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02.05 Nursing Care and Pathophysiology for Inflammatory Bowel Disease (IBD)

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Pathophysiology: there are two conditions in IBD that are characterized by chronic inflammation of the digestive tract. Ulcerative colitis causes long-lasting inflammation and ulcers in the digestive tract on the innermost lining. Crohn’s disease causes inflammation deep in the layers of the GI tract throughout.

Overview

  1. Autoimmune inflammatory conditions affecting the GI tract
  2. Periods of remissions and exacerbations

Nursing Points

General

  1. Ulcerative Colitis
    1. Affects colon & rectum
    2. Poor absorption of nutrients
    3. Edema + Lesions + Ulcers
    4. 10-20 Stools/day
      1. Blood & mucus
  2. Crohn’s
    1. Affects entire GI tract
    2. May affect other body systems (especially skin & lymphatic system)
    3. Thickening + scarring + abscesses
    4. 5-6 Stools/day
      1. Pus & mucus

Assessment

  1. Review specific lessons for Ulcerative Colitis and Crohn’s Disease

Therapeutic Management

  1. Major medication classes
    1. Corticosteroids
      1. Decreases inflammation
      2. Risk for Cushing’s Syndrome with chronic use
      3. i.e. Methylprednisolone
    2. Salicylates
      1. Inhibits pro-inflammatory chemicals (prostaglandins, interleukin-I, Tumor Necrosis Factor)
      2. i.e. Sulfasalazine
    3. Immunomodulators
      1. Decreases immune and inflammatory response
      2. Helps decrease need for corticosteroids
      3. i.e. Azathioprine or Methotrexate
    4. Antidiarrheals
      1. Decrease loss of fluid and electrolytes
      2. i.e. Loperamide
  2. Surgical options
    1. Bowel resection or Colectomy
      1. Ulcerative Colitis – curative
      2. Crohn’s – palliative
    2. Surgical removal of abscesses

Nursing Concepts

  1. Fluid & Electrolyte Balance
    1. Loss of fluids in diarrhea
    2. Loss of electrolytes in diarrhea
    3. Malabsorption
  2. Nutrition
    1. Anorexia
    2. Malabsorption
  3. Elimination
    1. Multiple stools/day
    2. Blood or mucus in stools

Patient Education

  1. Review specific lessons for Ulcerative Colitis and Crohn’s Disease

Reference Links

Study Tools

Video Transcript

So this lesson is going to be a quick introduction to inflammatory bowel disease.

So in general, inflammatory bowel diseases are autoimmune inflammatory conditions that primarily affect the GI tract. Now, some people question the autoimmune nature of these at times, but in both it is clear that there is an overactive immune and inflammatory response within the GI system. Inflammatory bowel diseases tend to go through periods of remission and exacerbation – meaning that they will show minimal symptoms for a while and then suddenly flare up and cause a lot of problems for the patients. Inflammatory bowel diseases tend to go through periods of remission and exacerbation. Now, each of these will have their own lesson to explore specific details of nursing care, but what I want to explore in this lesson is the major similarities and differences between the two. We’ll look a little at how to differentiate them, what the major medication classes and surgical options are, and our top nursing priorities for both types of inflammatory bowel disease.

So I want to help you guys see how to tell these apart. They’re both going to cause diarrhea and lesions in the GI tract, they’re both going to cause pain and cramping for the patient, but there is a way to tell the difference. The number one difference between the two is that Ulcerative Colitis only affects the large intestine or the colon. Colitis means inflammation of the colon. What we’ll usually see is the edema, lesions, and ulcerations will progressively move from the rectum, around the colon to the cecum. When these ulcerations are affecting the mucosal lining of the colon, we’re going to have a lot of trouble absorbing the nutrients and water from our food. So we will see multiple, multiple stools a day, especially during an exacerbation or “flare up”. Not only that, but these ulcerations are going to eat through the lining of the colon and cause a lot of bleeding. So these 10-20 stools a day tend to be bloody or mucousy stools. I had a friend in nursing school who had ulcerative colitis and this is not an exaggeration. It was so hard for her and we took her to the hospital multiple times.

Now, in contrast, Crohn’s Disease can affect ANY part of the GI tract from the mouth to the anus. And, it can actually affect other body systems like the skin and lymphatic system. You don’t need to know the specifics about that, but just know that it is not isolated to just the colon. In fact, where ulcerative colitis tends to spread systemically, crohn’s disease tends to have multiple regional areas of damage. So you might have some lesions in the mouth, stomach, small intestine, and large intestine all at once. With Crohn’s disease, the inflammation causes thickening and scarring of the walls of the GI tract, and we often see infected abscesses form. They will also have difficulty absorbing nutrients and water, so we see multiple stools a day – but not nearly as many as with Ulcerative Colitis. It is possible to have bloody stools with Crohn’s, but more often than not their stools are filled with pus and mucus because of those abscesses.

Now even though these diseases have their differences, there are some common med classes we use for both. The first is salicylates, the main example being sulfasalazine. These will inhibit multiple pro-inflammatory chemicals like prostaglandins, IL-2 and Tumor Necrosis Factor – so the goal is to inhibit multiple parts of the inflammatory process. We’ll also give corticosteroids like methylprednisolone to help decrease the inflammation in the GI tract. The problem with this is that patients who take corticosteroids chronically are at risk for Cushing’s Syndrome, which we’ll learn about in the Metabolic/Endocrine course. So, the third med class we give is called immunomodulators. You may have heard of some of these like methotrexate or remicade. The goal of these meds is to decrease the immune response and it can help decrease the need for corticosteroids, especially if the patient develops Cushing’s Syndrome. And finally we give all of these patients antidiarrheals like loperamide to help them absorb more fluids and nutrients and not have so many bowel movements every day.

As far as surgical options – it is possible to go in and remove some of the lesions or abscesses, but the other option is a colon resection, where they remove part of the colon, or a total colectomy with ileostomy where the remove the entire colon and create a stoma at the end of the small intestine. We talked a lot about stoma care in the diverticulitis lesson, so be sure to review that. But, the major thing I want you to see here is that removing the colon altogether can be considered curative for a patient with ulcerative colitis. Remember that ulcerative colitis is isolated to the colon and rectum. So if you remove those, you’ve removed the source of the problem. These patients will have an ileostomy for the rest of their lives, but they won’t have the multiple bloody stools a day or the pain and cramping associated with Ulcerative Colitis. My friend from nursing school actually ended up having this done so that she could live a more normal life. However, because Crohn’s disease affects the whole GI tract – removing part or all of the colon only serves to relieve some of their symptoms or problems – in other words, it’s only a palliative choice. It’s important that you know this so you can help patients understand their options.

Despite the differences, all inflammatory bowel diseases are going to have the same top nursing priorities. The first is fluid & electrolytes. Because of the poor absorption and diarrhea, we can see severe dehydration and electrolyte abnormalities. We also see that they struggle to absorb nutrients and oftentimes lose their appetite, so nutrition needs to be a priority as well. And finally, with multiple bloody stools a day, we prioritize the concept of elimination – that includes having a potty plan, but also doing really good peri care and being supportive of how frustrating this is for the patient. Check out the specific lessons as well as the care plan and case study attached to these lessons to see more detailed nursing interventions and rationales.

So, let’s recap. Inflammatory bowel diseases are highly inflammatory conditions within the GI tract. There are two types: Ulcerative Colitis, which only affects the colon and rectum, and Crohn’s Disease, which can affect the whole GI tract. There are some surgical options, but it’s important to know that a colectomy is only considered curative for Ulcerative Colitis. In Crohn’s disease, it would only be palliative. We use the same med classes for both types, salicylates, steroids, immunomodulators, and antidiarrheals. And, our nursing priorities are the same across the board – fluid & electrolytes, nutrition, and elimination. Make sure you check out the individual lessons on Ulcerative Colitis and Crohn’s Disease to learn more about what to do for those patients.

That’s it for this intro to inflammatory bowel disease. Make sure you check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!

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