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Collectively known as inflammatory bowel disease (IBD), Crohn disease and ulcerative colitis affect 1.5 million Americans, according to the Crohn's and Colitis Foundation of America. We show you how to distinguish between these two chronic disorders and develop a care plan for your patients.
IBD is a disorder that produces chronic, uncontrolled inflammation of the intestinal mucosa, which can affect any part of the gastrointestinal (GI) tract, causing edema, ulceration, bleeding, and profound fluid and electrolyte losses. Crohn disease and ulcerative colitis are collectively known as IBD. Managing fluid and electrolyte imbalances, nutritional deficiencies, infections, chronic pain, and body image disturbances are just some of the goals for the interprofessional healthcare team.
In this article, we'll help you understand the differences between Crohn disease and ulcerative colitis and care for your patients with these chronic inflammatory conditions.
The underlying cause of IBD isn't clearly understood. However, the research evidence suggests that bacteria and viruses or proteins (antibodies) cause the immune system to overreact and produce inflammation in the GI tract. Two known antibodies that are sometimes found in the serum of patients with IBD are antineutrophil cytoplasmic antibodies (ANCA) and antisaccharomyces cerevisiae antibodies (ASCA). In fact, ASCA are a diagnostic marker for Crohn disease, whereas ANCA are more likely to be identified in the serum of patients with ulcerative colitis. Other antibodies have been associated with IBD, including Escherichia coli antibodies, Pseudomonas fluorescens antibodies, and Clostridium species antibodies.
Environmental agents may be a trigger for the development of IBD, according to the CDC. IBD is more common in developed countries, and there's a noted north-to-south variation and a higher frequency in urban communities compared with rural areas. These observations suggest that urbanization is a potential contributing factor. It's postulated that this is the result of westernization of lifestyle, such as changes in diet and smoking and variances in exposure to sunlight, pollution, and industrial chemicals. According to evidence-based research, smoking is a risk factor for the development of Crohn disease.
Genetics and ethnicity are strong predictive factors in developing IBD. If a person has a relative with IBD, that person is 10 times more likely to have IBD and 30 times more likely if the relative is a sibling. Research studies have linked chromosome 16, or the IBD-1 gene, to IBD. The incidence of IBD is two to four times greater in people of Caucasian and Ashkenazic Jewish origin than in individuals from other ethnic groups.
The peak onset of IBD is between ages 15 and 30, but it can occur at any age. The incidence of ulcerative colitis is more frequent in men, whereas Crohn disease is more frequent in women.
Crohn disease and ulcerative colitis have similar characteristics and both are marked by periods of remission and flares (see Crohn disease versus ulcerative colitis). Let's take a closer look at the unique features of each disorder.
Primarily seen in adolescents, young adults, and older adults, Crohn disease is an inflammatory disorder affecting mostly the distal ileum and colon. The intestinal lining ulcerates and scar tissue develops (see Picturing Crohn disease). Generally separated by normal tissue, fistulas, fissures, and abscesses form. The wall of the bowel thickens and becomes fibrotic (hardened), which causes a narrowing of the bowel lumen-the space through which food passes. Formation of granulomas, inflammatory masses that result from a collection of immune cells called macrophages, occurs in many patients. Sometimes the lesions have a "cobblestone" appearance. A fibrotic bowel with abscesses and granulomas can lead to obstruction and perforation. Crohn disease results in the malabsorption of water and nutrients, which may lead to fluid and electrolyte imbalances.
Patients experience abdominal pain and cramping in the right lower quadrant of the abdomen, especially after a meal. Inflammation in the intestinal mucosa prevents water absorption, and the patient may experience more than 10 bloody diarrhea episodes each day. Anorexia, weight loss, cachexia, weakness, and fatigue are common. Fever may be present from the inflammatory process and/or infection. Anemia often results secondary to poor dietary intake and/or absorption of vitamins and nutrients. Lesions that bleed may also lead to anemia. Bright red blood may be observed in the stool because of bleeding lesions and/or excoriation of the anal mucosa due to the frequency and amount of diarrhea.
Diagnostic endoscopy (colonoscopy and sigmoidoscopy) confirms the presence of intestinal lesions. A barium study of the upper GI tract will commonly show a constriction of the terminal ileum in the patient with Crohn disease. This constriction is known as the "string sign."
In ulcerative colitis, inflammation begins in the rectum and extends proximally in an uninterrupted pattern to the proximal colon, eventually involving the entire length of the large intestine (see Picturing ulcerative colitis). The rectum is always involved. There are no "skip areas," meaning that the inflammatory lesions are continuous, unlike in Crohn disease. The intestinal lining ulcerates, bleeds, and becomes thickened and edematous. The bowel narrows and shortens. Granulomas, perforations, and abscesses can occur. The colon eventually loses its elasticity and its absorptive ability is reduced. Ulcerative colitis results in malabsorption of water and nutrients, which may lead to fluid and electrolyte imbalances.
Patients experience abdominal cramping pain with diarrhea, nausea, dehydration, weight loss, cachexia, and anemia. There may be a frequent urge to defecate followed by diarrhea stool that may contain blood. In fact, the patient may experience an average of 5 to 10 diarrhea stools each day that also contain mucus leading to anemia, hypovolemia, and malnutrition. Anemia is related to active bleeding and poor intake and/or absorption of nutrients. Chronic inflammation tends to destroy mature red blood cells and inhibit the production of new ones by decreasing the production of a hormone called erythropoietin, which stimulates red blood cell production.
Diagnostic endoscopy confirms the presence of intestinal lesions in ulcerative colitis. A barium enema can be used to identify ulcerations in the mucosa. The "stovepipe sign," which is a rigid shortened appearance of the colon, may be seen during a barium enema in a patient with chronic ulcerative colitis.
IBD can impact other areas of the body in addition to the GI system, including the eyes, liver, joints, and skin. Systemic complications that occur in IBD include nephrolithiasis, cholelithiasis, and pyelonephritis.
Peripheral arthritis is the most common extraintestinal symptom in IBD and may lead to pain in the joints of the hands, knees, and ankles. Spondylitis is sometimes referred to as "spinal arthritis" and can appear before GI symptoms in IBD. Spondylitis produces pain and muscle stiffness in the lower spine and sacroiliac joints. A more severe form of spinal arthritis is called ankylosing spondylitis, which can lead to inflammation of the eyes, lungs, and heart valves.
The skin may also be involved in the inflammatory process of IBD. Erythema nodosum is a type of panniculitis (inflammation of subcutaneous tissue) characterized by raised, red, tender nodules on the extremities, with the pretibial region most affected. It's more common in women than men and in people between the ages of 20 and 30. The presence of erythema nodosum along with abdominal pain and diarrhea may indicate a flare in IBD.
Ocular symptoms often accompany IBD. Assess your patient for eye tearing, burning, and itching that may indicate episcleritis-inflammation of the vascular layer beneath the conjunctiva. Scleritis is an even more serious disorder that may lead to visual changes.
It's important to remember that extraintestinal symptoms often correlate with the severity of GI symptoms in IBD. Remember this key point: The skin is often a mirror of what's happening systemically in your patient. Patients with IBD are also at greater risk for developing cancer of the colon and liver disease than the general population, according to evidence-based research. Keep abreast of any elevation in your patient's hepatic enzymes.
Perform a head-to-toe assessment of your patient during the health history interview. Some of the information you want to glean from your patient is the history of the disease, any lifestyle issues, current medication regimen, diet, quality and frequency of stools, and presence of pain. You may want to use a published tool to help evaluate the extent of disease activity in IBD. One of these tools is the Simple Clinical Colitis Activity Index, which requires the patient to answer questions about bowel movement frequency, feelings of urgency with bowel movements, blood in the stool, and general well-being. Points are assigned to each question and an overall score is determined. The greater the number of total points, the more significant the symptoms, which may indicate an increase in disease activity.
Make sure you emphasize abdominal assessment and your patient's fluid and electrolyte status. Assess the abdomen for contour, distension, firmness, or rigidity. A firm, rigid, or tender abdomen may indicate perforation or bowel obstruction. Auscultate bowel sounds for pitch and frequency. Hyperactive bowel sounds may correlate with frequent diarrhea stools. Higher pitched, hypoactive, or absent bowel sounds may indicate intestinal obstruction. Assess and record stool frequency, characteristics, and amount. Emotional stress and trigger foods may precipitate the onset of severe diarrhea.
Be on the lookout for symptoms of dehydration, bleeding, and infection. Frequent bloody diarrhea stool can quickly lead to dehydration. Poor skin turgor, dry mucous membranes, sunken eyeballs, and an elevation in serum blood urea nitrogen indicate dehydration. Electrolyte imbalances are common. Potassium depletion (hypokalemia) can occur quickly due to the fluid volume depletion that's seen in severe diarrhea. A reduction in serum red blood cells, hemoglobin, hematocrit, and platelets indicates blood loss. Keep in mind that the hemoglobin and hematocrit may actually be elevated in response to water loss. Intestinal perforation and abscesses may lead to fever, tachycardia, and leukocytosis.
Infectious processes and malabsorption often lead to a reduction in serum proteins and albumins. Infections can develop secondary to medications that are used to suppress the immune system in IBD. The erythrocyte sedimentation rate and C-reactive protein may be elevated in response to inflammation and/or infection. Remember that many patients with Crohn disease and ulcerative colitis may have antibodies contributing to the inflammatory process. A stool analysis is necessary to assess for bleeding, bacteria, viruses, or parasites.
There are many factors that alter nutrient intake in the patient with IBD. Nutrition abnormalities may be a result of malabsorption, decreased food intake, and intestinal losses. These deficiencies will differ depending on the location of disease activity and specific nutrient absorption found at these sites. Maintaining fluid balance and promoting optimal nutritional status are priority goals. Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacements are indicated to meet nutritional needs, reduce inflammation, and control pain and diarrhea. It's important to teach your patient nutritional strategies to help reduce and/or prevent disease flares (see Nutritional strategies to prevent or reduce symptoms). Total parenteral nutrition may be necessary when the patient is experiencing a severe flare, especially in Crohn disease.
Medications are often used to suppress inflammation, control symptoms, and replace or supplement essential nutrients that are poorly absorbed because of extensive disease in the GI tract. Many of the same medications are used to manage both Crohn disease and ulcerative colitis. Anti-inflammatory drugs are the first line of treatment for mild-to-moderate IBD. Antidiarrheals and antiperistaltic medications may also be used to rest the bowel. Don't forget that nonsteroidal anti-inflammatory drugs should be used with caution in patients with IBD because they can cause bleeding and even lead to ulcers in the GI tract. Sedatives are sometimes helpful to reduce stress during disease flares, but they shouldn't be used for an extended period of time.
Other medication classifications that are commonly used to treat IBD include aminosalicylates, corticosteroids, immunomodulators, antibiotics, and biologic modifiers (see Medications used to treat IBD). It's important to remember that many of these medications, including corticosteroids, immunomodulators, and biologic modifiers, cause suppression of the immune system and can lead to infection. Immunomodulators and biologic modifiers can predispose the patient to various forms of malignancy. Make sure you assess your patient's responses to these medications and promptly report any adverse reactions to the healthcare provider.
Probiotic supplements are sometimes taken orally to help establish normal intestinal flora, which aids in digestion and immune function. Vitamin supplements and iron preparations are also recommended, especially when the patient with IBD is experiencing anemia and fatigue.
Surgical intervention may be indicated in IBD. An important distinction to make regarding surgery for Crohn disease and ulcerative colitis is that surgery isn't curative in Crohn disease; inflammation may reoccur in previously healthy tissue following surgery. Despite this fact, surgery may still be indicated to control symptoms and prevent complications. The primary indication for surgery in patients with Crohn disease is bowel obstruction, which occurs in 75% of patients within 10 years of diagnosis. Other indications for surgery are perforation, fistulas, and abscess.
Approximately 25% of patients with ulcerative colitis require a colectomy-the surgical removal of a portion of the colon or the entire colon due to profuse bleeding, perforation, strictures, and cancer. A colostomy may be necessary when the disease is extensive in a patient with severe Crohn disease, whereas patients with severe ulcerative colitis may have an ileoanal anastomosis as an alternative to a permanent ileostomy.
Coping with chronic illness may be difficult for your patient. Emotional stress increases peristalsis, causing abdominal pain and discomfort to increase. It's important for your patient to participate in activities that reduce stress, depression, and anxiety. A reduction in stress also helps to normalize bowel function. Encourage your patient to engage in regular exercise to tolerance, such as walking, riding a bicycle, yoga, or going to the gym.
Remind your patient to drink plenty of fluids, eat a well-balanced diet, and avoid those foods that produce discomfort. Teach your patient to report infection or any adverse reactions to medications promptly. Emphasize the importance of avoiding consumption of alcohol and nicotine products. Encourage your patient to journal his or her daily experiences coping with IBD. Utilizing support groups and learning more about the disease process can be helpful to patients and families. Help your patients cope by joining them in their journey through the world of chronic illness.
* Avoid foods that produce GI discomfort.
* Avoid trigger foods, including high-fiber foods (nuts; raw, leafy vegetables; whole-grain cereals), high-fat foods (greasy, fried foods), caffeine, alcohol, spicy foods, and milk products.
* Ensure adequate intake of fluids, carbohydrates, protein, fats, fruits, and vegetables.
* Drink 8 to 10 glasses of water daily to prevent dehydration. If fluid intake doesn't keep up with diarrhea, kidney function may be affected.
* Avoid carbonated beverages because they can cause gas.
* Sip rather than gulp fluid intake (water). Gulping introduces air and can cause abdominal discomfort.
* Eat small meals. Patients who eat 5 to 6 small meals each day have less GI pain and discomfort than those who eat 2 to 3 large meals.
* Bread and rice are good sources of carbohydrate. Meats, fish, eggs, and poultry are good sources of protein. Make sure vegetables are included in the nutrition plan and that they're steamed, stewed, or baked. Healthy sources of fat include olive and canola oil.
* Contact the healthcare provider if eating 5 to 6 small meals a day is causing an increase in symptoms.
* Consider taking a daily multivitamin because IBD causes malabsorption of vitamins and nutrients from the intestinal tract.
* Talk with a dietitian.
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