Chapter 43 Inflammatory Bowel Disease
PATHOPHYSIOLOGY
Ulcerative colitis (UC) and Crohn’s disease (CD) are two major idiopathic inflammatory bowel disease (IBD) in children, with 15% falling in the indeterminate IBD category. They share many common characteristics such as diarrhea, pain, fever, and blood loss. The etiologies of both diseases are unknown, although recent research has focused on genetic (IBD disease gene on chromosome 16 [CARD15]), immunologic, dietary, and infectious causes. Some research implicates the presence in IBD of specific infectious agents such as Bacteroides fragilis, Mycobacterium paratuberculosis, paramyxoviruses, and Listeria monocytogenes; Campylobacter jejuni, Salmonella, Shigella, Yersinia, and Eschericia coli have also been associated with relapses of IBD. The single greatest risk factor for IBD is a positive family history (found in 15% to 30% of IBD patients). To date, there is no indication that emotional factors are the primary cause. The goal of therapy includes control of inflammation and associated signs and symptoms, improving nutritional status to allow optimal growth and sexual maturation, and good quality of life—both emotionally and physically.
An association between ankylosing spondylitis and the histocompatibility of human leukocyte antigen (HLA-B27) and inflammatory bowel disease is a possibility. Ulcerative colitis and Crohn’s disease have similar initial signs, including diarrhea, rectal bleeding, abdominal pain, fever, malaise, anorexia, weight loss, and anemia. Children may initially be seen with vague symptoms such as growth failure, anorexia, fever, and joint pains with or without gastrointestinal symptoms. Both conditions are characterized by remissions and exacerbations. Extracolonic manifestations such as joint problems, hepatobiliary conditions, skin rashes, and eye irritation can occur. Although the peak incidence of inflammatory bowel disease is between 15 and 25 years of age, 15% of all cases occur at age 15 years and younger. Prognosis is dependent on the following factors: (1) age at onset and rapidity of onset; (2) response to medical treatment; and (3) extent of involvement.
Ulcerative colitis is a recurrent inflammatory and ulcerative disease affecting primarily the large intestine. Lesions are continuous and involve the superficial mucosa, causing vascular congestion, capillary dilation, edema, hemorrhage, and ulceration. Muscular hypertrophy and deposition of fibrous tissue and fat result, which gives the bowel a “lead pipe” appearance because of narrowing of the bowel itself.
Crohn’s disease is an inflammatory and ulcerative disease affecting any part of the alimentary tract from the mouth to the anus. Rectal pain and bleeding from fissures and fistulas occurs in 25% of CD patients. Of CD patients, 10% have proctitis, and 70% of these patients will develop more extensive disease. The CD affects the deep walls of the bowel. The lesions are discontinuous, resulting in a “skipping” effect, with the diseased portions of the bowel separated by normal tissue. Fissures, fistulas, and thickened intestinal walls result. Granulomas occur in approximately 50% of cases.
INCIDENCE
1. Annual incidence of UC and CD is 4 to 10 cases in 100,000 children; 2 to 14 cases occur in 100,000 in the general population. IBD affects male and female equally.
2. Ulcerative colitis represents more than half of the 20,000 to 25,000 newly diagnosed cases of IBD each year.
3. Age range of peak incidence is 15 to 25 years.
4. White individuals are affected more often than African-American individuals; IBD not seen in third-world countries.
5. A high preponderance of cases occur in American Jews.
6. Of those with ulcerative colitis, 29% have a family history of the disease.
7. Of those with Crohn’s disease, 35% have a family history of the disease.
CLINICAL MANIFESTATIONS
Ulcerative Colitis
1. Frequent, bloody stools (number of stools varies from 4 to 24)—major symptom
2. Pain relief after defecation
4. Anorexia, pallor, and fatigue
9. Ten- to 20-pound weight loss over 2 months
10. Anemia, leukocytosis, increased erythrocyte sedimentation rate
11. Extraintestinal symptoms—skin rashes, arthritis
COMPLICATIONS
LABORATORY AND DIAGNOSTIC TESTS
1. Complete blood count—anemia
2. White blood cell count—increased with inflammation
3. Erythrocyte sedimentation rate—increased with inflammation
4. Hematocrit—decreased because of blood loss
5. Serum electrolyte levels—decreased potassium
6. Serum protein level—decreased proteins
7. Stool culture—for presence of infectious organisms
8. Hematest of stool—for presence of blood in stool
9. D-Xylulose absorption blood and urine test—to measure intestinal absorption when there are fatty stools
10. Sigmoidoscopy—to evaluate mucosa, rectum, sigmoid colon directly
11. Colonoscopy—to evaluate colon directly
12. Upper gastrointestinal tract radiographic series with small bowel follow-through—differential diagnosis
13. Barium enema—differential diagnosis
14. Biopsy—to determine type of inflammatory bowel disease; tissue specimens taken from several sites
MEDICAL AND SURGICAL MANAGEMENT
Ulcerative Colitis
Medical management is the primary treatment of ulcerative colitis and centers around drug therapy and nutritional support. Antidiarrheal preparations may be used along with antiinflammatory (nonabsorbable salicylate derivatives [mesalamine] and corticosteroid) agents to control or suppress the inflammatory process. Immunosuppressants (such as azathioprine [Imuran]) are often used in advanced cases. Analgesics and narcotics may also be given for pain. Dietary modifications may be needed when diarrhea, fistulas, or lactose intolerance is present. Therapy depends on the severity of the illness. If the illness is severe, the child may require intravenous (IV) hyperalimentation, administration of corticosteroids, and close observation for electrolyte imbalances, acidosis, anemia, and intestinal perforation. Surgical intervention is eventually needed in 25% of cases (uncontrolled hemorrhage, toxic megacolon, unrelenting pain and diarrhea, and others) and provides a cure.
Crohn’s Disease
Pharmacologic interventions for Crohn’s disease are similar to those for ulcerative colitis, with the addition of antibiotics to eradicate inflammatory bacterial agents. Metronidazole (Flagyl) is used in treating CD in patients with perianal involvement. Disease tends to recur when the drug is discontinued. It also suggests that this medication (metronidazole) may be effective in treating CD of the colon. Because there is no known cure for this disease, the treatment goals are to reduce bowel inflammation, correct nutritional deficiencies, and provide relief of symptoms. Nutritional support may include dietary modifications, vitamins, oral supplements, or hyperalimentation. Up to 70% of children with Crohn’s disease require surgery because of failure of medical management, intestinal fistulas or obstruction, and growth failure. The relapse rate 6 years after surgery is 60%. A recurrence is likely within 2 years, usually at the site of anastomosis.
Appropriate dietary support is imperative. A high-protein, high-carbohydrate, and low-fiber diet with normal amounts of fat is recommended, as well as daily vitamin, iron, and zinc supplements. Restrictive or bland diets result in poor intake and are often counterproductive.
Ileostomy
Ileostomy is performed to treat inflammatory bowel disease after medical therapeutic procedures have been unsuccessful. Ileostomy involves removal of the diseased portion of the bowel (small intestine), with the ileum used to form a stoma on the abdominal wall for bowel evacuation. A variety of surgical procedures may be used, depending on the extent and location of the affected portion of the bowel. An ileostomy with subtotal or total colectomy is performed on children who are malnourished and have moderate to severe rectal disease.
Colostomy
Permanent or temporary colostomies are performed for a variety of conditions. Permanent colostomies are performed for children with severe cases of Crohn’s disease. The sigmoid colostomy is most frequently performed. Most often, temporary colostomies (e.g., transverse loop and double-barrel colostomies) are performed in children. In all types of colostomy, an intact portion of the colon is brought through an abdominal incision and is sutured to the abdominal wall to form a stoma.
Surgical Outcomes
The surgery should result in amelioration of symptoms associated with the primary disease. The child is left with an abdominal stoma through which bowel contents are emptied into an attached appliance or into an abdominal pouch (Koch pouch). Although the child does not live with a normally functioning bowel after surgery, most children do well. If the child or adolescent or the parent learns to care properly for the colostomy or ileostomy, a life filled with educational, social, and athletic activities can be expected.
NURSING INTERVENTIONS
1. Promote and maintain proper hydration status.
2. Provide comfort and pain relief measures as indicated.
4. Promote and support optimal nutritional status.
5. Monitor child’s response to and untoward side effects of medications.
6. Monitor for, prevent, or report signs of potential or actual complications.
Preoperative Care
Prepare infant, child, or adolescent physically for surgery.
1. Monitor infant’s or child’s response to enemas, laxatives, stool softeners (to evacuate bowel preoperatively).
2. Monitor infant’s or child’s response to decompression of stomach and bowel (nasogastric [NG] tube and rectal tube).
3. Provide nothing by mouth for 12 hours before surgery.
4. Insert Foley catheter to decompress bladder.
5. Administer antibiotics to sterilize bowel.
6. Monitor vital signs every 4 hours.
7. Monitor for bowel complications (perforation, toxic megacolon, or enterocolitis).
Postoperative Care
1. Monitor child’s response to surgery.
2. Monitor for signs and symptoms of complications.
3. Promote return of peristalsis.
4. Promote and maintain fluid and electrolyte balance.
5. Alleviate or minimize pain and discomfort.
6. Provide stoma and skin care to promote healing and to prevent complications.
7. Provide ostomy care (refer to institutional manual for specific technical and institutional procedure).
8. Protect child from infection.
9. Facilitate development of realistic adaptive body image.
10. Encourage socialization with peers as means to cope with impact of disease.
11. Modify chronic sick role behavior by promoting socialization and normal daily activities.
Discharge Planning and Home Care
1. Instruct child, parents, and family about ostomy.
2. Instruct child or adolescent and parents to monitor for and report signs of complications.
3. Instruct child or adolescent and parents about administration of total parenteral nutrition or NG feedings.
4. Initiate referral to school nurse and teacher to promote continuity of care.
5. Refer to community organizations and other resources (Box 43-1).
Baron M. Crohn’s disease in children. Am J Nurs. 2002;102(10):26.
Behrman RE, Kiegman RM, Jenson HB. Nelson textbook of pediatrics, ed 17. Philadelphia: WB Saunders, 2004.
Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion. BMI for Children and Teens, 2003. (website) www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.htm Accessed April 21, 2006
Hay WW, et al. Current pediatric diagnosis and treatment, ed 17. New York: McGraw-Hill, 2005.
O’Brien ZS, Schudder LE. Pediatric nurse practitioner review and resource manual, ed 2. Maryland: American Nurses Credentialing Center–Institute for Credentialing Innovation, 2005.
Wong DL, et al. Maternal child nursing care, ed 3. St. Louis: Mosby, 2006.
