Ulcerative colitis

61 Ulcerative colitis




Overview/pathophysiology


Ulcerative colitis (UC) is a nonspecific, chronic inflammatory disease of the mucosa and submucosa of the colon. Generally the disease begins in the rectum and sigmoid colon, but it can extend proximally and uninterrupted as far as the cecum. In 30%-50% of cases, the rectum (proctitis) or rectosigmoid (proctosigmoiditis) is affected; in 30%-40% of cases, the disease extends to the splenic flexure (left-sided or distal colitis); and in 20%-30% of cases, the disease extends proximally to involve the entire colon (pancolitis). In some instances, a few centimeters of distal ileum are affected. This is sometimes referred to as backwash ileitis, and it occurs in only about 10% of patients with UC involving the entire colon. In the majority of patients, extent of colonic involvement is maintained from onset through the disease course, with the patient experiencing flare-ups and remissions. UC initially affects the mucosal layer. Eventually small mucosal layer abscesses form that ultimately penetrate the submucosa, spread horizontally, and allow sloughing of the mucosa, creating ulcerative lesions. The muscular layer (muscularis) generally is not affected, but the serosal layer may have congested and dilated blood vessels.


The cause of UC is unknown, but theories posit an interaction of external agents, host responses, and genetic immunologic factors creating the pathogenic responses. In a genetically susceptible subject, an outside agent or substance, such as a bacterium, virus, or other antigen, interacts with the body’s immune system to trigger the disease or may cause damage to the intestinal wall, initiating or accelerating the disease process. The resulting inflammatory response continues unregulated by the immune system. As a result, inflammation continues damaging the intestinal wall, causing symptoms of UC. Medical therapy is based upon symptomatic relief. The goals are to terminate the acute attack, induce and maintain remission, maintain quality of life, and prevent complications, both disease-related and therapy-related. Surgical intervention is indicated only when the disease is intractable to medical management or when the patient develops a disabling complication. Total proctocolectomy cures UC and results in construction of a permanent fecal diversion.


The most firmly established risk factor for developing inflammatory bowel disease (IBD) is a positive family history. There is a 10-fold increase in risk of IBD in first-degree relatives of patients with UC. Individuals with UC develop colonic adenocarcinomas at 10 times the rate of the general population. UC can occur at any age, but is generally diagnosed in the third decade of life with a second peak in the fifth and sixth decades. There is no difference in gender distribution; however, men are more likely than women to be diagnosed in the fifth and sixth decades of life. Incidence is higher in the Caucasian population and in Ashkenazi Jews than in nonwhite populations and in people of non-Jewish descent. UC is more prevalent in urban, developed countries with temperate climates than in rural, more southern countries. It is more common in nonsmokers and former smokers, suggesting that smoking has a protective effect and may decrease severity of symptoms. Appendectomy before age 20 may reduce risk.



Health care setting


Primary care; acute care for complications



Assessment




Signs and symptoms:


Bloody diarrhea (the cardinal symptom). The clinical picture can vary from acute episodes with frequent discharge of watery stools mixed with blood, pus, and mucus, accompanied by fever, abdominal pain, rectal urgency, and tenesmus, to loose or frequent stools, to formed stools coated with a little blood. However, nearly two thirds of patients have crampy abdominal pain and varying degrees of fever, vomiting, anorexia, weight loss, and dehydration. Remissions and exacerbations are common. Extracolonic manifestations also can occur, including polyarthritis, skin lesions (erythema nodosum, pyoderma gangrenosum), liver impairment, and ophthalmic complications (iritis, uveitis). Extracolonic manifestations may precede overt bowel disease, and their clinical activity may be related or unrelated to the clinical activity of the bowel disease.



Physical assessment:


With mild disease, there is no significant abdominal tenderness; left lower quadrant (LLQ) cramps are commonly relieved by defecation. With moderate disease, abdominal pain and tenderness may be present; mild fever (temperature 99°-100° F), anemia (hematocrit [Hct] 30%-40%), and hypoalbuminemia (3.0-3.5 g/dL) may be present. With severe disease, abdominal pain and tenderness are present, especially in the LLQ; distention and a tender, spastic anus also may be present; fever (temperature greater than 100° F), severe anemia (Hct less than 30%), and impaired nutrition with hypoalbuminemia (less than 3.0 g/dL) and weight loss are present. With rectal examination, the mucosa may feel gritty and the examining gloved finger may be covered with blood, mucus, or pus.



Risk factors:


Duration of active disease more than 10 yr, pancolitis, and family history of colonic cancer.



Diagnostic tests




Stool examination:


Reveals presence of frank or occult blood. Stool cultures and smears rule out bacterial and parasitic disorders. Stool is examined also for white blood cells (WBCs) and certain proteins, the presence of which suggests inflammation. Note: Collect specimens before barium enema is performed.



Sigmoidoscopy:


Reveals red, granular, hyperemic, and extremely friable mucosa; strips of inflamed mucosa undermined by surrounding ulcerations, which form pseudopolyps; and thick exudate composed of blood, pus, and mucus. Note: Enemas should not be given before the examination because they can produce hyperemia and edema and may cause exacerbation of the disease. A limited prep may be given to facilitate visualization during examination.



Colonoscopy:


Will help determine extent of the disease and differentiate UC from Crohn’s disease (CD) through both endoscopic appearance and histologic examination of biopsy tissues. Serial colonoscopy is also performed to monitor patients with chronic UC at risk for colon carcinoma. Note: This test may be contraindicated in patients with acute disease because of risk of perforation or hemorrhage.



Rectal biopsy:


Aids in differentiating UC from carcinoma and other inflammatory processes.



Barium enema:


Reveals mucosal irregularity from fine serrations to ragged ulcerations, narrowing and shortening of the colon, presence of pseudopolyps, loss of haustral markings, and presence of spasms and irritability. Double-contrast technique may facilitate detection of superficial mucosal lesions. With a double-contrast technique, barium is instilled into the colon as with a conventional barium enema, but most of the barium is then withdrawn and the colon is inflated with air, which causes a thin coating of barium to line the intestinal wall. The double-contrast technique has become the “gold standard” for evaluating patients for colitis. Note: Because they produce hyperemia and edema and may cause exacerbation of the disease, irritant cathartics and enemas should not be given before the examination.



Abdominal plain films (flat plate):


An important tool for screening severely ill patients when colonoscopy and barium enema are contraindicated. An abdominal flat plate may reveal fecal residue, appearance of mucosal margins, widening or thickening of visible haustra, and colonic wall diameter. In patients with suspected ileus, obstruction, or perforation, the flat plate film reveals abnormal gas and fluid levels or presence of free air in the peritoneal cavity.



Computed tomography (CT) scan:


Used to identify suspected complications of UC (i.e., toxic megacolon, pneumatosis coli).



Serum antibody testing:


Several serum antibodies are being evaluated for aiding in the development of noninvasive diagnostic techniques for UC. Some of these tests have been found to be useful in differentiating UC from CD.



Radionuclide imaging:


To identify extent of disease activity, especially when colonoscopy and barium enema are contraindicated. Injections of indium-111–labeled autologous leukocytes are used to identify areas of active inflammation.



Blood tests:


Anemia, with hypochromic microcytic red blood indices in severe disease, usually is present because of blood loss, iron deficiency, and bone marrow depression. WBC count may be normal to markedly elevated in severe disease. Sedimentation rate usually is increased according to illness severity. C-reactive protein elevation reflects degree of inflammation. Hypoalbuminemia and negative nitrogen (N) state occur in moderately severe to severe disease and result from decreased protein intake, decreased albumin synthesis in the debilitated condition, and increased metabolic needs. Electrolyte imbalance is common; hypokalemia is often present because of colonic losses (diarrhea) and renal losses in patients taking high doses of corticosteroids. Bicarbonate may be decreased because of colonic losses and may signal metabolic acidosis.





Nursing diagnoses:


Deficient fluid volume


Risk for bleeding


Risk for electrolyte imbalance

related to active loss occurring with diarrhea and gastrointestinal (GI) disorder/surgery


Desired Outcomes: Patient is normovolemic within 24 hr of admission as evidenced by balanced intake and output (I&O), urine output 30 mL/hr or more, urine specific gravity less than 1.030, good skin turgor, moist mucous membranes, stable weight, blood pressure (BP) 90/60 mm Hg or more (or within patient’s normal range), and respiratory rate (RR) 12-20 breaths/min. Serum electrolytes, Hct, hemoglobin (Hb), and red blood cells (RBCs) are all within optimal values as outlined in the third rationale, below.































ASSESSMENT/INTERVENTIONS RATIONALES
Assess for hypotension, increased heart rate (HR) and RR, pallor, diaphoresis, and restlessness. Assess stool for quality (e.g., is it grossly bloody and liquid?) and quantity (e.g., is it mostly blood or mostly stool?). Report significant findings to health care provider. These are signs of hemorrhage.
Assess for thirst, poor skin turgor (may not be a reliable indicator of hydration in the older adult), dryness of mucous membranes, fever, and concentrated (specific gravity greater than 1.030) and decreased urinary output. These are indicators of dehydration.
Assess I&O and urine specific gravity; weigh patient daily; and assess laboratory values to evaluate fluid, electrolyte, and hematologic status. These assessments evaluate fluid, electrolyte, and hematologic status. Optimal values are serum K+ 3.5 mEq/L or greater, Hct 40%-54% (male) and 37%-47% (female), Hb 14-18 g/dL (male) and 12-16 g/dL (female), and RBCs 4.5-6.0 million/mm3 (male) and 4.0-5.5 million/mm3 (female). Critical values: K+ less than 2.5 or greater than 6.5 mEq/L, Hct less than 15% or greater than 60%, Hb less than 5.0 g/dL or greater than 20 g/dL. Hypokalemia is common because of the prolonged diarrhea. Prolonged anemia may result in decreased Hct, Hb, and RBCs.
Assess frequency and consistency of stool. For frequent bowel movements, keep a stool count; measure liquid stools. Assess and record presence of blood, mucus, fat, and undigested food. Although bloody diarrhea is most commonly seen, the patient may experience acute episodes with frequent discharge of watery stools mixed with blood, pus, and mucus, accompanied by fever, abdominal pain, rectal urgency, and tenesmus; loose or frequent stools; or formed stools coated with a little blood.
Provide parenteral replacement of fluids, electrolytes, and vitamins as prescribed. These measures maintain the acutely ill patient, and are guided by laboratory test results.
Administer blood products and iron as prescribed. This will help correct existing anemia and losses caused by hemorrhage.
Provide bland, high-protein, high-calorie, low-residue diet, as prescribed, when patient is taking food by mouth (PO). Nutritional management varies with patient’s condition. In severely ill patients, total parenteral nutrition (TPN) along with nothing by mouth (NPO) status is prescribed to replace nutritional deficits while allowing complete bowel rest and improving patient’s nutritional status before surgery. For less severely ill patients, a low-residue elemental diet provides good nutrition with low fecal volume to allow bowel rest. A bland, high-protein, high-calorie, low-residue diet with vitamin and mineral supplements and excluding raw fruits and vegetables provides good nutrition and decreases diarrhea. Milk and wheat products are restricted to reduce cramping and diarrhea in patients with lactose and gluten intolerance.
Assess tolerance to diet. Cramping, diarrhea, and flatulence are signs that patient is not tolerating the diet.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Ulcerative colitis

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