Week 5 Nurse 530 Paper

Week 5 Nurse 530 Paper

Week 5 Nurse 530

Inflammatory bowel disease (IBD) refers to a group of idiopathic conditions caused by a dysregulated immune response with subsequent recurrent inflammation of the intestine (Lynch & Hsu, 2021). However, extraintestinal manifestations of these conditions such as erythema nodosum, arthritis, and oral ulceration among others are not uncommon. The two most common forms of IBD are ulcerative colitis and Crohn’s disease. The purpose of this paper is to explore the pathophysiology, clinical manifestations, evaluation, and treatment recommendations of the above mentioned conditions.

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Crohn Disease

Although the condition is idiopathic, studies suggest that the condition results from indecorous immune response to bowel insults from environmental factors such as infections, toxins, drugs, or intestinal microbes in genetically susceptible individuals (HLA-B27 association and mutations of NOD2 gene) (Ranasinghe & Hsu, 2021). Consequently, inflammation results from dysregulated IL-23-Th 17 signaling with subsequent local tissue damage followed by fibrotic scarring, stricture, obstruction, and strangulation of the bowel (Ranasinghe & Hsu, 2021). Additionally, intestinal aphthous ulcers and transmural fissures result in adherence of other organs, micro-perforation, and abscess formation while macro perforation into adjacent structures results in fistula formation. The disease can manifest anywhere in the gastrointestinal tract and extend through the entire bowel thickness with periods of remission and relapses.

Clinically, the patient presents with constitutional symptoms such as fatigue, low-grade fever, and weight loss, gastrointestinal symptoms particularly abdominal pain, chronic diarrhea, lower GI bleeding, palpable abdominal mass, malabsorption, and enterocutaneous/perianal fistulas (Lichtenstein et al., 2018). On the other hand, extraintestinal manifestations include enteropathic arthritis, uveitis, cholelithiasis, urolithiasis, erythema nodosum, pyoderma gangrenosum, and oral ulcerations (Lichtenstein et al., 2018).

Evaluation of a patient with suspected Crohn’s disease involves a thorough history and physical exam, endoscopy and intestinal biopsies, cross-sectional imaging, and laboratory studies. Findings suggestive of Crohn’s disease on ileocolonoscopy include skip lesions, linear/serpiginous ulcerations, cobblestone sign, erythema, fissures, strictures, and fistulas. Meanwhile, cross-sectional enterography may reveal edematous thickening, creeping fat, fistulas, and strictures while small bowel follow-through shows string sign(Ranasinghe & Hsu, 2021). Laboratory studies rule out differential, monitors the disease activity and identify complications, and include stool analysis, anti-saccharomyces cerevisiae antibodies (ASCA), inflammatory markers, fecal calprotectin/fecal lactoferrin, comprehensive metabolic panel, complete blood count, iron studies, folate, and vitamin B12 levels (Ranasinghe & Hsu, 2021).

Treatment recommendations include; tailoring therapy to disease severity, phase of the disease, and risk of progression to complications. Similarly, surgery to manage complications, lifestyle modifications to decrease the incidence of complications, and regular monitoring of disease activity as well as screening for complications (Lichtenstein et al., 2018). Pharmacotherapy includes induction and maintenance phases to manage acute flares and maintain remission respectively. Medications used include corticosteroids, biologics such as infliximab, vedolizumab, and ustekinumab, immunomodulators such as methotrexate and azathioprine, and 5 aminosalicylic acid derivatives such as sulfasalazine (Lichtenstein et al., 2018). Lastly, supportive management includes pain management, antidiarrheal therapy, lifestyle modifications, and dietary optimization.

Ulcerative Colitis

Ulcerative colitis is an IBD characterized by chronic mucosal inflammation limited to the colon, rectum, or cecum. Like its counterpart, it is idiopathic although risk factors include genetic predisposition, ethnicity (whites, Ashkenazi Jews), family history, intestinal infection, NSAIDs, and increased fat intake. Surprisingly, appendectomy and smoking have a protective effect(Lynch & Hsu, 2021). Studies suggest that abnormal interactions between commensal bacteria and host immune cells may be the underlying pathophysiologic mechanism of the disease. Dysregulation of intestinal epithelium results in activation of CD4+ cells with resultant secretion of proinflammatory cytokines (IL-6, IL-12, TNF-alpha) and chemokines (CXCL1, CXCL3, and CXCL8) which recruits neutrophils, NK cells and differentiation to Th 2 effector cells. Dysregulated immune response as evidenced by autoantibodies (pANCA) and Th2 cell-mediated response that subsequently results in local tissue damage (ulcerations, erosions, and necrosis) (Lynch & Hsu, 2021). The condition is characterized by ascending continuous pattern of inflammation from the rectum involving only the mucosa and submucosa.

Clinical features include intestinal symptoms such as bloody diarrhea, fecal urgency, abdominal pain, and tenesmus (Lynch & Hsu, 2021). However, extraintestinal symptoms include skeletal, ocular, primary sclerosing cholangitis, erythema nodosum, and pyoderma gangrenosum. Lastly, general symptoms include fatigue and fever. Evaluation of the patient includes history and physical examination, laboratory tests such as ESR, CRP, CBC, perinuclear ANCA, and stool analysis (Rubin et al., 2019). Similarly, colonoscopy and biopsy reveal proctosigmoiditis, friable mucosa with bleeding on contact, mucosal ulcerations, pseudopolyps loss of haustra, and mucosal folds (Rubin et al., 2019). Imaging techniques such as plain radiography demonstrate lead pipe appearance. MRI, CT, and ultrasound are additional imaging modalities.

Treatment involves both conservative pharmacotherapy and surgical (curative proctocolectomy) if medical therapy fails. Treatment recommendations involve general management such as rehydration, correction of nutrient deficiencies, and nutrition supplementation. Supportive care includes antidiarrheal agents, anticholinergic to relieve abdominal cramps and control of pain. Medical therapy depends on disease severity. Pharmacological agents used include 5-aminosalicylic acid derivatives, topical and systemic corticosteroids, anti-TNF agents, integrin receptor antagonists, JAK3 inhibitors, calcineurin antagonists(Rubin et al., 2019). Finally, surgical intervention (proctocolectomy with an ileal pouch-anal anastomosis) is curative.

Conclusion

Ulcerative colitis and Crohn’s disease are idiopathic although genetic predisposition and immune dysregulation play a critical role. Gastrointestinal symptoms, as well as extraintestinal manifestations, are a common feature of IBD. Treatment for IBD involves a combination of general measures, supportive, medical and surgical approaches, and disease severity is a key determinant.

References

Lichtenstein, G. R., Loftus, E. V., Isaacs, K. L., Regueiro, M. D., Gerson, L. B., & Sands, B. E. (2018). ACG clinical guideline: Management of Crohn’s disease in adults. The American Journal of Gastroenterology, 113(4), 481–517. https://doi.org/10.1038/ajg.2018.27

Lynch, W. D., & Hsu, R. (2021). Ulcerative Colitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459282/

Ranasinghe, I. R., & Hsu, R. (2021). Crohn Disease. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK436021/

Rubin, D. T., Ananthakrishnan, A. N., Siegel, C. A., Sauer, B. G., & Long, M. D. (2019). ACG clinical guideline: Ulcerative colitis in adults: Ulcerative colitis in adults. The American Journal of Gastroenterology, 114(3), 384–413. https://doi.org/10.14309/ajg.0000000000000152

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Describe the chronic relapsing inflammatory bowel diseases (ulcerative colitis and Crohn disease), and summarize the pathophysiology, clinical manifestations, evaluation, and treatment recommendations for each.