Inflammatory Bowel Disease
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Inflammatory bowel disease (IBD) is an umbrella term for a group of disorders that causes inflammation of the bowel such as ulcerative colitis (UC) and Crohn’s disease (CD).
Incidence
A.Approximately 1 to 2 million people in the United States have UC or CD.
B.IBD: 396 cases per 100,000/year.
C.UC: 0.5 to 24.5 cases per 100,000.
D.CD: 0.1 to 16 cases per 100,000.
Pathogenesis
A.IBD causes inflammation of the mucosa of the intestinal tract.
1.Ulceration.
2.Edema.
3.Bleeding.
4.Fluid and electrolyte loss.
B.Inflammatory mediators and cytokines disrupt intestinal mucosa, allowing chronic inflammatory processes to occur.
C.UC: Inflammation begins in the rectum (always involved) with 25% of cases confined to the rectum.
1.Disease progresses in a contiguous manner and does not skip sections of bowel as common in CD.
2.Pancolitis occurs in 10%.
D.CD: Can affect any part of the gastrointestinal tract from the mouth to the anus.
1.Three patterns of involvement.
a.Inflammatory disease.
b.Strictures.
c.Fistulas.
2.Involves all layers of bowel, not just mucosa and submucosa.
3.Pattern is discontinuous (unlike UC) and typically has skip areas of interspersed disease in two or more areas.
4.May have rectal sparing.
5.Anorectal complications common.
Predisposing Factors
A.Higher prevalence rate in Jewish populations.
B.Females have a slightly greater incidence.
C.Young adults 15 to 40 years old.
D.Living in a developed country, colder climates, and in urban areas.
E.Genetic disposition.
Subjective Data
A.Common complaints/symptoms.
1.Diarrhea.
2.Constipation.
3.Bowel movement issues such as pain or bleeding.
4.Abdominal cramping and pain.
a.Right lower quadrant pain in CD.
b.Left lower quadrant or periumbilical in UC.
5.Nausea and vomiting.
B.Common/typical scenario.
1.Patients typically complain of low grade fevers, sweats, malaise, or general fatigue with associated bowel movement changes that include pain or bleeding.
2.Patients may report irregular bowel patterns with either diarrhea or constipation or a combination of both.
3.Most patients report recurrent abdominal pain and diarrhea over several months to years.
4.May occur with or without blood or pus in the stool.
C.Family and social history.
1.Family history of IBD, celiac disease, or colorectal cancer.
2.Use of nonsteroidal anti-inflammatory drugs (NSAIDs).
3.History of smoking.
4.Recent travel.
5.Stress.
6.Dietary problems.
D.Review of systems.
1.Head, ear, eyes, nose, and throat (HEENT): Evidence or history of scleritis, anterior uveitis (redness, pain, itchiness), aphthous stomatitis (mouth sores).
2.Dermatology: Psoriasis, erythema nodosum.
3.Rheumatology: Inflammatory arthritis, ankylosing spondylitis.
4.Arthritis.
5.Gastrointestinal (GI): Liver disease, gallstones, blood or pus in stool, diarrhea, constipation.
6.Genitourinary (GU): History of kidney stones.
7.Fatigue, night sweats, loss of appetite, fever, or recent infection.
Physical Examination
A.Constitutional: Patients who become dehydrated may have fever or appear lethargic.
B.Gastrointestinal: Abdominal examination is often benign; a rectal examination can be done if there is concern for perianal fissures, fistulas, or evidence of rectal prolapse; occult stool may be present.
C.Cardiovascular: Tachycardia from dehydration may be present.
D.Skin: Pallor may be noted if there is anemia
Diagnostic Tests
A.Lab studies.
1.No laboratory test is specific for irritable bowel syndrome (IBS).
2.Complete blood cell (CBC) count to assess for anemia or infection.
3.Markers of nutritional status may have value if concern for significant deficiencies.
a.Albumin.
b.Prealbumin.
c.Vitamin B12.
d.Folate.
e.Transferrin.
4.Erythrocyte sedimentation rate (ESR) and C-reactive protein are useful markers for inflammation.
5.Perinuclear antineutrophil cytoplasmic antibodies (pANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA).
a.Positive pANCA and negative ASCA is more specific for UC.
b.Negative pANCA and positive ASCA is more specific for CD.
6.Stool studies.
a.Check stool culture, ova, and parasites.
b.Check Clostridium difficile infection with toxin assay.
B.Imaging studies.
1.Abdominal x-ray can be used to rule out other conditions.
a.Free air is consistent with toxic megacolon.
b.Dilated colon is consistent with colitis.
c.Osteoporosis may explain some pain symptoms.
2.Barium enema studies: Can be useful in diagnosing UC versus CD.
3.Ultrasound, MRI, and CT may be useful in identifying fistulas, abscesses, and stenosis.
C.Colonoscopy.
1.Most valuable tool to diagnose type of IBS.
2.Can be used to determine extent and severity.
3.Obtain tissue.
4.Document ulceration and assess inflammation.
D.Flexible sigmoidoscopy.
1.Limited length of scope can help diagnosis rectal bleeding and diagnose distal UC.
E.Esophagogastroduodenoscopy (EGD).
1.Used to evaluate upper GI tract symptoms.
2.Can evaluate ulceration.
Differential Diagnosis
A.Gastritis.
B.Colitis.
C.Abdominal infections.
D.Diverticulitis.
E.Appendicitis.
F.The differential diagnosis often depends on presentation.
1.If patients present with diarrhea consider:
a.Celiac disease.
b.Lactose intolerance.
c.Gastrointestinal infections.
d.Cancer of the GI tract.
2.If patients present with abdominal pain or gastrointestinal bleeding.
a.Arteriovenous malformations.
b.Cancer of the GI tract.
c.Colitis.
Evaluation and Management Plan
A.General plan.
1.Symptomatic therapy.
a.Treat underlying inflammation in outpatient setting.
b.Admit to hospital if surgical intervention required, uncontrolled pain, significant dehydration from vomiting, evidence of emergent complications such as toxic megacolon, severe colitis, or bowel obstruction.
c.Avoid antidiarrheals in acute phase because of risk of toxic megacolon.
d.Supportive care.
2.Start stepwise medical therapy.
a.Step 1: Treat with aminosalicylates +/− antibiotics (controversial for prophylactic use).
b.Step 2: Treat with corticosteroids. which provide rapid relief of symptoms.
c.Step 3: Treat with immune modifying agents if steroids fail or are required for prolonged periods.
d.Step 4: Experimental agents.
i.Thalidomide.
ii.Nicotine patch.
iii.Butyrate enema.
iv.Heparin subcutaneous injections.
3.Surgery.
a.Not curative in CD because of the skip lesions and more diffuse nature of the disease.
i.Performed in patients with complications such as strictures or fistulas.
ii.Recurrent inflammation in 93% of cases at 1 year post surgery.
b.Colectomy required in 2% to 30% of patients with UC.
i.Intractable inflammation.
ii.Medical therapy fails.
iii.Precancerous changes.
iv.Toxic megacolon.
v.Perforation.
4.Remission therapy.
a.Continue medications used to achieve remission.
b.Taper off steroids: No role in maintaining remission.
B.Patient/family teaching points.
1.Dietary changes: Certain foods and drinks can make symptoms worse; avoid foods that cause flare ups, particularly too much fiber, spicy food, alcohol, and caffeine.
a.Eat smaller meals more often.
b.Drink plenty of fluids.
2.Stress may exacerbate the condition.
3.Quit smoking to improve remission rates.
4.IBD may increase the risk of colon cancer. Colonoscopies should be done early and often.
5.If taking immunosuppressant therapy, the immune system’s ability to fight infection is reduced.
C.Pharmacotherapy.
1.Corticosteroids.
a.Treatment of choice in acute attack in intravenous form.
b.Inhibitors of inflammation.
c.Do not use for maintaining state of remission.
2.Immunosuppressants.
a.Steroid sparing agents.
b.Great in patients refractory to steroids.
3.5-Aminosalicyclic acid derivatives.
a.Reduce inflammatory reactions.
b.Useful in mild to moderate UC.
c.May be used to maintain remission in CD.
4.Tumor necrosis factor alpha.
a.Induces proinflammatory cytokines.
b.Promotes mucosal healing.
5.Antibiotics: Broad spectrum antibiotics to treat intestinal bacteria are controversial. Antibiotics are thought to reduce recurrence rate, particularly in CD, though therapy is not well established in UC. American College of Gastroenterology guidelines state that controlled trials have not consistently demonstrated efficacy.
a.May be used for complications associated with IBS.
i.Abscesses.
ii.Fistulas.
iii.Pouchitis.
b.Metronidazole.
c.Ciprofloxacin.
6.Histamine H2 antagonists: Reduce gastric acid secretion.
7.Proton pump inhibitors.
a.Reduce gastric acid secretion.
b.Used in patients who fail H2 antagonist therapy.
8.Antidiarrheals for symptomatic relief.
9.Anticholinergic/antispasmodic agents.
a.Treats spastic disorders or motility disturbances.
10.Probiotics: Certain strains (Escherichia-coli Nissle 1917 & VSL # 3 [Mutaflor, Ardeypharm]) have shown to be effective in mild-moderate IBD (esp. UC) comparable to Metronidazole.
11.Supplements.
a.Iron supplements.
b.Nutritional supplements.
c.Calcium and vitamin D supplements.
D.Discharge instructions.
1.Avoid foods with caffeine, spicy foods, or milk products.
2.Eat small meals several times a day instead of fewer big meals.
3.Follow-up with gastroenterologist.
Follow-Up
A.Follow-up with gastroenterologist.
Consultation/Referral
A.Refer to gastroenterology for medical management.
B.Consult surgery in UC if medical therapy fails.
C.Consult surgeon if severe disease or extraluminal complications.
D.Specialty consults to manage extracolonic manifestations.
1.Ophthalmology for uveitis.
2.Arthritis.
3.Dermatitis.
4.Dietician.
Special/Geriatric Considerations
A.The elderly may experience a delay in diagnosis because of the wide possibilities in the differential diagnosis.
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