and older adults, Crohn disease is an in-
flammatory disorder affecting mostly the
distal ileum and colon. The intestinal lining
ulcerates and scar tissue develops (see
Picturing Crohn disease). Generally separated
by normal tissue, fistulas, fissures, and ab-
scesses form. The wall of the bowel thickens
Crohn disease versus ulcerative colitis
Characteristics Crohn disease
Onset of symptoms Gradual
Location Diffuse
Distribution Can occur at any location in the GI tract,
more commonly found in the ileum
Type of lesion Patchy, positioned between areas of normal
tissue, and referred to as skip lesions
Extent of inflammation May extend through all bowel layers; may be
visible in the large intestine or invisible in the
higher GI tract
Blood in stool Occult
Weight loss Common
Perianal disease Common (fistula formation with abscesses)
Extraintestinal symptoms (joint pain, Common
skin lesions, inflammatory conditions
of the eyes)
Biopsy findings Signs of chronic inflammation, granulomas
Antibodies ASCA
Carcinogenesis Sometimes
Surgery Doesnt relieve chronicity
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and becomes fibrotic (hardened), which
causes a narrowing of the bowel lumen
the space through which food passes. For-
mation of granulomas, inflammatory
masses that result from a collection of im-
mune cells called macrophages, occurs in
many patients. Sometimes the lesions have
a cobblestone appearance. A fibrotic
bowel with abscesses and granulomas can
lead to obstruction and perforation. Crohn
disease results in the malabsorption of wa-
ter and nutrients, which may lead to fluid
and electrolyte imbalances.
Patients experience abdominal pain
and cramping in the right lower quadrant
of the abdomen, especially after a meal.
Inflammation in the intestinal mucosa
prevents water absorption, and the patient
may experience more than 10 bloody diar-
rhea episodes each day. Anorexia, weight
loss, cachexia, weakness, and fatigue are
Ulcerative colitis
Abrupt
Localized
Colon to rectum with continuous
lesions
Continuous from rectum to cecum,
without areas of healthy tissue
Limited to mucosal lining
Visible
Less common
Not common
Less common, but can occur
Signs of chronic inflammation,
granulomas rare
ANCA
Common
Curative
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Picturing Crohn disease
memory A closer look
jogger Serosa

To help you distinguish Muscularis Narrow lumen

Crohn disease from
Uninvolved
ulcerative colitis, remember:
(skipped) Thickened wall
Crohn has SKIPPING area
lesions on the mucosa while
ulcerative colitis has Linear
CONTINUOUS lesions. ulceration

Hyperplastic
lymph node

Granuloma

Lymphoid
follicle

Perforation

Abscess

Fistula into
loop of small
bowel
Mucosal surface
of the bowel in
Crohn disease

Granulomatous
lymphadenitis

Transmural
chronic
inflammation

Linear
ulcerations,
edema, and
inflammation What to look for
cause the
Malaise
cobblestone
Diarrhea
appearance of
Pain in the right lower quadrant
the bowel
Generalized abdominal pain
mucosa in
Fever
Crohn disease.
Weight loss

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 common. Fever may be present from the
inflammatory process and/or infection.
Diagnostic Anemia often results secondary to poor
endoscopy will dietary intake and/or absorption of vitamins
tell the tale. and nutrients. Lesions that bleed may also
lead to anemia. Bright red blood may be
observed in the stool because of bleeding
lesions and/or excoriation of the anal
mucosa due to the frequency and
amount of diarrhea.
Diagnostic endoscopy (colonos-
copy and sigmoidoscopy) con-
firms the presence of intestinal
lesions. A barium study of the
upper GI tract will commonly
show a constriction of the termi-
nal ileum in the patient with
Crohn disease. This constriction
is known as the string sign.
A closer look at
ulcerative colitis
In ulcerative colitis, inflammation begins
in the rectum and extends proximally in an
uninterrupted pattern to the proximal colon,
eventually involving the entire length of the
large intestine (see Picturing ulcerative colitis).
The rectum is always involved. There are
no skip areas, meaning that the inflamma-
tory lesions are continuous, unlike in Crohn
disease. The intestinal lining ulcerates,
bleeds, and becomes thickened and edema-
tous. The bowel narrows and shortens.
Granulomas, perforations, and abscesses can
occur. The colon eventually loses its elastic-
ity and its absorptive ability is reduced. Ul-
cerative colitis results in malabsorption of
water and nutrients, which may lead to
fluid and electrolyte imbalances.
Patients experience abdominal cramping
pain with diarrhea, nausea, dehydration,
weight loss, cachexia, and anemia. There
may be a frequent urge to defecate followed
by diarrhea stool that may contain blood. In
fact, the patient may experience an average
of 5 to 10 diarrhea stools each day that also
contain mucus leading to anemia, hypovole-
mia, and malnutrition. Anemia is related to
40 Nursing made Incredibly Easy! July/August 2012
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active bleeding and poor intake and/or
absorption of nutrients. Chronic inflamma-
tion tends to destroy mature red blood cells
and inhibit the production of new ones by
decreasing the production of a hormone
called erythropoietin, which stimulates red
blood cell production.
Diagnostic endoscopy confirms the pres-
ence of intestinal lesions in ulcerative colitis.
A barium enema can be used to identify
ulcerations in the mucosa. The stovepipe
sign, which is a rigid shortened appearance
of the colon, may be seen during a barium
enema in a patient with chronic ulcerative
colitis.
Extraintestinal symptoms
IBD can impact other areas of the body in
addition to the GI system, including the
eyes, liver, joints, and skin. Systemic com-
plications that occur in IBD include nephro-
lithiasis, cholelithiasis, and pyelonephritis.
Peripheral arthritis is the most common
extraintestinal symptom in IBD and may lead
to pain in the joints of the hands, knees, and
ankles. Spondylitis is sometimes referred to
as spinal arthritis and can appear before GI
symptoms in IBD. Spondylitis produces pain
and muscle stiffness in the lower spine and
sacroiliac joints. A more severe form of spinal
arthritis is called ankylosing spondylitis,
which can lead to inflammation of the eyes,
lungs, and heart valves.
The skin may also be involved in the
inflammatory process of IBD. Erythema
nodosum is a type of panniculitis (inflamma-
tion of subcutaneous tissue) characterized by
raised, red, tender nodules on the extremi-
ties, with the pretibial region most affected.
Its more common in women than men and
in people between the ages of 20 and 30. The
presence of erythema nodosum along with
abdominal pain and diarrhea may indicate a
flare in IBD.
Ocular symptoms often accompany IBD.
Assess your patient for eye tearing, burning,
and itching that may indicate episcleritis
inflammation of the vascular layer beneath
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 Picturing ulcerative colitis
Mucosal changes in ulcerative colitis

Descending
Transverse
colon
colon

Ascending
colon
Jejunum
Tenia coli

Haustra

Ileum
Cecum

Vermiform
appendix
Sigmoid colon

Rectum

Anus

External anal
What to look for
sphincter muscles
Recurrent bloody diarrhea (hallmark)

Cramping, pain, rectal urgency, and
diarrhea (from accumulation of blood
and mucus in the bowel)
Inflammation and ulceration
Irritability

Weight loss
Pay attention
Anorexia
to these telling
Nausea
Colon with ulcerative colitis signs and
Vomiting
symptoms.
Weakness

Prominent erythema and ulceration of the colon begin

in the ascending colon and are most severe in the rec-
tosigmoid area.

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 the conjunctiva. Scleritis is an even more
serious disorder that may lead to visual
Proper nutrition changes.
and medications Its important to remember that extraintes-
can help ease tinal symptoms often correlate with the
symptoms. severity of GI symptoms in IBD. Remember
this key point: The skin is often a mirror
of whats happening systemically in your
patient. Patients with IBD are also at greater
risk for developing cancer of the colon and
liver disease than the general population,
according to evidence-based research.
Keep abreast of any elevation in your
patients hepatic enzymes.
Patient assessment
Perform a head-to-toe assessment of
your patient during the health history
interview. Some of the information
you want to glean from your patient
is the history of the disease, any life-
style issues, current medication regi-
men, diet, quality and frequency of
stools, and presence of pain. You
may want to use a published tool to
help evaluate the extent of disease activ-
ity in IBD. One of these tools is the
Simple Clinical Colitis Activity Index,
which requires the patient to answer
questions about bowel movement fre-
quency, feelings of urgency with bowel
movements, blood in the stool, and gen-
eral well-being. Points are assigned to each
question and an overall score is determined.
The greater the number of total points, the
more significant the symptoms, which may
indicate an increase in disease activity.
Make sure you emphasize abdominal
assessment and your patients fluid and elec-
trolyte status. Assess the abdomen for con-
tour, distension, firmness, or rigidity. A firm,
rigid, or tender abdomen may indicate per-
foration or bowel obstruction. Auscultate
bowel sounds for pitch and frequency.
Hyperactive bowel sounds may correlate
with frequent diarrhea stools. Higher
pitched, hypoactive, or absent bowel sounds
may indicate intestinal obstruction. Assess
42 Nursing made Incredibly Easy! July/August 2012
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and record stool frequency, characteristics,
and amount. Emotional stress and trigger
foods may precipitate the onset of severe
diarrhea.
Be on the lookout for symptoms of dehy-
dration, bleeding, and infection. Frequent
bloody diarrhea stool can quickly lead to
dehydration. Poor skin turgor, dry mucous
membranes, sunken eyeballs, and an eleva-
tion in serum blood urea nitrogen indicate
dehydration. Electrolyte imbalances are
common. Potassium depletion (hypokale-
mia) can occur quickly due to the fluid vol-
ume depletion thats seen in severe diarrhea.
A reduction in serum red blood cells, hemo-
globin, hematocrit, and platelets indicates
blood loss. Keep in mind that the hemoglo-
bin and hematocrit may actually be elevated
in response to water loss. Intestinal perfora-
tion and abscesses may lead to fever, tachy-
cardia, and leukocytosis.
Infectious processes and malabsorption
often lead to a reduction in serum proteins
and albumins. Infections can develop sec-
ondary to medications that are used to sup-
press the immune system in IBD. The eryth-
rocyte sedimentation rate and C-reactive
protein may be elevated in response to
inflammation and/or infection. Remember
that many patients with Crohn disease and
ulcerative colitis may have antibodies con-
tributing to the inflammatory process. A
stool analysis is necessary to assess for
bleeding, bacteria, viruses, or parasites.
Managing symptoms with
proper nutrition
There are many factors that alter nutrient
intake in the patient with IBD. Nutrition
abnormalities may be a result of malabsorp-
tion, decreased food intake, and intestinal
losses. These deficiencies will differ depend-
ing on the location of disease activity and
specific nutrient absorption found at these
sites. Maintaining fluid balance and pro-
moting optimal nutritional status are
priority goals. Oral fluids and a low-
residue, high-protein, high-calorie diet
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with supplemental vitamin therapy and
iron replacements are indicated to meet
nutritional needs, reduce inflammation,
and control pain and diarrhea. Its impor-
tant to teach your patient nutritional strate-
gies to help reduce and/or prevent disease
flares (see Nutritional strategies to prevent or
reduce symptoms). Total parenteral nutrition
may be necessary when the patient is expe-
riencing a severe flare, especially in Crohn
disease.
Managing symptoms
with medications
Medications are often used to suppress
inflammation, control symptoms, and re-
place or supplement essential nutrients that
are poorly absorbed because of extensive
disease in the GI tract. Many of the same
medications are used to manage both
Crohn disease and ulcerative colitis. Anti-
inflammatory drugs are the first line of
treatment for mild-to-moderate IBD. Anti-
diarrheals and antiperistaltic medications
may also be used to rest the bowel. Dont
forget that nonsteroidal anti-inflammatory
drugs should be used with caution in pa-
tients with IBD because they can cause
bleeding and even lead to ulcers in the GI
tract. Sedatives are sometimes helpful to re-
duce stress during disease flares, but they
shouldnt be used for an extended period
of time.
Other medication classifications that are
commonly used to treat IBD include amino-
salicylates, corticosteroids, immunomodula-
tors, antibiotics, and biologic modifiers (see
Medications used to treat IBD). Its important
to remember that many of these medications,
including corticosteroids, immunomodula-
tors, and biologic modifiers, cause suppres-
sion of the immune system and can lead to
infection. Immunomodulators and biologic
modifiers can predispose the patient to vari-
ous forms of malignancy. Make sure you
assess your patients responses to these med-
ications and promptly report any adverse
reactions to the healthcare provider.
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Nutritional strategies to prevent or
reduce symptoms
Avoid foods that produce GI discomfort.
Avoid trigger foods, including high-fiber foods (nuts; raw, leafy vegeta-
bles; whole-grain cereals), high-fat foods (greasy, fried foods), caffeine,
alcohol, spicy foods, and milk products.
Ensure adequate intake of fluids, carbohydrates, protein, fats, fruits, and
vegetables.
Drink 8 to 10 glasses of water daily to prevent dehydration. If fluid intake
doesnt keep up with diarrhea, kidney function may be affected.
Avoid carbonated beverages because they can cause gas.
Sip rather than gulp fluid intake (water). Gulping introduces air and can
cause abdominal discomfort.
Eat small meals. Patients who eat 5 to 6 small meals each day have less
GI pain and discomfort than those who eat 2 to 3 large meals.
Bread and rice are good sources of carbohydrate. Meats, fish, eggs, and
poultry are good sources of protein. Make sure vegetables are included in
the nutrition plan and that theyre steamed, stewed, or baked. Healthy
sources of fat include olive and canola oil.
Contact the healthcare provider if eating 5 to 6 small meals a day is
causing an increase in symptoms.
Consider taking a daily multivitamin because IBD causes malabsorption
of vitamins and nutrients from the intestinal tract.
Talk with a dietitian.
Probiotic supplements are sometimes taken
orally to help establish normal intestinal flora,
which aids in digestion and immune func-
tion. Vitamin supplements and iron prepara-
tions are also recommended, especially
when the patient with IBD is experiencing
anemia and fatigue.
Surgery may be necessary
Surgical intervention may be indicated in
IBD. An important distinction to make re-
garding surgery for Crohn disease and ul-
cerative colitis is that surgery isnt curative
in Crohn disease; inflammation may reoccur
in previously healthy tissue following sur-
gery. Despite this fact, surgery may still be
indicated to control symptoms and prevent
complications. The primary indication for
surgery in patients with Crohn disease is
bowel obstruction, which occurs in 75% of
patients within 10 years of diagnosis. Other
indications for surgery are perforation, fis-
tulas, and abscess.
July/August 2012 Nursing made Incredibly Easy! 43
 Approximately 25% of patients with ulcer- peristalsis, causing abdominal pain and
ative colitis require a colectomythe surgi- discomfort to increase. Its important for
cal removal of a portion of the colon or the your patient to participate in activities that
entire colon due to profuse bleeding, perfo- reduce stress, depression, and anxiety. A
ration, strictures, and cancer. A colostomy reduction in stress also helps to normalize
may be necessary when the disease is exten- bowel function. Encourage your patient to
sive in a patient with severe Crohn disease, engage in regular exercise to tolerance, such
whereas patients with severe ulcerative coli- as walking, riding a bicycle, yoga, or going
tis may have an ileoanal anastomosis as an to the gym.
alternative to a permanent ileostomy. Remind your patient to drink plenty of
fluids, eat a well-balanced diet, and avoid
Helping patients cope those foods that produce discomfort. Teach
Coping with chronic illness may be difficult your patient to report infection or any
for your patient. Emotional stress increases adverse reactions to medications promptly.
Emphasize the importance of avoid-
Medications used to treat IBD ing consumption of alcohol and nico-
tine products. Encourage your
Medication classification Action Adverse reactions
patient to journal his or her daily
Aminosalicylates Act locally in the GI Nausea experiences coping with IBD.
sulfasalazine tract to reduce Vomiting
Utilizing support groups and learn-
mesalamine inflammation Abdominal cramping
ing more about the disease process
olsalazine Diarrhea
can be helpful to patients and fami-
balsalazide Indigestion
Headache lies. Help your patients cope by join-
ing them in their journey through the
Corticosteroids Rapidly produce Infections
prednisone immunosuppression Fluid retention
world of chronic illness.
methylprednisolone Weight gain
hydrocortisone High BP
Mood changes
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