Treatment

Treatment can be:

1. Medical
2. Surgical

Medical treatment for both Crohn disease (CD) and ulcerative coilitis (UC) is geared towards managing the inflammation and the symptoms.

Managing inflammation

Medications for managing inflammation in IBD can be categorized into 5 different classes:

1. aminosalicylates: Bowel-specific anti-inflammatory drug similar to NSAIDS
2. antibiotics: decreases infection that can cause inflammation
3. cortico-steroids: powerful anti-inflammatory drug
4. immuno-modifiers: changes how the body mounts an inflammatory response
5. biologics: prevents and reduces inflammation

IBD Treatment Pyramid

Medical treatment of IBD uses a step-wise approach, sometimes called the treatment pyramid. First line treatments, those at the bottom of the pyramid, have lower efficacy but higher safety margins. In contrast, experimental treatments at the top of the pyramid have high efficacy but also a high risk of serious side effects. (ref:http://www.d.umn.edu/~jfitzake/Lectures/DMED/LowerGI/IBD/Pyramid.html) Drugs from any level of the pyramid may be used alone or in combination with other drugs.

It is important to note that medical treatment for IBD requires an individualized approach because of the tricky act of balancing the side effects of medication.

Test yourself: You are the nurse for a patient with Crohn disease and he asks you why his medications are different than his neighbour's since they both have Crohn disease. How do you respond?

1. Let me call the doctor to verify.
2. There is no standard treatment for IBD because every patient is different.
3. option c
4. option d

Managing symptoms

1. Diarrhea:
   • Anti-diarrheals (e.g. loperamide)
   • Bulk forming agents - (e.g. psyllium) a fibre supplement that absorbs water in the intestines, creating bulk in the stools
   • Stool softeners (e.g. docusate, senna) - increases absorption of water and fat into stool, making it softer
2. Hemorrhoids: (frequency of bowel movements causes inflammation of the peri-anal area)
   • Topical steroids (e.g. hydrocortisone) - can reduce inflammation, swelling, and itchiness.
   • Zinc oxide (topical) - a mild astringent (shrinks mucous membranes of exposed tissues to reduce moisture, similar to anti-perspirants) with antimicrobial properties
   • Sitz bath - helps to alleviate symptoms by calming the inflammed tissues
3. Abdominal cramps:
   • Anti-spasmodics - relaxes the muscles of the GI tract
   • Bile-salt binders - bile salts bind fat for excretion, but it is irritating to the gut if it is left behind rather than excreted
   • Acid-reducing drugs (e.g. pantoprazole) - reduces acid that may cause heart burn
4. Pain:
   • Analgesics
   • NSAIDS - for control of joint pain, but can aggravate abdominal pain
5. Nutritional deficiency: (can be caused by excessive diarrhea, malabsorption, and side effects of medications that impairs absorption)
   • Vitamin and mineral supplements

Surgery

Ulcerative coilitis

In ulcerative coilitis, complete surgical removal of the large intestine (called a colectomy) is considered to be a "cure" as the inflammation will not return to other sections of the GI tract once the colon is removed. However, a colostomy bag will be needed to collect waste material.

Crohn disease

For Crohn disease, because inflammation can occur anywhere along the GI tract, removal of the colon will not prevent inflammation from occurring elsewhere. (ref) For this reason, surgery is not considered a cure. Despite this fact, 75% of individuals with Crohn disease will end up having bowel resections (ref) (that is, having part of their bowels surgically removed). The most common reason for bowel resections in individuals with Crohn disease is a bowel obstruction.

Previous Section:Clinical Manifestations                                    Home                                                Next Section:Nursing Care

Nursing Care

Because Ulcerative Colitis and Crohn’s Disease are similar and have similar treatments, the nursing care involved in each is also similar and consists largely of a supportive role

Ulcerative Colitis

The goals of treatment include resting the bowel, controlling inflammation, managing fluids and nutrition, managing stress, providing education about disease and treatment, and symptomatic relief. The nurse, therefore, must support the client in reaching and maintaining these goals.

Nursing care includes:

• Establish a good relationship with the client directed toward a therapeutic and supportive program
• Management of acute phase (hemodynamic stability, pain control, fluid and electrolyte balance, nutritional support.
• Accurate record of intakes and outputs
• Record/monitoring of number and characteristics of stools
• Good explanation of procedures, acknowledging any client apprehension
• Psychosocial support for emotional problems including frustration, fear, feelings of discouragement, grief, anxiety, embarrassment, and depression
• Management of discomfort and pain control
• Recognition of ineffective coping
• Restricted activity and possible bedrest (during severe exacerbation), and accompanying nursing interventions to prevent complications of immobility
• Adequate rest; schedule activities around rest periods
• Perianal skin care and prevention of skin breakdown (no harsh soap, barrier creams)
• Ensuring close proximity to bathroom and use of deodorizers can be helpful for episodes of diarrhea
• Client teaching is of utmost importance. Provide teaching related to disease progress and management, treatment (drugs, diet) and diagnostic tests and procedures
• Pre- and postoperative care for those clients undergoing surgery

Crohn's Disease

The goals of care and treatment include relieving symptoms, controlling inflammation, correcting nutritional problems, and promoting healing. The nursing care is similar to that of UC; the nurse must provide support in attaining and maintaining these goals.

Nursing care includes:

• Encourage self-care as client’s condition improves
• Provide frequent rest periods, advising of the importance of rest
• Promote the avoidance of emotional stress and strategies to control or minimize stress, while teaching about the stress components of the disease
• Skin care (specialized for clients that have perianal fistulas or abscesses)
• Pre- and postoperative care for those undergoing surgery
• Help client and family set realistic short- and long-term goals, acknowledging the chronic and intermittent nature of the disease
• Teaching is of utmost importance and needs to include the topics of diet management, drugs, perianal care, recurrent symptoms, and when to seek medical care

For clients that are using complimentary or alternative therapies, such as herbal remedies, to help treat and manage their IBD, the nurse should assess for and teach about dangerous interactions that can occur with other medications (N. Taylor & K. Taylor, 2011).

In contrast with the literature that stresses technical competence, research by Belling, Woods, and McLaren (2008) suggests that clients with IBD perceive the nursing roles and attributes of advice, support, caring, empathy, and disease management, to be of significant importance in their care.

Previous Section: Treatment                                                  Home                                                    Next Section: Case Study

Case Study

Case Study

Mr. Smokey Robinson is a 30 year old man who was admitted to the hospital from home with frequent bloody diarrhea over several days, sharp abdominal pain, and generalized weakness. During the health history interview, he reported suffering from chronic hemorrhoids and diarrhea and uses over-the-counter hydrocortisone cream at home. He also reported frequent joint pain, especially in the lower back.

Mr. Robinson has a history of smoking 20 cigarettes a day for 15 years. He lives in Sudbury, an urban city in Northern Ontario. He is single and works as a construction worker and reports disliking his job. He does not engage in physical activity outside of his work due to low energy and usually grabs a bite to eat at fast food restaurants on his way to and from work.

While in hospital, he underwent an endoscopy of the small intestine, a colonoscopy of the entire colon to look for lesions, and a barium study of the gut. Test results revealed the "string sign" - a constriction at the terminal ileum of the small intestine, a "cobblestone" appearance of the gut due to lesions and fibrosis with "skips" of normal tissue in between. His blood tests showed anemia and he was given 2 units of blood upon admission.

1. He was diagnosed with Crohn disease while in hospital. Which of his signs and symptoms are consistent with this diagnosis?
   
   • sharp abdominal pain
   • frequent bloody diarrhea
   • hemorrhoids
   • joint pain, especially in the lower back
   • constriction at the junction between the small intestine and the large intestine
   • lesions causing a cobblestone appearance to the guy
   • areas of normal tissue, as if the lesions "skipped" a section of the gut
   • anemia (from gastric bleeding)
2. He was started on aminosalicylates which is an antiinflammatory drug. He tells you that he knows someone who also has Crohn disease but that person is taking 3 different medications and wonders why he is receiving different treatments. What do you tell him?
   
   Treatment for IBD is individualized to the patient and the symptoms that they are experiencing.
3. What are your priority assessments for him while he is in the hospital?
   
   • Abdominal assessments: firm, rigid, tender abdomen may be from bowel obstruction or perforation; hyperactive bowel sounds may be from diarrhea; hypoactive bowel sounds may indicate constipation
   • Monitor for dehydration and electrolyte imbalance: poor skin turgor, dry mucous membranes, elevated BUN, low potassium/sodium
   • Signs and symptoms of infections
   • Pain: ensure patient's pain is managed
4. Mr. Robinson tells you that he "brought this on himself" for not exercising and not eating well and says, "It must be all this stress at work that gave me these ulcers." What do you tell him?
   
   Stress and diet have not been shown to be causative for IBD, but it may worsen a pre-existing condition.

References

References

Belling, R., Woods, L., & McLaren, S. (2008). Stakeholder perceptions of specialist inflammatory bowel disease nurses' role and personal attributes. International Journal of Nursing Practice, 14(1), 67-73.

Danese, S., Sans, M., Fiocchi, C. (2004) Inflammatory bowel disease: the role of environmental factors. Autoimmunity Reviews.3, 394 - 400.

Ferguson, L.R., Shelling, A.N., Browning, B.L., Huebner, C., Peterman,L.(2007) Genes, diet and inflammatory bowel disease. Mutation Research, 622,70 - 83.

Fiocchi, C.(1998) Inflammatory Bowel Disease: Etiology and Pathogenesis. Gastroenterology, 115, 182 - 205.

Heuther, S.E., & McCance, K.L. (2012). Understanding pathophysiology (5th ed.). St. Louis, MO: Mosby Elsevier.

Lewis, S.M., Heitkemper, M., Dirksen, S.R., Bucher, L., & O’Brien, P.G. (2010). Medical-surgical nursing in Canada (2nd ed.). Toronto, ON: Mosby Elsevier.

Taylor, N.S., & Taylor, K.M. (2011). Complementary and alternative medicine in inflammatory bowel disease. Gastrointestinal Nursing, 9(6), 32-39.