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Ulcerative Colitis

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Ulcerative Colitis

A. Description

Ulcerative colitis is an autoimmune disorder that, along with Crohn’s disease, is referred to as inflammatory bowel disease (IBD). IBD is characterized by diarrhea (up to 20 stools during acute exacerbation), crampy abdominal pain, and exacerbations (“flare-ups”)/remissions.

B. Pathophysiology

Ulcerative colitis usually starts in the rectum and moves in a continual fashion toward the cecum. Although there is sometimes mild inflammation in the terminal ileum, ulcerative colitis is a disease of the colon and the rectum. The inflammation and ulcerations occur in the mucosal layer, the inner-most layer of the bowel wall. Since it does not extend through all bowel wall layers, fistulas and abscesses are rare. Water and electrolytes cannot be absorbed through inflamed mucosa. Diarrhea with large fluid and electrolyte losses is a characteristic feature of damage to the colonic mucosa epithelium. Breakdown of cells results in protein loss through stool. Areas of inflamed mucosa form pseudo-polyps, tongue-like projections into the bowel lumen.

C. Common signs & symptoms or clinical manifestations

The common signs of ulcerative colitis include diarrhea, bloody stools, weight loss, abdominal pain, fever and fatigue. It is considered a chronic disorder a chronic disorder with mild to severe acute exacerbations that occur at unpredictable intervals over many years. The primary manifestations of ulcerative colitis are bloody diarrhea and abdominal pain. Pain may vary from the mild lower abdominal cramping associated with diarrhea to the severe, constant pain associated with acute perforations. With mild disease, diarrhea may consist of one to two semi formed stools daily that contain small amounts of blood. The patient may have no other manifestations. In moderate disease there is increased stool output (four to five stools per day), increased bleeding, and systemic symptoms (fever, malaise, anorexia). In severe disease, diarrhea is bloody, contains mucus, and occurs 10 to 20 times a day. In addition, fever, weight loss greater than 10% of total body weight, anemia, tachycardia, and dehydration are present.

D. Risk Factors

Epidemiologic studies show a higher incidence of ulcerative colitis in Caucasians and persons with Jewish heritage as well as, family members (especially monozygomatic compared with dizygotic twins). Overall, there have been 30 susceptible genes have been linked to IBD. Another risk factor to be aware of is gender and age. The incidence peaks at two points in life: adolescent to young adult (more often in females) and with older adults (more often in males). A diet low in fiber may also predispose a patient to ulcerative colitis. Other possible risk factors include stress, autoimmunity and infection may be causative agents.

E. Common Complications

Patients experience both local (confined to the GI tract) and systemic (extraintestinal) complications. GI tract complications include hemorrhage, strictures, perforation (with possible peritonitis), fistulas, and colonic dilation (toxic mega colon). Patients with toxic mega colon are at risk of perforation and may need an emergency colectomy. Toxic mega colon is more common with ulcerative colitis. Patients with long-standing ulcerative colitis are at risk for colorectal cancer. Periodic colonoscopy is recommended for patients who developed IBD at a young age or have had it more than 10 years. An increased incidence of thromboembolism is seen in ulcerative colitis. Kidney stones are also common due to fluid deficits from chronic diarrhea. Primary sclerosing cholangitis and gallstones are also associated with IBD. Routine liver function tests are important because primary sclerosing cholangitis can lead to liver failure.

F. All diagnostic procedures or tests done (include labs and other tests)

The diagnosis of IBD includes ruling out other diseases with similar symptoms and then determining whether the patient has ulcerative colitis or Crohn’s disease. Diagnostic studies also provide information about disease severity and complications. A CBC typically shows iron-deficiency anemia from blood loss. An elevated WBC count may be an indication of toxic mega colon or perforation. Decreases in serum sodium, potassium, chloride, bicarbonate, and magnesium levels are due to fluid and electrolyte losses from diarrhea and vomiting. Hypoalbuminemia is present with severe disease and is the result of poor nutrition or protein loss from the bowel. An elevated erythrocyte sedimentation rate reflects chronic inflammation. Stool cultures are obtained to determine if infection is present. Sigmoidoscopy and colonoscopy allow direct examination of the large intestine mucosa. Since ulcerative colitis usually begins in the rectum, rectal biopsies obtained during sigmoidoscopy may be adequate for diagnosis. Colonoscopy allows for examination of the entire large intestine and sometimes the most distal ileum. The extent of inflammation, ulcerations, pseudo-polyps, and strictures is determined, and biopsy specimens are taken for a definitive diagnosis. A double-contrast barium enema may show areas of granular inflammation with ulcerations. The colon may appear narrow and shortened, and pseudo-polyps may be present. A double-contrast study (in which air is introduced into the bowel after the expulsion of barium) is effective in detecting mucosal abnormalities in ulcerative colitis.

G. Common Treatment (include all the drugs of choice, surgical procedures-if any, and all other treatments)

The goals of treatment are to rest the bowel, control the inflammation, combat infections, correct malnutrition, alleviate any stress, provide symptomatic relief, and improve quality of life. The goals of drug treatment are to induce and then maintain a remission in order to improve the quality of life. Five major classes of medications are used to treat ulcerative colitis: aminosalicytes, antimicrobials, corticosteroids, immunosuppressants and biologic and targeted therapy. Sulfasalazine (Azulfidine) contains sulfapyridine and 5-aminosalicylic acid (5-ASA). Its exact mechanism of action is unknown, but topical application to the intestinal mucosa suppresses proinflammatory cytokines and other inflammatory mediators. Olsalazine (Dipentum) is prescribed for clients intolerant to sulfasalazine. Newer preparations have been developed to deliver 5-ASA to the terminal ileum and colon such as Mesalamine (Asacol, Pentasa, Rowasa). These drugs are as effective as sulfasalazine and are better tolerated when administered orally. Although no specific infectious agent has been identified, antimicrobials such as Metronidazole (Flagyl) and Ciprofloxacin (Cipro) are used. Corticosteroids such as prednisone and budesonide (Entocort), are used to achieve remission in IBD, but are not effective for maintaining the remission. They are primarily used to reduce inflammation and pain. Corticosteroids are given for the shortest possible time because of side effects associated with long-term use. Immunosuppressants like 6-mercaptopurine, azathioprine (Imuran), cyclosporine (Sandimmune), and methotrexate (Rheumatrex) are given to maintain remission after corticosteroid induction therapy. There are currently four major biologic and targeted medications. Three are anti-tumor necrosis factor (TNF) agents: inflixib (Remicade), adalimumab (Humira), and certolizumab pegol (Cimzia). They act by suppressing the immune response and an antibody is used to reduce tumor necrosis factor. The fourth, natalizumab (Tysabril), inhibits leukocyte adhesion and movement into inflamed tissue. Approximately 25% to 40% of patients with ulcerative colitis will need surgery at some time during their illness. Since ulcerative colitis affects only the colon, a total proctocolectomy is curative. Surgical procedures used to treat chronic ulcerative colitis include total colectomy with rectal mucosal stripping and ileoanal reservoir, total proctocolectomy with permanent ileostomy and total proctocolectomy with continent ileostomy (Kock pouch).

Colectomy with or without ileostomy

Descriptions of the procedure

The most commonly used procedure for ulcerative colitis is a total colectomy and ileoanal anastomosis with the formation of an ileoanal reservoir. This combination of two procedures is performed approximately 8 to 12 weeks apart. The initial procedure includes colectomy, rectal mucosectomy, ileal reservoir construction, ileoanal anastomosis, and temporary ileostomy. The second surgery involves closure of the ileostomy to direct stool toward the new reservoir. Adaption of the new reservoir occurs over the next 3 to 6 months, which usually results in a decreased number of bowel movements over a 24-hour period. The patient is able to control defecation at the anal sphincter. Patient selection criteria include absence of colorectal cancer, no small intestine disease, competent anorectal sphincter, and physical status adequate to permit lengthy surgery. In addition, the patient needs to be motivated and capable of understanding self-care instructions.

Indications

Some indications for surgical therapy for ulcerative colitis include: failure to respond to conservative therapy, fistulas, inability to decrease corticosteroids, intestinal obstruction, massive hemorrhage, perforation, severe anorectal disease, and suspicion of carcinoma.

Interpretation of Findings

Ulcerations and inflammation of the sigmoid colon and rectum are significant findings for ulcerative colitis.

Nursing Actions

Preoperative care:
-Is similar to care for clients with other abdominal surgeries
-Reinforce teaching on the type of surgery that is being performed
-If the creation of a stoma is planned, collaborate with an enterostomal therapy nurse regarding care related to the stoma
-Administer antibiotic bowel prep (neomycin sulfate), if prescribed
-Administer cleansing enema or laxative, if prescribed

Intraprocedure:
-Provide padding to the client’s bony prominences to provide comfort and prevent skin breakdown
-Communicate surgical progress to the client’s family members, if appropriate
-Assist in monitoring urine output and blood loss
-Document appropriate surgical events
-Assist in arranging postoperative until placement and communicate postoperative needs of the client

Postoperative care:
-Is similar to care for clients with other abdominal surgeries
-The client will be NPO and have a nasogastric tube to suction, unless the surgery was performed laparoscopically
-An ileostomy may drain as much as 1,000 mL/day. Prevent fluid volume deficit (Administer IV fluids if the client is NPO. Oral hydration may be administered later in the course of recovery).

Potential Complications (write at least 3)

Bleeding occurs due to deterioration of the bowel.
Nursing Actions
-Observe the client for indications of rectal bleeding.
-Monitor vital signs.
-Check laboratory values, especially hematocrit, hemoglobin, and coagulation factors.
Client Education
-Instruct the client to report rectal bleeding.
-Explain to the client the importance of bed rest

Fluid and electrolyte imbalance occurs due to loss of fluid through diarrhea and vomiting, and may occur with nasogastric suctioning.
Nursing Actions
-Monitor laboratory values and provide replacement therapy.
-Monitor weight
-Assess for signs of fluid volume deficit (poor skin turgor)
Client Education
-Instruct the client to record and report the number of loose stools
-Encourage the client to obtain adequate fluid intake
-Advise the client to follow the prescribed diet

Toxic mega colon occurs due to inactivity of the colon. Massive dilation of the colon occurs and the client is at risk for perforation.
Nursing Actions
-Maintain nasogastric suction.
-Administer IV fluids and electrolytes
-Administer prescribed medications (antibiotics, corticosteroids)
-Prepare the client for surgery (usually an ileostomy) if the client does not begin to show signs of improvement within 72 hrs. or less
Client Education
-Refer the client with ostomy to an enterostomal therapist and to an ostomate support group

References

Knippa, A. (2011). ATI Nursing Education:RN Adult Medical Surgical Nursing Edition. United States: Assessment Technologies Institue. Pgs 682-692

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., Camera, I. M. (2011). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis: Elsevier Mosby. Pgs 1022-1028

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