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Etiology And Clinical Manifestations Of Inflammatory Bowel Disease JASSIN M. JOURIA, MD DR. JASSIN M. JOURIA IS A MEDICAL DOCTOR, PROFESSOR OF ACADEMIC MEDICINE, AND MEDICAL AUTHOR. HE GRADUATED FROM ROSS UNIVERSITY SCHOOL OF MEDICINE AND HAS COMPLETED HIS CLINICAL CLERKSHIP TRAINING IN VARIOUS TEACHING HOSPITALS THROUGHOUT NEW YORK, INCLUDING KING’S COUNTY HOSPITAL CENTER AND BROOKDALE MEDICAL CENTER, AMONG OTHERS. DR. JOURIA HAS PASSED ALL USMLE MEDICAL BOARD EXAMS, AND HAS SERVED AS A TEST PREP TUTOR AND INSTRUCTOR FOR KAPLAN. HE HAS DEVELOPED SEVERAL MEDICAL COURSES AND CURRICULA FOR A VARIETY OF EDUCATIONAL INSTITUTIONS. DR. JOURIA HAS ALSO SERVED ON MULTIPLE LEVELS IN THE ACADEMIC FIELD INCLUDING FACULTY MEMBER AND DEPARTMENT CHAIR. DR. JOURIA CONTINUES TO SERVES AS A SUBJECT MATTER EXPERT FOR SEVERAL CONTINUING EDUCATION ORGANIZATIONS COVERING MULTIPLE BASIC MEDICAL SCIENCES. HE HAS ALSO DEVELOPED SEVERAL CONTINUING MEDICAL EDUCATION COURSES COVERING VARIOUS TOPICS IN CLINICAL MEDICINE. RECENTLY, DR. JOURIA HAS BEEN CONTRACTED BY THE UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL’S DEPARTMENT OF SURGERY TO DEVELOP AN E-MODULE TRAINING SERIES FOR TRAUMA PATIENT MANAGEMENT. DR. JOURIA IS CURRENTLY AUTHORING AN ACADEMIC TEXTBOOK ON HUMAN ANATOMY & PHYSIOLOGY. Abstract Although no singular known cause for inflammatory bowel disease exists, medical research has led to new treatments and a reduction in mortality rates associated with the disease. Inflammatory bowel disease includes a variety of gastrointestinal disorders that cause similar symptoms and impact a patient's quality of life. There is no cure, but symptomatic relief can be found with a variety of treatments, including medical, surgical, and nutritional. As with many diseases, a multifaceted approach is commonly the best for successful treatment of inflammatory bowel disease. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Health clinicians need to be able to differentiate between Ulcerative Colitis and Crohn's Disease, as well as be able to describe the clinical manifestations and potential effects of each on the gastrointestinal tract. Understanding the common causes and symptoms of inflammatory bowel disease, including the role that genetics may play and complications of the disease is essential for a clear understanding of the four types of medical and surgical techniques commonly used during treatment. Clinicians supporting nutritional therapies and other health or group support resources for patients and family members can be used during the treatment of inflammatory bowel disease. 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Course Purpose To provide health clinicians with knowledge of the potential causes of inflammatory bowel disease to improve the chances that this illness can be successfully treated or prevented. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. The exact reason why some people develop intestinal inflammation and tissue damage associated with inflammatory bowel disease (IBD) is a. b. c. d. 2. increased levels of microorganisms in the gut. genetic; i.e., a patient will get IBD if an ancestor had it. not exactly known. always due to poor diet. True or False: Dysbiosis is an imbalance in the number of beneficial and aggressive bacteria normally found in the intestinal tract. a. True b. False 3. The gastrointestinal tract contains trillions of bacteria that are said to a. b. c. d. 4. Two of the most common forms include those from the ________________________________ phyla. a. b. c. d. 5. interfere with metabolites. be beneficial to sustaining normal intestinal functioning. generally encourage harmful bacteria. interfere with equilibrium in the gut. Firmicutes and the Bacteroidetes Eubacterium and Lactobacillus Escherichia coli and Mycobacterium avium Enterobacteriaceae and Listeria monocytogenes Normally, the amounts of gut microbiota vary until age ___, and microorganism levels remain stable until approximately age 70. a. b. c. d. 3 12 21 30 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction Despite some of the differences in clinical manifestations and histology between the different forms of inflammatory bowel disease (IBD), there has yet to be confirmation of the exact reason why some people develop the intestinal inflammation and tissue damage associated with this illness. There are various theories on the potential causes of IBD. Although many patients have symptoms that are similar, not everyone demonstrates the same disease manifestations and the patterns of remission and disease exacerbations differ among patients. Research investigations have focused on several contributing factors of gut inflammation with promising outcomes identifying the reason why some people develop IBD. However, despite thorough research and extensive results in this area, questions still remain. Possible causes include changes in the levels of microorganisms (both aggressive and beneficial) in the gut, genetic factors, predisposition to the disease, and the significance of family history; additionally, important considerations include the role of diet, comparison between the diet of Western industrialized countries and those of developing countries, and the pathophysiological effects of a break in the protective mucosal barrier of the intestinal tract. Understanding the potential causes of inflammatory bowel disease improves the chances that this illness can be successfully treated or may someday be prevented from developing at all. Microbiota And The Development Of IBD Several studies have shown that intestinal microbiota play a role in the development of inflammatory bowel disease, including its continued presence in the gastrointestinal tract and the type of symptoms produced. Altered levels of intestinal microbiota, because of their important functions, have been associated with a number of chronic diseases affecting the gastrointestinal tract in addition to IBD, including irritable bowel syndrome, 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com dyspepsia, and nonalcoholic steatohepatitis, as well as some chronic illnesses that are considered to be systemic diseases, including diabetes and obesity.1,2 Normally, the gastrointestinal tract contains trillions of bacteria that are said to be beneficial to sustaining normal intestinal functioning. Among some of the routine functions of these microorganisms are production of certain metabolites, metabolism of some dietary carbohydrates, drug metabolism, immune regulation through prevention of harmful bacteria, and homeostasis through preservation of the intestinal mucosal lining.1,2 There are various species of bacteria existing in the intestinal tract; however, two of the most common forms include those from the Firmicutes and the Bacteroidetes phyla.3 These microorganisms are referred to as gut microbiota and the majority of organisms found in the intestinal tract at any one time are not considered harmful to the host, rather, they live within the host and are responsible for a number of protective mechanisms. The numbers of microbiota present can fluctuate somewhat throughout the lifespan. With intestinal disease, the numbers of gut microbiota may increase, although changes have also been related to various other factors, including advancing age, diet, and ethnicity. The large intestine contains approximately 70 percent of all microbiota in the human body.2 Typically, when discussing microbiota, particularly that which 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com impacts inflammation and ulcerations associated with IBD, it is related to the microorganisms found in the colon. There are various other factors that can affect the amounts of gut microbiota, some of which are non-modifiable factors. Age is related to the number of microbes found in the gut; the intestinal tracts of newborn infants are colonized at birth, while children and adolescents may have varying proportions of microorganisms, followed by stability of microorganism levels by the age of 30 and remaining so until approximately age 70.2 As people age, the fluctuations in numbers of bacteria increase, demonstrating alterations in proportions of Firmicutes and Bacterioidetes in older adulthood. When changes in the balance of some of these microorganisms are significant, the affected adult is at greater risk of frailty and illness.4 A condition known as intestinal dysbiosis occurs when there is an imbalance of beneficial and harmful bacteria or organisms. Other elements that can impact levels of gut microbiota include diet, use of antibiotics, ethnicity, and even socioeconomic status. Gut microbiota consist of various forms of bacteria, but also of many other types of microorganisms as well, including certain viruses, fungi, and protozoa. Although there is a large variety in the actual number of species present in the gut at any one time, there are actually only a few divisions that make up the majority of bacteria. Among these, the exact numbers vary between people, with each individual having more of some and less of others when compared to another person. Consequently, the types and amounts of microbiota that are considered normal can actually differ between persons.1-3 The healthcare community now recognizes that gut microbiota plays a significant role in health of the host (the person whose body the microorganisms inhabit). Alternatively, there are many diseases 7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com that are thought as being related to alterations in the levels of normal gut microbiota. In cases of inflammatory bowel disease, there is evidence that alterations in levels of gut microbiota play a role in the development of inflammation that occurs with the disease; however, the specific bacteria that are responsible for triggering inflammatory processes have not yet been isolated. Certain types of bacteria in the intestinal tract have been linked to the development of IBD and its associated inflammation, including strains of Escherichia coli and Mycobacterium avium species. Some other types of bacteria that have been linked specifically with Crohn’s disease include Yersinia enterocolitica and Listeria monocytogenes.3 According to Sartor, et al., in the American Journal of Gastroenterology36, there are four mechanisms that describe the relationship between IBD and gut microbiota: dysbiosis, which is an imbalance in the number of beneficial and aggressive bacteria normally found in the intestinal tract; the development of inflammation in the gut in combination with aberrations in the normal microbial flora; genetic defects of the host that involve an inability to retain normal amounts of gut microbiota, and faulty immune regulation. As mentioned, with the development of inflammation as part of the immune response, the T cells release cytokines and regulate some of the immune response. With any of the described mechanisms associated with IBD and gut microbiota, when aggressive microorganisms multiply within the gastrointestinal tract, the T cells will be exposed to more antigens because of the numbers present. Additionally, the affected person’s immunity may be below average in that he/she is unable to respond appropriately to foreign antigens and then further develops inflammation.1-3 8 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Although there are some bacteria in the intestinal tract that are considered beneficial and some that are antagonistic to a person’s health, there is no specific bacterial species that has been found to have all of the same effects in every person. Instead, an imbalance in the numbers of some types of bacteria alters their impact on health and an increase in some other kinds may be detrimental to overall health, all of which may vary between people.1,2 As previously mentioned, this imbalance is known as intestinal dysbiosis. Because of this imbalance, it can be difficult to pinpoint the direct role that gut microbiota have on the development of Crohn’s disease and ulcerative colitis. However, as stated, there are some bacteria that are known to be harmful when found in the intestinal tract and elevated numbers of some of these organisms have been seen in people with IBD. These bacteria may be related to the actual cause of IBD or their numbers may have grown as a result of inflammation from the disease. Certain bacteria are considered harmful in the intestinal tract and can contribute to intestinal inflammation in different methods. For example, C. difficile, when present in the gastrointestinal tract, secretes small amounts of toxins A and B, which can destroy intestinal cells. Toxin B, in particular, changes the shape of epithelial cells on the intestinal surface and causes the breakdown of actin (protein) molecules; the cells then can separate from the wall and ulcers can form.5,6 E. coli contribute to inflammation by adhering to epithelial cells in the mucosa and secreting tumor necrosis factor. Some other studies have also linked specific bacteria associated with development of inflammatory bowel disease. Mycobacterium is one type of microorganism that has been associated with IBD development. It is 9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com normally related to the growth of diseases such as tuberculosis and leprosy; however, it may also be associated with infection in adults with Crohn’s disease. Ongoing research is considering the effects of mycobacterium avium infection, which is similar to an intestinal infection that can develop in cattle, as a type of infection that could lead to Crohn’s symptoms if a person with genetic susceptibility consumes meat or dairy products from animals that contain this microorganism.1-3 Klebsiella, an anaerobic form of bacteria that has often been associated with respiratory infections as well as post-surgical sepsis in some patients, may also be related to development of some cases of IBD, particularly Crohn’s disease. Rashid, et al., in the International Journal of Rheumatology discuss the potential role of Klebsiella in the pathological damage of Crohn’s disease in the gastrointestinal tract, as well as its potential for causing inflammatory extra-intestinal symptoms of Crohn’s disease, including muscle and joint inflammation.82 There are many other studies that have focused on specific organisms as the cause of IBD inflammation and the research is still ongoing. Other types of bacteria that are being explored as having direct correlations with IBD development include the Proteus species, as well as previously noted virulent E. coli strains, and uncontrolled C. difficile infection. Because alterations in gut microbiota may be associated with inflammation of IBD and low levels of normal gut flora may prevent the body from protecting itself from certain antigens or foreign substances, using treatment that may further upset the balance of gut microbiota may cause additional complications. For example, certain immunomodulators such as TNF- blockers may increase the risk of developing systemic infections with 10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com opportunistic pathogens, which obviously perpetuates the problem of inflammation, rather than promoting healing of the gut. Therefore, it is important to keep the normal balance of microorganisms of the gut in mind when providing treatment for IBD, knowing that an imbalance may hinder relief from symptoms.7-9 In addition to the presence of increased levels of certain bacteria that contribute to inflammation with IBD, people with inflammatory bowel disease have also been shown to have reduced levels of certain types of microbiota in the intestinal tract, especially those that are considered beneficial bacteria, including Eubacterium and Lactobacillus.3 These bacteria play an important role in transforming dietary fiber into short-chain fatty acids. They also act as protective microorganisms against some other aggressive microorganisms that would normally contribute to disease. Consequently, a decrease in their numbers may more likely lead to inflammation. According to a clinical report in the Journal of Pediatric Gastroenterology and Nutrition, alterations in gut microbiota can also play a role in the development of infectious complications that often occur with IBD. Other studies also confirm the role of intestinal flora with IBD disease progression that may include intestinal abscesses and fistulas.9,10 Abscesses, as described, are pockets of infection that can occur anywhere along the gastrointestinal tract as a result of IBD. When there is an imbalance between aggressive microbiota and beneficial bacteria in the intestinal tract, an area of infection can develop if the immune system is unable to control the multiplication of infectious organisms and an abscess can form. Similarly, fistulae form because severe inflammation causes tissue breakdown and necrosis, leading to a channel between two tissue areas or two organs. An 11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com imbalance of microorganisms in the intestinal tract may be unable to prevent such tissue breakdown and the tunneling that occurs as a result.9,10 Probiotics may play a role in preventing development of inflammatory bowel disease as well. Probiotics are foods that are designed to populate the intestinal tract with beneficial bacteria when they are consumed. If inflammatory bowel disease is related to abnormalities in gut microbiota, then consumption of probiotics could possibly improve the balance of friendly versus aggressive bacteria by causing a shift toward healthy and beneficial microorganisms in the gut. An imbalance in T-helper (Th) cells of Th2 levels greater than Th1 levels can lead to an autoimmune disease and an inflammatory bowel disease. Research studies continue to investigate modulation of the gut immune responses, such as probiotic use to prevent inflammatory gut symptoms. The triggers associated with IBD flares may also be related to an imbalance in gut bacteria. For example, an illness unrelated to IBD may act as a trigger for a disease flare; acute and chronic illnesses can be related to an imbalance in the normal flora of the gut.9-13 Based on some of these causes and triggers, probiotic use could be a method of controlling bacterial levels to maintain intestinal homeostasis and to prevent disease flares associated with IBD. 12 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Based on the theory of intestinal dysbiosis being related to the development of inflammatory bowel disease, it stands to reason that probiotics should play a key role in the treatment and prevention of intestinal inflammation. However, studies have shown that this is still being researched and there is not one clear-cut method of introducing probiotics into the diet to control inflammatory bowel disease symptoms. Systematic reviews have indicated that while there is evidence to support the role of gut microbiota in the development of IBD symptoms and that probiotics could potentially alter this role in a favorable manner, further research is still needed to support the use of probiotics as prevention of ulcerative colitis, and no evidence supports the use of probiotics for Crohn’s disease.9,10,14 Although probiotics are very popular supplements on the market and some patients with IBD may use them to control their symptoms, they are not necessarily included as part of normal treatment. It is safe to say that alterations in gut microbiota play an important role in IBD and that certain microorganisms can interact favorably with the intestinal mucosa or they can cause harm and contribute to inflammation. Isolating an exact causative mechanism in this area still warrants further study. Breach of Intestinal Barrier The gastrointestinal tract repeatedly encounters various entities that can contribute to disease or harm to the body, but the intestinal wall is designed to act as a barrier to prevent certain substances from reaching circulation and potentially causing harm. The linings of both the small and large intestines are made up of epithelial cells that act as a physical barrier because of their closely packed structures and prevent microorganisms from invading the areas of the body outside of the gastrointestinal system. 13 nursece4less.com nursece4less.com nursece4less.com nursece4less.com In addition, the two mucosal layers of the intestinal tract — the mucosa and the submucosa — usually provide sufficient protection against microbes and harmful microorganisms that may cause illness and disease. As discussed, the goblet cells in the intestinal tract secrete mucus, which acts as a protective mechanism; goblet cells are also responsible for producing mucins, which are a type of protein that further work to maintain the intestinal barrier. Within the small intestine, protection is also provided by the presence of some goblet cells that secrete mucus; the small intestine also contains multitudes of villi that are responsible for nutrient absorption. In addition to goblet cells that secrete mucus, there are two other types of cells in the epithelial lining of the intestinal tract that provide protection. Paneth cells, named after the physiologist Joseph Paneth, are specific types of cells found in the epithelium of the small intestine, most often at the base of the crypts. They are necessary for providing some protection and defense against microbes. Paneth cells play a role in maintaining the barrier of the gastrointestinal barrier by secreting antimicrobial molecules known as defensins into the crypts of the intestinal tract in response to antigen presentation. Enteroendocrine cells secrete hormones that not only regulate some metabolic functions, they are also responsible for tissue repair.15 The intestinal barrier is specifically designed to allow the body to carry out some functions while simultaneously protecting it from some other entities. The small and large intestines are involved with nutrient and fluid absorption and the balance of electrolytes, all carried out with the assistance of the cells in the intestinal barrier. At the same time, these cells prevent other elements found in the digestive tract from entering circulation through a highly selective process. 14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Another role of gut microbiota in the protective mechanisms of the intestinal tract is to prevent overgrowth of harmful bacteria by stimulating defense mechanisms by the host. Some of the species of gut microbiota activate dendritic cells, which are antigen-presenting cells of the immune system and are responsible for presenting invading antigens to T cells. In response to activation of these cells, plasma cells in the mucosal layer of the intestine secrete secretory immunoglobulin A (IgA), an antibody that supports immune function and that is produced by the B lymphocytes. The release of IgA in turn provides protection for the mucosal barrier against invading pathogens.14,15 Low levels of secretory immunoglobulin A has been associated with IBD as well as with a number of gastrointestinal diseases, including celiac disease, chronic Candida infection, and bacterial overgrowth of the small intestine. However, a specific balance in the amount of secretory IgA must be present, as elevated levels of this immunoglobulin have also been associated with development of Crohn’s disease and ulcerative colitis, in addition to some viral infections, including infection with Epstein-Barr virus and cytomegalovirus. It is therefore important to consider the role of secretory IgA in the context of IBD development and its ability or lack of ability to protect the intestinal barrier. Deficiency in secretory IgA is not only related to the activity of gut microbiota and their ability to stimulate dendritic cells, but also to environmental and lifestyle factors, such as stress, poor diet, and infection, which are further highlighted below.6,14-18 Gut associated lymphoid tissues (GALT) are one of the largest components of the immune system within the body and are found in the gastrointestinal tract. GALT is a component of the immune system in the gastrointestinal tract that contains B and T lymphocytes. These tissues play an important 15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com role in protecting the body from infection and inflammation at the level of the intestinal barrier. Normally, the numbers of microbiota present within the gastrointestinal tract affect the composition of GALT. When there is an alteration in intestinal permeability and microorganisms are able to penetrate the mucosal lining, the GALT produces an inflammatory response. Further, antigens in the intestinal tract can actually adhere to the epithelial lining of the intestinal barrier, which increases the immune response, since the body seems to understand that a breach in this barrier can lead to systemic complications. In order to provide adequate protection, the intestinal lining must maintain a particular balance between cell growth and destruction. Old cells are eventually broken down and are replaced by new cells that continue the process of protection and providing a barrier. When there is a break in maintaining this balance, there is a risk of penetration of the intestinal barrier, which can lead to disease development and a breach in protective mechanisms. It is thought that weaknesses in the protective barrier of the intestinal lining can contribute to IBD development. Antoni, et al., in the World Journal of Gastroenterology, state that there are various factors that can contribute to a breakdown in intestinal barrier function, including defects in the mucus layer and mucus-producing cells of the epithelium, increased intestinal permeability, variations in the production of antimicrobial peptides normally produced by some of the epithelial cells, and increases in cell autophagy, which is a process of cell destruction.90 As a consequence of all of these factors, an imbalance develops between the gut microbes and the body’s defense mechanisms, and the immune system is disproportionately 16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com triggered, leading to an exaggerated immune response and chronic inflammation. While some specific types of bacteria have been identified as being associated with development of inflammation related to IBD, there is not one particular pathogen that is distinctive to all cases. Due to the large numbers of microorganisms that may be present in the intestinal tract, a breach in the intestinal barrier can lead to one or more mechanisms of harmful microbes entering circulation and stimulating the immune response. Some professionals use the term “leaky gut” to describe the intestinal permeability that could be responsible for some symptoms of IBD as well as other intestinal illnesses. The concept of a leaky gut is that the epithelial cells normally form a tight barrier that allows certain elements to pass, namely nutrients, electrolytes, and fluids, but that prevents other substances from breaking through. When a person supposedly has a leaky gut, there is a breakdown in the barrier, the epithelial cells do not maintain a tight wall with which to provide protection, and harmful elements are able to get by. Leaky gut syndrome has been associated with a number of gastrointestinal conditions, including IBD as well as many other systemic disorders (asthma, allergies, type 1 diabetes, rheumatoid arthritis, and psoriasis). The concept of a leaky gut is relatively the same as the concept of a breach in the intestinal barrier leading to an exaggerated inflammatory response. The mechanisms of how a breach develops are important considerations to take into account. The breach in the intestinal barrier may occur as a result of such factors as disease or environmental stressors, and in a manner similar to those triggers that prompt an inflammatory bowel disease flare. 17 nursece4less.com nursece4less.com nursece4less.com nursece4less.com The reason why some people are susceptible to IBD and develop the disease is partially explained by the idea of a leaky gut or breach in the intestinal barrier. Researchers at Emory University School of Medicine found that a person who is genetically susceptible to developing IBD and who has a chronically leaky gut is likely to develop IBD symptoms when there are defects in the immune system. This requires a multifactorial process that comes together to result in inflammation; such as genetic susceptibility, impairment of the immune system, and triggers that contribute to a breach in the intestinal barrier. Consequently, there is general agreement about the notion that the existence of a break in the lining of the intestinal tract allowing certain microorganisms to get through and cause inflammation does not adequately explain the cause of IBD in all cases. Instead, the concept of a leaky gut is typically combined with various other factors that all lead to increased inflammation and damage to the intestinal tissues that occurs with IBD. Diet And Inflammatory Bowel Disease The idea that diet contributes as a cause of inflammatory bowel disease comes from the fact that the incidences of diagnosed cases of IBD are on the rise, particularly within the U.S. and Europe. The increase in cases of IBD is occurring at the same time as an increase in several other disorders that also may be related to dietary intake, including type 2 diabetes and obesity. The diets of Westerners and Europeans differ from diets of those in developing countries where IBD is less prominent. The combinations of increased food intake due to large portions, as well as increased intake of items that could potentially harm the gastrointestinal tract or upset the balance of healthy gut microbiota could play a role in development of excess inflammation associated with IBD, as discussed here.10,17,18 18 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Gut microbiota are able to function in relation to diet. Many microorganisms found in normal gut flora obtain nutrients from the host’s diet, meaning that dietary factors and a person’s intake of food and nutrients can impact the work of normal gut microbiota. A significant amount of nutrients for gut microbiota come from digestion of dietary carbohydrates; i.e., the digestion and fermentation of some types of carbohydrates and fiber produce shortchain fatty acids, which are associated with the control of cell proliferation and serve anti-inflammatory purposes. Some elements of gut microbiota play a role in lipid metabolism as well. Adipocytes normally inhibit some of the activity of lipoprotein lipase, an enzyme that breaks down triglycerides to be used by the body for energy. Gut microbiota have been shown to restrain this inhibition in some instances, leading to weight changes. Inflammatory bowel disease shares some characteristics of chronic inflammation with obesity; people who are obese have increased levels of inflammatory cytokines that have been seen in people with Crohn’s disease and ulcerative colitis. A murine study by Paik, et al., in the Journal of Nutrition found that genetically susceptible mice that were given a high-fat diet had increased levels of mesenteric and gastrointestinal inflammation.95 Some of the mice in the study did not develop such inflammation, despite administration of the same high-fat diet; however, these mice had a different genetic background, which suggests that diet, when combined with genetic susceptibility toward inflammatory bowel disease, can play a role in IBD development. Gut microbiota mediate the synthesis of bile acids, which are important for lipid transport. The production of certain types of bile acids are associated with an increased risk of colorectal cancer, as well as some other types of gastrointestinal diseases. Gut bacteria can also produce lipopolysaccharides, 19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com which make up part of the cell wall in some forms of pro-inflammatory bacteria. Lipopolysaccharides can have an impact on the immune system; they are associated with increased inflammation and may contribute to the development of some forms of inflammatory conditions as well. The gut microbiota are responsible for metabolizing some amounts of polyphenols taken in through the diet. Polyphenols are micronutrients in the diet that are said to play a role in the prevention of certain chronic diseases, such as cardiovascular disease and certain types of cancer. These polyphenols are often bound to dietary sugars such as glucose, galactose, and ribulose. The microbiota in the intestinal tract transform polyphenols, where they can then be sent to other areas of the body via circulation. Some examples of polyphenols that exist in the diet include tannins, which are found in raspberries, strawberries, and grapes, and that are broken down by Butyrivibrio species in the gut. Polyphenols also include flavonoids. Flavanols are primarily found in onions, capers, and broccoli and are degraded by such microorganisms as Bacteroides distasonis, Enterococcus casseliflavus, and Bacteroides uniformis in the gut. Isoflavones found in soy, beans, and lentils, are degraded by Lactobacillus and Bifidobacterium in the intestinal tract. Flavonoids known as anthocyanidins are found in most types of red and blue berries; they are broken down by Lactobacillus plantarum, L. casei, L. acidophilus, and Bifidobacterium longum in the intestinal tract. While there is not one specific food or fluid that causes symptoms of inflammatory bowel disease, some foods can act as triggers for disease flares. The types and amounts of foods that lead to symptom flares vary between people but persons with IBD should be aware of possible connections. Some people have success with keeping a food diary to chronicle meals and snacks and to determine if there is a correlation 20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com between certain foods and symptoms. Some foods that cause flares in certain individuals also contain necessary nutrients for the body. Individuals who eliminate these foods from their diet in order to control IBD symptoms run the risk of suffering from nutrient deficiency. For example, fibrous foods can cause diarrhea in some people, yet fiber is an important component of the diet to promote normal stool excretion and to maintain normal cholesterol. Instead of completely eliminating foods with fiber, the person affected by these foods can try preparing them in a different manner, such as by cooking them to soften the foods, or through a process of trial and error to find alternative foods that are just as nutritious but that do not cause disease symptoms. Overall, the Western-style diet may be associated with an increased risk of developing chronic illnesses such as inflammatory bowel disease. The combination of factors, including high fat and calories, large amounts of refined carbohydrates, increased amounts of sugar and high-fructose corn syrup, and poor quality nutrients can all have negative consequences. Additionally, a Western-style diet often lacks important nutrients that are essential for gut health, including many vitamins, fiber, antioxidants, polyphenols, and minerals. The role of diet in the overall health of an individual should not be underestimated and diet as a proponent of inflammatory conditions such as IBD continues to be examined as a specific cause. Genetics And Inflammatory Bowel Disease The study of genetics and its relationship to development of IBD is ongoing through various research projects and investigations. It is well known that many patients with inflammatory bowel disease have a family history of some type of IBD. A family member’s disease may not necessarily be the 21 nursece4less.com nursece4less.com nursece4less.com nursece4less.com same or similar to a current patient’s diagnosis but the presence of some type of IBD in an ancestor’s medical history may mean that the current patient was predisposed to the diagnosis. The study of genetics describes how heredity affects the expression of certain traits within people. In examining how genetics causes IBD, clinicians are attempting to isolate specific genes to determine their contribution toward the disease process, as well as study the effects of bacterial genes that are specific to gut microbiota. This section provides an overview of the role of genetics in inflammatory bowel disease.1,2,28,43,47,95,96 Metagenomics of the Human Intestinal Tract (MetaHIT) is a project operating in eight different countries in Europe and is designed specifically to determine how genes associated with certain bacteria in the intestinal tract affect human disease. Through the many studies conducted by MetaHIT, the organization has speculated that there are more than 10 million different types of genes in the human body. Based on continued research into the connection between genetics and inflammatory bowel disease, studies continue to suggest that genetic abnormalities that affect the immune system may predispose some people to developing IBD. Genes play a role in the types of microbiota present in the intestinal tract, which can further influence health and the possibility of developing intestinal 22 nursece4less.com nursece4less.com nursece4less.com nursece4less.com disease. There has been some evidence of greater propensity for disease development in people who have low gene counts in the intestinal tract; defined as lower than average of the normal microbial genes in the gut. People who are considered to have lower numbers of microbial genes are more likely to have higher counts of pro-inflammatory bacteria in the intestinal tract, which may contribute to inflammatory bowel disease. Variations in the NOD2/CARD15 gene have been associated with the development of Crohn’s disease. Studies suggest that when these variations are present in some people, they are genetically predisposed to developing Crohn’s disease. The NOD2 gene codes for the creation of particular proteins that support immune system functioning. Certain cells in the gastrointestinal system express the NOD2 gene, including Paneth cells and monocytes of the immune system. The NOD2 gene plays a significant role in defending the body against foreign antigens, so when there are variations in the gene, the body may be more susceptible to certain diseases, and Crohn’s disease is one condition that is specifically involved when disparities exist. The NOD2/CARD15 gene has also been shown to impact the response to antibiotic therapy for some patients with perianal Crohn’s disease. Persons with Crohn’s disease affecting the perianal area may respond more favorably to antibiotic treatment when the NOD2/CARD15 wild type gene is present. Some studies have also found correlations with other genes when variations are present along with increased incidences of IBD. A variant in the ATG16L1 gene has also been associated with development of Crohn’s disease. There are some genetic polymorphisms of ATG16L1 that alter the immune system’s functioning and actually stimulate cell destruction of normal tissue. When the immune system is stimulated to this destruction, known as 23 nursece4less.com nursece4less.com nursece4less.com nursece4less.com autophagy, the process affects how antigens are exhibited and the immune response may not be activated at the appropriate times. In other words, when autophagy occurs, the body may be destroying healthy cells but failing to recognize the presentation of antigens that it should be fighting off instead. Specifically, the T300A variant of the ATG16L1 gene is one of the best known factors involved with development of Crohn’s disease. Some studies have examined the effects of reducing the chemical complex of T300A on inflammation associated with IBD. A study by Murthy, et al., in the journal Nature showed that starvation induced metabolic stress in macrophages (the cells of the immune system responsible for phagocytosis) increased the breakdown of T300A variants in the ATG16L1 gene, resulting in diminished autophagy.38 Further studies in mice have shown that maintaining another variant of ATG16L1 gene, the T316A variant, may result in problems with eliminating certain types of harmful bacteria in the gut, specifically Yersinia enterocolitica, an organism often responsible for gastrointestinal inflammation and diarrhea. The Paneth cells, as previously described, are also related to inflammation development when genetic variations exist. Paneth cells express the NOD2 genes but may also be related to irregularities with the ATG16L1 gene as well. Some studies with mice have shown that abnormalities of the ATG16L1 gene is sometimes correlated with abnormal Paneth cells when the norovirus species is present; the mouse norovirus studies were similar in structure to some noroviruses that infect humans to cause gastroenteritis. The studies about the specific relationship between Paneth cells and alterations in ATG16L1 are still ongoing but there is evidence that a connection exists 24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com between these two factors when viral antigens are also present, which can affect the maintenance of the mucosal lining of the intestinal tract. The study of genetics and its relationship to development of inflammatory bowel disease is widespread and extensive. Because of the many differences in genetic variations and their effects on the gastrointestinal system, research in this area is ongoing and evolving. It is reasonable to say that people with genetic susceptibility to IBD have a greater chance of developing symptoms, particularly when other factors are present, such as diet and lifestyle factors or other triggering influences. The specific genes involved that cause a person to become susceptible are still being investigated. Inflammatory Bowel Disease Symptoms Disease symptoms are the manifestations of how inflammatory bowel disease presents itself in the affected patient. Symptoms of IBD may be obvious, prompting a patient to seek help and treatment. Symptoms may also be subtle and nonspecific, in which they are difficult to distinguish from other illnesses. Inflammatory bowel disease typically causes periods where symptoms fluctuate. During flares, symptoms can be debilitating and painful, while at other times symptoms may be mild to non-existent. Depending on the extent of the disease, the symptoms of IBD may be considered mild, moderate, or serious, and any combination of severity may be present when symptoms develop. Most symptoms of IBD affect the gastrointestinal tract, often causing pain and disability when present. Other symptoms unrelated to the intestine also can occur, known as extra-intestinal symptoms; these often develop because of the effects of inflammation, pain, and bleeding associated with 25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com IBD and they are frequently related to the systemic influences of the disease, which are covered below.1,4-6,25-29,48-55,60-65,93-102 Anemia One of the most common manifestations of inflammatory bowel disease that is not specifically associated with bowel function is anemia, which is known as an extra-intestinal manifestation of IBD. Historically, anemia has been so common among patients with IBD that it has often been considered an unfortunate consequence of the disease and one that is simply to be expected. According to Rogler, et al., in the journal Frontiers in Medicine, approximately 27 percent of persons with Crohn’s disease and 21 percent of persons with ulcerative colitis suffer from anemia, with iron deficiency anemia being present in 57 percent of these cases.47 The presence and severity of anemia as an extra-intestinal symptom of IBD does not necessarily correlate with the areas or locations of tissue involved. The most common type of anemia associated with Crohn’s disease and ulcerative colitis is iron deficiency anemia. Iron deficiency anemia occurs when there are too few red blood cells in the body due to a lack of iron. Unfortunately, iron deficiency anemia is also frequently underdiagnosed among patients with IBD, despite its prevalence. The main reasons why individuals with IBD develop anemia are due to blood loss through frequent diarrhea and rectal bleeding. Diarrhea causes significant fluid loss, and for some people undigested food is found in the stool as well. If food is not absorbed in the intestinal tract and instead passes through the system quickly to be expelled as diarrhea, the body is not taking in enough nutrients from the food. In addition to iron malabsorption, there may be limited absorption of many other nutrients because of frequent diarrhea, including protein and fat. 26 nursece4less.com nursece4less.com nursece4less.com nursece4less.com The body needs iron to be able to maintain normal circulation and to produce enough blood cells. Most iron in the body is found in the blood and in the muscle tissues. Normally, the red blood cells carry oxygen to the body’s tissues when oxygen molecules attach to hemoglobin in the erythrocytes. Iron is needed to create hemoglobin, a protein that is made up of iron atoms bound to heme, which is the non-protein component. Decreased iron in the body, whether through inadequate iron stores, poor dietary intake, malabsorption, or through blood loss can impact erythropoiesis and results in poor oxygen delivery through diminished production of hemoglobin. When iron is absorbed by the small intestine, it is shifted to transferrin, which is created in the liver. This transferrin can then move iron to erythrocytes where it is needed for erythropoiesis. Extra iron that is not used in this manner is stored as hemosiderin or as ferritin. Iron is also recycled in the body and can be taken from old erythrocytes or from storage to be used as needed when iron absorption from food is poor. Hepcidin, a hormone that is secreted by the liver, is involved with iron regulation by controlling how iron enters circulation. It binds to a cellular iron transporter known as ferroportin, causing it to breakdown and thereby preventing iron absorbed from the duodenum to enter circulation. The synthesis of hepcidin and its effects on dietary iron absorption was first discovered in 2000. When iron deficiency develops, hepcidin production is suppressed. Alternatively, when plasma iron stores are elevated, hepcidin synthesis is increased. This prevents additional iron absorption from the intestine, which would otherwise further contribute to iron excess in the body. Hepcidin, therefore, is important for maintaining a normal balance of iron in the body and preventing iron deficiency as well as iron overload. 27 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Hepcidin levels seem to play a role in inflammatory bowel diseases, particularly in relation to its effects on iron and erythropoiesis. Elevated levels of hepcidin have been found in the urine of people suffering from active Crohn’s disease and elevated levels were correlated with increased Creactive protein and interleukin-6 in these cases. A review in the journal Advances in Clinical and Experimental Medicine also noted that hepcidin levels are often lower in patients with inflammatory bowel disease when compared to people with normal bowel function. The methods of regulating hepcidin levels in the body to control iron stores are still being studied, but people with IBD who have lower hepcidin levels can be at higher risk of problems with iron regulation, further leading to iron deficiency anemia. Iron depletion may develop initially, which is a condition that is a precursor to iron deficiency anemia and is usually much more common than actual anemia. Iron depletion describes a condition in which there are reduced amounts of iron stores in the body. The condition does not cause anemia unless iron levels are low enough that the body is unable to make enough red blood cells and hemoglobin levels drop. An individual with inflammatory bowel disease may initially develop iron depletion because of frequent diarrhea and malabsorption; however, it can often be asymptomatic or may cause mild symptoms that are not obvious right away, including fatigue and lethargy. For some people, iron deficiency could cause stomatitis, sore tongue, delayed wound healing, and hair loss. Malabsorption of iron due to damaged intestinal tissue is another cause of iron deficiency anemia. This condition is seen more commonly in patients with Crohn’s disease who have involvement of the small intestine. Iron absorption is impaired when inflammation impacts the small intestine, primarily the duodenum or the jejunum, the main sites of iron absorption in 28 nursece4less.com nursece4less.com nursece4less.com nursece4less.com the gastrointestinal tract. The human body loses some iron from stores through the sloughing of skin cells, but it does not actually excrete much iron from stores through the urinary or gastrointestinal systems. As a result, iron deficiency and anemia develop not when too much iron is excreted, but rather as a lack of appropriate iron absorption. As with iron depletion, iron deficiency anemia as a result of IBD causes symptoms of fatigue, poor concentration, lethargy, and poor stamina. The individual may also exhibit pallor or muscular weakness, or may be short of breath. Severe symptoms of iron deficiency anemia include changes in the shape of the nails, causing them to become brittle and spoon-shaped, as well as glossitis and cheilosis in the mouth, pruritis, dizziness, and irritability; some individuals also develop pica, in which they crave non-food items. Treatment of iron deficiency anemia requires supplemental iron in doses given once or twice a day. A standard, adult dose of iron is approximately 60 mg; only a certain amount of iron is absorbed with oral intake, so too large of a dose will not increase the chances of correcting a deficiency all at once. The excess will not be absorbed or used. Iron supplements should be taken on an empty stomach, as some foods can decrease absorption; however, vitamin C has been shown to improve iron absorption, so taking the supplement with a source of vitamin C, such as with a glass of orange juice, could improve its uptake. Dietary iron intake can also alleviate some of the negative effects of iron deficiency anemia. Dietary iron is available to the body in two different forms: heme iron and non-heme iron. Heme iron is found in foods that are meat based, including beef, chicken, turkey, and pork and is absorbed more 29 nursece4less.com nursece4less.com nursece4less.com nursece4less.com easily by the body when compared to non-heme iron, which requires certain gastric secretions to break it down to the ferrous state before it can be absorbed. Some other items, including tannins found in tea, polyphenols, and some antibiotics, can also limit absorption of non-heme iron. Sources of non-heme iron in foods include enriched breakfast cereals, beans, tofu, dried fruits, and seeds. A health clinician can determine that a patient with iron deficiency anemia is responding to iron supplementation by checking hemoglobin levels. Serum hemoglobin should rise slowly with iron supplementation and the patient will eventually suffer from fewer symptoms of iron depletion. However, treatment of the underlying IBD is essential for correcting iron deficiency, as no amount of supplementation will correct the loss that occurs from bleeding or intestinal damage due to inflammatory disease. People with IBD can be at risk of other types of anemia in addition to iron deficiency. The malabsorption of nutrients due to inflammation and intestinal damage can lead to nutrient deficiencies that are harmful to normal body processes. Vitamin B12 deficiency anemia may develop in some patients with Crohn’s disease because of malabsorption of the vitamin. This type of deficiency also causes a decrease in red blood cells, as vitamin B12 is needed for erythropoiesis. When vitamin B12 deficiency anemia occurs as a result of a lack of intrinsic factor in the stomach, which is needed to absorb vitamin B12, the condition is known as pernicious anemia. However, among other people, such as those with IBD, vitamin B12 anemia may develop when the areas of the intestinal tract that normally absorb vitamin B12 are damaged by the disease, such as in Crohn’s disease. The use of certain types of drugs for treatment of IBD, including methotrexate and 30 nursece4less.com nursece4less.com nursece4less.com nursece4less.com sulfasalazine, or when patients with IBD have had surgery to remove part of the small intestine, may further impair vitamin absorption. The symptoms of vitamin B12 deficiency can vary between persons; some symptoms are similar to those of iron deficiency anemia, while others are clearly different. Common symptoms of vitamin B12 deficiency anemia include numbness and tingling in the hands and feet, muscular weakness, ataxia, glossitis, fatigue, anorexia, nausea, diarrhea, and tachycardia. Vitamin B12 deficiency is a type of megaloblastic anemia that is often seen with folate deficiency. At times, both types of anemia may be present. A patient can best manage this type of anemia by increasing dietary intake of foods that contain B12 and folate, as well as taking vitamin B12 supplements. As with iron deficiency anemia, supplements and dietary changes may help to relieve some symptoms of anemia but unless malabsorption due to IBD (such as Crohn’s disease) is managed, the problem will continue. The long-term state of inflammation associated with inflammatory bowel disease can lead to a type of anemia known as anemia of chronic disease. This describes a condition in which there is decreased erythropoiesis and a shortened lifespan of the red blood cells because of the chronic damage from inflammation to the intestinal tract. Anemia of chronic disease is also associated with various other types of long-term illnesses, including chronic viral infections and cancer. Next to iron deficiency, anemia of chronic disease is the second most common type of anemia. Anemia of chronic disease is characterized by red blood cells that become microcytic over time, causing poor hemoglobin synthesis and deficiency in erythropoiesis. There is an increased production of certain types of 31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com cytokines, including interleukin-1 and tumor necrosis factor, which also contribute to poor production of erythropoietin and consequent limited erythropoiesis. The red blood cells have shorter lifespans with this type of anemia; there is also a decrease in red blood cell production when the bone marrow is unresponsive to erythropoietin stimulation. When red blood cells age, they are termed senescent red blood cells, meaning they are nearing the end of their life spans. Normally, the body removes extra iron from senescent red blood cells and puts it into storage. This iron is unable to be used for hemoglobin synthesis, so if red blood cells have shorter life spans, the body cannot recycle the iron to create more hemoglobin. Consequently, anemia develops because of a decrease in red blood cells and a drop in hemoglobin. Anemia of chronic disease often develops slowly, and the symptoms may not be noticeable when compared to the actual underlying disease process. For example, an individual struggling with frequent diarrhea, abdominal pain, and bloody stools related to ulcerative colitis may be less likely to notice an increase in fatigue that comes on slowly because of anemia of chronic disease. Laboratory findings may show an indication that something is wrong; transferrin saturation levels are often low and there may be alterations in reticulocyte hemoglobin content and mean corpuscular volume. Symptoms are often mild overall, and the anemia may be difficult to identify and pinpoint as the cause of the person’s symptoms. It usually responds well to treatment with erythropoietin. The most important form of treatment for anemia of chronic disease is management of the underlying condition contributing to the anemia; in this case, the anemia of chronic disease can develop from uncontrolled inflammatory bowel disease, so proper management of inflammation, severe 32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com diarrhea, and bleeding is paramount for controlling anemia. Erythropoietin, a growth factor that can be administered as an injection, stimulates the bone marrow to produce more red blood cells and is another standard form of treatment for this type of anemia, often when combined with chronic disease treatment. Treatment of anemia is usually successful with supplementation of the missing nutrient, typically with iron, vitamin B12, or folate. This type of treatment actually may provide greater benefits than treatment with medication to control inflammation of IBD. However, administration of supplements, including oral iron therapy, is often not well tolerated by people with inflammation of the bowel. When oral therapy is poorly tolerated and the effects of anemia are significant, including evidence of hemoglobin levels < 10 g/dL, intravenous iron therapy should be initiated, which has shown to be well tolerated and more effective than oral iron supplementation. While medical therapies for IBD can reduce inflammation and may eliminate bleeding from ulcers that can cause anemia, many patients have more success with treating anemia when these drugs are combined with nutrient supplements as specific treatment for the anemia. People with a history of anemia and IBD that is in remission should continue to have laboratory values checked on a routine basis, whether the effects of inflammation are present or not. Alves, et al., in the Sao Paulo Medical Journal recommend routine surveillance every 6 to 12 months for patients with remissive Crohn’s disease or ulcerative colitis, including testing of complete blood count, serum iron and ferritin levels, transferrin concentration and saturation, lactate dehydrogenase, and reticulocyte count, as well as B12 and folic acid levels in those at risk.7 The numbers of people who are suffering from anemia as a result of IBD is slowly decreasing as 33 nursece4less.com nursece4less.com nursece4less.com nursece4less.com health clinicians become more aware of this potential complication of the disease and seek to identify it and provide treatment during the early stages. Still, there are many cases that continue to be overlooked and are not treated until symptoms are severe and debilitating. Abdominal Pain Abdominal pain describes any type of pain that develops in the region below the chest and above the groin. It can be dispersed throughout the entire region or localized to one specific area. Abdominal pain is also described in various ways, and those with IBD may suffer from abdominal pain predominantly during times of disease flares when the pain is constant and occurring all the time, or intermittent, in which it comes and goes. Some people refer to abdominal pain associated with IBD as “stomach pain” or a “stomach ache,” although the pain is usually not associated with actual stomach organ. The pain that develops with inflammatory bowel disease is often related to the type of IBD present and the area most affected. In cases of ulcerative colitis, where the disease is located almost entirely in the colon and/or the rectum, the patient is more likely to experience pain in the lower abdomen. The pain associated with Crohn’s disease may be located in the areas affected, and so may occur anywhere throughout the abdomen, depending on whether the disease impacts more of the small intestine, the colon, or both areas. Among patients with IBD, abdominal pain may be a common symptom and one that many people tolerate; however, when abdominal pain increases in intensity and severity, it may be a sign that treatment methods need to be increased or modified. 34 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Abdominal pain most commonly develops during disease flares, when symptoms of inflammation and ulceration are present and are at their worst. A patient who is having an acute flare of ulcerative colitis may complain of severe abdominal pain that is unrelieved by pain relievers or antispasmodic medications designed to treat cramps and spasms in the gut. The pain may or may not be relieved temporarily following a bowel movement. Treatment administered to relieve inflammation and to control further disease flares may help with some abdominal pain. Use of non-steroidal anti-inflammatory agents (NSAIDs), while effective in managing a patient’s pain and inflammation from extra-intestinal symptoms, are not usually warranted for abdominal pain associated with IBD. These drugs can irritate the intestinal lining and could contribute to further pain for the patient. While there is no direct association between NSAID use and an increase in disease flares, the side effects of these drugs often mean that there may be other medications to use that are better options for pain control. Other options that have been used as alternatives for pain relief include opioid analgesics, antidepressants, and anticonvulsants. Some of these drugs can be used in combination or as adjuvant therapies to provide more relief. Medications prescribed solely for relief of abdominal pain are often not effective in relieving all abdominal pain. Instead, a patient affected with IBD may have more success with a combination of medication and psychotherapy, or by managing the disease process itself to reduce inflammation and ulceration associated with the illness. Medications should be continued throughout remission and taken as prescribed to avoid further flares of the disease and recurrent abdominal pain. Abdominal pain can cause multiple other effects for a patient because it can be painful enough to be debilitating. Many people suffering from acute 35 nursece4less.com nursece4less.com nursece4less.com nursece4less.com abdominal pain experience other symptoms as well, including nausea, vomiting, and anorexia. At times, pain can be so intense as to cause nausea for some people; if pain and nausea develop shortly after eating a meal, they could lead to vomiting of recent food intake. Often, abdominal pain is so intense that the affected person has little desire to eat. The pain may be worsened with food intake and the individual may want to avoid any pain exacerbation as much as possible. Frequent anorexia and missed meals leads to weight loss over time when the affected person does not take in enough calories or nutrients to meet daily recommendations and to sustain a healthy weight. Chronic abdominal pain can also cause psychological symptoms, particularly if a patient has difficulty controlling the pain and it affects quality of life. Unrelenting pain is linked with an increase in anxiety and depression for many; modifying activities to accommodate the pain, knowing that there have been many attempts at therapy or treatment to manage the pain but that have been unsuccessful can cause a person to feel disheartened and depressed. If abdominal pain worsens at certain times, such as following food intake, the individual may develop anxiety over eating or because of social situations, or have a fear of experiencing further pain. Abdominal pain associated with IBD is often related to inflammation and ulcerations in the gastrointestinal tract. The tissues of the small or large intestine, when they become inflamed, may swell and press on nearby nerves that serve the gastrointestinal system. This extra pressure may stimulate these nerves to send pain messages to the brain that abnormal activity is taking place in the gastrointestinal tract. While the abdominal pain can alert the brain to the presence of abnormal activity, it is often uncomfortable and not easily remedied. At times, abdominal pain may be 36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com the only symptom a patient is experiencing or it may be the symptom that leads the individual to seek help and a diagnosis. Ulcerations in the intestinal tract cause tissue breakdown and stimulation of nerve receptors, which can also lead to abdominal pain. The pain may be at the location of the ulcerated areas in the gastrointestinal tract, or it may radiate to other parts of the abdomen. At times, abdominal pain is a sign of a complication of IBD. A person with ulcerative colitis or Crohn’s disease may have successfully managed symptoms during times of disease flares for a while, but a change in the intensity or severity of abdominal pain may indicate that something else is wrong. An abscess in the gut, caused by a pocket of infection due to chronic inflammation and accumulation of microorganisms in a particular area can cause significant pain for the affected individual. Intestinal strictures, in which the lumen of the gastrointestinal tract becomes narrowed due to scarring or thickening of the intestinal wall may also lead to abdominal pain, particularly when digestion slows and there may be a buildup of gas in the intestine. Other causes of pain in the intestinal tract that have developed, often as a consequence of IBD, include gastritis, fistulas, fissures, adhesions, or small bowel obstruction. While IBD may be confused with irritable bowel syndrome, the two conditions are not the same. However, there is mounting evidence of a connection between inflammatory bowel disease and irritable bowel syndrome (IBS). The American College of Gastroenterology revealed that there is a potential overlap between the two disorders in that the inflammation associated with IBD could lead to the development of IBS. Further, there may be inflammation present even when the disease appears to be in remission, which can cause symptoms of IBS. Irritable bowel 37 nursece4less.com nursece4less.com nursece4less.com nursece4less.com syndrome is a chronic functional bowel disorder that causes symptoms of abdominal pain and diarrhea that are similar to those of IBD. The condition can also cause chronic constipation and abdominal bloating, although testing and diagnostic procedures typically are unable to pinpoint an exact cause of the discomfort and there are no changes in laboratory findings or testing results. The American College of Gastroenterology also showed that some antidepressants, which are often used for the treatment of IBS, have been used with some success in treatment of inflammatory bowel diseases. Tricyclic antidepressants (TCAs) are some of the more commonly prescribed drugs for treatment of IBS. When administered to patients with inflammatory bowel diseases, TCAs may be beneficial in managing some abdominal pain and diarrhea associated with IBD. A patient that presents with consistent abdominal pain needs further investigation and diagnostic procedures to identify the cause. If the patient has already been diagnosed with IBD and the pain is unrelated to a disease flare or it differs significantly from discomfort normally experienced during a flare, it should be investigated further to determine the cause, as the pain could be related to a complication of the disease. Diagnostic testing may involve laboratory testing and a physical examination. A complete blood count may indicate changes in leukocyte counts or may reveal infection or inflammation due to elevated white blood cell levels. A C-reactive protein level and erythrocyte sedimentation rate, if elevated, can indicate an increase in inflammation. A patient who is suffering from anemia may exhibit low albumin levels and when present, can help the health clinician to determine whether protein loss is ongoing. 38 nursece4less.com nursece4less.com nursece4less.com nursece4less.com The physical examination may reveal signs of pathology, including abdominal bloating or specific areas of tenderness. If laboratory evidence is lacking and the physical exam does not reveal an obvious, external source of the abdominal pain, the patient may need endoscopy or other imaging procedures to rule out complications. Depending on the location of the pain, a colonoscopy may be performed to examine the large intestine, the sigmoid colon, and the rectum, while an upper endoscopy may be needed to examine the esophagus, the stomach, and the duodenum of the small intestine. Unfortunately, abdominal pain seems to be very common and widespread among patients with IBD and it is often consistent, even after thorough assessment. According to Docherty, et al., in the Journal of Gastroenterology and Hepatology, approximately 20 percent of patients with IBD continue to have pain despite verification of inflammatory bowel disease remission.53 Regular abdominal pain, while a common element of disease flares associated with IBD, should be managed and treated to the fullest extent possible and not simply accepted as a symptom that a patient must learn to live with. Vomiting Vomiting describes the forceful expelling of stomach contents, whether it is voluntary or uncontrolled, through the contraction of the muscles in the stomach and the abdomen. Vomiting is often associated with nausea, a feeling of queasiness in the stomach that may also include the sensation of a headache or dizziness. For some patients with IBD, vomiting is a symptom that commonly develops during disease flares because of the pain and inflammation occurring in the intestinal tract. 39 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Nausea is controlled by the brain stem, near the regulatory centers of various other bodily functions. The area of the brainstem that controls emesis is actually known as the vomiting center. There are various mechanisms that can stimulate the vomiting center and that can cause a person to experience nausea and/or vomiting. The chemoreceptor trigger zone, also called the area postrema, is an area in the vomiting center that contains receptors for various neurotransmitters, including dopamine, serotonin, and substance P. Stimulation of these receptors or the nearby regulatory centers, including the vestibular center or the vagus nerve, can also stimulate vomiting. People with inflammatory bowel disease flares who have developed symptoms may be more likely to experience vomiting if some of their symptoms stimulate the receptors found in the chemoreceptor trigger zone of the vomiting center. For example, some people who have severe, unremitting pain develop nausea as a result. When IBD causes debilitating abdominal pain, the area postrema in the brain may eventually be stimulated, which activates the sympathetic and parasympathetic nervous systems to induce vomiting. Ongoing stress may also cause someone to experience vomiting because of activation of the dopamine receptors in the chemoreceptor trigger zone, which leads to the similar effects of emesis. Not all patients with inflammatory bowel disease experience vomiting as part of their symptoms of disease flares. For some people, vomiting may be a sign of a complication of the disease, particularly if it is not normally associated with flare symptoms. Vomiting may be a sign that a stricture has developed in the intestinal tract, a potential complication of IBD. When strictures form, the passage of food and fluids through the intestinal tract is slowed. Severe cases of strictures can lead to enough of an obstruction that 40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com very little material is able to pass through the intestine. This is not only painful for the patient but can also lead to slowed digestion and absorption, as well as intestinal blockage, in which the patient experiences pain, abdominal bloating, and nausea, as well as vomiting. In some cases of gastroduodenal Crohn’s disease, vomiting occurs because of the effects of the disease on the stomach lining. Because of chronic inflammation of the stomach and duodenum, a patient with gastric Crohn’s disease often experiences a feeling of fullness soon after eating, as well as indigestion, nausea, and vomiting. Vomiting may also be a sign of complications associated with gastroduodenal Crohn’s. Gastric outlet obstruction is one of the more common complications of Crohn’s affecting this area of the intestinal tract. When strictures close the opening of the passage between the stomach and the duodenum, food remains in the stomach and does not pass into the small intestine for further digestion. In addition to pain and bloating, gastric outlet obstruction can cause vomiting, early satiety, fullness in the abdomen, anorexia, nausea, indigestion, and weight loss. Another rare but significant complication of gastroduodenal Crohn’s disease that can cause excessive vomiting is when a fistula develops between the stomach and the colon. Known as gastrocolic fistula, this occurs as tunneling between the stomach and usually the transverse section of the colon; this complication most often develops when a patient has concomitant Crohn’s lesions in both the stomach and the colon. The patient with this type of fistula develops symptoms of abdominal pain, weight loss, diarrhea, and rectal bleeding in addition to vomiting. The vomiting that occurs in this case may contain stool, known as feculent vomiting. The patient may complain of a bad taste in the mouth or there may be the smell of stool on the breath. 41 nursece4less.com nursece4less.com nursece4less.com nursece4less.com This condition requires surgical intervention to correct the fistula. Fortunately, this type of vomiting is a rare complication of Crohn’s. Any patient that develops severe vomiting that contains fecal matter requires further evaluation for surgery. Treatment of vomiting often depends on its cause. Vomiting that occurs as a result of pain from inflammation or slowed motility (unrelated to gastric outlet obstruction) could be managed with antiemetic medications. These drugs work by blocking stimulation of the vomiting center in the brain. The chemoreceptor trigger zone is actually outside of the blood-brain barrier, which means that medications can reach it directly to control the sensations of nausea and to stop vomiting. A patient with regular vomiting may also try to eat smaller, more frequent meals and should continue to try to drink fluids to avoid dehydration. When vomiting develops as a result of a complication associated with IBD, such as an intestinal obstruction or fistula, the condition must be treated as soon as possible, since vomiting in these cases is almost always a sign that warrants further action. Frequent vomiting has its consequences, as the continued loss of food and fluid can result in weight loss and malnutrition. A patient who suffers from frequent vomiting associated with IBD is at risk of dehydration due to loss of fluids and electrolytes. It may be difficult to take in enough food or fluids, particularly if nausea is also present. The effects of stomach acid when it comes into contact with the lining of the esophagus during emesis can be harmful to the delicate tissues at the back of the throat and can erode enamel off of the teeth. While vomiting is a consequence of inflammatory bowel disease for some, like some other symptoms that are associated with Crohn’s disease or ulcerative colitis, vomiting is not a symptom to be ignored in hopes that it will go away. A patient who experiences ongoing vomiting as 42 nursece4less.com nursece4less.com nursece4less.com nursece4less.com part of disease flares should be given treatment and monitored for further problems related to this symptom. Diarrhea Diarrhea is a common clinical manifestation of inflammatory bowel disease. Diarrhea occurs as an increased urge to defecate with loose, watery stools as a result. The inflammation of the gastrointestinal tract causes destruction of the mucosal lining of the intestine, which increases the urge to have a bowel movement. For people with ulcerative colitis and Crohn’s disease that affects the colon, inflammation in the lining of the colon prevents the large intestine from adequately absorbing water from fecal material that passes through. Consequently, the material contains more water when it is expelled from the body, leading to the watery stool of diarrhea. Ulcerative colitis and Crohn’s disease cause frequent diarrhea; the stool is often bloody due to tissue breakdown and sloughing from the ulcers. The affected individual may have more than 10 loose stools per day in severe cases of the disease. Sometimes, the diarrhea contains both blood and pus, particularly if small pockets of infection are present or ulcerated areas contain excess microorganisms. A patient often suffers from increased urgency to have a bowel movement in addition to increased frequency, which is usually stimulated from the chronic inflammation in the intestinal tract. There is often considerable pain with defecation and release of gas. Diarrhea increases the risk of dehydration, so any patient who is struggling with ongoing diarrhea due to IBD should be evaluated for fluid loss and signs of dehydration. Patients should be encouraged to increase their oral intakes of fluids, particularly through fluids that do not contain caffeine or excess sugar, in order to replace some of the fluids lost through diarrhea. Liquid 43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com electrolyte supplements, such as sports drinks may also be needed. Intravenous fluid support is necessary in severe cases of dehydration as a result of chronic diarrhea, which provides not only the needed fluid for the body’s tissues, but the electrolytes lost through frequent diarrhea. The main electrolytes lost through frequent diarrhea include sodium, potassium, phosphorus, and magnesium, all of which can cause serious side effects of weakness, fatigue, and nausea. Diarrhea is most common when an individual is experiencing a disease flare, but during periods of remission, the diarrhea is often limited. The affected individual may still experience diarrhea on occasion during remission, a period that can last months or even years, but the majority of diarrhea that develops with IBD occurs during active symptoms associated with flares. Fulminant colitis, a severe form of ulcerative colitis, may occur in certain patients and can be the cause of significant complications, including toxic megacolon and bowel perforation. The term fulminant describes a condition that develops very suddenly and severely. People with fulminant ulcerative colitis tend to have significant diarrhea, evidenced by over 10 loose stools each day, as well as continuous rectal bleeding. The diarrhea associated with fulminant ulcerative colitis is often sudden and explosive, leading to loss of large volumes of stool and fluid. In addition to severe diarrhea, other symptoms associated with fulminant colitis include abdominal pain and bloating, anorexia, and fever. The condition is also sometimes called toxic colitis. The treatment of diarrhea depends on the extent to which the patient is passing loose stools, as well as whether there is pain, blood loss, or pus present in the stool. Some people find relief by using antidiarrheal 44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com medications, which can be purchased without a prescription. These drugs are useful in slowing intestinal motility so that the bowel has more time to absorb fluid and electrolytes as fecal material passes through. They may also relieve some of the cramping that often occurs with diarrhea. However, patients who take antidiarrheal medications should know that they are only for symptomatic use and they do not cure IBD, nor do they relieve inflammation. The source of the diarrhea is still present, even when taking antidiarrheals. Other medications used to treat Crohn’s disease and ulcerative colitis may help to relieve some of the inflammation in the intestinal tract that is contributing to diarrhea. These drugs are also not a cure for IBD, but they can help to minimize many of the symptoms that develop during flares, such as diarrhea. Treatment with corticosteroids and anti-inflammatory agents can reduce some of the inflammation and ulcerations in the intestinal tract and can promote remission, during which time the affected individual will be less likely to experience diarrhea. Even without a diagnosis of a complication due to Crohn’s or ulcerative colitis, there are instances when diarrhea is so persistent or unrelenting that it warrants medical attention. A patient with IBD should seek medical attention when diarrhea is more than the usual amount noted with flares or when it becomes very heavy and is unrelieved by any measures. Some people pass a small amount of pus or blood with diarrhea, which is not unusual, but larger amounts of pus, accompanied by fever or severe abdominal pain, as well as large blood clots in diarrhea warrant medical attention. Rectal Bleeding Blood loss from the rectum may occur as a relatively common symptom associated with Crohn’s disease or ulcerative colitis. Rectal bleeding is often 45 nursece4less.com nursece4less.com nursece4less.com nursece4less.com associated with diarrhea, in which the patient passes loose stools that contain blood. Mucus and discharge may also be combined with blood through diarrhea. Although rectal bleeding and diarrhea commonly occur together, rectal bleeding may also develop on its own, aside from diarrhea. There are many potential causes of rectal bleeding. Consequently, if a patient has not already been diagnosed with IBD, rectal bleeding and blood with a bowel movement is a cause for further testing. A patient who does have a diagnosis of IBD may become accustomed to some amount of rectal bleeding when disease flares occur. The bleeding may be mild and may consist of a few drops of blood seen on toilet paper; alternatively, rectal bleeding can also be much more serious and may consist of larger amounts of blood as well as blood clots. Frank, red blood indicates bleeding from near the anus or in the rectum, while dark red blood or blood that is mixed with stool is more likely to have passed through part of the intestine tract and indicates bleeding from within the gastrointestinal system. It should be noted, though, that bright red blood could come from higher in the gastrointestinal tract and it is not always an indication of a superficial wound or ulceration. Some patients with inflammatory bowel disease that affects the anus and/or the rectum are more likely to develop rectal bleeding when ulcerations cause tissue breakdown that leads to leakage of blood from the anus. Fissures and cracks in the skin of the anal opening can also lead to blood loss and are sometimes quite painful; however, depending on their depth and severity, fissures may not cause pain with defecation, even though they do often bleed. Patients with perianal Crohn’s disease can have rectal bleeding from various causes, as many of the lesions seen with this particular type of Crohn’s affects the skin around the anus and the perineum. 46 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Fistulizing disease describes an inflammatory bowel condition where the affected patient has developed fistulas or channels between areas of tissue. Patients with Crohn’s disease, because of the transmural nature of the disease, are often more likely to develop intestinal fistulas. A large percentage of fistulas develop around the anus and an opening may develop between the gastrointestinal tract and the outside of the body, such as between the rectum and the skin or between the anus and the vagina. Additionally, internal intestinal fistulas may also develop, which cannot be seen from outside of the body, but may still cause pain and rectal bleeding. In these cases, a small hole actually develops from part of the intestinal tract as the fistula connects the portion of the intestine with a nearby organ or another area of tissue. In some cases, rectal bleeding may be one of the only indications that gastrointestinal complications have developed because of inflammatory bowel disease. Bleeding from the rectum, while somewhat common with IBD, is not a normal process that should be considered simply part of the disease. When it occurs, rectal bleeding must be investigated to rule out potential complications and to prevent other consequences of the condition, such as infection or anemia. Rectal bleeding often contributes to anemia through blood loss, particularly when the bleeding is heavy and chronic. A patient may develop other symptoms in addition to bleeding, such as itching around the opening of the anus, pain with defecation, or unremitting leakage of mucus or fluid from the rectum. Blood loss is often obvious when the individual has a bowel movement or as noted on toilet paper when using the bathroom. In some situations, however, a stool sample may be needed to test for occult blood to determine if there are microscopic particles of blood within the stool or whether bleeding is occurring outside of bowel movements. 47 nursece4less.com nursece4less.com nursece4less.com nursece4less.com A patient experiencing rectal bleeding should have an examination to determine the cause of the bleeding, even if he/she already has a diagnosis of IBD. A stool sample or a sample of the blood can give an indication as to the location of the bleeding and whether there are other factors present, such as a potential infection. A rectal examination can identify the presence of lesions, strictures, fissures, or abscesses that have developed around the opening of the anus. Blood loss that appears dark and that may come from a lesion higher in the intestinal tract typically requires examination and diagnosis with endoscopy. Because rectal bleeding is also a potential sign of colorectal cancer and persons with IBD are at increased risk of developing this type of cancer, a biopsy should be performed to rule out potential malignancy. The patient should be further assessed for complications of blood loss in addition to anemia if the rectal bleeding is frequent or chronic, skin color and overall appearance shows pallor, and vital signs of tachycardia or drop in blood pressure occur, which is indicative of blood loss. The management of rectal bleeding may range from application of medication directly to the anus for minor lesions or fissures that are causing bleeding to possible surgery if damage within the intestinal tract is severe. Underlying sources of the bleeding are typically managed on a case-by-case basis to prevent hemodynamic instability, excessive blood loss, and patient discomfort from this symptom. Abdominal Cramps Cramping is a type of pain often felt in the abdomen that can be caused by a number of sources. Abdominal cramps may vary in intensity and severity and they may be intermittent or a constant source of pain for the patient. Some people experience abdominal cramping shortly after eating a meal, as the process of digestion and absorption affects the movement of food 48 nursece4less.com nursece4less.com nursece4less.com nursece4less.com through the intestinal tract. Cramping may also be associated with increased gas in the bowel, causing intermittent abdominal pain; abdominal cramping is often not serious but it can be quite painful. Cramping often occurs with spasms of the muscles in and around the intestinal tract. The smooth muscles of the intestines normally contract to move food through the gastrointestinal tract during digestion. Smooth muscles of the gut consist of two layers: one is circular and one is longitudinal. These muscular layers work together to flex and contract to promote peristalsis. Intestinal inflammation can cause abdominal cramping when the smooth muscles of the intestines do not work properly, leading to periods of dysmotility. The intestinal tract is a hollow organ that is squeezed by these abnormal contractions, leading to pain because of muscle spasms. The pain may be intermittent and is often irregular, corresponding to the timing of the smooth muscle spasms. The development of inflammation in the intestinal tract typically begins with the mucosal layer of the intestinal wall. This inflammation causes changes in the functions of the smooth muscles through activation of the immune system, which changes the environment. The immune cells, namely macrophages and cytokines, affect the contractility of the smooth muscle cells because they can actually alter the form and morphology of the smooth muscles. Abdominal cramping is often associated with diarrhea, but it can also occur on its own. One reason for abdominal cramping that develops with Crohn’s disease is the malabsorption of fatty acids in the small intestine. The ileum of the small intestine is responsible for fatty acid absorption. When damage from Crohn’s disease affects how these acids are absorbed, they are instead 49 nursece4less.com nursece4less.com nursece4less.com nursece4less.com excreted into the colon and the fat-soluble vitamins contained within them are not absorbed. Consequently, fatty acid secretion into the large intestine leads to abdominal cramping and resultant diarrhea and fluid loss through stool. Abdominal cramping is often associated with disease severity; consequently, a person with mild symptoms of IBD may have only mild, irregular abdominal cramps, while someone with severe inflammation and frequent diarrhea may be more likely to suffer from regular bouts of cramping and pain. Treatment of abdominal cramps may best be achieved by managing the underlying bowel disease through medical therapies designed to control inflammation. When cramping precedes or is associated with diarrhea, control of loose stools through antidiarrheal agents that improve motility may also be helpful in relieving abdominal cramps. Pain relievers such as acetaminophen and ibuprofen are generally not efficient in easing the pain of abdominal cramps. Antispasmodic medications such as hyocyamine and mebeverine may help to control smooth muscle contractions in the intestinal tract that contribute to abdominal cramps. They generally attach to certain receptor sites in the intestinal tract or act as smooth muscle relaxants to relieve spasms and abnormal contractions in the intestinal tract. It should be noted that use of these drugs, as with some other preparations designed to treat symptoms of IBD, do not completely stop the symptoms and only alleviate their severity. Treating IBD and using medical therapies to help a patient achieve remission is one of the only methods of truly eliminating the intestinal cramps that often occur as symptoms of the disease. 50 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Weight Loss Weight loss is a symptom that often occurs over time as the affected patient develops malnutrition and has difficulty absorbing important nutrients. Weight loss may develop in a patient with IBD for various reasons, whether related to malnutrition due to poor nutrient absorption, because of social factors related to eating, or because of loss of important nutrients through frequent and excessive bowel movements and diarrhea. One of the more common reasons for weight loss in patients with IBD is because of malabsorption of nutrients in the gastrointestinal tract. The small intestine is responsible for absorption of a significant amount of nutrients to be used by the body for energy and to maintain overall health. Carbohydrate, fat, and protein absorption, as well as absorption of important vitamins and minerals takes place almost exclusively in the small intestine, which allows the body to continue to maintain healthy organs and tissues. When areas of intestinal absorption become damaged due to IBD, the patient may take in fewer nutrients and more materials may be excreted, unabsorbed in the stool. Over time, the frequent loss of nutrients that occurs during disease flares can lead to electrolyte imbalances, anemia, and weight loss when nutrients are not replenishing the body. Loss of appetite is common with IBD. A person diagnosed with the disease may have a general distaste for food and little desire to eat due to the effects of eating, which sometimes causes rapid symptoms of abdominal pain and diarrhea. A patient may avoid eating to prevent symptoms, further contributing to weight loss. Other effects of symptoms, such as anemia and fatigue, may make eating a chore and the individual may have too little energy to consume much food. Depression because of having a chronic 51 nursece4less.com nursece4less.com nursece4less.com nursece4less.com illness, as well as anxiety over when symptoms may develop can also cause a loss of interest in eating and in food overall, as well as contributing to weight loss and a decrease in overall appearance and self-care. Frequent diarrhea associated with IBD may be another factor that contributes to weight loss. As with damage to the intestinal tract that causes a lack of absorption of important nutrients, diarrhea also prevents nutrient absorption when the transit time of food is greatly increased through the intestinal tract. Instead of getting adequate nutrients from food, the body uses what it has in storage, which can quickly deplete any reserves and can lead to weight loss. A patient with IBD, particularly after a period of time spent struggling with pain and other symptoms, often not only struggles with weight loss, but also develops a general appearance of being unwell. In addition to other symptoms, he/she may also suffer from fatigue, lethargy, and malaise, as well as fever and complaints of joint and muscle pain, which can significantly impact overall activity levels. Symptoms that are unrelated to the gastrointestinal tract often occur during a flare when other gastrointestinal symptoms are also present. People with IBD may need to increase their calorie intake to avoid excess weight loss. This is especially important during times of disease flares when excess diarrhea, vomiting, or bloody stool is present. Patients should be taught about the importance of continuing to eat and selecting the correct foods that will minimize symptoms but still provide energy. An increase of 500 calories per day during times of active symptoms may be necessary for some people with IBD to prevent consistent weight loss. Depending on a patient’s general state of health and the associated symptoms of IBD, a diet plan may be necessary to ensure that the patient is able to take in enough calories to maintain a normal weight. A registered dietitian may be able to 52 nursece4less.com nursece4less.com nursece4less.com nursece4less.com guide the patient toward making appropriate food choices that will ensure adequate nutrient intake. Additionally, the treatment of other symptoms associated with IBD can prevent some weight loss by averting some of the causes of malabsorption and diarrhea. By getting control of other symptoms, resulting weight loss can be controlled and minimized. Diagnosis Of Inflammatory Bowel Disease Diagnosis of inflammatory bowel disease requires testing to specifically identify the disease present and to rule out other forms of gastrointestinal illness, such as diverticulitis, celiac disease, or irritable bowel syndrome. In patients with ulcerative colitis and Crohn’s disease, there are no exact tests that will definitively diagnose the conditions; instead, diagnosis is often one of exclusion of other illnesses when the disease presents with characteristic symptoms and diagnostic measures identify its typical manifestations.66-80,100 For some, diagnosis may take months or years to achieve, particularly when symptoms are intermittent and occur only during flares. For example, in the case of Behcet’s disease, an affected patient may have intermittent abdominal pain, rectal bleeding, and diarrhea that occur over the course of several months. Testing may confirm that the patient has an IBD, but it may take months to actually determine that it is Behcet’s disease and not another inflammatory condition. While it is helpful to know that an IBD is the cause of a patient’s symptoms, certain illnesses may be treated in slightly different ways, so it is important to also know which type of IBD is present to better determine the course of treatment. Some diagnostic tests are routine for anyone seeking help for IBD symptoms. A patient may need initial laboratory testing, such as a complete blood count and metabolic panel, to determine if underlying factors are 53 nursece4less.com nursece4less.com nursece4less.com nursece4less.com present, including anemia, infection, or electrolyte imbalances. C-reactive protein (CRP) is often ordered initially to determine the presence of inflammation; an erythrocyte sedimentation rate (ESR) may or may not be included as part of an initial examination as well. Often, a stool sample is necessary to check for occult blood, the presence of infection or pus, or excess fat in stool and to determine consistency, such as in the cases of chronic diarrhea. There is not one particular type of infectious organism causing IBD that may be found in a stool sample, but there may be indicators of infection or bleeding, including pus, mucus, and blood in the stool. Radiographic images, including abdominal x-rays, are normally not performed as part of diagnostic testing, unless a patient is suffering from such severe symptoms that performing endoscopic procedures would be damaging and too invasive. Abdominal x-rays can be useful in detecting some complications that have developed as a result of IBD, including toxic megacolon or intestinal perforation, so these kinds of tests are often employed when a patient presents with severe symptoms that indicate complications, rather than as part of routine diagnosis of IBD. Physical examination is of some benefit to determine if there are obvious outward signs of IBD, as well as to assess for any extra-intestinal disease manifestations. The health clinician should assess a patient’s history for connections that could indicate a diagnosis of IBD, including assessment of family history of the disease, as well as the frequency and severity of diarrhea and other symptoms present, including their effects on overall health and wellbeing. An examination of a patient’s abdomen usually does not reveal IBD, but it could identify particular areas of tenderness and pain, as well as any masses or bulges that are associated with another illness and 54 nursece4less.com nursece4less.com nursece4less.com nursece4less.com that would most likely rule out IBD. A visual inspection of the anus and the perineum may be necessary if the patient complains of rectal bleeding or has lesions and ulcerations on the anus. A digital rectal examination may be needed in cases of perianal Crohn’s disease. Inspection of the perianal area may show fissures, fistulas, or lesions on the skin and at the anal opening. The digital examination can help the clinician to determine whether stenosis, skin tags, or strictures are present in the anus, but the process should be done very gently to avoid further tissue trauma. When identifying and diagnosing IBD most measures involve inspection and assessment of the intestinal tract to look for characteristic signs of inflammation and ulcers. Diagnostic procedures often include an assessment of stool to check for the presence of inflammation in the gut, visual inspection of the intestinal tract through endoscopy, and evaluating tissue samples through biopsy. Inflammatory Markers in Stool Markers of inflammation found in stool can identify the presence of inflammatory disease. These biomarkers may also help to predict the course of the disease and its severity. When inflammation is present in the intestinal tract, biomarkers will be shed by the inflamed mucosa into the stool; when a stool sample is checked and these markers are present, the clinician can know that inflammation is occurring somewhere along the intestinal tract. Biomarkers of inflammation may indicate the presence of other inflammatory diseases of the gastrointestinal tract as well, so they are not necessarily specific for IBD, but they do provide an initial indication of inflammation. 55 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Calprotectin is one of the main inflammatory markers found in stool when inflammation is present. It is a type of antimicrobial protein found within several kinds of white blood cells. Lehmann, et al., in Therapeutic Advances in Gastroenterology note that calprotectin is most often found in neutrophilic granulocytes, the most abundant type of white blood cell, in which calprotectin makes up almost 60 percent of the cytoplasm within its cells.100 Calprotectin is also found in other cells of the immune system, including within macrophages and monocytes. When there is excess inflammation in the intestinal tract, the inflammatory cells will release calprotectin in the stool as evidence. While the presence of calprotectin does not specifically provide a diagnosis of IBD, the biomarker is elevated in stool samples of patients with ulcerative colitis and Crohn’s disease and its presence can differentiate whether the patient has an inflammatory disease or some other type of gastrointestinal disorder, such as irritable bowel syndrome. Calprotectin, as a biomarker, can be found in other body fluids in addition to stool, including in plasma, urine, synovial fluid, cerebrospinal fluid, and saliva. It is also detected upon biopsy when a sample of tissue from the affected area of the intestinal tract is obtained. However, the stool test for calprotectin is simple and straightforward and is most often used for detecting inflammatory bowel disease. A patient may provide a stool sample for analysis. Because calprotectin is typically found throughout stool in a homogenous pattern rather than settling in certain areas of the sample, almost any test area of the stool can indicate the existence of calprotectin when it is present. This method of testing is an inexpensive and straightforward approach to initially identifying inflammation in a noninvasive manner. 56 nursece4less.com nursece4less.com nursece4less.com nursece4less.com A second type of inflammatory biomarker, lactoferrin, may also be detected in stool in patients with inflammatory bowel disease. Lactoferrin is a glycoprotein that is also released by neutrophils in the intestinal tract. When inflammation develops in the intestine, neutrophils move from the bloodstream into the mucosal wall to engulf antigens and protect the body as part of the immune response. The lactoferrin released from these white blood cells is then shed into the stool, the presence of which can be assessed after a patient has a bowel movement and provides a stool sample. As with calprotectin, fecal lactoferrin levels can differentiate between inflammatory conditions such as IBD and other gastrointestinal disorders that may have similar symptoms, including irritable bowel syndrome. Studies have shown that elevated levels of lactoferrin in the stool are indicative of inflammation caused by IBD, particularly in cases of moderateto-severe inflammatory disease. Lactoferrin is stable within a stool sample and like calprotectin, it can be tested with relative ease and speed after obtaining a stool sample from a patient. Lactoferrin is not specifically diagnostic of IBD; however, it can be used as a screening process to differentiate from IBS, it can assess the severity of flares in patients already diagnosed with IBD, and it can determine whether a patient undergoing a workup for potential IBD requires further testing through endoscopy. In addition to testing inflammatory markers in stool, the health clinician may need to check stool for occult blood and may perform a stool culture to assess for infection within the gastrointestinal tract. Because some kinds of intestinal infections, such as C. difficile infection, can cause similar symptoms to IBD and may even demonstrate inflammatory biomarkers in the stool, further confirmatory testing is often necessary. When inflammatory markers are present in the stool, further testing through 57 nursece4less.com nursece4less.com nursece4less.com nursece4less.com endoscopy is typically required to support this evidence and to definitively diagnose IBD. Colonoscopy The main test used for diagnosis of IBD is colonoscopy, a visual inspection of the components of the large intestine. Colonoscopy is considered the gold standard in diagnosing IBD; the test determines the presence of IBD, its extent and severity, and it can differentiate Crohn’s disease from ulcerative colitis. Colonoscopy enables the endoscopist to visualize the lining of the gastrointestinal tract and to view the condition of the tissues involved. It also allows for tissue sampling for biopsy, which can aid with the final diagnosis of the type of IBD, as well as rule out other possible causes of the patient’s symptoms, including cancer. Colonoscopy is also valuable in that it can act as a guide for treatment. Depending on the extent of damage present and the condition of the tissue within the gastrointestinal tract, the clinician may have a better idea of the most appropriate course to take for treatment, including administration of specific types of medications or surgery as part of management of the condition. Often, colonoscopy is performed early in the diagnostic process, before implementing other measures. The European Crohn’s and Colitis 58 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Organization (ECCO) recommends that an ileocolonoscopy should be performed shortly after a patient is referred for diagnosis of IBD and possibly before introducing any medical therapies. An ileocolonoscopy is an endoscopic examination of the ileum of the small bowel and of the colon. The American Society for Gastrointestinal Endoscopy (ASGE) has the same recommendations for IBD diagnosis. This is because therapy through use of medications may obscure some of the evidence of inflammation that might normally be seen upon colonoscopy. When Crohn’s disease that affects the colon or when ulcerative colitis of the large intestine is suspected, standard colonoscopy, with or without examination of the ileum, is warranted. Colonoscopy allows for inspection of the mucosal lining of the large intestine, including that of the rectum, the colon, and the terminal ileum. Based on the appearance of the affected tissue, colonoscopy cannot only identify inflammatory bowel disease, but it can often differentiate between ulcerative colitis and Crohn’s disease. This type of examination is effective in distinguishing between the two conditions in 90 percent of cases. Patients with ulcerative colitis may begin with flexible sigmoidoscopy as part of endoscopic diagnostic procedures. Flexible sigmoidoscopy allows the healthcare provider to visualize and sample the tissue at the distal end of the gastrointestinal tract and to determine whether the disease has spread beyond the sigmoid portion of the large intestine. The tube used with a sigmoidoscope is shorter than that used with colonoscopy; alternatively, the scope used with colonoscopy is longer and more flexible. Flexible sigmoidoscopy is also particularly effective when a patient is suffering from inflammation that is located primarily in the rectum but not in other parts of the large intestine. It may also be used for patients with Crohn’s disease, 59 nursece4less.com nursece4less.com nursece4less.com nursece4less.com but because Crohn’s tends to impact more areas of the gastrointestinal tract distal to the sigmoid colon, sigmoidoscopy is less often used as a first-line method of diagnosis. A diagnosis of IBD is initially made based on the appearance of the intestinal tract. The tissue may have a grainy texture and it bleeds easily when touched. In severe cases, the lining of the gastrointestinal tract may ooze or bleed freely with no stimulation. The greater the severity of the disease and the longer time period a patient has been struggling with symptoms, the clinician can expect to see more tissue damage upon colonoscopy. Over time, the appearance of the intestinal lining becomes pocked and has deep grooves; the ulcerations may extend to form one or two very large areas of macerated tissue, rather than single areas of ulcers. Abscesses and infection may lead to the release of pus or purulent exudate. Crohn’s disease demonstrates a cobblestone appearance, deep ulcers with skip lesions, and potential involvement of the ileocecum. Fistulas are often more common with Crohn’s disease when compared to ulcerative colitis and there may be rectal sparing, in which the rest of the colon is affected but the rectum is not. Alternatively, characteristics that differentiate ulcerative colitis from Crohn’s disease include continuous areas of inflammation that may extend into the rectum and the anus, abnormal blood vessel patterns, and superficial ulcerations. Ulcerative colitis also sometimes demonstrates a cecal patch of inflammation, in which disease features center around the appendix and the cecum. Strictures and narrowing associated with colonic obstruction tend to be less common in ulcerative colitis and are more frequently seen with Crohn’s disease. 60 nursece4less.com nursece4less.com nursece4less.com nursece4less.com A patient should undergo colonoscopy if there is evidence of complications of IBD, such as toxic megacolon. The procedure of performing a colonoscopy is relatively straightforward and typically painless for the patient. Most people have more trouble with the preparation requirements of the procedure, rather than the actual process, as preparation often requires clearing the colon with a laxative and following a clear liquid diet beforehand. Patients should avoid any elements that may give evidence of intestinal inflammation, such as by using NSAIDs, prior to colonoscopy. If inflammatory markers are not present in the stool, a patient with suspected IBD may still need colonoscopy to officially evaluate the intestinal tract. Colonoscopy should be done for any patient who is suffering from severe symptoms suggestive of IBD, such as iron deficiency anemia, rectal bleeding, and weight loss, to examine the intestinal tract and to determine whether the symptoms have an inflammatory cause or if they are related to another type of gastrointestinal illness. Biopsy Biopsy of the mucosal tissue is an essential part of the diagnostic process. Mucosal biopsy is needed to determine whether a patient is suffering from a type of inflammatory bowel disease or another form of illness that causes intermittent inflammation and/or tissue damage. Following biopsy, the tissue is examined for histologic manifestations specifically associated with certain types of IBD. Because distinctive forms of inflammatory bowel disease may manifest differently when examined microscopically, histological evidence is needed through biopsy to confirm. For example, microscopic colitis, which consists of lymphocytic and collagenous forms, appears differently when examined under a microscope when compared to some other segments of inflammatory bowel. 61 nursece4less.com nursece4less.com nursece4less.com nursece4less.com There is not one specific type of histological criteria available that differentiates IBD from other types of colitis. In other words, examination of a tissue biopsy can only pinpoint what is most likely to be IBD based on inflammation and the presence of certain biomarkers, but the presence of inflammation upon biopsy examination does not definitively diagnose IBD. More than one tissue sample is often needed to get an accurate picture of the condition. During the initial evaluation, the American Society for Gastrointestinal Endoscopy (ASGE) suggests taking at least 2 biopsy specimens from 5 sites throughout the portion of the bowel examined, including the ileum and the rectum. A patient undergoing testing for IBD diagnosis may have a colonoscopy with one or more tissue samples taken to distinguish the type of inflammatory condition present. A tissue biopsy allows the pathologist to determine whether IBD is present and to differentiate what type of inflammatory disease has developed; and, a tissue biopsy provides information to assess a patient’s clinical state and the progression of the disease. Depending on how long a patient had the disease, the tissue samples for biopsy may show variations in cellular appearance suggestive of different stages of disease and healing. James Kyle, author of the book Crohn’s Disease, suggests that histopathological examination of tissues during biopsy should be considered on a spectrum, rather than having a single, exact manifestation. Cellular manifestations that lie within this spectrum could be better indications of an IBD diagnosis. Upon biopsy examination, Crohn’s disease exhibits a granulomatous appearance and the tissue may be thickened, solidified, and inflamed. Because Crohn’s disease is most common in the ileocecal region of the intestinal tract, there is often a greater amount of affected tissue located in 62 nursece4less.com nursece4less.com nursece4less.com nursece4less.com the terminal ileum when compared to other areas of the colon. The surface of the mucosa appears wrinkled with the cobblestone appearance; upon microscopic examination, there may be pockets or clusters of cells and small nodules. There are often collections of white blood cells present due to inflammation and some blood vessels may be more prominent in the submucosal layer of tissue. Alternatively, ulcerative colitis may appear differently upon histological examination. The tissue is damaged from the inflammation and there are often greater numbers of neutrophils present. These white blood cells may have invaded the crypts of the intestinal wall layers and the depths of the crypts may be shortened somewhat. The Paneth cells may have an abnormal appearance and there are greater numbers of certain cells present, including lymphocytes and plasma cells. Diagnosis of other types of IBD often requires biopsy of tissue, as diagnosis following symptoms or visual inspection of the intestinal tract does not always provide confirmation. For example, Behcet’s disease, because it causes skin lesions in addition to gastrointestinal inflammation, often requires a skin biopsy to confirm this specific type of IBD. Diagnosis of Behcet’s may be made following a biopsy of lesions from the mouth, genitals, or skin that develop with this disease. In some cases, strictures are present in the gastrointestinal tract; these occur when the intestinal lumen is narrowed, often from damage due to inflammation. There is a small risk that strictures develop because of tissue hyperplasia, in which the tissue grows abnormally out of control because it contains cancerous cells. When strictures are present, a patient may need to have a biopsy of some of the tissue to determine its substance and to ensure that the tissue is not malignant. Cancerous cells are much less commonly the cause of strictures; instead, they are more likely to develop due to 63 nursece4less.com nursece4less.com nursece4less.com nursece4less.com inflammation and tissue damage, but it is still important to rule out malignancy when strictures develop. A colonoscopy with biopsy is often performed when considering a patient with IBD as a possible surgical candidate. Patients with abnormal cell proliferation in the intestinal tract, as seen with colonoscopy, become surgical candidates for colectomy because of the increased risk of cancer due to cell abnormalities. This abnormal cell proliferation, known as dysplasia, is graded according to its appearance and size. Many surgeons, upon discovering dysplasia in the large intestine, will consider a patient as a colectomy candidate to reduce cancer risk. In fact, the presence of dysplasia, regardless of its size and grade, is an indication for colectomy. Ulcerative colitis and Crohn’s disease increase the risk of colorectal cancer when compared to those in the general population. People who have more severe conditions of colitis and larger portions of the colon affected seem to be at greater risk of colorectal cancer when compared to those who have milder cases of the disease. Additionally, those who have one-third or more of the colon affected seem to have a higher risk of cancer development, according to the Crohn’s and Colitis Foundation of America (CCFA). Patients with extensive disease and symptoms should have routine colonoscopies as directed by their physicians; these tests should also include tissue biopsies from different sections of the intestinal tract to assess for cancerous lesions. Colonoscopy and biopsy are used as part of diagnosis of inflammatory bowel disease in its initial presentation and to differentiate the specific form of the disease; additionally, biopsy may be needed when there are signs of malignancy, and also after a patient has been diagnosed with 64 nursece4less.com nursece4less.com nursece4less.com nursece4less.com IBD due to the increased risk of cancer associated with this type of bowel disease. Summary Despite some of the differences in clinical manifestations and histology between the different forms of inflammatory bowel disease (IBD), there has yet to be confirmation of the exact reason why some people develop the intestinal inflammation and tissue damage associated with this illness. There are various theories on the potential causes of IBD. Research investigations have focused on several contributing factors of gut inflammation with promising outcomes identifying the reason why some people develop IBD. However, despite thorough research and extensive results in this area, questions still remain. There are only possible causes for IBD such as changes in the levels of microorganisms (both aggressive and beneficial) in the gut, genetic factors, predisposition to the disease, and the significance of family history; additionally, important considerations include the role of diet, and the pathophysiological effects of a break in the protective mucosal barrier of the intestinal tract. Understanding the potential causes of inflammatory bowel disease has improved. This has and will continue to improve the chances that this illness can be successfully treated or may someday be prevented from developing at all. Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. 65 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. The exact reason why some people develop intestinal inflammation and tissue damage associated with inflammatory bowel disease (IBD) is a. b. c. d. 2. increased levels of microorganisms in the gut. genetic; i.e., a patient will get IBD if an ancestor had it. not exactly known. always due to poor diet. True or False: Dysbiosis is an imbalance in the number of beneficial and aggressive bacteria normally found in the intestinal tract. a. True b. False 3. The gastrointestinal tract contains trillions of bacteria that are said to a. b. c. d. 4. Two of the most common forms include those from the _________________________ phyla. a. b. c. d. 5. interfere with metabolites. be beneficial to sustaining normal intestinal functioning. generally encourage harmful bacteria. interfere with equilibrium in the gut. Firmicutes and the Bacteroidetes Eubacterium and Lactobacillus Escherichia coli and Mycobacterium avium Enterobacteriaceae and Listeria monocytogenes Normally, the amounts of gut microbiota vary until age ___, and microorganism levels remain stable until approximately age 70. a. b. c. d. 3 12 21 30 66 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. People who have lower numbers of microbial genes are more likely to have higher counts of a. b. c. d. 7. Factors that may impact levels of gut microbiota include all of the following EXCEPT a. b. c. d. 8. pro-inflammatory bacteria in the intestinal tract. antimicrobial molecules known as defensins. microbiota that transform polyphenols. Firmicutes and the Bacteroidetes. diet. socioeconomic status. intestinal homeostasis. use of antibiotics. True or False: Irritable bowel syndrome is the most common form of inflammatory bowel disease. a. True b. False 9. When Clostridium difficile is present in the gastrointestinal tract, it secretes small amounts of a. b. c. d. microorganisms known as fungi. Eubacterium and Lactobacillus. toxins A and B. tumor necrosis factor. 10. People with inflammatory bowel disease may have reduced levels of beneficial bacteria such as a. b. c. d. Lactobacillus. Mycobacterium avium. Enterobacteriaceae. Listeria monocytogenes. 67 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11. One of the most common, extra-intestinal manifestations of inflammatory bowel disease that is not specifically associated with bowel function is a. b. c. d. Clostridium difficile. dysbiosis. intestinal homeostasis. anemia. 12. Escherichia coli contribute to inflammation by adhering to epithelial cells in the mucosa and secreting a. b. c. d. toxins A and B. hepcidin. harmful bacteria. tumor necrosis factor. 13. True or False: It is well-known that many patients with inflammatory bowel disease have a family history of some type of IBD. a. True b. False 14. Red blood cells carry oxygen to the body’s tissues but this process may be affected because decreased iron in the body can impact which of the following processes? a. b. c. d. Production of biomarkers An increase in hepcidin synthesis Erythropoiesis Autophagy 15. Variations in genes, such as a variant in the ATG16L1 gene, may alter the immune system’s functioning and actually stimulate cell destruction of normal tissue by the body, which is known as a. b. c. d. autophagy. intestinal homeostasis. dysbiosis. necrosis. 68 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16. When iron is absorbed by the small intestine, it is bound to the protein _______________ and then transported by this protein to erythrocytes where it is used for erythropoiesis. a. b. c. d. transferrin defensin hepcidin ferroportin 17. True or False: When iron deficiency develops, hepcidin production is suppressed; alternatively, when plasma iron stores are elevated, hepcidin synthesis is increased. a. True b. False 18. Malabsorption of iron due to damaged intestinal tissue is seen more commonly in patients with ________________ who have involvement of the small intestine. a. b. c. d. irritable bowel syndrome ulcerative colitis Crohn’s disease Behcet’s disease 19. Generally, the better option for pain relief for a patient who has severe abdominal pain associated with an acute flare of ulcerative colitis is the use of a. b. c. d. pain relievers. antispasmodic medications. non-steroidal anti-inflammatory agents (NSAIDs). opioid analgesics. 20. A C-reactive protein (CRP) blood test may be ordered for a patient with IBD symptoms to determine the presence of what condition? a. b. c. d. Anemia Infection Electrolyte imbalances Inflammation 69 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21. Radiographic images, including abdominal x-rays, are performed as part of diagnostic testing for IBD a. b. c. d. because it is less invasive than endoscopy. only if endoscopy would damage the gastrointestinal tract. on a routine basis. if the type of IBD is indeterminate. 22. True or False: Iron deficiency and anemia develop when too much iron is excreted, not because of a lack of iron absorption. a. True b. False 23. Vomiting that occurs as a result of pain from inflammation or slowed motility (unrelated to gastric outlet obstruction) could be managed with a. b. c. d. antiemetic medications. opioid analgesics. pain relievers. iron supplements. 24. The main test used for diagnosis of IBD is the a. b. c. d. x-ray. colonoscopy. digital examination. C-reactive protein (CRP) blood test. 25. A patient with regular vomiting may also try the following: a. b. c. d. eat larger meals but less often. try to eat smaller meals but more often. consume more dairy products. drink less to avoid vomiting. 70 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26. The flexible sigmoidoscopy is particularly effective when a patient is suffering from inflammation that is located primarily in what part of the gastrointestinal tract? a. b. c. d. The transverse colon The large intestine The rectum All of the above 27. True or False: Based on the appearance of the affected tissue, colonoscopy cannot only identify inflammatory bowel disease, but it can often differentiate between ulcerative colitis and Crohn’s disease. a. True b. False 28. Flexible sigmoidoscopy may also be used for patients with Crohn’s disease a. b. c. d. as a first-line method of diagnosis. because this disease impacts the entire gastrointestinal tract. impacts the ileum. but not as a first-line method of diagnosis. 29. _______________________, a severe form of ulcerative colitis, may occur in certain patients and can be the cause of significant complications, including toxic megacolon and bowel perforation. a. b. c. d. Irritable bowel syndrome Diverticulitis Fulminant colitis Behcet’s disease 30. In some cases, strictures are present in the gastrointestinal tract; these occur when the intestinal lumen is ____________, often from damage due to inflammation. a. b. c. d. perforated narrowed cancerous widened 71 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31. When strictures are present, a patient may need to have a biopsy of some of the tissue to determine its substance and a. b. c. d. to to to to ensure that the tissue is not malignant. ensure that the tissue is not perforated. identify the type of IBD. identify gastric outlet obstruction. 32. True or False: Lactoferrin is a type of inflammatory biomarker that may be detected in the stool of patients with inflammatory bowel disease. a. True b. False 33. The term fulminant, which refers to a form of ulcerative colitis, describes a condition that develops a. b. c. d. very suddenly and severely. slowing. anywhere along the gastrointestinal tract. inflammatory tissue over time. 34. Diarrhea associated with fulminant ulcerative colitis a. b. c. d. is not usually accompanied by rectal bleeding. typically occurs once a week. is often sudden and explosive. is rarely present. 35. True or False: Colonoscopy is effective in distinguishing between ulcerative colitis and Crohn’s disease in 90 percent of cases. a. True b. False 36. Patients with dysplasia in the intestinal tract have what condition? a. b. c. d. Tumor necrosis factor Imbalance in beneficial and aggressive bacteria Severe anemia Abnormal cell proliferation 72 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37. Fulminant colitis is sometimes called a. b. c. d. abdominal colitis. irritable bowel syndrome. toxic colitis. diverticulitis. 38. True or False: Cancerous cells are commonly caused by strictures. a. True b. False 39. In the case of Behcet’s disease, an affected patient may have _________________ abdominal pain, rectal bleeding, and diarrhea that occur over the course of several months. a. b. c. d. intermittent mild daily severe, hourly 40. A visual inspection of the anus and ________________ may be necessary if the patient complains of rectal bleeding or has lesions and ulcerations on the anus. a. b. c. d. the transverse colon the ileum the perineum All of the above 73 nursece4less.com nursece4less.com nursece4less.com nursece4less.com CORRECT ANSWERS: 1. The exact reason why some people develop intestinal inflammation and tissue damage associated with inflammatory bowel disease (IBD) is c. not exactly known. p. 5: “Despite some of the differences in clinical manifestations and histology between the different forms of inflammatory bowel disease (IBD), there has yet to be confirmation of the exact reason why some people develop the intestinal inflammation and tissue damage associated with this illness.” 2. True or False: Dysbiosis is an imbalance in the number of beneficial and aggressive bacteria normally found in the intestinal tract. a. True p. 7: “A condition known as intestinal dysbiosis occurs when there is an imbalance of beneficial and harmful bacteria or organisms.” 3. The gastrointestinal tract contains trillions of bacteria that are said to b. be beneficial to sustaining normal intestinal functioning. p. 6: “Normally, the gastrointestinal tract contains trillions of bacteria that are said to be beneficial to sustaining normal intestinal functioning.” 4. Two of the most common forms include those from the _________________________ phyla. a. Firmicutes and the Bacteroidetes. p. 6: “There are various species of bacteria existing in the intestinal tract; however, two of the most common forms include those from the Firmicutes and the Bacteroidetes phyla.” 74 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5. Normally, the amounts of gut microbiota vary until age ______, and microorganism levels remain stable until approximately age 70. d. 30 p. 7: “Age is related to the number of microbes found in the gut; the intestinal tracts of newborn infants are colonized at birth, while children and adolescents may have varying proportions of microorganisms, followed by stability of microorganism levels by the age of 30 and remaining so until approximately age 70.” 6. People who have lower numbers of microbial genes are more likely to have higher counts of a. pro-inflammatory bacteria in the intestinal tract. p. 23: “People who are considered to have lower numbers of microbial genes are more likely to have higher counts of proinflammatory bacteria in the intestinal tract, which may contribute to inflammatory bowel disease.” 7. Factors that may impact levels of gut microbiota include all of the following EXCEPT c. intestinal homeostasis. p. 7: “A condition known as intestinal dysbiosis occurs when there is an imbalance of beneficial and harmful bacteria or organisms. Other elements that can impact levels of gut microbiota include diet, use of antibiotics, ethnicity, and even socioeconomic status.” 8. True or False: Irritable bowel syndrome is the most common form of inflammatory bowel disease. b. False p. 37: “While IBD may be confused with irritable bowel syndrome, the two conditions are not the same. However, there is mounting evidence of a connection between inflammatory bowel disease and irritable bowel syndrome (IBS).” 75 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9. When Clostridium difficile is present in the gastrointestinal tract, it secretes small amounts of c. toxins A and B. p. 9: “For example, C. difficile, when present in the gastrointestinal tract, secretes small amounts of toxins A and B, which can destroy intestinal cells.” 10. People with inflammatory bowel disease may have reduced levels of beneficial bacteria such as a. Lactobacillus. p. 11: “In addition to the presence of increased levels of certain bacteria that contribute to inflammation with IBD, people with inflammatory bowel disease have also been shown to have reduced levels of certain types of microbiota in the intestinal tract, especially those that are considered beneficial bacteria, including Eubacterium and Lactobacillus.” 11. One of the most common, extra-intestinal manifestations of inflammatory bowel disease that is not specifically associated with bowel function is d. anemia. p. 26: “One of the most common manifestations of inflammatory bowel disease that is not specifically associated with bowel function is anemia, which is known as an extra-intestinal manifestation of IBD.” 12. Escherichia coli contribute to inflammation by adhering to epithelial cells in the mucosa and secreting d. tumor necrosis factor. p. 9: “E. coli contribute to inflammation by adhering to epithelial cells in the mucosa and secreting tumor necrosis factor.” 76 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13. True or False: It is well-known that many patients with inflammatory bowel disease have a family history of some type of IBD. a. True p. 21: “It is well known that many patients with inflammatory bowel disease have a family history of some type of IBD.” 14. Red blood cells carry oxygen to the body’s tissues but this process may be affected because decreased iron in the body can impact which of the following processes? c. Erythropoiesis. p. 27: “Decreased iron in the body, whether through inadequate iron stores, poor dietary intake, malabsorption, or through blood loss can impact erythropoiesis and results in poor oxygen delivery through diminished production of hemoglobin.” 15. Variations in genes, such as a variant in the ATG16L1 gene, may alter the immune system’s functioning and actually stimulate cell destruction of normal tissue by the body, which is known as a. autophagy. pp. 23-24: “There are some genetic polymorphisms of ATG16L1 that alter the immune system’s functioning and actually stimulate cell destruction of normal tissue. When the immune system is stimulated to this destruction, known as autophagy, the process affects how antigens are exhibited and the immune response may not be activated at the appropriate times. In other words, when autophagy occurs, the body may be destroying healthy cells but failing to recognize the presentation of antigens that it should be fighting off instead.” 77 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16. When iron is absorbed by the small intestine, it is bound to the protein _______________ and then transported by this protein to erythrocytes where it is used for erythropoiesis. a. transferrin p. 27: “When iron is absorbed by the small intestine, it is shifted to transferrin, which is created in the liver. This transferrin can then move iron to erythrocytes where it is needed for erythropoiesis.” 17. True or False: When iron deficiency develops, hepcidin production is suppressed; alternatively, when plasma iron stores are elevated, hepcidin synthesis is increased. a. True p. 27: “When iron deficiency develops, hepcidin production is suppressed. Alternatively, when plasma iron stores are elevated, hepcidin synthesis is increased.” 18. Malabsorption of iron due to damaged intestinal tissue is seen more commonly in patients with ________________ who have involvement of the small intestine. c. Crohn’s disease p. 28: “Malabsorption of iron due to damaged intestinal tissue is another cause of iron deficiency anemia. This condition is seen more commonly in patients with Crohn’s disease who have involvement of the small intestine.” 19. Generally, the better option for pain relief for a patient who has severe abdominal pain associated with an acute flare of ulcerative colitis is the use of d. opioid analgesics. p. 35: “A patient who is having an acute flare of ulcerative colitis may complain of severe abdominal pain that is unrelieved by pain relievers or antispasmodic medications designed to treat cramps and spasms in the gut.… Use of non-steroidal anti-inflammatory agents (NSAIDs), while effective in managing a patient’s pain and inflammation from extra-intestinal symptoms, are not usually warranted for abdominal pain associated with IBD.… Other options 78 nursece4less.com nursece4less.com nursece4less.com nursece4less.com that have been used as alternatives for pain relief include opioid analgesics, antidepressants, and anticonvulsants.” 20. A C-reactive protein (CRP) blood test may be ordered for a patient with IBD symptoms to determine the presence of what condition? d. Inflammation pp. 53-54: “Some diagnostic tests are routine for anyone seeking help for IBD symptoms. A patient may need initial laboratory testing, such as a complete blood count and metabolic panel, to determine if underlying factors are present, including anemia, infection, or electrolyte imbalances. C-reactive protein (CRP) is often ordered initially to determine the presence of inflammation; an erythrocyte sedimentation rate (ESR) may or may not be included as part of an initial examination as well.” 21. Radiographic images, including abdominal x-rays, are performed as part of diagnostic testing for IBD b. only if endoscopy would damage the gastrointestinal tract. p. 54: “Radiographic images, including abdominal x-rays, are normally not performed as part of diagnostic testing, unless a patient is suffering from such severe symptoms that performing endoscopic procedures would be damaging and too invasive.” 22. True or False: Iron deficiency and anemia develop when too much iron is excreted, not because of a lack of iron absorption. b. False p. 29: “As a result, iron deficiency and anemia develop not when too much iron is excreted, but rather as a lack of appropriate iron absorption.” 79 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23. Vomiting that occurs as a result of pain from inflammation or slowed motility (unrelated to gastric outlet obstruction) could be managed with a. antiemetic medications. p. 42: “Treatment of vomiting often depends on its cause. Vomiting that occurs as a result of pain from inflammation or slowed motility (unrelated to gastric outlet obstruction) could be managed with antiemetic medications.” 24. The main test used for diagnosis of IBD is the b. colonoscopy. p. 58: “The main test used for diagnosis of IBD is colonoscopy, a visual inspection of the components of the large intestine.” 25. A patient with regular vomiting may also try the following: b. try to eat smaller meals but more often. p. 42: “A patient with regular vomiting may also try to eat smaller, more frequent meals and should continue to try to drink fluids to avoid dehydration.” 26. The flexible sigmoidoscopy is particularly effective when a patient is suffering from inflammation that is located primarily in what part of the gastrointestinal tract? c. The rectum p. 59: “Flexible sigmoidoscopy is also particularly effective when a patient is suffering from inflammation that is located primarily in the rectum but not in other parts of the large intestine.” 80 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27. True or False: Based on the appearance of the affected tissue, colonoscopy cannot only identify inflammatory bowel disease, but it can often differentiate between ulcerative colitis and Crohn’s disease. a. True p. 59: “Based on the appearance of the affected tissue, colonoscopy cannot only identify inflammatory bowel disease, but it can often differentiate between ulcerative colitis and Crohn’s disease.” 28. Flexible sigmoidoscopy may also be used for patients with Crohn’s disease d. but not as a first-line method of diagnosis. p. 59: “Flexible sigmoidoscopy is also particularly effective when a patient is suffering from inflammation that is located primarily in the rectum but not in other parts of the large intestine. It may also be used for patients with Crohn’s disease, but because Crohn’s tends to impact more areas of the gastrointestinal tract distal to the sigmoid colon, sigmoidoscopy is less often used as a first-line method of diagnosis.” 29. _______________________, a severe form of ulcerative colitis, may occur in certain patients and can be the cause of significant complications, including toxic megacolon and bowel perforation. c. Fulminant colitis p. 44: “Fulminant colitis, a severe form of ulcerative colitis, may occur in certain patients and can be the cause of significant complications, including toxic megacolon and bowel perforation.” 30. In some cases, strictures are present in the gastrointestinal tract; these occur when the intestinal lumen is ____________, often from damage due to inflammation. b. narrowed p. 63: “In some cases, strictures are present in the gastrointestinal tract; these occur when the intestinal lumen is narrowed, often from damage due to inflammation. 81 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31. When strictures are present, a patient may need to have a biopsy of some of the tissue to determine its substance a. and to ensure that the tissue is not malignant. p. 63: “When strictures are present, a patient may need to have a biopsy of some of the tissue to determine its substance and to ensure that the tissue is not malignant.” 32. True or False: Lactoferrin is type of inflammatory biomarker that may be detected in the stool of patients with inflammatory bowel disease. a. True p. 57: “A second type of inflammatory biomarker, lactoferrin, may also be detected in stool in patients with inflammatory bowel disease.” 33. The term fulminant, which refers to a form of ulcerative colitis, describes a condition that develops a. very suddenly and severely. p. 44: “Fulminant colitis, a severe form of ulcerative colitis, may occur in certain patients and can be the cause of significant complications, including toxic megacolon and bowel perforation. The term fulminant describes a condition that develops very suddenly and severely.” 34. Diarrhea associated with fulminant ulcerative colitis c. is often sudden and explosive. p. 44: “The term fulminant describes a condition that develops very suddenly and severely. People with fulminant ulcerative colitis tend to have significant diarrhea, evidenced by over 10 loose stools each day, as well as continuous rectal bleeding. The diarrhea associated with fulminant ulcerative colitis is often sudden and explosive, leading to loss of large volumes of stool and fluid.” 82 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35. True or False: Colonoscopy is effective in distinguishing between ulcerative colitis and Crohn’s disease in 90 percent of cases. a. True p. 59: “Based on the appearance of the affected tissue, colonoscopy cannot only identify inflammatory bowel disease, but it can often differentiate between ulcerative colitis and Crohn’s disease. This type of examination is effective in distinguishing between the two conditions in 90 percent of cases.” 36. Patients with dysplasia in the intestinal tract have what condition? d. Abnormal cell proliferation p. 64: A colonoscopy with biopsy is often performed when considering a patient with IBD as a possible surgical candidate. Patients with abnormal cell proliferation in the intestinal tract, dysplasia as seen with colonoscopy, become surgical candidates for colectomy because of the increased risk of cancer due to cell abnormalities. This abnormal cell proliferation, known as dysplasia, is graded according to its appearance and size. Many surgeons, upon discovering dysplasia in the large intestine, will consider a patient as a colectomy candidate to reduce cancer risk. In fact, the presence of dysplasia, regardless of its size and grade, is an indication for colectomy.” 37. Fulminant colitis is sometimes called c. toxic colitis. p. 44: “In addition to severe diarrhea, other symptoms associated with fulminant colitis include abdominal pain and bloating, anorexia, and fever. The condition is also sometimes called toxic colitis.” 38. True or False: Cancerous cells are commonly caused by strictures. b. False pp. 63-64: “Cancerous cells are much less commonly the cause of strictures; instead, they are more likely to develop due to inflammation and tissue damage, but it is still important to rule out 83 nursece4less.com nursece4less.com nursece4less.com nursece4less.com malignancy when strictures develop.” 39. In the case of Behcet’s disease, an affected patient may have _________________ abdominal pain, rectal bleeding, and diarrhea that occur over the course of several months. a. intermittent p. 53: “For example, in the case of Behcet’s disease, an affected patient may have intermittent abdominal pain, rectal bleeding, and diarrhea that occur over the course of several months.” 40. A visual inspection of the anus and ________________ may be necessary if the patient complains of rectal bleeding or has lesions and ulcerations on the anus. c. the perineum p. 55: “A visual inspection of the anus and the perineum may be necessary if the patient complains of rectal bleeding or has lesions and ulcerations on the anus.” References Section The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. 1. 2. 3. Nair, M., Peate, I. (2015). Pathophysiology for nurses at a glance. Malden, MA: John Wiley & Sons, Ltd. Peppercorn, M., Kane, S. (2016, Sep.). Patient education: Ulcerative colitis (beyond the basics). Retrieved from http://www.uptodate.com/contents/ulcerative-colitis-beyond-thebasics Parray, F., Wani, M., Malik, A., Wani, S., Bijli, A., Irshad, I., Ul-Hassan, N. (2012, Nov.). Ulcerative colitis: A challenge to surgeons. Int J Prev Med. 3(11): 749-763. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086/ 84 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2015, Aug.). Questions and answers about Behçet’s disease. Retrieved from http://www.niams.nih.gov/health_info/Behcets_Disease/default.asp National Organization for Rare Disorders (NORD). (2015). Behçet’s syndrome. Retrieved from http://rarediseases.org/rarediseases/behcets-syndrome/ Skef, W., Hamilton, M., Arayssi, T. (2015, Apr.). Gastrointestinal Behçet’s disease: A review. World J Gastroenterol. 21(13): 3801-3812 Alves, R., Miszputen, S., Figueiredo, S. (2014, Apr.). Anemia and inflammatory bowel disease: prevalence, differential diagnosis and association with clinical and laboratory variables. Sao Paulo Med J. 132(3). Retrieved from http://www.scielo.br/scielo.php?script=sci_arttext&pid=S151631802014000300140 Crohn’s & Colitis.com. (2016). Understanding Crohn’s disease. Retrieved from https://www.crohnsandcolitis.com/crohns University of Maryland Medical Center. (2012, Dec.). Crohn’s disease. Retrieved from http://umm.edu/health/medical/reports/articles/crohns-disease Kim, S. and Koh, H. (2015). Nutritional aspect of pediatric inflammatory bowel disease: its clinical importance. Korean J. Pediatr. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4644763/. Crohn’s and Colitis Foundation of America. (2015, Jan.). Intestinal complications. Retrieved from http://www.ccfa.org/assets/pdfs/intestinalcomps.pdf Crohn’s and Colitis Foundation of America. (2012, Sep.). Understanding your risk: C. diff. Retrieved from http://online.ccfa.org/site/PageNavigator/2012_09_enews_landing.htm l Crohn’s and Colitis Foundation of America. (2015, Jan.). Arthritis and joint pain. Retrieved from http://www.ccfa.org/assets/pdfs/arthritiscomplications.pdf Jandhyala, S.M., et al. (2015). Role of the normal gut microbiota. World J. Gastroenterol. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4528021/. Mace, O.J. and Marshall, F. (2015). Pharmacology and physiology of gastrointestinal enteroendocrine cells. Pharmacol Res Perspect. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4506687/. Kansal, S., Wagner, J., Kirkwood, C., Catto-Smith., A. (2013). Enteral nutrition in Crohn’s disease: An underused therapy. Gastroenterology Research and Practice, Volume 2013, Article ID 85 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 482108, 11 pages. Retrieved from https://www.hindawi.com/journals/grp/2013/482108/ Ruemmele, F. (2016). Role of diet in inflammatory bowel disease. Ann Nutr Metab. 68(suppl 1): 33-41. 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