11.11 Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic disorder that is characterized by inflammation in the gastrointestinal tract. IBD is an umbrella term used to describe two disorders called ulcerative colitis and Crohn’s disease. In ulcerative colitis (UC), this inflammation is limited to the two layers of the colon, the mucosa and submucosa, most commonly in the rectum. In Crohn’s disease (CD), inflammation can occur anywhere in the GI tract, from the mouth to the anus, and the inflammation affects all three layers of the colon. With both disorders, signs and symptoms can also occur outside the GI tract, commonly referred to as extraintestinal manifestations. Neither ulcerative colitis or Crohn’s disease can be cured, and both disorders carry an increased risk for cancer of the GI tract.^[1],[2],[3]

Both UC and CD are linked to an autoimmune response; however, the exact cause is unknown. It is thought that this autoimmune response could be triggered by normal intestinal bacteria, certain drugs/toxins, or infectious processes. There are also several risk factors for developing IBD^[4],[5],[6]:

• Genetics/family history of IBD
• Clients aged 15-30 years and 60 or older
• Northern European/Jewish ancestry

IBD is also more common in developed countries and in cold climates.^[7],[8],[9]

Pathophysiology

In IBD, extreme inflammation leads to breakdown of the mucosal layer of the GI tract. This breakdown allows exposure to intestinal viruses or bacteria that can also cause increased inflammation.^{[10],[11],[12]}

In clients with UC, inflammation leads to edema and ulcerations that can bleed. This inflammation spreads in a uniform fashion, starting in the rectum and proceeding up the colon. Over time, the colon becomes inflexible and shortened, ultimately losing the folds (haustra) in the colon.^{[13],[14],[15]}

In clients with CD, the inflammation starts out with a singular lesion, which goes on to develop into a deeper ulceration. Unlike UC, which has a uniform spread, a hallmark sign of CD are skip lesions. These are lesions that “skip” around the GI tract, leaving areas of normal or unaffected bowel between them. Over time, the affected areas develop a “cobblestone” appearance. The continued inflammation and resulting scar tissue can lead to the formation of strictures (narrowing) or fistulas (an abnormal passageway between two organs), causing bowel obstruction.^{[16],[17],[18]} See Figure 11.33^[19] for an illustration of the differences between CD and UC.

The inflammation of IBD is not limited to the GI tract and can occur in joints/bones, bile ducts, mouth (e.g., canker sores), eyes, and skin.^{[20],[21],[22]}

Assessment

Physical Exam

Although UC and CD share similar characteristics, there are some key differences between the two in signs and symptoms that may be found during assessment. See Table 11.11 for the similarities and differences between the signs and symptoms of UC and CD.^{[23],[24],[25]}

Table 11.11. Comparison of Ulcerative Colitis and Crohn’s Disease

Common Laboratory and Diagnostic Tests

A variety of laboratory and diagnostic tests may be used to diagnose IBD, as well as to rule out other disorders that can cause similar symptoms^[26],[27]:

Laboratory Tests

• A complete blood count (CBC) may indicate anemia due to blood loss in stool and an elevated white count due to inflammation. Elevated platelet levels may be seen with Crohn’s disease, increasing the client’s risk for developing deep vein thrombosis (DVT), pulmonary embolism, and cerebrovascular accident (CVA).
• A comprehensive metabolic panel (CMP) may show decreased albumin levels if malnutrition is occurring. Altered electrolyte levels may also occur with severe diarrhea.
• Elevated markers of inflammation such as a C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) may occur.
• A variety of stool studies can be used to help diagnose IBD, as well as rule out other conditions. For example, fecal calprotectin levels may be elevated due to inflammation. Stool can also be examined for ova and parasites to rule out a parasitic infection.^[28],[29]

Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.”

Diagnostic Tests

• Endoscopy is the gold standard for confirming the presence of IBD by taking a biopsy of the affected tissue. This can be done via EGD but is more commonly done via a colonoscopy.
• Barium studies can also be useful in diagnosing IBD because they can show the characteristic “lead pipe appearance” that is common with UC and the skip lesions that are common in CD.
• Ultrasounds, abdominal X-rays, CT scans, and MRIs can also be ordered to assess for complications caused by IBD such as perforation, bowel obstructions, fistulas, and strictures.^[30],[31]

Nursing Diagnosis

Nursing priorities for those suffering from inflammatory bowel disease include symptom management, preventing complications, and ensuring adequate nutrition.

Nursing diagnoses for clients with inflammatory bowel disease are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Possible nursing diagnoses for those with inflammatory bowel disease are as follows^{[32],[33],[34]}:

• Diarrhea
• Acute Pain
• Deficient Fluid Volume
• Impaired Skin Integrity
• Risk for Infection
• Imbalanced Nutrition: Less than Body Requirements
• Risk for Infective Coping

Outcome Identification

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, and realistic. These outcomes should be achievable within a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes include the following:

• The client will exhibit formed stool that occurs at the client’s normal frequency until the next follow-up appointment.
• The client will rate their pain at 3 or less on a scale of 0 to 10 within two hours.
• The client will exhibit blood pressure and heart rate within normal limits for age, moist mucous membranes, and urine output appropriate for their age during hospitalization.
• The client will exhibit skin in the peri-area that is an appropriate color for race and free from skin breakdown during symptoms of diarrhea.
• The client will verbalize three methods to reduce their risk of contracting an infection after the teaching session.
• The client will maintain a weight within a healthy range that is appropriate for their height until their next follow-up appointment.

Interventions

Medical Interventions

Medical treatment for IBD can be categorized as medication therapy and surgical management.

Specific interventions for IBD will depend on the severity of the disorder, but the ultimate goal is to achieve remission.^[35],[36]

Medications

Medication therapy for IBD is often prescribed in a stepwise approach to achieve symptom management. The first step is the use of aminosalicylates, such as mesalamine. If the client does not achieve symptom control with aminosalicylates, the second step adds a steroid medication until inflammation is decreased. Step-three drugs, also known as immune-modifying agents (i.e., thiopurines) or biological drugs (i.e., anti-TNF-alpha medications), are used when steroids do not achieve the desired effect. Step-four medications are disease specific (i.e., for UC or CD) and tend to be experimental with multiple side effects. Many medications used to treat IBD suppress the immune system, increasing the client’s risk for infection.^{[37],[38].[39],[40]}

An alternative approach to stepwise therapy is a step-down approach. This type of therapy refers to the prescription of potent medications first that are then scaled back after symptoms are under control. This approach is generally used for clients with severe cases of IBD or at high-risk for complications.^{[41],[42],[43],[44]}

Lastly, probiotics and antidiarrheals may be used in some clients. Probiotics will help replenish natural flora, and antidiarrheals will help reduce the frequency of stools.^{[45],[46],[47],[48]}

Surgical Management

Surgical removal of the colon (total colectomy) may be required for clients with UC if the disease cannot be controlled with medications or if complications are present. After surgery, the client has a stoma and colostomy collection bag. Although this surgery will cure the gastrointestinal symptoms of UC, it will not cure any extraintestinal manifestations of the disorder.^{[50],[51],[52],[53]}

Surgery may be required for clients with severe CD disease or when complications are present. The site of the surgery is determined by the affected portion of the GI tract and the purpose of the surgery.^{[54],[55],[56],[57]}

Nursing Interventions

When providing nursing care to clients with IBD, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching^{[58],[59],[60],[61],[62]}:

Nursing Assessments

• Assess the client for signs and symptoms of malnutrition and anemia, as these can be caused by poor intake or poor absorption of nutrients.
• Assess the intake and output of the client, noting the number of calories consumed, as well as consistency, characteristics, and frequency of stools.
• Assess for elevated temperature, elevated heart rate, increased white blood cell count, and increased pain, as these could indicate a complication such as perforation and peritonitis. Low blood pressure, elevated heart rate, and low-grade fever may also occur with dehydration.
• Assess the client’s weight daily to monitor for malnutrition, as well as fluid loss due to diarrhea.
• Assess electrolyte levels (particularly potassium and magnesium), as levels can be decreased due to diarrhea.
• Complete frequent abdominal assessments, as altered bowel sounds, increased pain, or distention may mean that a complication such as bowel obstruction or perforation has occurred.

Nursing Actions

• Encourage frequent colonoscopies (every one to two years) due to the high risk of cancer development.
• Seek referrals to mental health services if needed as anxiety and depression are common.
• Encourage the client to receive appropriate vaccinations due to their increased risk for illness.
• Administer intravenous fluids or total parenteral nutrition (TPN) as ordered. TPN may be needed for clients with severe disease or during acute flare-ups.
• Ensure referrals to a stoma nurse if the client has a stoma present.
• Administer IBD medications per provider order.
• Encourage the client to drink two liters of fluid per day to prevent dehydration.
• Encourage the client to join a support group consisting of others with IBD to strengthen their support system.
• Provide peri-care after bowel movements and apply barrier cream as needed.

Client Teaching

The following teaching topics are typically included in health teaching about IBD:

• Teach the client about the disease process, treatment, and self-managing the disorder. Many medications used to treat IBD have serious side effects that should be reported to the health care provider.
• Review symptoms of perforation and when to seek emergency care.
• Encourage bone mineral density testing as prescribed by their health care provider due to the increased risk of osteoporosis from steroid medications.
• Avoid NSAIDs because they may increase symptoms.
• Avoid foods that may increase symptoms such as dairy, caffeine, alcohol, and foods high in fat and fiber. Clients may benefit from a diet that is bland and high in protein, calories, and vitamins.

Evaluation

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.