Ulcerative colitis
Ulcerative colitis: Excerpt from Professional Guide to Diseases (Eighth Edition)
Ulcerative colitis is an inflammatory, usually chronic disease that affects the mucosa of the colon. It invariably begins in the rectum and sigmoid colon and commonly extends upward into the entire colon; it rarely affects the small intestine, except for the terminal ileum. Ulcerative colitis produces edema (leading to mucosal friability) and ulcerations. Severity ranges from a mild, localized disorder to a fulminant disease that may cause a perforated colon, progressing to potentially fatal peritonitis and toxemia.
Causes and incidence
Although the etiology of ulcerative colitis is unknown, it’s thought to be related to abnormal immune response in the GI tract, possibly associated with food or bacteria such as Escherichia coli. Stress was once thought to be a cause of ulcerative colitis, but studies show that although it isn’t a cause, it does increase the severity of the attack.
Ulcerative colitis occurs primarily in young adults, especially in women. It’s also more prevalent among those of Jewish ancestry, indicating a possible familial tendency. The incidence of the disease is unknown; however, some studies indicate as many as 10 to 15 out of 100,000 persons have the disease. Onset of symptoms seems to peak between ages 15 and 30; another peak occurs between ages 50 and 70.
Signs and symptoms
The hallmark of ulcerative colitis is recurrent attacks of bloody diarrhea, in many cases containing pus and mucus, interspersed with asymptomatic remissions. The intensity of these attacks varies with the extent of inflammation. It isn’t uncommon for a patient with ulcerative colitis to have as many as 15 to 20 liquid, bloody stools daily. Other symptoms include spastic rectum and anus, abdominal pain, irritability, weight loss, weakness, anorexia, nausea, and vomiting.
Ulcerative colitis may lead to complications, such as hemorrhage, stricture, or perforation of the colon. Other complications include joint inflammation, ankylosing spondylitis, eye lesions, mouth ulcers, liver disease, and pyoderma gangrenosum. Scientists think that these complications occur when the immune system triggers inflammation in other parts of the body. These disorders are usually mild and disappear when the colitis is treated.
Patients with ulcerative colitis have an increased risk of developing colorectal cancer; children with ulcerative colitis may experience impaired growth and sexual development.
Diagnosis
CONFIRMING DIAGNOSIS Sigmoidoscopy showing increased mucosal friability, decreased mucosal detail, and thick inflammatory exudate suggests this diagnosis. Biopsy can help confirm it.
Colonoscopy may be required to determine the extent of the disease and to evaluate strictured areas and pseudopolyps. (Biopsy would then be done during colonoscopy.) Barium enema can assess the extent of the disease and detect complications, such as strictures and carcinoma.
A stool sample should be cultured and analyzed for leukocytes, ova, and parasites. Other supportive laboratory values include decreased serum levels of potassium, magnesium, hemoglobin, and albumin as well as leukocytosis and increased prothrombin time. An elevated erythrocyte sedimentation rate correlates with the severity of the attack.
Treatment
The goals of treatment are to control inflammation, replace nutritional losses and blood volume, and prevent complications. Supportive treatment includes bed rest, I.V. fluid replacement, and a clear-liquid diet. For patients awaiting surgery or showing signs of dehydration and debilitation from excessive diarrhea, total parenteral nutrition (TPN) rests the intestinal tract, decreases stool volume, and restores positive nitrogen balance. Blood transfusions or iron supplements may be needed to correct anemia.
Immunomodulators or 5-aminosalicylates may be used to decrease the frequency of attacks. Drug therapy to control inflammation includes steroids. Antispasmodics and antidiarrheals are used only in patients whose ulcerative colitis is under control but who have frequent, loose stools.
Alert Antispasmodics and antidiarrheals may precipitate massive dilation of the colon (toxic megacolon) and are generally contraindicated.
Surgery is the last resort if the patient has toxic megacolon, fails to respond to drugs and supportive measures, or finds symptoms unbearable. A common surgical technique is proctocolectomy with ileostomy. Another procedure, the ileoanal pull-through, is being performed in more cases. This procedure entails performing a total proctocolectomy and mucosal stripping, creating a pouch from the terminal ileum, and anastomosing the pouch to the anal canal. A temporary ileostomy is created to divert stool and allow the rectal anastomosis to heal. The ileostomy is closed in 2 to 3 months, and the patient can then evacuate stool rectally. This procedure removes all the potentially malignant epithelia of the rectum and colon. Total colectomy and ileorectal anastomosis isn’t as common because of its mortality rate (2% to 5%). This procedure removes the entire colon and anastomoses the terminal ileum to the rectum; it requires observation of the remaining rectal stump for any signs of cancer or colitis.
Pouch ileostomy (Kock pouch or continent ileostomy), in which the surgeon creates a pouch from a small loop of the terminal ileum and a nipple valve from the distal ileum, may be an option. The resulting stoma opens just above the pubic hairline and the pouch is emptied periodically through a catheter inserted in the stoma. In ulcerative colitis, a colectomy may be performed after 10 years of active disease because of the increased incidence of colon cancer in these cases. Performing a partial colectomy to prevent colon cancer is controversial.
Special considerations
Patient care includes close monitoring for changes in status.
❑ Accurately record intake and output, particularly the frequency and volume of stools. Watch for signs of dehydration and electrolyte imbalances, especially signs and symptoms of hypokalemia (muscle weakness and paresthesia) and hypernatremia (tachycardia, flushed skin, fever, and dry tongue). Monitor hemoglobin level and hematocrit, and give blood transfusions as ordered. Provide good mouth care for the patient who’s allowed nothing by mouth.
❑ After each bowel movement, thoroughly clean the skin around the rectum. Provide an air mattress or sheepskin to help prevent skin breakdown.
❑ Administer medications, as ordered. Watch for adverse effects of prolonged corticosteroid therapy (moon face, hirsutism, edema, and gastric irritation). Be aware that corticosteroid therapy may mask infection.
❑ If the patient needs TPN, change dressings as ordered, assess for inflammation at the insertion site, and check capillary blood glucose levels every 4 to 6 hours.
❑ Take precautionary measures if the patient is prone to bleeding. Watch closely for signs of complications, such as a perforated colon and peritonitis (fever, severe abdominal pain, abdominal rigidity and tenderness, and cool, clammy skin) and toxic megacolon (abdominal distention and decreased bowel sounds).
For the patient requiring surgery:
❑ Carefully prepare the patient for surgery, and inform him about ileostomy.
❑ Do a bowel preparation, as ordered.
❑ After surgery, provide meticulous supportive care and continue teaching correct stoma care.
❑ Keep the nasogastric tube patent. After removal of the tube, provide a clear-liquid diet and gradually advance to a low-residue diet, as tolerated.
❑ After a proctocolectomy and ileostomy, teach good stoma care. Wash the skin around the stoma with soapy water and dry it thoroughly. Apply karaya gum around the stoma’s base to avoid irritation, and make a watertight seal. Attach the pouch over the karaya ring. Cut an opening in the ring to fit over the stoma, and secure the pouch to the skin. Empty the pouch when it’s one-third full.
❑ After a pouch ileostomy, uncork the catheter every hour to allow contents to drain. After 10 to 14 days, gradually increase the length of time the catheter is left corked until it can be opened every 3 hours. Then remove the catheter and reinsert it every 3 to 4 hours for drainage. Teach the patient how to insert the catheter and how to take care of the stoma.
❑ Encourage the patient to have regular physical examinations.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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