1. Understanding Lower Bowel Disease

2. Knowing Inflammatory Bowel Disease
Ulcerative Colitis
Crohn’s Disease
Similarities
Cause unknown
Geographic distribution
Genetic component
Chronic recurring inflammation of the
intestinal tract
Possible causes:
Infectious agent because it produces changes similar to those of infectious diarrhea, but no specific organism identified.
Autoimmune reaction from the presence of others such as lupus
Food allergies
Heredity
Geography – occurs more in US and northern Europe, More prevalent in Jewish populations
Genetic – familial

3. Inflammatory Bowel Disease Comparison
Ulcerative Colitis
Usual onset – young to middle age
Affects mucosa and submucosa of the colon and rectum
Common symptoms
weight loss
rectal bleeding
diarrhea
severe tenesmus
Complications
Perforation
Megacolon
Hemorrhage
Crohn’s Disease
Usual onset – young
Can affect any portion of the GI tract and the entire thickness of the bowel wall
Common symptoms
diarrhea
cramping
fever
malabsorption
Complications
Fistulas
Strictures
Abscesses
Perforation
Colitis Confined to rectum and sigmoid in most patients
15-35 with a second peak at 50-70
Diarrhea is the predominant symptom. Number of stools based on the severity of the disease, mild fewer than five, severe 6-10 or more bloody stools per day. Fecal urgency and tenesmus. Left lower quadrant cramping relieved by defecation
Results anemia, hypovolemia, and malnutrition
Tenesmus – spasmodic contraction of anal or bladder sphincter with pain and persistent desire to empty the bowel or bladder with involuntary ineffectual straining efforts
Complications
Toxic megacolon acute motor paralyis and dilation of the colon to greater than 6 cm
May be triggered by electrolyte imbalances or narcotic administration
Symptoms include fever, tachycardia, hypotension, dehydration, abdominal tenderness and cramping
Perforation leading to peritonitis rare
Risk for colon cancer increased
Crohns – usually affects the terminal ileum and ascending colon
Areas of involvement are usually discontinuous meaning lesions and then areas of normal bowel
Begins with shallow ulcers cobblestone appearance
Non bloody stools
Symptoms vary by section of the colon involved.
Obstruction is a common complication with distension, cramoing, pain and nausea and vomiting
Fistulas may be asymptomatic but may develop abscess with chills, fever, tender abdominal mass, and leukocytosis
Perforation uncommon. Increases rsik for cancer but not as much as colitis

4. Inflammatory Bowel Disease
Cobblestoning
Crohns
Ulcerative Colitis

5. Collaborative Care Diagnostics Medications Nutrition Surgery
Goals of Care Ulcerative Colitis
Rest the bowel
Control inflammation
Combat infection
Control malnutrition
Alleviate stress
Provide symptomatic relief
Goals of Care Crohns
Control inflammatory process
Relieve symptoms
Correct metabolic and nutritional problems and promote healing
Diagnostics
Small Bowel and Barium Enema
Instruct the patient to follow a clear liquid diet for 24 hours, Withhold fluids for eight hours
Administer laxatives, enemas, or suppositories as ordered
Barium is inserted with lubricated tube experience a sense of fullness and feel need to defecate
Expel barium following the procedure
Stools may be white for next couple of days.
Small Bowel series administration of barium , hold food for eight hours prior. Encourage fluids post procedure to facilitate passage of barium. Stools may be white for up to 72 hours.
Sigmoidoscopy – consent, clear liquid, laxative or enema the night before Left side position, biopsy may be taken
Report pain, fever, chills, or rectal bleeding
Colonoscopy – consent, liquid diet, bowel prep, arrange for transportation may receive sedation
Stool exams
CBC with Hg and HCT
Serum protein
Folic acid
Liver enzymes if sclerosing cholangitis is expected.

6. Medications Antimicrobials Corticosteroids Sedatives Antidiarrheals
Hematinics and Vitamins
Sulfonamide antibiotics antiinflammatory effect on intestsinal mucosa used in Crohns with large bowel involvement;
Assess renal and liver function
Contraindicated in pregnancy and or sensitivity to sulfa and or salicyclates
Take oral preps after meals
Drink at least 2 quarts of water to prevent kidney damage
Causes sensitivity to the sun
Notify doctor of skin rash, hives, sore throat, bleeding
Mesalamine (Rowasa) and Olsalazine (Dipentum) cause fewer side effects available as suppositories, suspension or enema
Corticosteroids - used for acute episodes antiinflammatory
Sedatives to reduce anxiety
Antidiarrheals such as Lomotil to decrease motility
Hematinics to address anemia

7. Nutrition Individualized Goals Adequate nutrition without exacerbating
symptoms
Correct and prevent malnutrition
Replace fluid and electrolytes losses
Prevent weight loss
Traditionally NPO during acute episodes.
High calorie, high protein, low residue avoid raw fruits and vegetables, seeds, nuts
May need parenteral feedings

8. Nursing Diagnosis
Diarrhea related to irritated bowel and intestinal hyperactivity
Anxiety related to possible social embarrassment, diagnostic tests, and treatments
Imbalanced Nutrition: Less than Body Requirements related to decreased intake, decreased absorption, and increased nutrient loss through diarrhea
Impaired Skin Integrity related to diarrhea and altered nutritional status
Ineffective Coping related to chronic disease, lifestyle changes, stress and pain
Ineffective Therapeutic Regimen Management related to lack of knowledge of disease course, lifestyle adjustments, nutritional and drug
therapy

9. Colorectal Cancer Risk factors Age over 50 Polyps Family History
Inflammatory Bowel Disease
Exposure to Radiation
High animal Fat and calorie intake
Most are adenocarcinomas that began as polyps. No symptoms until advanced. Slow growing
Early symptoms include change in bowel habits, pain , anorexia, weight loss. May have palpable mass.

10. Colon Polyps Sessile (villous) Pedunculated (tubular) Familial
Polyp is a mass of tissue that arises from the bowel wall and protrudes into the lumen. May develop anywhere in the bowel but they occur most often in the sigmoid colon and rectum.
Identified by their structure – the laRGER THE SIZE THE GREATER THE RISK
Silent disease may bleed intermittently.
Villous polyp – cauliflower like
Pedunculated – stalk like stem
Familial autosomal dominant genetic disorder usually develops after puberty risk of malignancy 100% by age 40 if not treated. Every six month screening
Screening begins at age 50 and then every 5 years

11. Collaborative Care Screening Diagnostic tests Surgery Radiation
Chemotherapy
Screening digital rectal exam beginning at age 40 annual fecal occult blood testing at age 50
Diagnostic tests
CBC
Fecal occult blood
CEA – tumor marker detected in patient s with cancer used to estimate prognois, monitor treatment and detect recurrence
Sigmoidoscopy/colonoscopy
CT scan
Tissue biopsy
Sigmoid colostomy is the most common permanent colostomy performed particularly for cancer of the colon

12. Surgical Interventions
Performed when necessitated by complications
or failure of conservative treatment measures
Crohns: resection with end to end anastomosis
Ulcerative colitis
Total Colectomy
Ostomy
Permanent
Temporary or loop
Continent (Kock’s) ileostomy
Bowel obstruction is the leading indication for surgery in Crohn’s disease
Total colectomy (with ileal pouch anal anastomosis) procedure of choice for extensive ulcerative colitis usually perform temporary (2- 3 month) loop ileostomy at the same time to allow anal anastomosis to heal
Ostomy is a surgically created opening between the intestine and the wall of the abdomen. Name based on location.
Ileostomy usually remove colon, rectum, and anus. Temporary sometimes performed to allow healing of tissue.
Kock’s ileostomy an intraabdominal reservoir is constructed with a nipple valve.

13. Ileostomy Facts Stool consistency is liquid to semi-liquid
Fluid requirements may be increased
No bowel regulation
Use of pouch and skin barriers
No irrigation
Indications for surgery: ulcerative colitis, crohns, diseased or injured colon, birth defetcs, familial polypois, trauma, cancer

14. Nursing Diagnosis for Patients with a Colostomy/Ileostomy
Risk for Impaired Skin Integrity – related to irritation from fecal drainage, irritation from appliance, and lack of knowledge
Disturbed Body Image – related to presence of ostomy and odor
Imbalanced Nutrition: Less than Body Requirements - related to lack of knowledge of appropriate foods and decreased appetite
Ineffective Sexuality Patterns - related to perceived loss of sexual appeal and possibility of seepage of fecal material during sexual activity
Risk for Deficient Fluid Volume - related to excess fluid loss from ileostomy or diarrhea with colostomy and decreased intake

15. Stoma Characteristics
Color
Rose to red
Pale
Blanching, dark red to
purple
Edema
Mild to moderate
Moderate to severe
Bleeding
Small amount
Moderate to large
Cause
Viable stoma
Anemia
Inadequate blood supply
Normal initial postop
Trauma to stoma, medical cause
Obstruction
Allergic reaction
Gastroenteritis
Small amount normal
Coag deficiency, varices, GI bleed

16. Colostomy Comparisons
Ascending
Stool consistency semiliquid
Fluid requirement increased
No bowel regulation
Pouch ans skin barriers
Irrigation no
Indications: perforating diverticulitis, tumors
Transverse: semiliquid to semiformed, irrigation no
Sigmoid: formed stool , no change in fluids, bowel regulation possible, may need irrigation, cancer of the rectum or
perforating diverticulum

17. Other Bowel Disorders Celiac Disease Hernias Intestinal Obstruction
Diverticular Disease
Irritable Bowel
Lactase Deficiency
Celiac – sprue flattening of mucosa with loss of villi sensitivity to gliadin fraction of gluten, a cereal protein cause unknown cause with malabsorption
Manifestations are abdominal bloating, and cramps, diarrhea, steatorrhea, anemia and nutrient deficiencies
Complications GI malignancies and intestinal lymphoma
Testing stool fats, IgA IgG antibodies, protein, albumin, electrolytes, protime
Treatment – vitamin replacements, may need Vit K, gluten free diet high in calories and protein, low in fat
Hernias- defect in the abdominal wall that allows abdominal content to protrude out of the abdominal cavity. Classified by location – inguinal, umbilical, incisional
Surgery usual treatment
Obstruction – failure of bowel contents to move through bowel lumen. Small intestine usually affected. May be mechanical from scar tissue, hernias, tumors, IBD, or obstruction of lumen
Functional peristalsis fails to move contents
Manifestations vary based on location –SBO nausea, vomiting, distension, tenderness, hypovolemia, tachycardia, temp elevation, decrease in urine output Fluid and electrolyte changes
LBO – colon dilation, constipation, colicky pain, vomiting
RX decompression, surgery
Diverticular disease - saclike projections of mucosa through the muscular layer of the colon, may occur anywhere in GI tract – usually asymptomatic, episodic pain usually left sided, constipation/diarrhea complications include hemorrhage an diverticulitis
Diverticulitis – inflammation
Complications – abscess and peritonitis, bowel obstruction, fistula formation, hemorrhage
Diagnostic tests – WBC, hemoccult tets, Barium enema, abdominal x-ray, CT, sigmoid, colonoscopy
Meds – Flagyl, Septra, Bacrim, mild – severe Mefoxin, Zosyn, Timentin Talwin or Demerol for pain
Diet – high fiber avoid items with seeds
May need Surgery
Irritable Bowel – spastic colon increased reactivity in response to stimuli Hypersecretion of mucous
abdominal pain and change in bowel habits
Bulk forming laxatives, anticholinergics, antidepressants and increase in fiber
Lactase Deficiency – genetic enzyme absence may have secondary causes results in lactose intolerance
Lactose free diet elimination of milk and milk products