Inflammatory

Bowel Disease
 Introduction
• The term inflammatory bowel disease refers to two chronic inflammatory GI
disorders:
 regional enteritis (ie, Crohn’s disease or granulomatous colitis)
and
 ulcerative colitis

• Both disorders have striking similarities but also several differences

• People between the ages of 10 and 30 are at greatest risk

• Despite vast amounts of research, the cause of IBD is still unknown

 Introduction
• Researchers think it is triggered By:
 environmental agents such as:
 Pesticides
 food additives
 Tobacco
 Radiation

 Nonsteroidal anti-inflammatory drugs have been found to exacerbate IBD

 Allergies and immune disorders have also been suggested as causes

 Abnormal response to dietary or bacterial antigens has been suggested


REGIONAL ENTERITIS (CROHN’S DISEASE)
 Introduction
• Regional enteritis commonly occurs in adolescents or young adults but can
appear at any time of life

• It is more common in women

• It can occur anywhere along the GI tract

 but the most common areas are the distal ileum and colon

• Crohn’s disease is seen two times more often in patients who smoke than in
nonsmokers
 Pathophysiology

• Regional enteritis is a subacute and chronic inflammation

 that extends through all layers (ie, transmural lesion) of the bowel wall
from the intestinal mucosa

• It is characterized by periods of remissions and exacerbations

• The disease process begins with edema and thickening of the mucosa

• Ulcers begin to appear on the inflamed mucosa

• These lesions are not in continuous contact with one another and are
separated by normal tissue
 Pathophysiology

• Fistulas, fissures, and abscesses form as the inflammation extends into the
peritoneum

• Granulomas occur in one half of patients

• As the disease advances

 the bowel wall thickens
and
 becomes fibrotic,
and
 the intestinal lumen narrows
 Clinical Manifestations
• prominent lower right quadrant abdominal pain
 Results from scar tissue and the formation of granulomas interfere with the ability of the intestine to transport
products of the upper intestinal digestion through the constricted lumen
 resulting in crampy abdominal pains

 Because eating stimulates intestinal peristalsis, the crampy pains occur after meals
 To avoid these bouts of crampy pain:
 the patient tends to limit food intake

 reducing the amounts and types of food to such a degree that normal nutritional requirements are
not met

 The result in:

 weight loss
 Malnutrition

 Clinical Manifestations

• diarrhea unrelieved by defecation

 Caused by ulcers in the membranous lining of the intestine and other
inflammatory changes result
 in a weeping, swollen intestine that continually empties an irritating
discharge into the colon
 Disrupted absorption causes chronic diarrhea and nutritional deficits
 The result is a person who is thin and emaciated from inadequate food
intake and constant fluid loss.

• Fever and leukocytosis occur

• In some patients, the inflamed intestine may perforate, leading to intra-

abdominal and anal abscesses.
 Clinical Manifestations

• Abscesses, fistulas, and fissures are common

• Symptoms extend beyond the GI tract and commonly include:

 joint involvement (eg, arthritis)
 skin lesions (eg, erythema nodosum)
 ocular disorders (eg, conjunctivitis)
 oral ulcers

• The clinical course and symptoms can vary;

 in some patients, periods of remission and exacerbation occur


 Assessment and Diagnostic Findings

• A proctosigmoidoscopic examination is usually performed initially to

determine whether the rectosigmoid area is inflamed

• A stool examination is also performed; the result may be positive for occult
blood and steatorrhea (ie, excessive fat in the feces)

• The most conclusive diagnostic aid for regional enteritis is a barium study of
the upper GI tract that shows the classic “string sign” on an x-ray film of
the terminal ileum, indicating the constriction of a segment of intestine

• A barium enema may show ulcerations (the cobblestone appearance

described earlier), fissures, and fistulas
 Assessment and Diagnostic Findings

• A CT scan may show bowel wall thickening and fistula tracts

• A complete blood cell count is performed to assess hematocrit and

hemoglobin levels (usually decreased) and the white blood cell count (may
be elevated)

• The sedimentation rate is usually elevated

• Albumin and protein levels may be decreased, indicating malnutrition

 Complications

• intestinal obstruction or stricture formation

• perianal disease

• fluid and electrolyte imbalances

• malnutrition from malabsorption

• fistula and abscess formation

 The most common is the enterocutaneous fistula (ie, between the small bowel and the skin)

 Abscesses can be the result from fluid accumulation and infection

• Patients with regional enteritis are also at increased risk for colon cancer
ULCERATIVE COLITIS
 Introduction
• Ulcerative colitis is a recurrent ulcerative and inflammatory disease of the
mucosal and submucosal layers of the colon and rectum

• The incidence of ulcerative colitis is highest in Caucasians and people of

Jewish heritage

• The peak incidence is between 30 and 50 years of age

• It is a serious disease, accompanied by systemic complications and a high

mortality rate

• Eventually, 10% to 15% of the patients develop carcinoma of the colon

 Pathophysiology

• Ulcerative colitis affects the superficial mucosa of the colon and is

characterized by:
 multiple ulcerations
 diffuse inflammations
 desquamation or shedding of the colonic epithelium

• Bleeding occurs as a result of the ulcerations

• The mucosa becomes edematous and inflamed

 Pathophysiology

• The lesions are contiguous, occurring one after the other

• Abscesses form, and infiltrate is seen in the mucosa and submucosa with clumps of
neutrophils in the crypt lumens (ie, crypt abscesses)

• The disease process usually begins in the rectum and spreads proximally to involve the
entire colon

• Eventually, the bowel:

 Narrows
 Shortens
 and thickens
 because of muscular hypertrophy and fat deposits
 Clinical Manifestations

• The clinical course is usually one of exacerbations and remissions

• The predominant symptoms of ulcerative colitis are:

 Diarrhea

 lower left quadrant abdominal pain

 intermittent tenesmus

 rectal bleeding
 Clinical Manifestations

• The patient may have:

 Anorexia

 weight loss

 Fever

 Vomiting

 Dehydration
 Clinical Manifestations

• the feeling of an urgent need to defecate

• passage of 10 to 20 liquid stools each day

• Hypocalcemia and anemia frequently develop

• Rebound tenderness may occur in the right lower quadrant

• Extra intestinal symptoms include:

 skin lesions (eg, erythema nodosum)
 eye lesions (eg, uveitis)
 joint abnormalities (eg, arthritis)

 Assessment and Diagnostic Findings

• The patient should be assessed for:

 Tachycardia
 Hypotension
 Tachypnea
 Fever
 Pallor

• Other assessments include:

 the level of hydration
 nutritional status

• The abdomen should be examined for characteristics of:

 bowel sounds
 Distention
 tenderness
 Assessment and Diagnostic Findings
• The stool is positive for blood
• laboratory test results reveal:
• a low hematocrit
• Low hemoglobin concentration
• elevated white blood cell count
• low albumin levels, and an electrolyte imbalance.
 Assessment and Diagnostic Findings

• Abdominal x-ray studies show:

 Free air in the peritoneum
 bowel dilation
 obstruction

• Sigmoidoscopy or colonoscopy
 are valuable in distinguishing this condition from other diseases of the
colon with similar symptoms
 May reveal friable, inflamed mucosa with exudate and ulcerations
 Assessment and Diagnostic Findings

• barium enema:
 show mucosal irregularities
 focal strictures or fistulas
 shortening of the colon
 dilation of bowel loops

• CT scanning, magnetic resonance imaging, and ultrasound can identify abscesses and
perirectal involvement

• Careful stool examination for parasites and other microbes

 performed to rule out dysentery caused by common intestinal organisms, especially
 Entamoeba histolytica
 Clostridium difficile
 Complications

• toxic megacolon: acute toxic colitis with dilatation of the colon (total or segmental)
 the inflammatory process extends into the muscularis;
 inhibiting its ability to contract and resulting in colonic distention
 Symptoms include:
 Fever
 abdominal pain and distention
 vomiting, and fatigue
 Colonic perforation
• Perforation
• Bleeding
 as a result of:
 Ulceration
 vascular engorgement
 Medical Management of Chronic Inflammatory Bowel
Disease

• Medical treatment for regional enteritis and ulcerative colitis is aimed at:
 reducing inflammation

 suppressing inappropriate immune responses

 providing rest for a diseased bowel so that healing may take place

 improving quality of life

 preventing or minimizing complications

NB: Management depends on the disease location, severity, and

 Medical Management of Chronic Inflammatory Bowel Disease

• NUTRITIONAL THERAPY
 Fluid and electrolyte imbalances from dehydration caused by diarrhea are corrected by
intravenous therapy.

 low-residue, high-protein, high-calorie diet


 supplemental vitamin therapy and iron replacement are prescribed to meet nutritional
needs, reduce inflammation, and control pain and diarrhea

 Any foods that exacerbate diarrhea are avoided

 Milk may contribute to diarrhea in those with lactose intolerance
 Cold foods and smoking are avoided because both increase intestinal motility
 Medical Management of Chronic Inflammatory Bowel
Disease

• PHARMACOLOGIC THERAPY
 Sedatives and antidiarrheal and antiperistaltic medications
 are used to minimize peristalsis to rest the inflamed bowel

• Aminosalicylate formulations such as sulfasalazine (Azulfidine)

 are often effective for mild or moderate inflammation
 and are used to prevent or reduce recurrences in long-term maintenance
regimens

• Newer sulfa-free aminosalicylates (eg, mesalamine have been developed

and shown effective in preventing and treating recurrence of inflammation
 Medical Management of Chronic Inflammatory
Bowel Disease
• Antibiotics are used for secondary infections

• Corticosteroids are used to treat severe and fulminant disease.

 corticosteroids are also widely used in the treatment of distal colon disease

• Immunomodulators (eg, azathioprine, 6-mercaptopurine, methotrexate,

cyclosporin) have been used to alter the immune response
 Medical Management of Chronic Inflammatory Bowel
Disease

• SURGICAL MANAGEMENT
 When nonsurgical measures fail to relieve the severe symptoms of IBD

 surgery may be recommended

 The most common indications for surgery are:

 medically intractable disease
 poor quality of life
 complications from the disease or medical therapy