ULCERATIVE COLITIS Definition Ulcerative colitis is a chronic inflammation that causes chronic inflammation of the digestive tract, specifically

the large intestine (colon). It usually affects the innermost lining of the large intestine (colon) and rectum. In patients with ulcerative colitis, ulcers and inflammation of the inner lining of the colon lead to symptoms ofabdominal pain, diarrhea, andrectal bleeding. Ulcerative colitis is closely related to another condition of inflammation of the intestines called Crohn's disease. Together, they are frequently referred to as inflammatory bowel disease (IBD). Ulcerative colitis and Crohn's diseases are chronic conditions that can last years to decades. Men and women are affected equally. They most commonly begin during adolescence and early adulthood, but they also can begin during childhood and later in life. It is found worldwide, but is most common in the United States, England, and northern Europe. It is especially common in people of Jewish descent. Ulcerative colitis is rarely seen in Eastern Europe, Asia, and South America, and is rare in the black population. For unknown reasons, an increased frequency of this condition has been recently observed in developing nations. First degree relatives of people with ulcerative colitis have an increased lifetime risk of developing the disease, but the overall risk remains small. Pathophysiology The cause of ulcerative colitis is unknown but scientists believe that ulcerative colitis likely involves abnormal activation of the immune system in the intestines. In patients with ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader. When the disease is active, the lamina propia of the mucosa becomes heavily infiltrated with a mixture of acute and chronic inflammatory cells. There is a predominant increase in mucosal Ig G production, evidence of complement activation, and activation of macrophages and T cells. This immunological activity is associated with the release of vast array of immune mediators. These mediators directly affect the epithelial function which may increase permeability and lead to ischemia. The continued abnormal activation of the immune systems causes chronic inflammation and ulceration. Causes Immune system. Some scientists think a virus or bacterium may trigger ulcerative colitis. The digestive tract becomes inflamed when your immune system tries to fight off the invading microorganism (pathogen). It's also possible that inflammation may stem from an autoimmune reaction in which your body mounts an immune response even though no pathogen is present. Heredity. Because you're more likely to develop ulcerative colitis if you have a parent or sibling with the disease, scientists suspect that genetic makeup may play a contributing role. Risk Factors Age. Ulcerative colitis can occur at any age, but ulcerative colitis often affects people in their 30s. Some people may not develop the disease until their 50s or 60s.

Race or ethnicity. Although whites have the highest risk of the disease, it can occur in any race. If you're of Jewish descent, your risk is even higher. Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease. Isotretinoin (Accutane) use. It is a powerful medication sometimes used to treat scarring cystic acne or acne that doesn't respond to other treatments. Although cause and effect hasn't been proved, studies have reported the development of inflammatory bowel disease with isotretinoin use. Nonsteroidal anti-inflammatory medication. Although these medications haven't been shown to cause ulcerative colitis, they can cause similar signs and symptoms. Additionally, these medications can make existing ulcerative colitis worse, and may make your initial diagnosis more difficult.

Diagnostic tests Many tests are used to diagnose ulcerative colitis. A physical exam and medical history are usually the first step. Blood tests may be done to check for anemia, which could indicate bleeding in the colon or rectum, or they may uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. A stool sample can also reveal white blood cells, whose presence indicates ulcerative colitis or inflammatory disease. In addition, a stool sample allows the doctor to detect bleeding or infection in the colon or rectum caused by bacteria, a virus, or parasites. A colonoscopy or sigmoidoscopy are the most accurate methods for making a diagnosis of ulcerative colitis and ruling-out other possible conditions, such as Crohn's disease, diverticular disease, or cancer. For both tests, the doctor inserts an endoscopea long, flexible, lighted tube connected to a computer and TV monitorinto the anus to see the inside of the colon and rectum. The doctor will be able to see any inflammation, bleeding, or ulcers on the colon wall. During the exam, the doctor may do a biopsy, which involves taking a sample of tissue from the lining of the colon to view with a microscope. Sometimes x rays such as a barium enema or CT scans are also used to diagnose ulcerative colitis or its complications. Manifestations Diarrhea mixed with blood mucus Weight loss Blood on rectal examination Abdominal pain Loss of appetite fever Gastrointestinal bleeding Joint pain Nausea and vomiting Complications Severe bleeding Perforated colon

Severe dehydration Liver disease Osteoporosis Inflammation of your skin, joints and eyes An increased risk of colon cancer Toxic megacolo

Management A. Medical Managements 1. Drug therapy Aminosalicylate - These medicines may relieve symptoms and inflammation in the intestines and help IBD go into remission (a period without symptoms). They also may help prevent the disease from becoming active again. Corticosteroids - decreasing inflammation and reducing the activity of the immune system. Immunomodulators - weaken or modulate the activity of the immune system. That, in turn, decreases the inflammatory response. Other drugs may be given to relax the patient or to relieve pain, diarrhea, or infection 2. Surgery Ileostomy - the surgeon creates a small opening in the abdomen, called a stoma, and attaches the end of the small intestine, called the ileum, to it. Waste will travel through the small intestine and exit the body through the stoma. The stoma is about the size of a quarter and is usually located in the lower right part of the abdomen near the beltline. A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed. Ileoanal anastomosis - which allows the patient to have normal bowel movements because it preserves part of the anus. In this operation, the surgeon removes the colon and the inside of the rectum, leaving the outer muscles of the rectum. The surgeon then attaches the ileum to the inside of the rectum and the anus, creating a pouch. Waste is stored in the pouch and passes through the anus in the usual manner. B. Nursing Managements 1. Keep the patient hydrated and comfortable. 2. Encourage patient to engage on open-ended conversation and attempt to explore how the patient sees the situation. 3. Educate the patient on nutrition and how to handle stress in life. 4. Restricting the physical activity of the patient 5. Smoking cessation Nursing Diagnosis Impaired tissue integrity Acute/chronic pain Risk for infection Imbalanced nutrition Diarrhea Risk for deficient fluid volume Anxiety Knowledge deficit

CHRONS DISEASE Definition Crohn's disease is a chronic transmural inflammatory disease that usually affects the distal ileum and colon. It primarily causes ulcerations (breaks in the lining) of the small and large intestines, but can affect the digestive system anywhere from the mouth to the anus. It is named after the physician who described the disease in 1932. It also is called granulomatous enteritis or colitis, regional enteritis, ileitis, or terminal ileitis. Crohn's disease is related closely to another chronic inflammatory condition that involves only the colon called ulcerative colitis. Together, Crohn's disease and ulcerative colitis are frequently referred to as inflammatory bowel disease (IBD). Ulcerative colitis and Crohn's disease have no medical cure. Once the diseases begin, they tend to fluctuate between periods of inactivity (remission) and activity (relapse). Crohns disease affects men and women equally and seems to run in some families. About 20 percent of people with Crohns disease have a blood relative with some form of inflammatory bowel disease, most often a brother or sister and sometimes a parent or child. Crohns disease can occur in people of all age groups, but it is more often diagnosed in people between the ages of 20 and 30. People of Jewish heritage have an increased risk of developing Crohns disease, and African Americans are at decreased risk for developing Crohns disease. Pathophysiology The initial lesion starts as an inflammatory infiltrate around intestinal crypts that subsequently develops into ulceration of the superficial mucosa. The inflammation progresses to involve deeper layers and forms non-caseating granulomas. These granulomas involve all layers of the intestinal wall and the mesentery and regional lymph nodes. The finding of these granulomas is highly suggestive of CD, yet their absence does not exclude the diagnosis. Early endoscopical findings include hyperaemia and oedema of the inflamed mucosa. This progresses to discrete deep superficial ulcers located transversely and longitudinally, creating a cobblestone appearance. These lesions are separated by healthy areas known as skip lesions. Acute trans-mural inflammation results in bowel obstruction due to mucosal oedema associated with spasm. Chronic trans-mural inflammation thickens the bowel wall and leads to scarring, luminal narrowing, and stricture formation. This may lead to fistulisation, sinus tract formation, perforation, and/or abscess formation. Chronic inflammation also damages the intestinal mucosa, resulting in deficient absorptive ability. This can lead to malnutrition, dehydration, and vitamin and nutrient deficiencies. Involvement of the terminal ileum interferes with bile acid absorption, which leads to steatorrhoea, fat-soluble vitamin deficiency, and gallstone formation. Excessive fat in the stool binds to calcium, thereby increasing oxalate absorption and predisposing to oxalate kidney stone formation. In addition to manifestations related to the GI tract, CD may involve multiple extraintestinal organs and systems including skin, joints, mouth, eyes, liver, and bile ducts. Some of these disorders have autoimmune mechanisms.

Causes Immune system. It's possible that a virus or bacterium may trigger Crohn's disease. When your immune system tries to fight off the invading microorganism, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too. Heredity. Crohn's is more common in people who have family members with the disease, leading experts to suspect that one or more genes may make people more susceptible to Crohn's disease. However, most people with Crohn's disease don't have a family history of the disease. Risk Factors Age. Crohn's disease can occur at any age, but you're likely to develop the condition when you're young. Most people who develop Crohn's disease are diagnosed before they're 30 years old. Ethnicity. Although whites have the highest risk of the disease, it can affect any ethnic group. If you're of Eastern European (Ashkenazi) Jewish descent, your risk is even higher. Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease. As many as 1 in 5 people with Crohn's disease has a family member with the disease. Cigarette smoking. Cigarette smoking is the most important controllable risk factor for developing Crohn's disease. Smoking also leads to more severe disease and a greater risk of surgery. If you smoke, stop. Discuss this with your doctor and get help. There are many smoking-cessation programs available if you are unable to quit on your own. Where you live. If you live in an urban area or in an industrialized country, you're more likely to develop Crohn's disease. Because Crohn's disease occurs more often among people living in cities and industrial nations, it may be that environmental factors, including a diet high in fat or refined foods, play a role in Crohn's disease. People living in northern climates also seem to have a greater risk of the disease. Diagnostic Tests Blood tests may be done to check for anemia, which could indicate bleeding in the intestines. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. By testing a stool sample, the doctor can tell if there is bleeding or infection in the intestines. The doctor may do an upper GI series to look at the small intestine. For this test, the person drinks barium, a chalky solution that coats the lining of the small intestine, before x rays are taken. The barium shows up white on x-ray film, revealing inflammation or other abnormalities in the intestine. If these tests show Crohns disease, more x rays of both the upper and lower digestive tract may be necessary to see how much of the GI tract is affected by the disease. The doctor may also do a visual exam of the colon by performing either a sigmoidoscopy or a colonoscopy. For both of these tests, the doctor inserts a long, flexible, lighted tube linked to a computer and TV monitor into the anus. A sigmoidoscopy allows the doctor to examine the lining of the lower part of the large intestine, while a colonoscopy allows the doctor to examine the lining of the entire large intestine. The doctor will be able to see any inflammation or

bleeding during either of these exams, although a colonoscopy is usually a better test because the doctor can see the entire large intestine. The doctor may also do a biopsy, which involves taking a sample of tissue from the lining of the intestine to view with a microscope. Manifestations Diarrhea. The inflammation that occurs in Crohn's disease causes cells in the affected areas of your intestine to secrete large amounts of water and salt. Because the colon can't completely absorb this excess fluid, you develop diarrhea. Intensified intestinal cramping also can contribute to loose stools. Diarrhea is a common problem for people with Crohn's. Abdominal pain and cramping. Inflammation and ulceration may cause the walls of portions of your bowel to swell and eventually thicken with scar tissue. This affects the normal movement of contents through your digestive tract and may lead to pain and cramping. Mild Crohn's disease usually causes slight to moderate intestinal discomfort, but in more-serious cases, the pain may be severe and include nausea and vomiting. Blood in your stool. Food moving through your digestive tract may cause inflamed tissue to bleed, or your bowel may also bleed on its own. You might notice bright red blood in the toilet bowl or darker blood mixed with your stool. You can also have bleeding you don't see (occult blood). Ulcers. Crohn's disease can cause small sores on the surface of the intestine that eventually become large ulcers that penetrate deep into and sometimes through the intestinal walls. You may also have ulcers in your mouth similar to canker sores. Reduced appetite and weight loss. Abdominal pain and cramping and the inflammatory reaction in the wall of your bowel can affect both your appetite and your ability to digest and absorb food. Other manifestations Fever Fatigue Arthritis Eye inflammation Mouth sores Skin disorders Inflammation of the liver or bile ducts Delayed growth or sexual development, in children Complications Bowel obstruction. Crohn's disease affects the thickness of the intestinal wall. Over time, parts of the bowel can thicken and narrow, which may block the flow of digestive contents through the affected part of your intestine. Some cases require surgery to remove the diseased portion of your bowel. 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) and anus. Fistulas. Sometimes ulcers can extend completely through the intestinal wall, creating a fistula an abnormal connection between different parts of your intestine, between your intestine and skin, or between your intestine and another organ, such as the bladder or

vagina. When internal fistulas develop, food may bypass areas of the bowel that are necessary for absorption. An external fistula can cause continuous drainage of bowel contents to your skin, and in some cases, a fistula may become infected and form an abscess, a problem that can be life-threatening if left untreated. Fistulas around the anal area (perianal) are the most common kind of fistula. Anal fissure. This is a crack, or cleft, in the anus or in the skin around the anus where infections can occur. It's often associated with painful bowel movements. This may lead to a perianal fistula. 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. Additionally, anemia is common in people with Crohn's disease. Colon cancer. Having Crohn's disease that affects your colon increases your risk of colon cancer.

Managements A. Medical Managements 1. Drug Therapy Anti-Inflammation Drugs. Most people are first treated with drugs containing mesalamine, a substance that helps control inflammation. Sulfasalazine is the most commonly used of these drugs. Patients who do not benefit from it or who cannot tolerate it may be put on other mesalamine-containing drugs, generally known as 5-ASA agents, such as Asacol, Dipentum, or Pentasa. Possible side effects of mesalamine-containing drugs include nausea, vomiting, heartburn, diarrhea, and headache. Cortisone or Steroids. Cortisone drugs and steroidscalled corticosteriods provide very effective results. Prednisone is a common generic name of one of the drugs in this group of medications. In the beginning, when the disease is at its worst, prednisone is usually prescribed in a large dose. The dosage is then lowered once symptoms have been controlled. These drugs can cause serious side effects, including greater susceptibility to infection. Immune System Suppressors. Drugs that suppress the immune system are also used to treat Crohns disease. Most commonly prescribed are 6-mercaptopurine or a related drug, azathioprine. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. These drugs may cause side effects like nausea, vomiting, and diarrhea and may lower a persons resistance to infection. When patients are treated with a combination of corticosteroids and immunosuppressive drugs, the dose of corticosteroids may eventually be lowered. Some studies suggest that immunosuppressive drugs may enhance the effectiveness of corticosteroids. Infliximab (Remicade). This drug is the first of a group of medications that blocks the bodys inflammation response. The U.S. Food and Drug Administration approved the drug for the treatment of moderate to severe Crohns disease that does not respond to standard therapies (mesalamine substances, corticosteroids, immunosuppressive agents) and for the treatment of open, draining fistulas. Infliximab, the first treatment approved specifically for Crohns disease, is an anti-TNF substance. Additional research will need to be done in

order to fully understand the range of treatments Remicade may offer to help people with Crohns disease. Antibiotics. Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or prior surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or metronidazole. Antidiarrheal and fluid replacements. Diarrhea and crampy abdominal pain are often relieved when the inflammation subsides, but additional medication may also be necessary. Several antidiarrheal agents could be used, including diphenoxylate, loperamide, and codeine. Patients who are dehydrated because of diarrhea will be treated with fluids and electrolytes.

2. Surgery During surgery, your surgeon removes a damaged portion of your digestive tract and then reconnects the healthy sections. In addition, surgery may also be used to close fistulas and drain abscesses. A common procedure for Crohn's is strictureplasty, which widens a segment of the intestine that has become too narrow. Nursing Managements 1. Provide emotional support to the patient and his family. 2. Schedule patient care to include rest periods throughout the day. 3. If the patient is receiving parenteral nutrition, provide meticulous site care. 4. Give iron supplements and blood transfusion as ordered. 5. Administer medications as ordered. 6. Provide good patient hygiene and meticulous oral care if the patient is restricted to nothing by mouth. 7. Record fluid intake and output, weigh the patient daily. 8. If the patient is receiving TPN, monitor his condition closely. 9. Evaluate the effectiveness of medication administration. 10. Emphasize the importance of adequate rest. 11. Give the patient a list of foods to avoid, including lactose-containing milk products, spicy or fried high-residue foods. 12. Teach the patient about the prescribed medications, their desires effects and possible adverse reactions. Nursing Diagnosis Bleeding Impaired tissue integrity Risk for infection Acute/chronic pain Imbalanced nutrition Diarrhea Risk for deficient fluid volume Anxiety Knowledge deficit

Mariano Marcos State University College of Health Sciences Department of Nursing City of Batac

ULCERATIVE COLITIS & CHRONS DISEASE

Requirement for RLE 103

Submitted By:

ROSARIO, Roxette SALACUP, Justin Darrell SANCHEZ, Venice SARIBAY, Renz Marion SILVESTRE, Chramilen SOLSOLOY, Greazel TAGUICANA, Frenely Mae TESORO, Jeslen VALLEJO, Claire VELASCO, Karen
BSN III B Group 5

August 11, 2011