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IBD is bowel inflammation with manifestations resulting in...
- Inflammatory cells
- Inflammatory chemical mediators
What is the cause of IBD and is it familial?
- Unknown cause b/c its autoimmune
- Familial tendency
What are the S&S of IBD?
- Fecal urgency
- Weight loss
Are the S&S of IBD constant and how severe are they?
- Remission/ exacerbation patterns (come and go)
- Systemic manifestations are mild to furminating (extreme)
What are the 3 proposed causative factors of IBD?
- Immune (autoimmune w/ no trigger or defective immunoregulation
- Genetics (it is a familial tendency)
- Infectious origin (something got into you somehow)
If there is a cause... its a 2ndary disease
Define Crohn's Disease (1 type of IBD)
An inflammation of the GI tract that extends through all layers of the intestinal wall (transmural- diff from Ulcerative colitis)
What group develops Crohn's Disease?
- Young adults and adolescents
- European origin or certain subcultures (some jews)
Where does Crohn's Disease occur in lower GI tract?
- Most commonly is proximal colon aka "ileocecal region" where the large and small bowel meet
What precipitates a Crohn's attack?
What do Crohn's lesions look like?
- Sharply demarcated
- Inflamed granulation tissue
- Lesions surrounded by normal appearing tissue (skip pattern- red then damaged)
- Deep fissures
- Wall thickening
List clinical manifestations for Crohn's Disease
- RLQ abdominal pain
- Weight loss
- Malabsorption (results in hypoalbuminemia, steatorrhea- gray fat stool, anemia)
- Also- fever, weakness, F&E losses, bleeding
What are complications of Crohn Disease?
- Fibrosing strictures- hardening areas altering peristalsis
- Fistulas (bowel to bladder, vagina, out of body)
- Abscesses (perianal or peritoneal)
- Cancer (caused by dysplasia)
Define Ulcerative Colitis
- Inflammatory disease of MUCOSA of rectum and colon
- Unlike Crohn's b/c mucosa not transmural
What is the location of Ulcerative colitis?
- Rectum or rectosigmoid
- Rare- subtotal or total colon)
List the disease features of Ulcerative colitis
- Active inflammation
- Ulceration- extensive
- Continuous injury (Crohn's was cobblestone)
- Epithelial cell changes cause cancer
List clinical manifestations of Ulcerative Colitis
- Diarrhea- severe, bloody, mucous threads
- Pain- lower abdominal (targeted end of colon)
- Exacerbation and remission pattern (not constant)
Compare LGI types of Inflammation
- Crohns: Granulomatous (lesions of inflammed granulated tissue)
- Colitis: Ulcerative/ exudative
Compare LGI level of injury
- Crohns: All layers (transmural)
- Colitis: Mucosa
Compare LGI Area of Involvement
- Crohn: ileum/ proximal colon (or anywhere)
- Colitis: Limited to rectum and sigmoid colon
Compare LGI rectal bleeding
- Crohn: Rare
- Colitis: Common (rectal area is only location of colitis)
Compare LGI fistulas/ strictures
- Crohn: common (transmural through tissue)
- Colitis: rare (only affects mucosal layer)
Compare LGI Cancer Development
- Crohn: Possible
- Colitis: Possible
Compare LGI Fat/ Vitamin malabsorption
- Crohn: Yes (in small intestines) (transmural)
- Colitis: No (only damages mucosa)
State prototype drug for Antiinflammatory drug group 5-Aminosalicylates (5-ASA)
List indications for use mesalamine (Rowasa) 5-ASA
- Mild to moderate IBD
- 1st line therapy
List delivery forms of mesalamine (Rowasa) 5-ASA
- Rectal for local effect (colitis or rare crohn)
- PO for small bowel (crohns)
What does 5-ASA "prodrug" mean?
- Chemical makeup does nothing when broken down (no systemic effects)
- Only works when it attaches to receptor sites (locally)
What does 5-ASA (Rowasa) break down into?
- 5-ASA (active* antiiflammatory ingredient)
- Sulfapyridine (effects unknown, responsible for adverse effects)
What are the SE of 5-ASA?
- Mesalamine (Rowasa) has less SE than other forms of 5-ASA
- GI- abdominal discomfort, gas, nausea
- Flu-like symptoms
- Hematologic disorders (rare)
List Pt Teaching for 5-ASA mesalamine (Rowasa)
- Drug is photosensitive- keep in foil container until use, will stain surfaces and material
- **Report symptoms of Acute Intolerance Syndrome- cramping, acute abdominal pain, bloody diarrhea (same as disease but more severe), May be accompanied with fever, rash, & H/A
- Delayed therapeutic effect- 3 to 21 days!
- Monitor CBC
What is the prototype drug for Glucocorticoids?
List the uses and delivery of Glucocorticoid Budesonide
- Symptom relief
- Induction of remission
- Short term relief (never long term- think steroid adverse effects "olive" look)
- Give PO or IV (broken down by liver- generally local)
State the prototype drug for Immunomodulator therapy
- infliximab (Remicade)
- -ab = antibody
What is the MOA of infliximab (Remicade)?
- Monoclonal (designer- target specific things) antibody
- Binds with and inactivates TNF-alpha (proinflammatory) - Tumor necrosis factor
What is the indication for use of infliximab (Remicade)?
- Mod to severe Crohn dx or ulcerative colitis
- only used when conventional/ modern does not work
What is the mode of delivery of infliximab (Remicade)?
- Induction regimen (intermittent for 6 weeks)
- Maintenance infusions
- can significantly reduce exacerbation
List SE of infliximab (Remicade)
- Infusion reactions (fever, chills, urticaria, cardiopulmonary rxns)
- Increased risk for lymphoma
- (not 1st line therapy)
List prototype immunosuppresant agents
- azathioprine (Imuran)
- mercaptopuring (Purinethol)
State indications for use and delivery of Imuran and Purinethol
- Induce/ maintain remission (not acute, takes 6 months)
- Second-line adjunct therapy (take with mainstream drug)- (toxic, kept as backup)
- not approved for IBD but commonly used
List SE of immunosuppressants Imuran and Purinethol
- Bone marrow suppression
List Nsg implications for immunosuppressants (Imuran and Purinethol)
- Pt teaching- S&S of infection, anemia, bleeding
- Monitor CBC for bone marrow depression
- Monitor pancreatic enzymes
Condition in small pouches in lining of colon that bulge outward through weak spots
State location and incidence of Diverticulosis
- Location: Sigmoid colon
- Incidence: 30% people over 60 yrs and 80% people over 80 yrs
List contributing factors of Diverticulosis
- Dietary factors- not enough fiber
- Physical Activity- sedentary
- Bowel habits- constipation
- Effects of aging- weakness
State manifestations and complications of Diverticulosis
- Inflammation leads to perforation, rupture, and absesses leading to peritonitis (rare)
What causes Diverticulitis manifestations?
- Abcess formation
List common complaints and duration of Diverticulitis manifestations
- Pain- severe lower abdominal
- Systemic fever and chills
- Duration: days then goes away
State complications and tx of Diverticulitis
- Peritonitis- e. coli
- Hemorrhage- vessel bursts
- Bowel obstruction
- Fistula formation- bursts then attaches
Treatment: broad spectrum antibiotic therapy
Inflammatory response of serous membrane that lines abdominal cavity and covers visceral organs
What is the common cause of Peritonitis?
- Break in the system causing death of bowel and bacteria escaping into the peritoneum
- Trauma- stab or gun shot wound
How does bacteria access peritoneal cavity causing peritonitis?
- It escapes from the bowel through fissure, rupture (diverticulitis), or trauma
- Historical: common cause of death in war
What are common conditions that cause Peritonitis?
- Perforated peptic ulcer
- Ruptured appendix
- Perforated diverticulum
- Gangrenous (dead) bowel
- Pelvic inflammatory disease (PID)
- Gangrenous gallbladder (dead tissue)
What are the local manifestations of Peritonitis?
- Translocation of ECF (extra cellular fluid) in peritoneal cavity
- Rigid "board-like" abdomen- from tense internal infection
What are the systemic manifestations of Peritonitis?
- elevated WBC
- (starts to look shocky)
What are the late manifestations of Peritonitis?
- Shock- inflammation causes edema causing a large shift of fluids (ECF in peritoneum) leading to shock
What are the complications of Peritonitis?
- Adhesions (attaches elsewhere causes dec. peristalsis and discomfort)
- Multiorgan failure (resulting from shock)