Ulcerative Colitis

DEFINITION

a chronic disease of the large intestine, also known as the colon, in which the
lining of the colon becomes inflamed and develops tiny open sores, or ulcers,
that produce pus and mucus which can cause abdominal discomfort and frequent
emptying of the colon
The result of an abnormal response by your body's immune system.
*Normally, the cells and proteins that make up the immune system protect you
from infection. In people with IBD, however, the immune system mistakes food,
bacteria, and other materials in the intestine for foreign or invading substances.
When this happens, the body sends white blood cells into the lining of the
intestines, where they produce chronic inflammation and ulcerations.

INCIDENCE
The annual incidence of ulcerative colitis is between 1 to 10 cases per 100,000 people,
depending on the region studied. The peak age-specific incidence occurs near 20
years, and a second smaller peak occurs near age 50 years. The prevalence of
ulcerative colitis ranges from 10 to 70 per 100,000 people, but some North American
studies have shown prevalence as high as 200 per 100,000 people. In the United
States, males and females are equally affected, but both whites and Ashkenazi Jews
are at much higher risk of developing inflammatory bowel disease than the general
population. Ulcerative colitis patients are most often never smokers or non-smokers,
with no more than 10% being current cigarette smokers. Worldwide, ulcerative colitis
cases are concentrated in North America, Europe, and Australia, and a north-south
gradient exists, with higher incidence rates in higher latitudes. For unknown reasons, a
history of appendectomy is protective against the development of ulcerative colitis.
In a given year, 48% of people with ulcerative colitis are in remission, 30% have mild
disease activity, 20% have moderate disease activity, 1 to 2% have severe disease.
Seventy percent of patients who have active disease in a given year will have another
episode of active disease in the following year. Only 30% of those in remission in a
given year will have active disease in the following year. The longer a person with
ulcerative colitis remains in remission, the less likely he or she is to experience a flareup of the disease in the following year.
ETIOLOGY
Although considerable progress has been made in IBD research, investigators do not
yet know what causes this disease.

Studies indicate that the inflammation involves a complex interaction of factors:

Genetics: While ulcerative colitis tends to run in families, researchers have been unable
to establish a clear pattern of inheritance. Studies show that up to 20% of people with
ulcerative colitis will also have a close relative with the disease.
Age: This disease affects people of all ages. However, it is most likely to develop in
ages 15 and 30 and over 60.
Race: The disease is more common among white people of European origin and
among people of Jewish heritage.
Environment: Foreign substances (antigens) in the environment may be the direct
cause of the inflammation, or they may stimulate the body's defenses to produce an
inflammation that continues without control. Researchers believe that once the IBD
patient's immune system is "turned on," it does not know how to properly "turn off" at the
right time. As a result, inflammation damages the intestine and causes the symptoms of
IBD. That is why the main goal of medical therapy is to help patients regulate their
immune system better.
Diet: A high-fat diet may also slightly increase the chance of getting ulcerative colitis
Medications: Isotretinoin (Accutane) is a medication sometimes used to treat scarring
cystic acne that can cause ulcerative colitis.
Signs and Symptoms
Types of Ulcerative Colitis
1.Ulcerative Proctitis

30% of all patients with ulcerative colitis, the illness begins as ulcerative proctitis
Bowel inflammation is limited to the rectum.
Milder form due its limited extent (usually < 6 inches of the rectum)
It is associated with fewer complications and offers a better outlook than more
widespread disease.

2.Proctosigmoiditis
Affects the rectum and the sigmoid colon
Symptoms include bloody diarrhea, cramps, and a constant feeling of the need to
pass stool, known as tenesmus.
Moderate pain on the lower left side of the abdomen may occur in active disease.

3.Left-sided Colitis
Begins at the rectum and extends as far as a bend in the colon near the spleen
called the splenic flexure.
Symptoms include loss of appetite, weight loss, diarrhea, severe pain on the left
side of the abdomen, and bleeding.
4.Pan-ulcerative (total) Colitis
Affects the entire colon
Symptoms include diarrhea, severe abdominal pain, cramps, and extensive
weight loss.
Potentially serious complications include massive bleeding and acute dilation of
the colon (toxic megacolon), which may lead to an opening in the bowel wall that
may require surgery.
Ulcerative colitis may also cause additional symptoms such as:

joint pain
joint swelling
nausea
vomiting
skin ulcers
mouth sores

COMPLICATIONS

Increases the risk of colon cancer

Sepsis

Severe dehydration

Ankylosing spondylitis - inflammation of joints between the spinal bones

PATHOPHYSIOLOGY
DIA

Blood tests: A blood test involves drawing blood. A lab technologist will analyze the
blood sample. A doctor may use blood tests to check for anemia, infection and
inflammation.
Stool tests: A stool test is the analysis of a sample of stool. It is used to check for
blood, bacteria and parasites. It can also help rule out GI disorders.
Colonoscopy: This exam allows your doctor to view your entire colon using a thin,
flexible, lighted tube with an attached camera. It can show irritated and swollen

tissue, ulcers, and abnormal growths such as polypsextra pieces of tissue that
grow on the inner lining of the intestine. If the gastroenterologist suspects ulcerative
colitis, he or she will biopsy the patient's colon and rectum. A biopsy is a procedure
that involves taking small pieces of tissue for examination with a microscope.
Flexible sigmoidoscopy: Flexible sigmoidoscopy is a test that uses a flexible,
narrow tube with a light and tiny camera on one end, called a scope, to look inside
the rectum, the sigmoid colon, and sometimes the descending colon. The doctor will
look for signs of bowel diseases and conditions such as irritated and swollen tissue,
ulcers, and polyps. If your colon is severely inflamed, your doctor may perform this
test instead of a full colonoscopy.
X-ray: If you have severe symptoms, your doctor may use a standard X-ray of your
abdominal area to rule out serious complications, such as a perforated colon.
CT scan: A CT scan of your abdomen or pelvis may be performed if your doctor
suspects a complication from ulcerative colitis or inflammation of the small intestine.
A CT scan may also reveal how much of the colon is inflamed.
Chromoendoscopy: Chromoendoscopy is a technique of spraying a blue liquid dye
during the colonoscopy in order to increase the ability of the endoscopist specialist
to detect slight changes in the lining of your intestine. The technique may identify
early or flat polyps which can be biopsied or removed. It is common to have blue
bowel movements for a short time following this procedure.

Treatment
The primary goal in treating ulcerative colitis is to help patients regulate their immune
system better.
Medical Management
Aminosalicylates (5-ASA)
Work at the level of the lining of the GI tract to decrease inflammation

Effective in treating mild-to-moderate episodes of ulcerative colitis and useful as

a maintenance treatment in preventing relapses of the disease

Work best in the colon and are not particularly effective if the disease is limited to
the small intestine

Examples: Sulfasalazine, mesalamine, olsalazine, and balsalazide

Corticosteroids
Nonspecifically suppress the immune system and are used to treat moderate to
severely active ulcerative colitis. (By "nonspecifically," we mean that these drugs

do not target specific parts of the immune system that play a role in inflammation,
but rather, that they suppress the entire immune response.)

These drugs have significant short- and long-term side effects and should not be
used as a maintenance medication.

Examples: Prednisone, methylprednisolone and budesonide

Immunomodulators
Modulates or suppresses the bodys immune system response so it cannot
cause ongoing inflammation

Used in people for whom aminosalicylates and corticosteroids havent been

effective or have been only partially effective

Effective in maintaining remission in people who havent responded to other

medications given for this purpose.

Immunomodulators may take several months to begin working.

Antibiotics

May be used when infections occur

Examples: Metronidazole, ampicillin, ciprofloxacin

Biologic Therapies
These therapies represent the latest treatment class used for people suffering
from moderate-to-severe ulcerative colitis.

These treatments are called biologics because, unlike chemical medications,

they are made out of material found in life, usually proteins. Many biologic
treatments are proteins called antibodies, which normally are part of the body's
immune defense.

The antibodies used for biologic therapy have been developed to bind and
interfere with the inflammatory process in the disease.

Anti-diarrheal medications

For severe diarrhea, loperamide (Imodium) may be effective.

Use anti-diarrheal medications with great caution because they may increase the
risk of toxic megacolon.

Pain relievers

For mild pain, your doctor may recommend acetaminophen (Tylenol)

Iron supplements

If you have chronic intestinal bleeding, you may develop iron deficiency anemia
and be given iron supplements.

Surgical Management
1.Proctocolectomy with ileostomy
A proctocolectomy is surgery to remove a patient's entire colon and rectum.
An ileostomy is a stoma, or opening in the abdomen, that a surgeon creates from a part
of the ileumthe last section of the small intestine. The surgeon brings the end of the
ileum through an opening in the patient's abdomen and attaches it to the skin, creating
an opening outside of the patient's body. The stoma most often is located in the lower
part of the patient's abdomen, just below the beltline.
People who have this type of surgery will have the ileostomy for the rest of their lives.
2.Proctocolectomy and ileoanal reservoir
An ileoanal reservoir is an internal pouch made from the patient's ileum. This surgery is
a common alternative to an ileostomy and does not have a permanent stoma. Ileoanal
reservoir is also known as a J-pouch, a pelvic pouch, or an ileoanal pouch anastomosis.
The ileoanal reservoir connects the ileum to the anus. The surgeon preserves the outer
muscles of the patient's rectum during the proctocolectomy. Next, the surgeon creates
the ileal pouch and attaches it to the end of the rectum. Waste is stored in the pouch
and passes through the anus.
After surgery, bowel movements may be more frequent and watery than before the
procedure. People may have fecal incontinencethe accidental passing of solid or
liquid stool or mucus from the rectum. Medications can be used to control pouch
function. Women may be infertile following the surgery.
Nursing Management
1.Acute Pain

Administer pain medications as ordered.

Provide sitz bath as appropriate.

Cleanse rectal area with mild soap and water or wipes after each stool and
provide skin care.

Provide comfort measures (back rub, reposition) and diversional activities.

Instruct patient to assume position of comfort (knees flexed).

2.Imbalanced Nutrition less than Body Requirements

Weigh daily.

Encourage bed rest and limit activity during acute phase of illness.

Recommend rest before meals.

Provide oral hygiene.

Avoid or limit foods that might cause or exacerbate abdominal cramping,

flatulence (milk products, foods high in fiber or fat, alcohol, caffeinated
beverages, chocolate, peppermint, tomatoes, orange juice).

Resume or advance diet as indicated (clear liquids progressing to bland, low

residue; then high-protein, high-calorie, caffeine-free, non spicy, and low-fiber as
indicated).

3.Risk for Fluid Volume Deficit

Assess vital signs (BP, pulse, temperature).

Monitor I&O. Note number, character, and amount of stools.

Maintain bed rest; avoid exertion.

Observe for excessively dry skin and mucous membranes, decreased skin
turgor, slowed capillary refill.

Administer parenteral fluids, blood transfusions as indicated.

Administer antidiarrheal medications as ordered.