INFLAMMATORY BOWEL DISEASE (IBD)

Inflammatory bowel disease (IBD) is an umbrella term used to describe disorders that
involve chronic inflammation of your digestive tract. IBD can be debilitating and
sometimes leads to life-threatening complications. An idiopathic disease caused by a
dysregulated immune response to host intestinal microflora. It results from a complex interplay
between genetic and environmental factors. Similarities involve (1) chronic inflammation of the
alimentary tract and (2) periods of remission interspersed with episodes of acute inflammation.
There is a genetic predisposition for IBD, and patients with this condition are more prone to the
development of malignancy.

Types of IBD include:

 Ulcerative colitis
 Crohn's disease

Ulcerative Colitis
- This condition causes long-lasting inflammation and sores
(ulcers) in the innermost lining of your large intestine (colon)
and rectum. It occurs in the large intestine (colon) and the
rectum. Damaged areas are continuous (not patchy) – usually
starting at the rectum and spreading further into the colon.
Inflammation is present only in the innermost layer of the
lining of the colon.

Crohn’s Disease
- This type of IBD is characterized by inflammation of the lining
of your digestive tract, which often spreads deep into affected
tissues. Both ulcerative colitis and Crohn's disease usually
involve severe diarrhea, abdominal pain, fatigue and weight
loss. It can affect any part of the GI tract (from the mouth to
the anus)—Most often it affects the portion of the small
intestine before the large intestine/colon. Damaged areas
appear in patches that are next to areas of healthy tissue.
Inflammation may reach through the multiple layers of the
walls of the GI tract.
Ulcerative colitis and Crohn's disease have some
complications in common and others that are specific to each condition.
Complications found in both conditions may include:

 Colon cancer. Having IBD increases your risk of colon cancer. General colon
cancer screening guidelines for people without IBD call for a colonoscopy every
10 years beginning at age 50. Ask your doctor whether you need to have this test
done sooner and more frequently.
  Skin, eye and joint inflammation. Certain disorders, including arthritis, skin
lesions and eye inflammation (uveitis), may occur during IBD flare-ups.

 Medication side effects. Certain medications for IBD are associated with a small
risk of developing certain cancers. Corticosteroids can be associated with a risk
of osteoporosis, high blood pressure and other conditions.

 Primary sclerosing cholangitis. In this condition, inflammation causes scars

within the bile ducts, eventually making them narrow and gradually causing liver
damage.

 Blood clots. IBD increases the risk of blood clots in veins and arteries.

Complications of Crohn's disease may include:

 Bowel obstruction. Crohn's disease affects the full thickness of the intestinal wall. Over
time, parts of the bowel can thicken and narrow, which may block the flow of digestive
contents. You may require surgery to remove the diseased portion of your bowel.

 Malnutrition. Diarrhea, abdominal pain and cramping may make it difficult for you to eat
or for your intestine to absorb enough nutrients to keep you nourished. It's also common
to develop anemia due to low iron or vitamin B12 caused by the disease.

 Ulcers. Chronic inflammation can lead to open sores (ulcers) anywhere in your digestive
tract, including your mouth and anus, and in the genital area (perineum).

 Fistulas. Sometimes ulcers can extend completely through the intestinal wall, creating a
fistula — an abnormal connection between different body parts. Fistulas near or around
the anal area (perianal) are the most common kind. In some cases, a fistula may become
infected and form an abscess.

 Anal fissure. This is a small tear in the tissue that lines the anus or in the skin around
the anus where infections can occur. It's often associated with painful bowel movements
and may lead to a perianal fistula.

Complications of ulcerative colitis may include:

 Toxic megacolon. Ulcerative colitis may cause the colon to rapidly widen and
swell, a serious condition known as toxic megacolon.
  A hole in the colon (perforated colon). A perforated colon most commonly is
caused by toxic megacolon, but it may also occur on its own.

 Severe dehydration. Excessive diarrhea can result in dehydration

Signs and Symptoms

Signs and symptoms of the two common forms of inflammatory bowel disease, Crohn
disease and ulcerative colitis, are similar and overlap, often making it difficult to
distinguish between the two. Symptoms usually develop gradually over time but
sometimes may appear suddenly and without notice. There may be times when the
disease is active (flares), when symptoms are most noticeable, and periods of
remission, when signs and symptoms subside, sometimes for months or years at a
time.
While signs and symptoms vary in severity and differ from person to person, the
most common ones include:
 Abdominal cramps and pain
 Persistent diarrhea
 Bleeding from the rectum (blood in the stool)
 Loss of appetite and unexplained weight loss

Less common signs and symptoms may include:

 Fever
 Fatigue
 Anemia
 Joint pain
 Skin rashes
 In children and youth, failure to thrive and delayed growth

Laboratory Tests & Diagnostics

There is no single laboratory test that can definitively diagnose inflammatory bowel disease
(IBD). However, laboratory testing is an important tool for evaluating a person who may have
IBD. If a person has persistent diarrhea and abdominal pain, an initial set of tests are done to
help evaluate the person's condition. These may be done in conjunction with imaging tests,
such as an X-ray or CT scan.
Examples of some common initial tests include:
CBC (complete blood count) to check for anemia; bleeding caused by IBD and similar
conditions can lead to anemia
CMP (comprehensive metabolic panel) to help evaluate the person's general health
Fecal occult blood test or fecal immunochemical test to look for blood in the stool
CRP (C-reactive protein) to look for inflammation; this test may also be used later to help
distinguish IBD from irritable bowel syndrome (IBS) and may be used after diagnosis to monitor
the course of the disease
ESR (erythrocyte sedimentation rate) to detect inflammation, if CRP is not available.
Endoscopic procedures

 Colonoscopy. This exam allows your doctor to view your entire colon using a thin,
flexible, lighted tube with an attached camera. During the procedure, your doctor can
also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue
sample can help confirm a diagnosis.

 Flexible sigmoidoscopy. Your doctor uses a slender, flexible, lighted tube to

examine the rectum and sigmoid, the last portion of your colon. If your colon is
severely inflamed, your doctor may perform this test instead of a full colonoscopy.

 Upper endoscopy. In this procedure, your doctor uses a slender, flexible, lighted
tube to examine the esophagus, stomach and first part of the small intestine
(duodenum). While it is rare for these areas to be involved with Crohn's disease, this
test may be recommended if you are having nausea and vomiting, difficulty eating or
upper abdominal pain.

 Capsule endoscopy. This test is sometimes used to help diagnose Crohn's disease
involving your small intestine. You swallow a capsule that has a camera in it. The
images are transmitted to a recorder you wear on your belt, after which the capsule
exits your body painlessly in your stool. You may still need an endoscopy with a
biopsy to confirm a diagnosis of Crohn's disease.

 Balloon-assisted enteroscopy. For this test, a scope is used in conjunction with a

device called an overtube. This enables the doctor to look further into the small bowel
where standard endoscopes don't reach. This technique is useful when a capsule
endoscopy shows abnormalities, but the diagnosis is still in question.

Imaging procedures
 If you have severe symptoms, your doctor may use a standard X-ray of your
X-ray.
abdominal area to rule out serious complications, such as a perforated colon.
 Computerized tomography (CT) scan. You may have a CT scan — a special X-ray technique that
provides more detail than a standard X-ray does. This test looks at the entire bowel as
well as at tissues outside the bowel. CT enterography is a special CT scan that provides
better images of the small bowel. This test has replaced barium X-rays in many medical
centers.
 An MRI scanner uses a magnetic field and radio waves to
Magnetic resonance imaging (MRI).
create detailed images of organs and tissues. An MRI is particularly useful for evaluating
a fistula around the anal area (pelvic MRI) or the small intestine (MR enterography).
Unlike a CT, there is no radiation exposure with an MRI.
What causes IBD?

The exact cause of IBD is unknown, but IBD is the result of a defective
immune system. A properly functioning immune system attacks foreign
organisms, such as viruses and bacteria, to protect the body. In IBD, the
immune system responds incorrectly to environmental triggers, which
causes inflammation of the gastrointestinal tract. There also appears to be a
genetic component—someone with a family history of IBD is more likely to
develop this inappropriate immune response.
How is IBD diagnosed?

IBD is diagnosed using a combination of endoscopy (for Crohn’s disease) or

colonoscopy (for ulcerative colitis) and imaging studies, such as contrast
radiography, magnetic resonance imaging (MRI), or computed tomography
(CT). Physicians may also check stool samples to make sure symptoms are
not being caused by an infection or run blood tests to help confirm the
diagnosis.

How is IBD treated?

Several types of medications may be used to treat IBD: aminosalicylates,

corticosteroids (such as prednisone), immunomodulators, and the newest
class approved for IBD—the “biologics”. Several vaccinations for patients
with IBD are recommended to prevent infections. Severe IBD may require
surgery to remove damaged portions of the gastrointestinal tract, but
advances in treatment with medications mean that surgery is less common
than it was a few decades ago. Since Crohn’s disease and ulcerative colitis
affect different parts of the GI tract, the surgical procedures are different for
the two conditions.
 Treatment
The goal of inflammatory bowel disease treatment is to reduce the inflammation that triggers
your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to
long-term remission and reduced risks of complications. IBD treatment usually involves either
drug therapy or surgery.
Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. Anti-
inflammatories include corticosteroids and aminosalicylates, such as mesalamine (Asacol HD, Delzicol,
others), balsalazide (Colazal) and olsalazine (Dipentum). Which medication you take depends on the
area of your colon that's affected.
Immune system suppressors.
These drugs work in a variety of ways to suppress the immune response that releases inflammation-
inducing chemicals in the intestinal lining. For some people, a combination of these drugs works better
than one drug alone.
Some examples of immunosuppressant drugs include azathioprine (Azasan, Imuran), mercaptopurine
(Purinethol, Purixan), cyclosporine (Gengraf, Neoral, Sandimmune) and methotrexate (Trexall).
One class of drugs called tumor necrosis factor (TNF)-alpha inhibitors, or biologics, works by neutralizing
a protein produced by your immune system. Examples include infliximab (Remicade), adalimumab
(Humira) and golimumab (Simponi). Other biologic therapies that may be used are natalizumab
(Tysabri), vedolizumab (Entyvio) and ustekinumab (Stelara).
Antibiotics
Antibiotics may be used in addition to other medications or when infection is a concern — in cases of
perianal Crohn's disease, for example. Frequently prescribed antibiotics include ciprofloxacin (Cipro) and
metronidazole (Flagyl).
Other medications and supplements
In addition to controlling inflammation, some medications may help relieve your signs and symptoms,
but always talk to your doctor before taking any over-the-counter medications. Depending on the
severity of your IBD, your doctor may recommend one or more of the following:

 Anti-diarrheal medications. A fiber supplement — such as psyllium powder (Metamucil)

or methylcellulose (Citrucel) — can help relieve mild to moderate diarrhea by adding bulk
to your stool. For more severe diarrhea, loperamide (Imodium A-D) may be effective.

 Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol,
others). However, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and
diclofenac sodium (Voltaren) likely will make your symptoms worse and can make your
disease worse as well.

 Iron supplements. If you have chronic intestinal bleeding, you may develop iron
deficiency anemia and need to take iron supplements.

 Calcium and vitamin D supplements. Crohn's disease and steroids used to treat it can
increase your risk of osteoporosis, so you may need to take a calcium supplement with
added vitamin D.
Nutritional support

Your doctor may recommend a special diet given via a feeding tube (enteral nutrition) or
nutrients injected into a vein (parenteral nutrition) to treat your IBD. This can improve
your overall nutrition and allow the bowel to rest. Bowel rest can reduce inflammation in
the short term.

If you have a stenosis or stricture in the bowel, your doctor may recommend a low-
residue diet. This will help to minimize the chance that undigested food will get stuck in
the narrowed part of the bowel and lead to a blockage.

Surgery

If diet and lifestyle changes, drug therapy, or other treatments don't relieve your IBD
signs and symptoms, your doctor may recommend surgery.

 Surgery for ulcerative colitis. Surgery can often eliminate ulcerative colitis. But
that usually means removing your entire colon and rectum (proctocolectomy).

In most cases, this involves a procedure called an ileal pouch anal anastomosis.
This procedure eliminates the need to wear a bag to collect stool. Your surgeon
constructs a pouch from the end of your small intestine. The pouch is then
attached directly to your anus, allowing you to expel waste relatively normally.

In some cases a pouch is not possible. Instead, surgeons create a permanent

opening in your abdomen (ileal stoma) through which stool is passed for collection
in an attached bag.

 Surgery for Crohn's disease. Up to one-half of people with Crohn's disease will
require at least one surgery. However, surgery does not cure Crohn's disease.

During surgery, your surgeon removes a damaged portion of your digestive tract
and then reconnects the healthy sections. Surgery may also be used to close
fistulas and drain abscesses.

The benefits of surgery for Crohn's disease are usually temporary. The disease
often recurs, frequently near the reconnected tissue. The best approach is to follow
surgery with medication to minimize the risk of recurrence.
IBD is not Irritable Bowel Syndrome (IBS)

IBD should not be confused with irritable bowel syndrome or IBS.

Although people with IBS may experience some similar symptoms
to IBD, IBD and IBS are very different. Irritable bowel syndrome is
not caused by inflammation and the tissues of the bowel are not
damaged the way they are in IBD. Treatment is also different.

IBD is not celiac disease…

Celiac disease is another condition with similar symptoms to IBD.

It is also characterized by inflammation of the intestines. However,
the cause of celiac disease is known and is very specific. It is an
inflammatory response to gluten (a group of proteins found in
wheat and similar grains). The symptoms of celiac disease will go
away after starting a gluten-free diet, although it usually will be
months before the full effects of the new diet will be reached.
 PATHOPHYSIOLOGY
PRECIPITATING FACTORS PREDISPOSING FACTORS
-Smoking - Age
-Ethnicity -Gender
-Family History -Genetics
-Nonsteroidal anti-inflammatory medications -Immune system
 NURSING DIAGNOSIS
 Diarrhea related to the inflammation of the bowel.
 Acute pain related to increased peristalsis and GI
inflammation.
 Risk for deficient fluid volume related to anorexia,
nausea and diarrhea.
 Imbalance nutrition less than body requirements
related to dietary restrictions, nausea and
malabsorption.
 Activity intolerance related to fatigue.
 Ineffective coping related to fatigue.
 Deficient knowledge related to unfamiliarity with
resources.