Ulcerative Colitis, Crohn's Disease and Other Inflammatory Bowel

Ulcerative Colitis, Crohn’s Disease And Other Inflammatory Bowel Diseases

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.

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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.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Course Purpose

To provide health clinicians with knowledge of the etiology, diagnosis and treatment of inflammatory bowel disease.

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.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Inflammatory bowel disease (IBD) is actually a group of disorders that

a. similarly cause inflammation in the gastrointestinal tract. b. affect the same areas of the intestine. c. respond treatment in the same way. d. All of the above

2. True or False: All types of IBD develop along the gastrointestinal tract in the areas of the small or large intestines.

a. True b. False

3. Two of the most common types of inflammatory bowel disease (IBD) are

a. ulcerative proctitis and Crohn’s disease. b. ulcerative proctosigmoiditis and proctitis. c. ulcerative colitis and sclerosing cholangitis. d. ulcerative colitis and Crohn’s disease.

4. Sclerosing cholangitis causes inflammation and scarring within the

a. the cecum. b. bile ducts. c. descending colon. d. the ileum.

5. ______is a chronic condition that causes inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa.

a. Ulcerative proctosigmoiditis b. Behcet’s disease c. Ulcerative colitis d. Sclerosing cholangitis

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction

The chronic gastrointestinal condition of inflammatory bowel disease (IBD) is a recurring disease characterized by inflammation, tissue deterioration, and ulceration in different regions of the gastrointestinal system. The most common types of IBD are ulcerative colitis and Crohn’s disease. The different types of IBDs may develop anywhere along the gastrointestinal tract from the mouth to the anus, although most cases are confined to areas of the small or large intestines. Inflammatory bowel disease causes periods of active illness in which affected persons suffer from multiple symptoms that include pain and diarrhea, followed by periods of remission, in which there are few to no symptoms at all. The chronic nature of the disease has confounded physicians who have researched its causes and the most appropriate forms of treatment to be able to induce remission and alleviate some of the debilitating symptoms.

Overview Of Inflammatory Bowel Disease

Inflammatory bowel disease is actually a group of disorders that all cause similar effects of inflammation in the gastrointestinal tract. The diseases that are classified as IBD often produce similar symptoms, but they also have variations in their causes, the areas of the intestine involved, and their response to treatments. Two of the most common types of IBD are ulcerative colitis and Crohn’s disease. Although there are varying conditions that fall under the classification of being inflammatory bowel diseases, ulcerative colitis and Crohn’s are the most well known conditions of IBD because they are the most common. Both of these diseases cause intestinal inflammation, pain, and tissue damage in the gastrointestinal tract. Ulcerative colitis primarily affects the large intestine, while Crohn’s disease is most 5

nursece4less.com nursece4less.com nursece4less.com nursece4less.com common in the small intestine, but can occur anywhere along the digestive tract. Inflammatory bowel disease has been, at times, confused with some other conditions that affect the gastrointestinal tract, including irritable bowel syndrome and general colitis. While these conditions may be disabling to those who suffer from them, they are not the same as inflammatory bowel diseases, which require extensive treatment and daily management when symptoms develop.

Inflammatory bowel disease is characterized by fluctuations in the course of the disease that involve periods of acute symptoms followed by periods of remission when few or no symptoms are present. During a disease flare the symptoms reappear; a flare can be brief with symptoms lasting for a few days, or the flare could last for months.1 There is greater risk of tissue damage, disease complications, or possibly permanent harm to the patient, when a flare episode becomes prolonged and symptoms persist.

The type and extent of the symptoms that occur during a flare vary between people, as well as the inflammatory bowel disease type. Some people experience debilitating symptoms that affect their ability to live a normal life, while others exhibit mild symptoms that are uncomfortable but that are short lived. Common symptoms that develop during disease flares for people with IBD include diarrhea and urgent bowel movements, rectal bleeding, abdominal pain and cramping, fever, fatigue, nausea and vomiting, and weight loss. The main goals of treatment for IBD symptoms are to induce periods of remission (in which few of these symptoms are present), and to maintain remission for as long as possible.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Ulcerative Colitis

Ulcerative colitis, a chronic condition that causes inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa, was first recognized approximately 150 years ago as a distinct disease. Although clinicians have long recognized the existence of this particular type of inflammatory bowel disease, the underlying causes and the specific forms of treatment are areas where knowledge continues to develop.

Ulcerative colitis typically only causes inflammation of the large intestine and the rectum; alternatively, the small intestine remains largely unaffected. The exact cause of ulcerative colitis and the reasons why some people develop the condition are not known, but research suggests potential environmental or genetic causes. People who develop ulcerative colitis often have a family member with IBD; up to 25 percent of people with ulcerative colitis have a first-degree relative with some form of inflammatory bowel disease. The combination of family history of the disease and environmental triggers, such as infection or smoking cessation, can lead to development of ulcerative colitis.2

An environmental trigger, such as a period of illness or stress, can lead to a period of intense symptoms, further ulcer development and a flare episode. Normally, the person with ulcerative colitis struggles with painful symptoms during times of flares, but these are often on an intermittent basis. The disease has periods of remission and exacerbation when symptoms are present. A trigger that causes a flare activates the immune system, causing an autoimmune response in which the body attacks the lining of the large intestine and/or the 7

nursece4less.com nursece4less.com nursece4less.com nursece4less.com rectum, leading to tissue breakdown and ulcer formation. As discussed, there are various situations and substances that can lead to disease flares.

Although stress is known to be a triggering factor for a disease flare, uncontrolled stress is not the cause of ulcerative colitis or of any other type of IBD. Some people who experience intense emotional stress may suffer from digestive symptoms; the term stress ulcer has even been used among some in the lay public to describe a stomach or intestinal ulcer that develops as a result of stress. While stress and intense emotions associated with difficult situations can be overwhelming and can lead to health issues, it is important to understand that IBD develops due to other causes related to the gastrointestinal tract and inflammation, not solely because of stress. Stress and tension can trigger disease flares and so stressors should be managed to prevent symptom recurrence.

Ulcerative colitis most often occurs in adolescents, young adults, and those of middle age. It is most commonly diagnosed between the ages of 15 and 40 years, and again after age 60. It is less commonly diagnosed for the first time in adults of middle age to older adulthood; however, a diagnosis at a younger age, combined with the ongoing need for the treatment of flares and active disease, may mean that the condition in an affected patient will persist throughout adulthood. Approximately 5 percent of first-time cases of ulcerative colitis are diagnosed after age 60.3 The condition is also more likely to develop in industrialized countries, particularly in the United States and Europe; the increased incidences of ulcerative colitis found in these countries are thought to be partially associated with diet.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com The inflammation that develops with ulcerative colitis affects the lining of the colon, most often the layers closest to the intestinal lumen. This inflammation can occur anywhere in the large intestine; it may only develop in small patches or it could affect the entire colon. In some cases, the rectum is involved as well, or the rectum may be the only site involved at all. The inflammation causes tissue breakdown of the colon’s mucosal layer, leading to sores and ulcers that may contain pus, mucus, or blood. The inflammation and ulcerations are not present at all times; in fact, they may be in various stages of healing, depending on whether the person is in disease remission. During a flare, the inflammation and tissue damage causes multiple symptoms of abdominal pain, diarrhea and an increased need for a bowel movement. The loose stools often contain pus and blood, and episodes of diarrhea may occur many times in a day.

In addition to the classic symptoms associated with ulcerative colitis (diarrhea, abdominal pain, weight loss, and rectal bleeding), the affected patient may suffer from extra-intestinal symptoms that are unrelated to the gastrointestinal tract. There are a number of conditions affecting the liver and the gall bladder that may develop with ulcerative colitis. These illnesses may be more likely to develop because of the close proximity of these organs with the intestinal tract. A small percentage of patients develop sclerosing cholangitis, which causes inflammation and scarring within the bile ducts. Other complications commonly seen with these organs include fatty liver disease, gallstones, chronic hepatitis, and pancreatitis.4 Extra- intestinal manifestations that may be seen with ulcerative colitis that are beyond those affecting the liver, gallbladder, or pancreas include joint and muscle pain, septic arthritis, erythema nodosum (small, red

nursece4less.com nursece4less.com nursece4less.com nursece4less.com bumps, swelling, and inflammation most commonly seen on the fronts of the legs), irritation of the iris of the eye, kidney stones, and deep vein thrombosis.5

Although symptoms can encumber those patients affected with ulcerative colitis, their intensity and severity may fluctuate throughout the course of the disease. When symptoms do develop, their effects are related to the area of the intestinal tract most affected. In the case of ulcerative colitis, because the disease affects the colon and/or the rectum, the patient with the disease will most often suffer from the effects that occur when the large intestine and the rectum are damaged and are not working properly.

Large Intestine

Also known as the colon or the large bowel, the large intestine makes up a significant portion of the final segment of the gastrointestinal tract. The large intestine is the main site of fluid absorption from fecal matter before it is expelled from the body. The large intestine consists of several parts and connects with the small intestine at the cecum; from that point, it is made up of the ascending colon, the transverse colon, the descending colon, and the sigmoid colon, which precedes the rectum and the anus. The large intestine is approximately 2½ inches in diameter and is roughly 7½ feet long.

When inflammation develops within the large intestine, it can impact how well the various areas of the colon are able to perform their routine duties. The inflammatory process is complex, designed as the body’s response to exposure to certain antigens and as a form of protection. 10

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It is well known that inflammation can develop as the body’s response to its own cells in an autoimmune process or as a result of dysregulation of the normal course of cell-mediated or humoral immunity. When inflammation occurs with ulcerative colitis, it may be the result of various factors. The initial triggering factor stimulates the immune system to respond by sending certain substances to the site. In the case of ulcerative colitis, this site is somewhere in the colon or the rectum.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Once activated, the immune system initially sends macrophages to the area, which are designed to engulf and destroy antigens. The activation of these macrophages stimulates the release of more cytokines, leading to the inflammatory cascade, which is the continued activation and release of cells of the immune system to protect the body.

Cytokines are produced by the cells of the immune system, mainly the B cells, T cells, NK cells, and macrophages. The T-helper cells are responsible for producing many cytokines, therefore, inflammatory processes associated with different types of IBD may be driven by either T-helper 1 (Th1) cells or T-helper 2 (Th2) cells.6 In the case of ulcerative colitis, the disease is said to have a Th2-like mediated response, based on the types of cytokines released.3,6 There are a number of different cytokines that may be released during the inflammatory process, and each one plays a specific role. Some cytokines are responsible for inducing inflammation and are considered to be pro-inflammatory cytokines. Interleukin-1 (IL-1), for example, stimulates various cells to initiate inflammation and stimulates the hypothalamus to increase body temperature when inflammation is developing. Tumor necrosis factor-alpha (TNF-α) also further induces inflammation and promotes fever in the affected individual.24

Alternatively, some cytokines are designed to suppress the inflammatory response once it occurs. Interleukin-4 promotes the growth of B cells, while IL-10 inhibits some of the work of macrophages, thereby restraining further inflammation. The role of these cytokines is to initiate repair and healing of tissue when inflammation has developed. One of the main reasons for the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com inflammatory response within the body is to increase blood flow to the affected site, so areas that are inflamed become red and warm. Nearby blood vessels dilate to increase blood flow, which can also increase the risk of bleeding if the tissue becomes friable and breaks down.

The inflammation that develops with ulcerative colitis is associated with a breakdown of intestinal tissue that leads to ulcers in the gastrointestinal tract. The triggering event leads to an inflammatory response, leading to the release of immune cells and inflammatory mediators, which only prolongs the inflammatory response. It is thought that this derangement of the inflammatory response occurs as a result of the patient’s immune system response and subsequent inflammation development. It is also possible bacterial flora present in the intestinal tract of the patient with ulcerative colitis plays a role in affecting the integrity of the mucosal lining of the large intestine, which may make it more prone to tissue breakdown and ulcer formation.3 As mentioned above, a person with ulcerative colitis can develop inflammation and ulcers in any part of the large intestine. The condition ranges in severity from affecting only one portion of the large intestine to causing inflammation and lesions throughout the entire colon.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com The lining of the intestinal tract consists of four main layers: the mucosa, the submucosa, the muscularis layer, and the adventitious layer. While most areas of the gastrointestinal tract consist of these four layers, the cells of the large intestine contain some different elements within its layers. In comparison to some other areas, the cells of the mucosal layer in the large intestine are simple columnar epithelial cells, which are densely packed. The intestinal lumen of the large intestine does not contain villi; the intestinal villi are part of the mucosa of the small intestine. The mucosal layer also contains many goblet cells, which are responsible for secreting mucus into the intestinal tract to keep the surface lubricated. The mucosal layer also contains many crypts, which are chambers that extend down toward the submucosal layer. Stem cells are located in the middle or at the bottom of these crypts, and are responsible for creating new epithelial cells.8

The submucosa contains connective tissue, as well as nerves and blood vessels. These elements provide a supportive framework for the other layers of the large intestine. The muscularis layer contains smooth muscles that are responsible for the contractions of the colon that move materials and feces along the intestinal tract.9 The outer layer, which is the adventitious layer, is responsible for secreting mucus to keep its surface lubricated so that it does not adhere to other nearby organs.

The ulceration associated with ulcerative colitis often begins with stimulation of the inflammatory process and the progresses to tissue breakdown. White blood cells and other inflammatory cells travel to the base of the crypts to form abscesses. The small abscesses that

nursece4less.com nursece4less.com nursece4less.com nursece4less.com have formed within the crypts spread and connect with other nearby abscesses until there is a large area of swollen and damaged tissue. The overlying material then starts to break down and the topmost layers of tissue are shed into the lumen. The ulceration associated with ulcerative colitis often only affects the mucosal and submucosal layers of the intestinal tract, but typically does not extend down into the muscularis layer.3 The disease process associated with ulcerative colitis differs from Crohn’s disease; with Crohn’s disease, ulcerations can extend through all layers of the intestinal tract.

As the inflammation persists and the layers of the colon continue to sustain damage, the mucosal and submucosal intestinal layers become even more swollen and inflamed. There may be pseudopolyps, which have the appearance of polyps, but are actually collections of scar tissue that develop when ulcers are healing. Pseudopolyps are not associated with an increased risk of colon cancer and they are typically not removed unless they cause a blockage in the intestinal tract. The ulcers that develop may be sporadic along the intestinal tract, but more commonly, enough ulcerations form close together and are eventually connected, leading to large areas of ulcerated tissue. The disease may cover one or more segments of the large intestine, depending on severity. In some cases, all areas of the colon are involved. Ulcerative colitis that affects the entire large intestine, including the ascending, transverse, descending, and sigmoid portions is sometimes called pan-colitis.

The inflammation and ulcerations eventually spread through the submucosa of the large intestine. Small fissures and cracks form in the submucosa, which contribute to tissue breakdown. The tissue bleeds

nursece4less.com nursece4less.com nursece4less.com nursece4less.com and becomes necrotic, leading to sloughing of cell debris into the colonic lumen. Over time, scar tissue can develop and the affected portions of the mucosa become thickened and scarred. Many times, only partial healing occurs before the next disease flare, so the patient has areas of ulcers in limited stages of healing alternating with fibrous, thickened tissue.

Increased vascularity to the ulcerated portions of the intestinal tract increases the risk of bleeding. The portions of the colon affected no longer work properly because the tissue has become fibrous and dense, increasing the risks of gastrointestinal complications. The patient often develops frequent and severe diarrhea, dehydration from a loss of fluid through the stool, and sodium imbalances from an inability to reabsorb salt and water in the colon. Ulcerative colitis is also associated with occasional severe complications that require additional treatment and hospitalization.

Because ulcerative colitis primarily affects the large intestine, the patient with this illness is at risk of several complications that are associated with colonic damage, whether due to the physiological breakdown of the intestinal wall and the protective mucosa, or because of the colon’s inability to perform its normal functions due to sustained damage from the disease. A person with ulcerative colitis is at risk of toxic megacolon, a severe complication that can be life- threatening if it is not contained. Toxic megacolon develops when the lumen of the large intestine widens and dilates. Consequently, undigested material and fecal matter cannot be moved through the large intestine. Air and gas also build up within the colon and the patient is at risk of colonic rupture.10 This condition causes severe

nursece4less.com nursece4less.com nursece4less.com nursece4less.com abdominal pain and distention and the patient should seek emergency care for help since toxic megacolon requires prompt treatment to prevent further consequences. Prompt treatment often includes emergency surgery. If toxic megacolon is left untreated it may be fatal.

Bowel perforation is another potential complication that is associated with severe cases of ulcerative colitis. When ulcers are large and deep and inflammation is widespread, the wall of the colon can become weakened to the point that it ruptures, spilling its contents into the abdominal cavity. This can quickly lead to severe infection and can become life threatening if not treated immediately. Bowel perforation is more commonly associated with cases of toxic megacolon. When a patient presents with possible bowel perforation, there are few medical therapies administered once the condition is diagnosed. Instead, emergency surgery is almost always required to remove the damaged areas of the colon.

Ulcerative colitis and other forms of IBD that affect the large intestine increase the risk of Clostridium difficile infection in the gastrointestinal tract. C. difficile infection tends to cause severe diarrhea, which may make it difficult to establish IBD versus C. difficile as the cause of diarrhea. This infection is often a healthcare-associated infection, in which patients contract it while in the hospital or healthcare environment. The infection is also more common among patients who are taking immunosuppressant medications as part of treatment for IBD.11

nursece4less.com nursece4less.com nursece4less.com nursece4less.com In addition to the potential complications described above, ulcerative colitis symptoms during times of disease flares can range in severity from mild to overwhelming. As discussed, ulcerative colitis is characterized by ongoing periods of active symptoms followed by periods of remission. During flares, damage from inflammation and ulcers lead to rectal bleeding, bloody diarrhea, and destruction of the mucosa of the large intestine. Once the flare subsides and symptoms abate, partial healing occurs until the next flare. This partial healing of the affected areas is what is usually involved in the next flare. The affected portions of the large intestine are never quite free from ulceration and diseased tissue, even if the patient is not having active symptoms. Over time, because of the ongoing damage to the intestinal tract, the patient with ulcerative colitis suffers from disrupted bowel function and the large intestine no longer operates in a normal manner.

The damage to the large intestine leaves the affected patient at risk of fluid depletion due to abnormal absorption of water and electrolytes in the colon. There may be subsequent electrolyte imbalances, which can cause a variety of abnormal symptoms as well. During flares, the patient often experiences abdominal pain and when symptoms are worse after eating, he may choose to eat less food in order to avoid symptom development; ultimately, this can lead to weight loss and loss of muscle mass. Ultimately, when large areas of the colon are affected and the patient is experiencing severe symptoms that are significantly impacting quality of life, surgery to remove some of the diseased portions of the bowel may be necessary as part of therapy.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Rectum

The inflammation and tissue destruction of the large intestine seen with ulcerative colitis can also affect the rectum; rectal involvement of ulcerative colitis may be in addition to colonic involvement or it may develop on its own. Approximately 46 percent of patients with ulcerative colitis have rectal involvement, called ulcerative proctitis when it affects only the rectum, and ulcerative proctosigmoiditis when the sigmoid colon is also involved.12

The rectum describes the last six inches of the large intestine; it begins just after the sigmoid colon. As stool passes through the large intestine, it is mostly stored in the descending colon, just before reaching the sigmoid colon. Once the descending colon is full, stool is then passed into the rectum where it is stored until defecation. When the stool enters the rectum, the individual typically feels the urge to have a bowel movement. The end of the rectum terminates in the anus, which is the opening through which stool passes with defecation. Ulcerative proctitis occurs when the inflammation and lesions associated with ulcerative colitis affect this area of the intestinal tract.

Burakoff, et al., in the book Medical Therapy of Ulcerative Colitis, defines ulcerative proctitis as the inflammation and ulcerations of the disease that is limited to the rectum or the first 15 to 20 cm from the anal verge. In contrast, the patient with ulcerative proctosigmoiditis has disease involvement of the rectum but that also extends into the large intestine.13 A portion or all of the sigmoid colon may be involved. The sigmoid colon is approximately 40 cm in length from where it adjoins the rectum. Ulcerative proctitis typically causes uncomfortable symptoms similar to those seen with ulcerative colitis affecting other 19

nursece4less.com nursece4less.com nursece4less.com nursece4less.com areas. The affected patient most often experiences frequent diarrhea and bloody stools; however, some symptoms are more pronounced because of the effects of the disease on the rectum. Tenesmus may be a common symptom with proctitis, which is the sudden and persistent urge to have a bowel movement. Tenesmus may occur even if no stool is present in the rectum and defecation is not imminent. In addition to blood in the stool or diarrhea, the affected patient may have a mucous discharge from the rectum that is not associated with a bowel movement. Damage to the anal sphincter, which normally holds stool in the body until an appropriate time for defecation, may cause leakage of stool from the rectum when diarrhea is present.14

In contrast to the rectum, the sigmoid colon is the lower portion of the large intestine that is situated between the descending colon and the rectum. The sigmoid colon is the narrowest portion of the large intestine. It appears to be S-shaped because of how it curves as it advances toward the rectum. Ulcerative colitis rarely affects only the sigmoid colon; the clinical manifestations of the disease usually also include either the rectum, the left side of the large intestine, or both. Ulcerative inflammation in the sigmoid colon may also be part of pan- colitis when ulcerative colitis affects the entire large intestine.

The symptoms of ulcerative proctosigmoiditis are very similar to those of proctitis. The affected individual often has frequent urges to have a bowel movement and suffers from tenesmus whether stool has passed into the rectum or not. Diarrhea, bloody stools, and mucous drainage from the rectum are also present with proctosigmoiditis. Stool incontinence can occur with leakage of diarrhea, which is often embarrassing for the affected patient; the person with ulcerative colitis

nursece4less.com nursece4less.com nursece4less.com nursece4less.com that leads to stool incontinence may avoid social activities and events to avoid the humiliation of an accidental loss of stool.

The treatments for proctitis and proctosigmoiditis are similar to those of ulcerative colitis that affects other portions of the colon. The patient may benefit from systemic medications that control pain and inflammation and that suppress the immune response. Because of the location of the inflammation, proctitis and proctosigmoiditis are also often managed successfully with medications that are administered rectally, including rectal suppositories and enemas. The direct contact of the medication with the affected tissue may result in greater pain relief and resolution of inflammation with fewer systemic side effects of the drugs.

Crohn’s Disease

One of the most common forms of inflammatory bowel disease is Crohn’s disease, which affects approximately 700,000 people in the United States. Crohn’s is a chronic disease that causes inflammation in the intestinal tract, with periods of disease exacerbations (flares) followed by periods of remission. However, for some people, Crohn’s disease causes continuous symptoms that do not abate without treatment. The disease is thought to affect men and women equally and it most often develops during adolescence and young adulthood, between the ages of 15 and 35 years.15 Crohn’s disease is also sometimes referred to as regional enteritis.

There are many similarities between Crohn’s disease and ulcerative colitis, such that the two conditions are sometimes confused. Although Crohn’s disease affects other portions of the gastrointestinal tract 21

nursece4less.com nursece4less.com nursece4less.com nursece4less.com beyond those impacted by ulcerative colitis, many of the pathological manifestations of these two conditions are so similar that in approximately 10 percent of patients, the actual diagnosis cannot be determined between the two.3

As with other forms of IBD, Crohn’s disease is thought to develop due to a combination of genetic factors and environmental triggers that lead to disease flares. Genetic factors are thought to be more prominent in the development of Crohn’s when compared to some other types of inflammatory bowel diseases.16 Up to 20 percent of people with Crohn’s disease have a relative afflicted with some type of inflammatory bowel disease.15 The environmental triggers that lead to disease flares can occur from any number of events, including severe stress or infection.

Crohn’s disease is more commonly seen in industrialized countries, including the United States and Europe, as opposed to its presence in developing nations. Because of this, certain factors that appear within industrialized countries, including lifestyle factors, pollution, and diet may all play a role in acting as triggers for flares of the disease. Some particular population groups are also at greater risk of developing Crohn’s disease. For example, the condition targets people of Ashkenazi Jewish descent: this population is almost 5 times at higher risk of developing Crohn’s when compared to the general population.16 Crohn’s disease is also more commonly seen in people who are Caucasian and is less common in those of Hispanic or Asian ethnicities.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Unlike ulcerative colitis and some other forms of IBD, Crohn’s disease can cause inflammation along any part of the gastrointestinal tract and is not limited to specific areas. The symptoms that each person manifests often vary, depending on the main area of the intestinal tract affected. For example, an individual with Crohn’s disease affecting the proximal end of the small intestine in the duodenum and jejunum may suffer from anemia and malnutrition due to poor nutrient absorption because of damage to the intestinal wall. Alternatively, someone with Crohn’s disease that impacts the majority of the gastrointestinal tract, including the large intestine, may have lower abdominal pain and frequent, bloody diarrhea.

In contrast to ulcerative colitis, the inflammation and ulceration that occurs with Crohn’s disease can affect all layers of the gastrointestinal tract. This is often described as being transmural, in which the lesions cause full-thickness ulcerations. When the disease affects all intestinal layers, there may be a greater risk of strictures and narrowing of the intestinal lumen, as full-thickness lesions may be more likely to produce scarring.

The transmural nature of the disease also increases the risk of other gastrointestinal complications, such as intestinal abscesses and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com fistulas, which are more commonly seen with Crohn’s when compared to some other types of IBD. The surface of the intestinal lining often appears rough with a “cobblestone” appearance that is characteristic of Crohn’s disease. The areas of ulceration may or may not be consistent and close together. Some affected areas of tissue may contain large patches of ulcerations of varying thickness, while in some other areas, lesions are not connected and there is healthy tissue in between. These ulcers are often referred to as skip lesions and they are more commonly seen with Crohn’s disease, but are less often seen with some other forms of IBD.

Although it can affect any part of the gastrointestinal tract, the inflammation from Crohn’s most often develops in the distal portion of the small intestine — the ileum — and the junction between the small intestine and the cecum, known as the ileocecal region. The symptoms of the disease and the amount of damage caused by the inflammation may range in severity from being classified as mild with few bouts of diarrhea or other symptoms and few complications, to severe, in which the patient has significant symptoms that disrupt daily life and requires extensive medical treatment.

Crohn’s disease not only causes inflammation, pain, and tissue damage within the gastrointestinal tract, but persons diagnosed with this condition also tend to suffer from other systemic problems that are not necessarily related to the intestines at all. Crohn’s disease also tends to cause liver and gallbladder diseases, including an elevated risk for gallstones; patients are also at increased risk of blood clots and their associated consequences, such as stroke and pulmonary embolism. Arthralgia and arthritis are two common extra-intestinal

nursece4less.com nursece4less.com nursece4less.com nursece4less.com complaints; arthritis is said to affect up to 30 percent of people with Crohn’s.17 Some people also develop skin nodules, skin ulcers that appear similar to those seen in the intestinal tract, and psoriasis.

As with other types of IBD, research continues to uncover reasons why some people develop Crohn’s disease, why it flares, and why the symptoms arise. There are a number of factors that can contribute to disease flares in susceptible people, but there are various theories as to why some people are more susceptible to intestinal inflammation than others.

Smoking tobacco is a factor that has been associated with increased incidences of disease flares among those with Crohn’s disease. For those with IBD who smoke, quitting increases the likelihood of maintaining periods of remission. People diagnosed with Crohn’s disease who have quit smoking have reported fewer disease flares, while those who continue to smoke often report increased incidences of flares, increased need for medications to control inflammation, and a more frequent need for surgical intervention.1

Other potential factors that seem to be related to Crohn’s disease development include alterations in specific genes in the body, which can lead to problems with defense mechanisms that would normally protect the intestinal lining. An abnormal response of the immune system is another possible cause of Crohn’s development. As with ulcerative colitis, when inflammation related to Crohn’s develops in the intestinal tract, it is because the body is releasing certain cytokines as part of its defense mechanisms. An alteration in the ability to release cytokines, or a disruption in how the body recognizes certain factors as

nursece4less.com nursece4less.com nursece4less.com nursece4less.com being foreign antigens, can all affect disease development. The T- helper cells also play a role in the inflammatory process associated with Crohn’s disease. As described, ulcerative colitis is considered to have a Th2-mediated response to inflammation, but Crohn’s disease tends to exhibit a Th1 response.18 This classification is given in large part to the types of cytokines produced by the T cells when inflammation of Crohn’s progresses.

As discussed, Crohn’s differs from ulcerative colitis in that it can affect any portion of the gastrointestinal tract. Although it is most commonly seen in the ileum and at the junction of the small and large intestines, Crohn’s disease has been seen in some patients at any area of the gastrointestinal tract, from the anorectal area to the upper GI area of the mouth and esophagus.

Perianal Crohn’s Disease

Perianal Crohn’s disease affects the anus and the surrounding tissues. Perianal Crohn’s may occur as its own set of symptoms or the disease may flare at the same time as other intestinal areas. This particular type of Crohn’s disease is characterized by pain, inflammation, swelling, and lesions around the anal opening, in the anal sphincter, and on the perianal tissue. Approximately one-third of patients with Crohn’s disease develop perianal Crohn’s symptoms.19

People with perianal Crohn’s disease often suffer from symptoms that are similar to those that occur when the disease affects the rectum. There may be a frequent urge to have a bowel movement, and defecation is painful. The affected person may be incontinent of stool from an inability to maintain normal function of the anal sphincter. 26

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Additionally, the individual may have pain or itching around the anus and may pass blood, pus, or mucus with stools. Anal sphincter stenosis may also develop with significant damage from inflammation, in which the tissue around the anus becomes stenotic and the sphincter does not work properly; the opening of the anus decreases in size and there may be difficulty with passing stool. However, for many patients with Crohn’s affecting the anus, these strictures and stenosis develop slowly and they may adjust to routinely passing stool even when the opening has narrowed.20

There is often great discomfort with having perianal Crohn’s disease, whether it is because of physical manifestations that affect the ability to have a normal bowel movement or due to social implications of this particular type of disease. The individual may suffer embarrassment and social anxiety because of an inability to control defecation and fear of stool odor on clothing or of soiling the clothes from stool incontinence. Consequently, Crohn’s disease that affects the anus, while often only impacting one area of the gastrointestinal tract, can still significantly diminish quality of life among affected individuals.

When the tissue around the anus becomes severely inflamed and ulcerated, abscesses can develop in the area. These have the appearance of large sores or boils; the tissue is red and swollen and the sore may be filled with pus. Abscesses are extremely painful for the affected patient. Fistulas, which occur when an abnormal channel forms between tissues, may also develop between the anal opening and the rectum because of deep ulcers that have formed.16 Fistulas may also occur between the rectum and the bladder, the vagina, or the surrounding skin. When a fistula develops, the affected person will

nursece4less.com nursece4less.com nursece4less.com nursece4less.com often experience bleeding and mucus discharge near the opening of the anus. Fistulas around the anus are also very painful for patients when having a bowel movement and the fistula is likely to become infected if not treated. These fistulas are most common in patients with Crohn’s disease when compared to persons with other types of inflammatory bowel diseases.

Anal fissures may also develop as a complication of Crohn’s disease when ulcerated tissue causes skin breakdown at the anal opening. This can cause deep grooves and cracks in the skin, which can be very painful for the patient, particularly when having a bowel movement, and they are more likely to develop as a result of frequent, heavy bowel movements. The fissures can be superficial and only affect the upper layers of skin, or they can be deep. The depth of the fissures is related to the amount of pain it causes for the patient and its ability to heal. Superficial fissures typically heal completely with medical therapy.

Skin tags may appear as benign growths on the skin near or in the anus. These are almost always non-malignant but they also remain once they develop.20 A skin tag may appear during a disease flare but even when symptoms have resolved, the skin tag often remains. The skin tags are also unaffected by treatment and they typically remain, even when other areas are healed because of treatment. Skin tags may become irritated or inflamed, which can be uncomfortable for the patient. Usually they are left alone because they are benign, but if they grow large enough to affect defecation, they may need to be removed.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com The main forms of treatment for perianal Crohn’s involve medications, diet and lifestyle changes, and in some cases, surgical intervention. The main goals of treatment for this specific form of Crohn’s disease are to improve symptoms of pain and stool incontinence, control inflammation, prevent the spread of painful and debilitating complications, and to improve patient quality of life.

Crohn’s Disease of the Large Intestine

Crohn’s disease may affect the large intestine. The disease may be isolated entirely to the colon or it may affect the large intestine in addition to other areas of the gastrointestinal tract. When the disease develops in the large intestine, it can be limited to specific areas of the colon or it may cause tissue damage along the entire length of the large intestine. Crohn’s disease that affects only the ileum and the large intestine is known as ileocolitis. Approximately 50 percent of people with the disease have Crohn’s ileocolitis.21

Crohn’s that affects the large intestine causes the characteristic tissue injury and inflammation as seen in other areas of the gastrointestinal tract. There may be abscesses and pockets of infection at various points along the intestinal tract. Because Crohn’s can potentially cause transmural effects, there may be damage at all layers of the lining of the colon, from the inner mucosal layer to the outer adventitious layer. The effects of Crohn’s in the large intestine impair its ability to carry out normal functioning of fluid and electrolyte absorption. Since the majority of nutrient absorption takes place in the small intestine, the large intestine receives the leftover, undigested material. At the point when this material reaches the large intestine, it is in liquid form. The colon then absorbs much of the water from this material as it passes 29

nursece4less.com nursece4less.com nursece4less.com nursece4less.com through. The material becomes feces by the time it reaches the rectum, due in large part to the absorption of water and salts in the colon and the work of the microbiota within the intestinal tract. When damage affects the large intestine, the affected patient may suffer from electrolyte imbalances and fluid loss.

The patient with Crohn’s disease that affects the large intestine is at risk of several complications that impact this particular area of the gastrointestinal tract, including intestinal blockage, abscesses, and bile salt diarrhea. The ulcers and inflammation from Crohn’s disease can cause scarring in the intestinal tract, leading to thickening of tissue and potentially narrowing the lumen of the colon. The movement of material through the colon slows, which can cause stool impaction.

Because Crohn’s disease affects all layers of the intestinal tract, abscesses, which are pockets of infection that contain pus, can develop in the intestinal wall and cause it to bulge.10 Abscesses are more commonly seen in patients with Crohn’s disease when compared to those with other types of IBD, although they can form in anyone with an inflammatory bowel condition. Because the ileocecal region of the intestinal tract is the main location of bile acid absorption, as well as the most common location of ulcer development in Crohn’s disease, bile salt diarrhea can develop in some patients. This occurs when bile acids are not absorbed and excess fat remains in the gastrointestinal tract. This condition leads to fat malabsorption and causes more bouts of diarrhea.

Crohn’s that affects the large intestine is the type of the disease that most often results in severe diarrhea, rectal bleeding, and anal

nursece4less.com nursece4less.com nursece4less.com nursece4less.com abscesses or fistulas. While other diseased areas of the gastrointestinal tract also cause a number of painful symptoms and potential complications, Crohn’s that primarily affects the colon seems to cause the highest risk of problems. Patients with Crohn’s affecting the colon are also more likely to suffer from extra-intestinal symptoms of the disease, including joint pain and skin lesions.1

Crohn’s Disease of the Small Intestine

The small intestine is the longest portion of the gastrointestinal tract. Its name refers to the diameter of the intestinal lumen rather than its length. The average length of the small intestine is approximately 20 feet long in adults. It connects with the stomach at its proximal end and consists of three main parts, each of which has various functions. The duodenum receives food from the stomach, which is mixed with secretions from the pancreas and liver to promote digestion. The second segment is the jejunum, which starts just after the duodenal- jejunal flexure of the small intestine. It is in the jejunum that the majority of nutrients are absorbed into circulation to be used by the body. The final segment of the small intestine, the ileum, receives the remainder of the material passing through the intestinal tract. Some nutrient absorption takes place in the ileum as well before the rest of the undigested material is pushed into the large intestine.

Nutrient absorption is an essential activity of the small intestine, and damage to this area of the intestinal tract can result in several metabolic consequences, including malnutrition, weight loss, and wasting. The small intestine digests and absorbs nutrients through a specific process that is carried out by its design. As food enters the small intestine, it is known as chyme, which is mixed and moved 31

nursece4less.com nursece4less.com nursece4less.com nursece4less.com through the smooth muscle contractions of the intestine. The luminal surface contains millions of microscopic projections known as microvilli, which greatly increase the surface area of the small intestine and which facilitate nutrient absorption. The intestinal wall also contains lymph channels, which are responsible for absorption of fats and fat-soluble vitamins.

Patients with Crohn’s disease are at risk of malnutrition when the inflammation and ulcers in the small intestine disrupt absorptive processes. The majority of nutrient absorption takes place in the duodenum and the jejunum of the small intestine. After eating a meal, most fatty acids, amino acids from proteins, vitamins, minerals, and glucose from carbohydrates are absorbed in the proximal sections of the small intestine. The ileum is primarily responsible for absorbing vitamin B12 as well as bile salts.

When ulcers and inflammation penetrate these areas of the small intestine, the villi on the mucosal surface are damaged and can no longer absorb nutrients properly. Likewise, fats and fat-soluble vitamins are unable to be absorbed by the corresponding lymph channels. The patient instead passes the nutrients along through the rest of the digestive tract where they are eventually excreted from the body. Malnutrition due to malabsorption in the small intestine can lead

nursece4less.com nursece4less.com nursece4less.com nursece4less.com to a number of symptoms and problems, which can range from electrolyte abnormalities when these nutrients are not absorbed properly to severe weight loss and protein energy malnutrition from loss of fat and protein. Larger sections of the small intestine affected by Crohn’s disease result in a greater risk of malabsorption. Additionally, some patients with severe disease have affected portions of the small intestine surgically removed as part of treatment. This surgical intervention, while often effective in disease management, can contribute to malabsorption and malnutrition.

There are several subtypes of Crohn’s disease that are named based on the area of the intestinal tract most affected. Jejunoileitis describes Crohn’s disease that primarily affects the jejunum and the ileum of the small intestine but few other locations. It is often confused with some other diseases that may only impact only this portion of the intestinal tract, such as celiac disease, irritation from use of NSAIDs, or gastrointestinal infection. Crohn’s disease that is classified as jejunoileitis is often much more aggressive compared to Crohn’s disease in other locations of the gastrointestinal tract.22 The patient with disease manifestations in this area may suffer more severe symptoms, the disease may spread to other areas of the intestine, and there is greater potential for complications. Ileitis describes Crohn’s that affects only the ileum, and ileocolitis affects the ileum and the colon. Ileocolitis is considered the most common form of Crohn’s disease. Other subtypes describe Crohn’s that affects the stomach and duodenum as well as the large intestine only.1

Patients with Crohn’s that primarily affects the small intestine will usually suffer from abdominal pain, and they may also experience

nursece4less.com nursece4less.com nursece4less.com nursece4less.com nausea and vomiting. The symptoms that develop may depend on the area of the small intestine affected. Crohn’s that impairs the duodenum often leads to weight loss, malnutrition, anemia, and loss of appetite. Jejunoileitis often causes severe abdominal cramps after eating, as well as diarrhea and an increased risk of fistula formation. When Crohn’s affects the ileum, there is often severe diarrhea and cramping, accompanied by significant weight loss and an increased risk of fistula and abscess formation.23

Other significant complications can develop as well when Crohn’s affects the small intestine. For some patients, bacterial overgrowth can occur in the small intestine when the normal amounts of bacteria present expand and multiply. Most people with this condition develop abdominal pain, bloating, excess gas, and diarrhea. The symptoms may or may not differ much from symptoms experienced during a disease flare, which may make it difficult to diagnose based on symptoms alone. Bacterial overgrowth typically requires treatment with antibiotics to return the levels of microorganisms back to normal.

Small bowel obstruction describes a condition in which there is narrowing or blockage of an area of the small intestine leading to slowed transit of food and chyme through the digestive tract and impaired nutrient absorption. The patient with Crohn’s disease affecting the small intestine is at

nursece4less.com nursece4less.com nursece4less.com nursece4less.com risk of small bowel obstruction due to damage in the intestinal lining that causes strictures and tissue thickening. The inflammation of the disease leads to fibrotic changes that eventually narrow the size of the intestinal lumen.

Because the small intestine is so long and is centrally located along the gastrointestinal tract, the ability to reach strictures and areas of tissue damage through endoscopy may be limited. A report in the journal Neurogastroenterology & Motility described small bowel strictures as “unresponsive to medical management, necessitating surgical intervention.”24 When strictures develop, small intestinal motility is slowed significantly; this can be quite problematic for the affected individual, as it can cause intestinal obstruction, malabsorption, and malnutrition. As stated, the condition typically requires surgery to correct because of its location within the intestinal tract.

Unfortunately, Crohn’s most commonly affects the small intestine, meaning that patients are at risk of some very serious consequences. The central location of the small intestine and its important work of digestion and absorption indicate that disease development in this area can be destructive to the affected patient’s overall health and quality of life.

Gastroduodenal Crohn’s Disease

Gastroduodenal Crohn’s disease is a subtype of the condition in which inflammation, ulcers, and scarring develop in the stomach and in the duodenum of the small intestine. The antrum of the stomach, which is the largest and lowest portion of the stomach that stores ingested food, is the most common area involved with this type of Crohn’s, 35

nursece4less.com nursece4less.com nursece4less.com nursece4less.com along with the most proximal portion of the small intestine. The manifestations of gastroduodenal Crohn’s disease are often non- specific and may be mistaken for another condition, particularly if Crohn’s has not been diagnosed elsewhere in the intestinal tract. Gastroduodenal Crohn’s disease often has symptoms and manifestations similar to H. pylori infection, peptic ulcer disease, gastroenteritis, or Zollinger-Ellison syndrome, a condition in which there is overproduction of gastric acid and peptic ulcers in the stomach due to a pancreatic tumor.25

People who develop primarily gastroduodenal Crohn’s often have difficulties with eating and may experience anorexia and nausea with consequent weight loss.1 Scarred tissue in the duodenum may restrict the passage of food as the stomach empties into the small intestine and the patient may suffer from increased nausea and vomiting as a result. Other symptoms commonly associated with Crohn’s disease in this area include fatigue, early satiety, dyspepsia described as a feeling of indigestion, and epigastric pain, particularly after eating.

Although Crohn’s disease most commonly affects the small and large intestines, a number of patients have mild concomitant inflammation in the stomach and duodenum. A report in the Video Journal and Encyclopedia of GI Endoscopy stated that 20 to 60 percent of patients with Crohn’s disease undergoing upper endoscopy manifest mild inflammation and gastritis in the stomach and duodenum; however, severe inflammation that causes symptoms of Crohn’s that affects this area of the intestinal tract accounts for only 4 percent of cases.26 Most people who develop Crohn’s disease in the stomach have inflammation and Crohn’s ulcerations in other parts of the intestinal tract as well; if

nursece4less.com nursece4less.com nursece4less.com nursece4less.com the inflammation is only found in the stomach, it is often a precursor to disease development in other areas.25

Gastroduodenal Crohn’s disease causes thickening in the folds of the stomach as well as the characteristically bumpy, cobblestone appearance associated with Crohn’s disease. The tissues in the affected areas, often the antrum and the duodenum, become thickened and digestion and food passage slows. There is inflammation that worsens during time of disease flares, and tissue breakdown leads to ulcerations forming within the stomach cavity and on the interior lining of the duodenum. The affected areas of the stomach pouch cannot distend with food intake because they are thickened. The tissue is erythematous, friable, and easily prone to breakdown and bleeding, and fissures or cracks may form, most often at the junction of the head of the duodenum.25

Crohn’s disease that affects the stomach is treated with similar medical therapies as those used for treatment of the disease in other areas of the gastrointestinal tract, including systemic corticosteroids, immunomodulator drugs, and biologic therapies. If H. pylori infection is present, the patient may need antibiotics to control the spread of the infection. Additionally, most patients with stomach manifestations benefit from proton pump inhibitor medications to control stomach acid secretion. These drugs are often effective in controlling excess gastric acid secretion, but they do not reduce inflammation present with the disease. Therefore, most patients have success in treating gastroduodenal Crohn’s disease with a combination of therapies to suppress gastric acid production and to reduce inflammation and pain.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Gastroduodenal Crohn’s disease increases the risk of gastric outlet obstruction, which occurs as a blockage at the opening between the stomach and the small intestine. The effects of Crohn’s can cause stricture formation when inflammation and lesions affect the lower portion of the stomach, the pyloric sphincter, or the duodenum. The tissue is thickened and does not transport food in a normal manner needed for digestion. The affected patient often suffers from gastroesophageal reflux, frequent vomiting after meals, early satiety, and pain in the area of the stomach.27 Consequently, the person can suffer from significant weight loss and dehydration as well as continued pain and symptoms of gastritis. The condition must be corrected quickly to prevent further health deterioration.

When strictures develop to cause obstruction, endoscopic balloon dilatation may be effective in widening the affected area and it reduces the need for surgical intervention. If gastric outlet obstruction causes enough problems with digestion and results in pain and malabsorption that is ongoing despite attempts at dilatation, the patient may need surgery to remove some of the diseased areas and to widen any strictures that have developed. Approximately one-third of patients with gastroduodenal Crohn’s disease eventually require surgery to manage complications of this particular type of IBD.25

Crohn’s Disease of the Esophagus

Crohn’s disease that develops in the esophagus is a rare form of the illness: of all the locations throughout the gastrointestinal system where Crohn’s disease develops, the esophagus seems to be the area least affected.28 The lesions and inflammation that occur in other parts of the intestinal tract with Crohn’s disease can also develop in the 38

nursece4less.com nursece4less.com nursece4less.com nursece4less.com esophagus anywhere from the pharynx at the back of the throat to the lower esophageal sphincter connecting the esophagus to the stomach. Esophageal Crohn’s disease may sometimes be confused with other inflammatory illnesses of the esophagus, most often gastroesophageal reflux disease.

As with Crohn’s disease affecting the mouth, esophageal Crohn’s disease is most often associated with inflammation and tissue changes of the disease affecting other areas as well, including within the large or small intestines. The esophageal lesions are rarely exhibited prior to a formal Crohn’s diagnosis or as a precursor to intestinal manifestations. In most cases, the individual with esophageal Crohn’s has already been diagnosed with intestinal Crohn’s disease and is managing the symptoms that develop with flares affecting that area of the gastrointestinal tract.

Inflammation and lesions of esophageal Crohn’s are often patchy and may be distributed throughout the esophagus, rather than being localized to one distinct area. Many patients suffer from pain in the back of the throat, non-cardiac chest pain, or epigastric pain, depending on the areas of the esophagus most often affected. The esophageal tissue is often inflamed and fragile and can bleed easily. The affected patient may exhibit blood in the stool that has passed through the digestive tract. Other noted manifestations are similar to the disease in the intestinal tract and include cracks or fissures in the esophagus, a cobblestone appearance to the tissue, thickened folds in the tissue, and even tracheoesophageal fistula, in which tunneling develops between the esophagus and the trachea.28

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Pain and difficulty with swallowing are two of the more common symptoms of this particular type of Crohn’s. A patient may have difficulty swallowing various textures of foods and the patient’s diet may become limited only to foods that he may tolerate. Swallowing liquids can be problematic and there may be an increased risk of aspiration of fluids into the lungs when swallowing is impaired. A patient may have the sensation of food or an object being stuck in his throat. To avoid weight loss and malnutrition associated with poor food intake, the patient may need a modified diet during times of disease flares to be able to take in enough food.

When Crohn’s disease affects the esophagus, the disease flares and periods of remission tend to be correlated with intestinal flares. In other words, when the individual is experiencing severe symptoms associated with a disease flare affecting the intestine, the esophageal symptoms will most likely present themselves at the same time. Alternatively, when the small bowel or colonic symptoms go into remission, the esophageal symptoms also tend to abate at the same time.

The tissue damage and scarring that develops when Crohn’s affects the esophagus it can lead to tissue thickening and narrowing of the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com esophagus. Strictures often develop in the esophagus when the inflamed tissue partially heals before breaking down again. The lumen of the esophagus eventually narrows, which can block the passage of food and fluids into the stomach. The patient may experience difficulty swallowing or may regurgitate food after eating. The condition is most often treated by balloon dilatation, in which a tube is passed into the esophagus and held at the narrowed area. The balloon is inflated at the affected site, which stretches and opens the tissue.

Fistula formation can be a significant complication of esophageal Crohn’s disease. According to Ji, et al. in the World Journal of Gastroenterology, fistula formation occurs in approximately 33 percent of patients with Crohn’s disease.29 Although the majority of fistulas develop near the anus and the perineum, when Crohn’s affects the esophagus, there is the potential for tunneling and connection between the esophagus and nearby airway structures. This type of complication can cause problems with eating and breathing normally and it requires surgical correction to restore normal tissue. Also, a fistula may form between the esophagus and the bronchus (esophagobronchial), between the esophagus and the trachea (tracheoesophageal), or the esophagus and the mediastinum (esophagomediastinal).

Fistula formation occurs when there is enough tissue damage from ulceration or lesions that the tissue breaks down and is eroded away. Diagnosis of an esophageal fistula requires prompt treatment to prevent aspiration of food or saliva into the lungs. Normally, the body’s reflexes close the epiglottis to prevent food from entering the trachea when an individual eats or drinks, but the connection between the esophagus and the airway can still lead to food aspiration if a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com fistula develops, which almost always leads to airway infection and pneumonia if not rapidly treated. The patient is often fed with a feeding tube to avoid trying to swallow food and potentially aspirating food or fluids into the lungs. Surgical intervention is needed to correct the defect and to close the wall between the connecting structures. The process often requires a time of healing in which the affected patient will have pain and difficulty eating and drinking and may need a feeding tube for an extended period until the complication has resolved.

Esophageal Crohn’s disease, while rare, may be underdiagnosed as a clinical entity. Because many of its symptoms are similar to those of other esophageal conditions, it may be incorrectly treated as another illness. It may then take months or even years to formulate the correct diagnosis in this case and to allow for proper treatment and healing of the affected area.

Orofacial Crohn’s Disease

Orofacial Crohn’s disease is a rare sub-type of Crohn’s in which the affected patient develops inflammation and ulceration in the tissues of the mouth in a manner similar to lesions in the intestinal tract. The symptoms of orofacial Crohn’s may appear prior to a diagnosis of intestinal Crohn’s disease or the lesions may develop around the same time as the wounds in the intestinal tract. The individual with orofacial Crohn’s disease almost always has inflammation and ulcers associated with Crohn’s in other areas of the gastrointestinal tract, such as in the small intestine or in the colon.30

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Orofacial Crohn’s disease may be confused with other conditions that affect the mouth; i.e., orofacial Crohn’s disease may be confused with orofacial granulomatosis, which is a condition that causes overgrowth of granulation tissue, primarily in the mouth. However, according to Zbar, et al., in the Journal of Crohn’s and Colitis, the major difference between Crohn’s disease in the mouth and orofacial granulomatosis is that the patient with Crohn’s disease has concomitant lesions and inflammation elsewhere in the gastrointestinal tract, while orofacial granulomatosis typically only affects the mouth.31 Oral Crohn’s disease rarely only affects the mouth. The patient may have mouth lesions as an extension of intestinal Crohn’s manifestations, or the oral form of the disease is a precursor to the development of the intestinal form.

The particular signs and symptoms of orofacial Crohn’s disease include inflammation of the gums and buccal mucosa, swelling of the lips, ulcerations in the folds between the inner cheek and gums, cracks and fissures in the corners of the mouth or on the lips, mucosal tags, periodontal disease and tooth caries, ulcerations on the hard and soft palates, and the characteristic cobblestone appearance on the inner lining of the cheeks.30 Often, affected patients tend to have more than one symptom occurring at the same time.

Crohn’s disease that affects the mouth can be very painful. The lesions, swelling, and fissures can impair food intake and cause difficulties with other activities, including talking, drinking, or swallowing. The patient’s sense of taste may be altered due to the mouth sores, which can make adequate food intake difficult. The oral lesions may make eating and swallowing painful. The patient may be less likely to eat or drink because ingesting food or fluids and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com swallowing may be too uncomfortable. Certain foods are often avoided entirely because they only exacerbate the pain of the condition; many people with mouth lesions avoid any food or liquids that are irritating to the open tissue, such as citrus fruits or drinks, spicy foods, or those that are very salty. Sores may also impact a person’s ability to speak clearly, as the patient may try to compensate for painful lesions on the oral mucosa.

As with Crohn’s lesions that impact other areas of the intestinal tract, orofacial Crohn’s symptoms develop in a pattern of disease exacerbation, or flares, followed by periods of remission for most people. As a person enters a period of remission, the ulcerated tissue in the mouth begins to heal. Depending on the extent of the lesions, the tissue may heal completely or it may form a scar. If the time of remission is relatively short, the ulcer may not have enough time to heal completely before another disease flare begins.

During times of flares, the patient is usually very careful with what he eats and drinks, as this is typically a natural response to mouth pain. In addition to monitoring food and fluid intake, the individual should use a soft toothbrush to gently clean the teeth without damaging gum tissue. Because oral Crohn’s disease is associated with an increased risk of dental caries and periodontal disease, it is important for the affected patient to see a dentist on a routine basis for cleanings and to inspect the oral tissue and the teeth for changes.

The treatment for orofacial Crohn’s disease often involves both systemic and topical preparations. Systemic medications used for the management of intestinal lesions to reduce inflammation and to

nursece4less.com nursece4less.com nursece4less.com nursece4less.com control pain can be helpful in managing mouth inflammation as well. Topical preparations are applied directly to the affected areas of the mouth and may relieve some pain and inflammation on contact. Corticosteroid mouthwashes have been shown to be effective in relieving some pain and inflammation of oral Crohn’s lesions. The patient rinses the mouth with the steroid solution to allow the fluid to contact all surfaces of the mouth and gums before spitting it out.

Antibiotic mouthwashes may also be administered to reduce the risk of mouth infections. There is a risk of infection in the mouth due to food and fluid intake and it is important that the affected patient practice regular oral hygiene to keep the tissues clean. However, the risk of infection is still immediate and the individual may need antibacterial mouth rinses to cleanse the mouth of excess microorganisms that could cause complications such as abscesses in the teeth or gums. Other medications may also be applied to soothe sensitive tissue and to control pain. Some mouth rinses that contain lidocaine act as anesthetics for short periods to numb the tissues and relieve some pain. Oral pastes or gels can also be applied to affected areas to act as anesthetics and control mouth pain.

Additional Types Of Inflammatory Bowel Disease

The majority of the literature focuses on inflammatory bowel disease address Crohn’s disease and ulcerative colitis, as these two forms of the disease make up the greater part of cases of IBD. However, there are additional types of inflammatory bowel diseases that may have similar manifestations and complications as Crohn’s and ulcerative colitis, but that are technically different diseases, whether due to their causes, influences, or manifestations. Additional types of IBD, while 45

nursece4less.com nursece4less.com nursece4less.com nursece4less.com rare, can be just as serious as Crohn’s disease or ulcerative colitis and because of their infrequency, they may be difficult to detect or may be classified as being the same as the former diseases. It is therefore important to understand some other types of inflammatory bowel diseases that may be less common but that require their own forms of treatment and management.

Microscopic Colitis

A less common form of inflammatory bowel disease, microscopic colitis, is a condition in which there is inflammation of the gastrointestinal tract. The inflammatory process of this disease may not be fully apparent on visual inspection or examination.

The condition was observed for decades but it was not until 1980 that researchers devised an actual term for the illness.32 A patient suffering from microscopic colitis experiences pain and diarrhea but there is no obvious source during examination. The condition only affects the large intestine, the sigmoid colon, and the rectum. This specific type of inflammatory bowel disease most commonly affects older adults, with a higher percentage of older females than males affected by collagenous colitis, one of the subtypes of the disease.71 46

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Microscopic colitis is often classified as being one of two different types: lymphocytic colitis and collagenous colitis.34 The two classifications often appear very much the same but have differences in histopathology. Lymphocytic colitis results in an increased number of lymphocytes. The tissue usually appears normal but with more lymphocytes than typical within the sample. Diagnosis of lymphocytic colitis involves a tissue sample that is examined microscopically. The tissue shows an increase in the number of lymphocytes in the tissue and the epithelial layer of the mucosa in the affected area is damaged. There is also inflammation or damage to the connective tissue layer of the mucosa but not an increase in the amount of collagen present, as is seen with collagenous colitis.33

Collagenous colitis occurs when areas of collagen under the epithelium solidify and the tissue overall becomes concentrated and thick. Collagen is normally present in the submucosal layer of the intestinal tract, so evidence of collagen in a tissue sample for biopsy does not necessarily isolate collagenous microscopic colitis. The condition is considered to be the collagenous form of the disease when the collagen has thickened and there is a greater than normal amount present. It may be necessary to visualize several tissue samples to make a comparison between the amounts of collagen present in different areas of the intestinal tract. Upon histological examination, collagenous colitis demonstrates a band of collagen underneath the epithelial layer of at least 10 µm; it also shows damage to the epithelial cells of the intestinal tract, and damage to the lamina propria, which is a layer of connective tissue that makes up part of the mucosal layer of the intestinal tract.33 Collagenous microscopic colitis may or may not involve increased numbers of lymphocytes within the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com tissue as well. The actual incidence of this subtype of microscopic colitis is approximately 1.8 cases per 100,000 people.32

Microscopic colitis is diagnosed after a tissue sample has been examined for microscopic evidence of inflammation and tissue damage. During endoscopy used for diagnostic procedures, the physician is usually not able to see any evidence of inflammation, even though the patient complains of symptoms. The intestinal mucosa, upon endoscopy, appears normal or almost normal. However, when chronic diarrhea is present and the patient is experiencing colitis symptoms, a biopsy should be performed to further examine the tissue samples for evidence of microscopic inflammation.

The exact cause of microscopic colitis is unknown. As with Crohn’s disease, ulcerative colitis, and other forms of IBD, microscopic colitis development may be related to a combination of genetic factors and environmental triggers; intestinal irritation due to chronic NSAID use, autoimmune factors, or a combination thereof may also be possible causes of this particular type of inflammation. Lymphocytic and collagenous microcolitis cause the same kinds of symptoms, even though they appear differently on a microscopic level and their disease processes differ slightly. People with microscopic colitis typically have frequent, watery diarrhea with or without abdominal pain and cramping; patients may have 5 to 10 watery stools per day, but some people have many more. The diarrhea is not caused by infection and there are few other complications associated with the condition, unlike some other forms of IBD. The stool output of microscopic colitis also often differs from some other types of IBD in that stool is loose but does not contain blood, pus, or mucus.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com The Crohn’s and Colitis Foundation of America (CCFA) states that there may be a link between microscopic colitis and celiac disease, an autoimmune condition in which damage develops in the intestinal tract after ingestion of gluten, a protein found in wheat products. The connection is considered because some people with celiac disease have microscopic inflammation in the intestinal tract that appears similar to that often seen with microscopic colitis.35 The symptoms between microscopic colitis and celiac sprue are also similar in that they cause chronic diarrhea and abdominal pain. When formulating a diagnosis for the cause of intestinal pain and inflammation, celiac disease should be ruled out as a possible cause of the inflammation of microscopic colitis by performing a thorough histological exam to assess the affected cells.

Microscopic colitis can often be managed with anti-diarrheal medications to control stool bulk by slowing intestinal motility so that more water can be absorbed in the large intestine. These products are available by prescription or they can be purchased as over-the-counter preparations. Patients with microscopic colitis may take these anti- diarrheal medications to help control their symptoms of diarrhea and abdominal pain, but patients should know that these drugs do not actually treat the inflammation or cure the disease. Some types of drugs that may be used include loperamide or diphenoxylate.

The treatments for inflammation associated with both types of microscopic colitis are typically the same. To treat the inflammation that occurs with microscopic colitis, the patient often needs some of the same medical therapies as those used for management of other types of IBD, including some anti-inflammatory medications or

nursece4less.com nursece4less.com nursece4less.com nursece4less.com immunomodulators. Corticosteroids may also be used on a short-term basis when symptoms are severe, but these drugs are not recommended as part of long-term treatment for microscopic colitis.

Approximately 7 percent of patients with the collagenous form of microscopic colitis also suffer from inflammatory arthritis that affects one or more joints in the body.32 It is usually managed through anti- inflammatory drugs administered for treatment of the colitis. Other autoimmune diseases may also be associated with collagenous microscopic colitis, which may indicate a potential connection between this type of IBD and an autoimmune process. Common conditions that are seen with collagenous colitis include Sjögren’s syndrome, thyroiditis, and myasthenia gravis.

Unlike Crohn’s disease or ulcerative colitis, microscopic colitis has not been shown to increase the risk of colon cancer. The disease, while producing inflammation and some of the same symptoms as other types of IBD, does not necessarily cause the same complications and problems. While patients with microscopic colitis still often struggle with its symptoms and it is a form of inflammatory bowel disease, the condition often responds well to treatment and is rarely serious enough to lead to some of the harmful outcomes that are sometimes seen with other forms of IBD.

Diversion Colitis

Diversion colitis refers to inflammation of the mucosal lining of a part of the intestinal tract that is not functional, often because of surgery for the creation of a colostomy. With placement of a colostomy, the feces are directed through a certain portion of the bowel so that they 50

nursece4less.com nursece4less.com nursece4less.com nursece4less.com will be excreted through the stoma and into the colostomy bag. The defunctioned colon is the portion of the intestinal tract that has been diverted from the fecal stream because of a diverting colostomy. It is this defunctioned portion of the colon that develops inflammation associated with diversion colitis.

Diversion colitis develops in the large intestine and is usually considered to be benign, although it can cause unpleasant symptoms and some complications for affected patients. Patients with diversion colitis develop lymphoid follicular hyperplasia, which is an increase in the size of lymph node follicles due to increased numbers of white blood cells. The condition also causes bleeding of mucosal tissue, mucous plugs, edema, ulcerations, and erythema, and the tissue overall becomes more fragile. While lymphoid follicular hyperplasia is a very common element in patients who develop diversion colitis, there is not one single identifying characteristic of the condition.

Unlike many other forms of IBD, diversion colitis is usually asymptomatic or produces only mild symptoms. As a result, many cases go undiagnosed or are misdiagnosed as another type of IBD or as another gastrointestinal condition altogether, such as irritable bowel syndrome. Of patients who do experience symptoms, the most common manifestations include abdominal pain, pain in the pelvic or rectal areas, tenesmus, low-grade fever, and blood and mucosal discharge from the rectum.36 Symptoms can develop right away following colostomy surgery or they may take several years to manifest.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com The reason some people develop diversion colitis are not clear. Several potential causes of the condition have been hypothesized, including bacterial overgrowth, malnutrition, bowel ischemia, low levels of short- chain fatty acids, or the presence of certain toxins in the intestinal tract.36 Diversion colitis may also be more likely to develop as a type of immune response, however, further research is needed to determine if this type of response is an actual factor in disease development.

Patients who have undergone colostomy or ileostomy are those who suffer from diversion colitis when it develops. Some patients have preexisting IBD, which is the reason for colostomy placement to begin with. A review by Kabir, et al., in the International Journal of Surgery found that of patients who developed diversion colitis who had colostomies, 91% already had a diagnosis of inflammatory bowel disease. Approximately 87 percent of patients with preexisting ulcerative colitis and 33 percent of patients with Crohn’s disease suffer from symptomatic diversion colitis;36 unfortunately, despite undergoing surgical intervention as treatment for IBD, diversion colitis may develop afterward. Although diversion colitis may not be as significant in symptoms as other cases of ulcerative colitis or Crohn’s disease, it remains a complication that warrants treatment following surgical management and colostomy.

Once the bowel has been restored and reanastomosis has been achieved, diversion colitis almost always resolves. In fact, following reanastomosis and resolution of diversion colitis, many patients develop symptoms that seem unrelated to typical IBD symptoms, such as constipation, dyspepsia, and abdominal bloating.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Some people with diversion colitis have been treated with enemas that contain short-chain fatty acids. Normally, bacteria in the colon help to ferment dietary fiber and produce short-chain fatty acids. These fatty acids are responsible for upholding some of the structure and integrity of the gastrointestinal tract. They are also absorbed in the large intestine during the process of sodium and water absorption through the colon. Once they are absorbed, they provide fuel for the epithelial cells of the colon. They are thereby beneficial in maintaining a healthy intestinal tract; however, those with diversion colitis have been shown to have low levels of these short-chain fatty acids in the gastrointestinal system. This is typically because of the colostomy surgery. The fecal stream, which is the process of feces moving and being routed through the intestinal tract, normally supplies short-chain fatty acids to the cells of the colon; however, with a colostomy, the cells in the diverted portion of the bowel do not receive as many short- chain fatty acids, which can affect their integrity and can lead to symptoms of diversion colitis.37

An early study in the New England Journal of Medicine tested the effects of enema administration of short-chain fatty acids in solution to patients with diversion colitis and found that patients who received enemas had diminished colitis symptoms and decreased intestinal inflammation. The symptoms returned when the enemas were discontinued. One patient maintained remission from diversion colitis for 14 months by administering twice-daily enemas of short-chain fatty acids.38 Despite these findings, there have been other studies that have not resulted in the same outcomes and have found little evidence of the success of short-chain fatty acid administration. Still, since some patients have benefited from this type of therapy, it may be an

nursece4less.com nursece4less.com nursece4less.com nursece4less.com option for treatment of diversion colitis, particularly in situations where other measures do not seem successful.

Because diversion colitis is only seen among patients who have had colostomy or ileostomy surgery to divert a portion of the intestine, the condition is not as frequently seen as other types of IBD. However, it is a very real complication for those who have undergone surgery and who develop its symptoms. Any patient who is preparing for ostomy surgery as treatment of IBD should be educated about the potential for diversion colitis as a possible complication. Although it is relatively uncommon, education about the condition can still prepare surgical patients for the possibility of needing to handle this outcome.

Behcet’s Disease

Behcet’s disease is a form of IBD that is more common in Middle Eastern countries and in Asia when compared to the United States. Behcet’s disease is an inflammatory condition that causes ulcers in the mouth and on the genitalia, as well as inflammation in the gastrointestinal tract, blood vessels, the eye, the brain, and the spinal cord. A Turkish physician, Dr. Hulusi Behçet, first discovered the disease in the 1930s.39

Behcet’s disease most commonly develops in young adults, but it has been seen in people of all ages. As with other types of IBD, the inflammation that occurs with Behcet’s often develops as a result of a triggering event in susceptible people. Those who have a family history of inflammatory bowel conditions or autoimmune disease are more likely to develop Behcet’s disease and when an environmental trigger happens, inflammation and ulcers develop. Behcet’s is thought to be 54

nursece4less.com nursece4less.com nursece4less.com nursece4less.com an autoimmune process in that the associated inflammation occurs when the body attacks its gastrointestinal and vascular systems. Other studies have found that people with Behcet’s are more likely to have a specific type of human leukocyte antigen in the blood but the exact mechanisms for why these individuals then develop Behcet’s disease is not entirely clear.40

In addition to being classified as a type of inflammatory bowel disease, Behcet’s is also a musculoskeletal disorder because it is a type of vasculitis that causes inflammation of the blood vessels. In fact, most of the symptoms that develop with Behcet’s disease are from the effects of inflammation of the blood vessels in the affected individual. The majority of people with Behcet’s develop aphthous stomatitis: inflammation and ulcerations in the mouth that are similar in appearance to canker sores. These ulcers are painful and can make eating very difficult. The ulcers are usually round with erythematous borders and they may be shallow or they can be deep enough to impact more than one layer of tissue. Often, ulcers develop as single lesions but they can form clusters as well. They occur during flares of Behcet’s disease and then heal during periods of remission, usually without causing permanent scarring.40

Approximately half of all patients with Behcet’s disease also suffer from ulcers on the genitalia.39 These areas of inflammation and ulceration are most prominently found on the scrotum in men and on the vulva in women and are similar in appearance to the ulcers and sores that develop in the mouth. However, unlike the mouth sores associated with the condition, the ulcers that develop on the genitalia

nursece4less.com nursece4less.com nursece4less.com nursece4less.com with Behcet’s are often deeper and tend to leave scars after they have healed.40

There are various other symptoms seen with Behcet’s disease that do not necessarily affect the gastrointestinal tract, including sores on the skin, which appear as red, pus-filled lesions. There may be inflammation of the eye, most commonly the iris and the uvea, although the retina may also become inflamed and the patient may have vision loss, excess tear production, and photophobia. Severe cases of eye inflammation may lead to complete blindness. Because the disease tends to affect persons of Middle Eastern and Asian descent more commonly than in Europe or the United States, cases of eye inflammation are much more common in impacted countries. Behcet’s disease eye involvement is the leading cause of blindness in Japan.40

Central nervous system involvement leads to meningitis or meningoenchephalitis, and the affected patient may develop severe headaches, problems with walking or coordination, and seizures. The disease affects the vascular system, causing thrombophlebitis, which leads to pain, swelling, and inflammation associated with small blood clots in the peripheral vascular system. Approximately 50 percent of patients with Behcet’s disease develop arthritis in one or several joints in the body, causing pain, swelling, and difficulties with joint movement.40 The joint inflammation is more severe during times of flares.

Behcet’s disease also affects the gastrointestinal tract when ulcers develop along the intestinal lining. The ulcers are similar to the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com aphthous stomatitis found in the mouth with this condition. The ulcers cause symptoms of abdominal pain and diarrhea. When the ulcers bleed, the patient also demonstrates blood in the stool. Often, the ulcerations and their accompanying symptoms are similar to and sometimes mistaken for Crohn’s disease or ulcerative colitis. It is therefore important to understand the signs and symptoms that are common to Behcet’s but that are not present with ulcerative colitis or Crohn’s disease.

According to the International Study Group for Behcet’s Disease, a diagnosis of Behcet’s disease can occur when the patient has had mouth sores at least three times in the past 12 months. In addition, other common symptoms of Behcet’s include eye inflammation with loss of vision, recurring genital sores, skin lesions, or a positive pathergy test, in which a reaction develops following a small skin prick.39,41

The gastrointestinal manifestations associated with Behcet’s can lead to significant disability and increased mortality for affected patients. The oral ulcers that develop with Behcet’s are early signs of the disease, while gastrointestinal involvement tends to develop between 4 and 6 years after initial onset of symptoms. The gastrointestinal ulcers of Behcet’s disease can develop at any point along the gastrointestinal tract, including within the large and small intestines; however, the most common location of ulcer development is near the ileocecal valve. The ulcers can also develop on other organs of the gastrointestinal system, such as the stomach and the pancreas.41

nursece4less.com nursece4less.com nursece4less.com nursece4less.com According to Skef, et al., in the World Journal of Gastroenterology, the gastrointestinal effects of Behcet’s disease are classified according to two different types: neutrophilic phlebitis and large vessel disease. It is the neutrophilic phlebitis that causes inflammation and ulcer development. In contrast, those with large vessel disease suffer from inflammation of the blood vessels that support the gastrointestinal tract, mainly the mesenteric arteries, which leads to blood vessel occlusion and resulting ischemia and infarct.41

Because ulcers can develop anywhere along the gastrointestinal tract with Behcet’s the symptoms the patient experiences may be specific to the region of the area involved. For example, while rare, esophageal ulcers can develop in some people with Behcet’s disease, which can cause symptoms of dysphagia, odynophagia, and chest pain behind the sternum, and the patient may experience symptoms consistent with relaxation of the lower esophageal sphincter. Persons with ulcers affecting the stomach and duodenum may suffer from symptoms similar to those of pyloric stenosis or from gastroparesis.

The most common areas of ulcer development in gastrointestinal cases of Behcet’s are in the ileum of the small intestine, the cecum, and the junction between the small and large intestines at the ileocecal valve. The entire large and/or small intestine may also be affected; however, ulcer development in the rectum is very rare, accounting for approximately 1 percent of patients. The patient with inflammation and ulcers from Behcet’s is at risk of numerous complications, including stenosis and strictures in the intestinal tract, fistulas, abscess formation, and intestinal perforation.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com The treatment of Behcet’s disease is often similar to that used for Crohn’s disease and ulcerative colitis and may consist of systemic corticosteroids, immunomodulator drugs, and biologic agents to control inflammation. These drugs are not only helpful in reducing inflammation in the gastrointestinal tract but they often manage the inflammation of other body systems that are prominent with this particular disease. In addition to these therapies, various medications may be used to treat specific problems associated with Behcet’s, such as eye drops to prevent corneal or retinal damage, mouthwash that controls pain and inflammation in the mouth and throat, and topical ointment for genital ulcerations.

Although Behcet’s disease has many similarities to Crohn’s and ulcerative colitis, it is fortunately a rare type of autoimmune disorder. A patient who develops this particular disease may be able to manage its symptoms and prevent complications through standard therapy used for other forms of inflammatory bowel disease.

Indeterminate Colitis

There are times when it is difficult to determine the actual type of inflammatory bowel disease as symptoms may overlap with one another. When it is not clear whether a patient’s symptoms are caused by Crohn’s disease or ulcerative colitis, the patient is diagnosed with indeterminate colitis. Approximately 15 percent of people with IBD have indeterminate colitis.42

People with indeterminate colitis typically have symptoms only affecting the large intestine. This means that the condition could be ulcerative colitis or Crohn’s disease affecting only the colon. 59

nursece4less.com nursece4less.com nursece4less.com nursece4less.com A diagnosis of Crohn’s disease or ulcerative colitis obviously requires extensive diagnostic testing that includes a review of the patient’s symptoms, a physical examination, laboratory testing, a complete medical and family history, endoscopic procedures to visualize the intestinal tract, and often a biopsy to test tissue histology. Despite the extensive nature of diagnostic testing available for these specific diseases, there are times when it is still unclear which type of IBD is present. Both ulcerative colitis and Crohn’s disease have diagnostic criteria that must be present to make a formal diagnosis. Indeterminate colitis may be a diagnosis given when symptoms affect the large intestine and the patient does not have enough diagnostic criteria to completely fulfill a diagnosis of either Crohn’s disease or ulcerative colitis.43

According to an article in the Journal of Gastroenterology and Hepatology Research, indeterminate colitis is considered to be a temporary diagnosis, given to initiate treatment for the affected patient and put in place until further testing or changes in the pathophysiology of the disease reveals which type of IBD is present.43 Although the term is somewhat controversial for use, indeterminate colitis is included as part of the International Classification of Diseases, Tenth Revision (ICD-10). Some clinicians prefer to call the condition Inflammatory Bowel Disease, Unclassified.

Indeterminate colitis typically possesses many of the same physiological manifestations in the colon as seen with Crohn’s disease and ulcerative colitis, although the severity and intensity of the condition varies between patients. The disease causes areas of inflammation in the large intestine that may lead to tissue breakdown

nursece4less.com nursece4less.com nursece4less.com nursece4less.com and necrosis of ulcers. The ulcerations may affect one or more layers of the intestinal tract, often leaving no indication as to whether the condition is actually Crohn’s disease, which often causes transmural ulcerations, or ulcerative colitis, which typically only affects the first two layers of the colon.

The inflammation and ulcerations associated with indeterminate colitis are often seen throughout the entire large intestine but rarely in the rectum. Often, the right and transverse sections of the colon are affected more frequently than the left side.43 There may be intermittent alterations in tissue areas that give the appearance of skip lesions associated with Crohn’s disease. Some areas of the bowel may be dilated slightly and fissures can be present. The fissures that are seen with this type of colitis often differ from those noted with Crohn’s disease. Fissures associated with indeterminate colitis are described as “knife-like” because of their appearance and depth.43 They may also appear V-shaped, with wider openings on the mucosal surface and becoming narrower with greater depth.

Patients with indeterminate colitis also suffer from a variety of symptoms that are similar or even the same as those seen with other forms of IBD, including frequent diarrhea, abdominal pain, rectal bleeding, and abdominal cramping. The symptoms may be exacerbated during times of disease flares and may then dissipate when the patient enters remission.

The treatment for indeterminate colitis is often similar to that given for ulcerative colitis. Many patients with this type of disease have benefitted from administration of anti-inflammatory agents,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com immunosuppressants, corticosteroids, and biologic therapies. In many cases, surgery to remove the diseased portions of the colon is often necessary when symptoms are severe and complications have developed. Unfortunately, because indeterminate colitis may be used as an interim diagnosis, the patient who is suffering from symptoms of this particular type of IBD may need to continue to undergo testing and assessment for changes for a longer period when compared to someone else with more straightforward symptoms. The condition may change over time, which could allow the diagnosing clinician to definitively diagnose indeterminate colitis as either Crohn’s disease or ulcerative colitis.

Unless the symptoms and the pathophysiology of the disease actually reveals which type of IBD is present, the patient will often benefit from medical therapies and prescribed remedies. The term itself may be controversial, but because indeterminate colitis seems to respond well to the same types of therapy administered for other kinds of IBD and it can be surgically corrected when needed, the patient with indeterminate colitis can still benefit from standard forms of medical therapies used for management of inflammation.

Summary

The chronic gastrointestinal condition of inflammatory bowel disease is a recurring disease characterized by inflammation, tissue deterioration, and ulceration in different regions of the gastrointestinal system. The most common types of IBD are ulcerative colitis and Crohn’s disease. The different types of IBDs may develop anywhere along the gastrointestinal tract from the mouth to the anus, although most cases are confined to areas of the small or large intestines. 62

nursece4less.com nursece4less.com nursece4less.com nursece4less.com Inflammatory bowel disease causes periods of active illness in which affected persons suffer from multiple symptoms that include pain and diarrhea, followed by periods of remission, in which there are few to no symptoms at all. The chronic nature of the disease has confounded clinicians and medical scientists who have researched its causes and the most appropriate forms of treatment to be able to induce remission and alleviate some of the debilitating symptoms.

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.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Inflammatory bowel disease (IBD) is actually a group of disorders that

a. similarly cause inflammation in the gastrointestinal tract. b. affect the same areas of the intestine. c. respond treatment in the same way. d. All of the above

2. True or False: All types of IBD develop along the gastrointestinal tract in the areas of the small or large intestines.

a. True b. False

3. Two of the most common types of inflammatory bowel disease (IBD) are

a. ulcerative proctitis and Crohn’s disease. b. Behcet’s disease and proctitis. c. ulcerative colitis and sclerosing cholangitis. d. ulcerative colitis and Crohn’s disease.

4. Sclerosing cholangitis causes inflammation and scarring within the

a. the cecum. b. bile ducts. c. descending colon. d. the ileum.

5. ______is a chronic condition that causes inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa.

a. Ulcerative proctosigmoiditis b. Behcet’s disease c. Ulcerative colitis d. Sclerosing cholangitis

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. Behcet’s disease is an inflammatory condition that causes ulcers

a. in the mouth and on the genitalia. b. inflammation in the gastrointestinal tract. c. the eye, the brain, and the spinal cord. d. All of the above

7. The ulceration associated with ulcerative colitis often will only affect ______of the intestinal tract.

a. the muscularis layer b. submucosal layer c. muscularis and submucosal layers d. the mucosal and submucosal layers

8. Ulcerative colitis differs from Crohn’s disease because with Crohn’s disease, ulcerations typically

a. cause Clostridium difficile infection. b. extend through all layers of the intestinal tract. c. are limited to the colon and rectum. d. does not develop in the ileum.

9. True or False: Inflammatory bowel disease (IBD) may be caused solely by uncontrolled stress.

a. True b. False

10. ______is an infection that is often contracted by a patient while in a hospital or healthcare environment.

a. Microscopic colitis b. Celiac disease c. Clostridium difficile d. H. pylori

11. True or False: True or False: Approximately 15 percent of people with IBD have indeterminate colitis.

a. True b. False 65

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12. ______can cause inflammation along any part of the gastrointestinal tract and is not limited to specific areas.

a. Crohn’s disease b. Pan-colitis c. Ulcerative colitis d. Sclerosing cholangitis

13. With ______the surface of the intestinal lining often appears rough with a “cobblestone” appearance that is characteristic of that disease.

a. vasculitis b. indeterminate colitis c. Crohn’s disease d. sclerosing cholangitis

14. Ulcerative colitis that affects the entire large intestine, including the ascending, transverse, descending, and sigmoid portions is sometimes called

a. pan-colitis. b. Behcet’s disease. c. indeterminate colitis. d. sclerosing cholangitis.

15. True or False: Smoking tobacco is a factor that has been associated with increased incidences of disease flares among those with Crohn’s disease.

a. True b. False

16. Ulcerative colitis and other IBDs that affect the large intestine may be difficult to distinguish from a Clostridium difficile infection because they share the same

a. “cobblestone” appearance. b. symptom, severe diarrhea. c. symptomatic inflammation in the mouth and throat. d. symptomatic psoriasis.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17. Inflammation from Crohn’s disease most often develops in the distal portion of the small intestine known as ______and the ileocecal region.

a. the bile ducts b. the cecum c. the duodenum d. the ileum

18. ______is an autoimmune condition in which damage develops in the intestinal tract after ingestion of gluten, a protein found in wheat products.

a. H. pylori b. Gastroparesis c. Pyloric stenosis d. Celiac disease

19. The Crohn’s and Colitis Foundation of America (CCFA) states that there may be a link between microscopic colitis and

a. celiac disease. b. musculoskeletal disorder. c. H. pylori. d. gastroparesis.

20. True or False: Ileocolitis is considered the most common form of Crohn’s disease.

a. True b. False

21. Behcet’s disease is a type of inflammatory bowel disease and a ______because it is a type of vasculitis that causes inflammation of the blood vessels.

a. autoimmune disorder b. gastrointestinal disorder c. musculoskeletal disorder d. gluten disorder

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22. The administration of an enema of short-chain fatty acids in solution to patients with ______decreased intestinal inflammation but the symptoms usually returned when the enemas were discontinued.

a. diminished colitis b. indeterminate colitis c. microscopic colitis d. diversion colitis

23. Collagenous colitis occurs when areas of collagen under the epithelium solidify and the tissue overall becomes

a. diffused and thins out. b. impaired and thins out. c. perforated and takes on a “cobblestone” texture. d. concentrated and thick.

24. With ______there may be inflammation of the eye, and severe cases of eye inflammation may lead to complete blindness.

a. celiac disease b. Sjögren’s syndrome c. Behcet’s disease d. pan-colitis

25. True or False: Microscopic colitis has been shown to increase the risk of colon cancer.

a. True b. False

26. When it is not clear whether a patient’s inflammatory bowel symptoms are caused by Crohn’s disease or ulcerative colitis, the patient is diagnosed with

a. a Clostridium difficile infection. b. pan-colitis. c. Behcet’s disease d. indeterminate colitis.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27. Common autoimmune diseases that are seen with collagenous colitis include

a. myasthenia gravis. b. gastroparesis. c. Clostridium difficile. d. vasculitis.

28. Patients with microscopic colitis typically have frequent, watery diarrhea

a. caused by infection. b. with or without abdominal pain and cramping. c. associated with all the other IBD symptoms. d. All of the above

29. People with indeterminate colitis typically have symptoms only affecting

a. the large intestine. b. the mouth and esophagus. c. the small intestine. d. the ileum.

30. The treatment for ______includes the administration of anti-inflammatory agents, immunosuppressants, corticosteroids, and biologic therapies.

a. celiac disease b. indeterminate colitis c. aphthous stomatitis d. diversion colitis

31. True or False: The majority of people with Behcet’s develop aphthous stomatitis.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32. The small intestine is

a. named “small” because of its length. b. approximately 8 feet long in adults. c. the longest portion of the gastrointestinal tract. d. All of the above

33. Patients with ______develop lymphoid follicular hyperplasia, which is an increase in the size of lymph node follicles due to increased numbers of white blood cells.

a. celiac disease b. Sjögren’s syndrome c. Behcet’s disease d. diversion colitis

34. True or False: Because of the controversy associated with classifying indeterminate colitis as an IBD, it is NOT included as part of the International Classification of Diseases, Tenth Revision (ICD-10).

a. True b. False

35. The group most likely to suffer from microscopic colitis is

a. males of all ages. b. older females. c. young males. d. adolescent females.

36. The areas of the gastrointestinal tract that may be affected by microscopic colitis include

a. the large intestine. b. the small intestine. c. the stomach. d. All of the above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37. The major difference between Crohn’s disease in the mouth and orofacial granulomatosis is that the patient with Crohn’s disease also have

a. overgrowths of granulation tissue. b. inflammation and scarring within the bile ducts. c. gastrointestinal tract lesions and inflammation. d. aphthous stomatitis (similar to canker sores) in the mouth.

38. According to an article in the Journal of Gastroenterology and Hepatology Research, indeterminate colitis is considered to be ______given to initiate treatment for the affected patient.

a. a final diagnosis b. a non-IBD diagnosis c. a temporary diagnosis d. a pre-diagnosis classification

39. ______is a form of ulcerative colitis that includes rectal involvement of the rectum only and NOT other areas of the colon.

a. diversion colitis b. indeterminate colitis c. proctosigmoiditis d. ulcerative proctitis

40. True or False: Diversion colitis develops in the large intestine and usually develops into colon cancer.

a. True b. False

41. True or False. The exact cause of microscopic colitis has been well identified.

a. True. b. False.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com CORRECT ANSWERS:

1. Inflammatory bowel disease (IBD) is actually a group of disorders that

a. similarly cause inflammation in the gastrointestinal tract.

p. 5: “Inflammatory bowel disease is actually a group of disorders that all cause similar effects of inflammation in the gastrointestinal tract.”

2. True or False: All types of IBD develop along the gastrointestinal tract in the areas of the small or large intestines.

b. False

pp. 5-6: “Both of these diseases cause intestinal inflammation, pain, and tissue damage in the gastrointestinal tract. Ulcerative colitis primarily affects the large intestine, while Crohn’s disease is most common in the small intestine, but can occur anywhere along the digestive tract.”

3. Two of the most common types of inflammatory bowel disease (IBD) are

d. ulcerative colitis and Crohn’s disease.

p. 5: “Two of the most common types of IBD are ulcerative colitis and Crohn’s disease.”

4. Sclerosing cholangitis causes inflammation and scarring within the

b. bile ducts.

p. 9: “A small percentage of patients develop sclerosing cholangitis, which causes inflammation and scarring within the bile ducts.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5. ______is a chronic condition that causes inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa.

c. Ulcerative colitis

p. 7: “Ulcerative colitis [is] a chronic condition that causes inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa….”

6. Behcet’s disease is an inflammatory condition that causes ulcers

a. in the mouth and on the genitalia. b. inflammation in the gastrointestinal tract. c. the eye, the brain, and the spinal cord. d. All of the above

p. 54: “Behcet’s disease is an inflammatory condition that causes ulcers in the mouth and on the genitalia, as well as inflammation in the gastrointestinal tract, blood vessels, the eye, the brain, and the spinal cord.”

7. The ulceration associated with ulcerative colitis often will only affect ______of the intestinal tract.

d. the mucosal and submucosal layers

p. 15: “The ulceration associated with ulcerative colitis often only affects the mucosal and submucosal layers of the intestinal tract, but typically does not extend down into the muscularis layer.”

8. Ulcerative colitis differs from Crohn’s disease because with Crohn’s disease, ulcerations typically

b. extend through all layers of the intestinal tract.

p. 15: “The disease process associated with ulcerative colitis differs from Crohn’s disease: with Crohn’s disease, ulcerations can extend through all layers of the intestinal tract.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9. True or False: Inflammatory bowel disease (IBD) may be caused solely by uncontrolled stress.

b. False

p. 8: “Although stress is known to be a triggering factor for a disease flare, uncontrolled stress is not the cause of ulcerative colitis or of any other type of IBD.”

10. ______is an infection that is often contracted by a patient while in a hospital or healthcare environment.

c. Clostridium difficile

p. 17: “[C. difficile] is often a healthcare-associated infection, in which patients contract it while in the hospital or healthcare environment.”

11. True or False: Approximately 15 percent of people with IBD have indeterminate colitis.

a. True

p. 59: “Approximately 15 percent of people with IBD have indeterminate colitis.”

12. ______can cause inflammation along any part of the gastrointestinal tract and is not limited to specific areas.

a. Crohn’s disease

p. 23: “Unlike ulcerative colitis and some other forms of IBD, Crohn’s disease can cause inflammation along any part of the gastrointestinal tract and is not limited to specific areas.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13. With ______the surface of the intestinal lining often appears rough with a “cobblestone” appearance that is characteristic of that disease.

c. Crohn’s disease

p. 24: “The surface of the intestinal lining often appears rough with a “cobblestone” appearance that is characteristic of Crohn’s disease.”

14. Ulcerative colitis that affects the entire large intestine, including the ascending, transverse, descending, and sigmoid portions is sometimes called

a. pan-colitis.

p. 15: “Ulcerative colitis that affects the entire large intestine, including the ascending, transverse, descending, and sigmoid portions is sometimes called pan-colitis.”

15. True or False: Smoking tobacco is a factor that has been associated with increased incidences of disease flares among those with Crohn’s disease.

a. True

p. 25: “Smoking tobacco is a factor that has been associated with increased incidences of disease flares among those with Crohn’s disease.”

16. Ulcerative colitis and other IBDs that affect the large intestine may be difficult to distinguish from a Clostridium difficile infection because they share the same

b. symptom, severe diarrhea.

p. 17: “Ulcerative colitis and other forms of IBD that affect the large intestine increase the risk of Clostridium difficile infection in the gastrointestinal tract. C. difficile infection tends to cause severe diarrhea, which may make it difficult to establish IBD versus C. difficile as the cause of diarrhea.”

d. the ileum

p. 24: “Although it can affect any part of the gastrointestinal tract, the inflammation from Crohn’s most often develops in the distal portion of the small intestine—the ileum—and the junction between the small intestine and the cecum, known as the ileocecal region.”

18. ______is an autoimmune condition in which damage develops in the intestinal tract after ingestion of gluten, a protein found in wheat products.

d. Celiac disease

p. 49: “The Crohn’s and Colitis Foundation of America (CCFA) states that there may be a link between microscopic colitis and celiac disease, an autoimmune condition in which damage develops in the intestinal tract after ingestion of gluten, a protein found in wheat products.”

19. The Crohn’s and Colitis Foundation of America (CCFA) states that there may be a link between microscopic colitis and

a. celiac disease.

20. True or False: Ileocolitis is considered the most common form of Crohn’s disease.

a. True

p. 33: “Ileocolitis is considered the most common form of Crohn’s disease.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21. Behcet’s disease is a type of inflammatory bowel disease and a ______because it is a type of vasculitis that causes inflammation of the blood vessels.

c. musculoskeletal disorder

p. 55: “In addition to being classified as a type of inflammatory bowel disease, Behcet’s is also a musculoskeletal disorder because it is a type of vasculitis that causes inflammation of the blood vessels.”

22. The administration of an enema of short-chain fatty acids in solution to patients with ______decreased intestinal inflammation but the symptoms usually returned when the enemas were discontinued.

d. diversion colitis

p. 53: “An early study in the New England Journal of Medicine tested the effects of enema administration of short-chain fatty acids in solution to patients with diversion colitis and found that patients who received enemas had diminished colitis symptoms and decreased intestinal inflammation.”

23. Collagenous colitis occurs when areas of collagen under the epithelium solidify and the tissue overall becomes

d. concentrated and thick.

p. 47: “Collagenous colitis occurs when areas of collagen under the epithelium solidify and the tissue overall becomes concentrated and thick.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24. With ______there may be inflammation of the eye, and severe cases of eye inflammation may lead to complete blindness.

c. Behcet’s disease

p. 56: “There are various other symptoms seen with Behcet’s disease that do not necessarily affect the gastrointestinal tract, including sores on the skin, which appear as red, pus- filled lesions. There may be inflammation of the eye, most commonly the iris and the uvea, although the retina may also become inflamed and the patient may have vision loss, excess tear production, and photophobia. Severe cases of eye inflammation may lead to complete blindness.”

25. True or False: Microscopic colitis has been shown to increase the risk of colon cancer.

b. False

p. 50: “Unlike Crohn’s disease or ulcerative colitis, microscopic colitis has not been shown to increase the risk of colon cancer.”

26. When it is not clear whether a patient’s inflammatory bowel symptoms are caused by Crohn’s disease or ulcerative colitis, the patient is diagnosed with

d. indeterminate colitis.

p. 59: “When it is not clear whether a patient’s symptoms are caused by Crohn’s disease or ulcerative colitis, the patient is diagnosed with indeterminate colitis. Approximately 15 percent of people with IBD have indeterminate colitis.”

27. Common autoimmune diseases that are seen with collagenous colitis include

a. myasthenia gravis.

p. 50: “Common conditions that are seen with collagenous colitis include Sjögren’s syndrome, thyroiditis, and myasthenia gravis.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28. Patients with microscopic colitis typically have frequent, watery diarrhea

b. with or without abdominal pain and cramping.

p. 48: “People with microscopic colitis typically have frequent, watery diarrhea with or without abdominal pain and cramping;….”

29. People with indeterminate colitis typically have symptoms only affecting

a. the large intestine.

p. 59: “People with indeterminate colitis typically have symptoms only affecting the large intestine.”

30. The treatment for ______includes the administration of anti-inflammatory agents, immunosuppressants, corticosteroids, and biologic therapies.

b. indeterminate colitis

pp. 61-62: “The treatment for indeterminate colitis is often similar to that given for ulcerative colitis. Many patients with this type of disease have benefitted from administration of anti-inflammatory agents, immunosuppressants, corticosteroids, and biologic therapies.”

31. True or False: The majority of people with Behcet’s develop aphthous stomatitis.

a. True

p. 55: “The majority of people with Behcet’s develop aphthous stomatitis: inflammation and ulcerations in the mouth that are similar in appearance to canker sores.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32. The small intestine is

c. the longest portion of the gastrointestinal tract.

p. 31: “The small intestine is the longest portion of the gastrointestinal tract. Its name refers to the diameter of the intestinal lumen rather than its length. The average length of the small intestine is approximately 20 feet long in adults.”

33. Patients with ______develop lymphoid follicular hyperplasia, which is an increase in the size of lymph node follicles due to increased numbers of white blood cells.

d. diversion colitis

p. 51: “Patients with diversion colitis develop lymphoid follicular hyperplasia, which is an increase in the size of lymph node follicles due to increased numbers of white blood cells.”

b. False

p. 60: “Although the term is somewhat controversial for use, indeterminate colitis is included as part of the International Classification of Diseases, Tenth Revision (ICD-10). Some clinicians prefer to call the condition Inflammatory Bowel Disease, Unclassified.”

35. The group most likely to suffer from microscopic colitis is

b. older females.

p. 46: “This specific type of inflammatory bowel disease most commonly affects older adults, with a higher percentage of older females than males affected by collagenous colitis, one of the subtypes of the disease.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36. The areas of the gastrointestinal tract that may be affected by microscopic colitis include

a. the large intestine.

p. 46: “A patient suffering from microscopic colitis experiences pain and diarrhea but there is no obvious source during examination. The condition only affects the large intestine, the sigmoid colon, and the rectum.”

37. The major difference between Crohn’s disease in the mouth and orofacial granulomatosis is that the patient with Crohn’s disease also have

c. gastrointestinal tract lesions and inflammation.

p. 43: “[A]ccording to Zbar, et al., in the Journal of Crohn’s and Colitis, the major difference between Crohn’s disease in the mouth and orofacial granulomatosis is that the patient with Crohn’s disease has concomitant lesions and inflammation elsewhere in the gastrointestinal tract, while orofacial granulomatosis typically only affects the mouth.”

38. According to an article in the Journal of Gastroenterology and Hepatology Research, indeterminate colitis is considered to be ______given to initiate treatment for the affected patient.

c. a temporary diagnosis

p. 60: “According to an article in the Journal of Gastroenterology and Hepatology Research, indeterminate colitis is considered to be a temporary diagnosis, given to initiate treatment for the affected patient and put in place until further testing or changes in the pathophysiology of the disease reveals which type of IBD is present.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39. ______is a form of ulcerative colitis that includes rectal involvement of the rectum only and NOT other areas of the colon.

d. ulcerative proctitis

p. 19: “Approximately 46 percent of patients with ulcerative colitis have rectal involvement, called ulcerative proctitis when it affects only the rectum, and ulcerative proctosigmoiditis when the sigmoid colon is also involved.”

40. True or False: Diversion colitis develops in the large intestine and usually develops into colon cancer.

b. False

p. 51: “Diversion colitis develops in the large intestine and is usually considered to be benign, ….”

41. True or False. The exact cause of microscopic colitis has been well identified.

b. False.

p. 48. “The exact cause of microscopic colitis is unknown.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com References

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.

1. Crohn’s and Colitis Foundation of America (CCFA). (2009, Apr.). Managing flares and other IBD symptoms. New York NY: CCFA 2. Peppercorn, M., Kane, S. (2016, Sep.). Patient education: Ulcerative colitis (beyond the basics). Retrieved from http://www.uptodate.com/contents/ulcerative-colitis-beyond-the- basics 3. 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/ 4. Crohn’s and Colitis Foundation of America. (2012, May). Liver disease and IBD. Retrieved from http://www.ccfa.org/resources/liver-disease-and- ibd.html?referrer=https://www.google.com/ 5. University of Alberta IBD Clinic. (2016). What are extra-intestinal manifestations of IBD? Retrieved from http://www.ibdclinic.ca/what-is-ibd/complications/ 6. Strober, W., Fuss, I. (2011, May). Pro-inflammatory cytokines in the pathogenesis of IBD. Gastroenterology 140(6): 1756-1767. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3773507/ 7. Kennedy, A. (2015). The inflammatory response. Retrieved from http://primer.crohn.ie/the-inflammatory-response 8. Bowen, R. (2000, May). Gross and microscopic anatomy of the large intestine. Retrieved from http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/large gut/anatomy.html 9. Taylor, T. (2016). Large intestine. Retrieved from http://www.innerbody.com/anatomy/digestive/large-intestine 10. Crohn’s and Colitis Foundation of America. (2015, Jan.). Intestinal complications. Retrieved from http://www.ccfa.org/assets/pdfs/intestinalcomps.pdf 11. 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_landin g.html

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12. Sandborn, W., et al. (2015, Apr.). Budesonide foam induces remission in patients with mild to moderate ulcerative proctitis and ulcerative proctosigmoiditis. Gastroenterology 148(4): 740- 750. Retrieved from http://www.gastrojournal.org/article/S0016- 5085(15)00154-7/fulltext 13. Dewint, P., et al. (2014). Adalimumab combined with ciprofloxacin is superior to adalimumab monotherapy in perianal fistula closure in Crohn’s disease: a randomized, double-blind, placebo controlled trial (ADAFI). Gut 2014; 63: 292-299. 14. Colon & Rectal Surgery Associates. (2016). What is ulcerative proctitis? Retrieved from http://www.colonrectal.org/services.cfm/sid:6694/ulcerative_proc titis/index.html 15. Crohn’s & Colitis.com. (2016). Understanding Crohn’s disease. Retrieved from https://www.crohnsandcolitis.com/crohns 16. University of Maryland Medical Center. (2012, Dec.). Crohn’s disease. Retrieved from http://umm.edu/health/medical/reports/articles/crohns-disease 17. Crohn’s and Colitis Foundation of America. (2015, Jan.). Arthritis and joint pain. Retrieved from http://www.ccfa.org/assets/pdfs/arthritiscomplications.pdf 18. Lashner, B. (2013, Jan.). Crohn’s disease. Retrieved from http://www.clevelandclinicmeded.com/medicalpubs/diseasemana gement/gastroenterology/crohns-disease/ 19. IBD Relief. (2016). What is perianal Crohn’s disease? Retrieved from https://www.ibdrelief.com/learn/what-is-ibd/what-is-crohns- disease/perianal-crohns 20. De Zoeten, E., Pasternak, B., Mattei, P., Kramer, R., Kader, H. (2013, Sep.). Diagnosis and treatment of perianal Crohn disease: NASPGHAN clinical report and consensus statement. JPGN 57(3): 401-412. 21. IBD Relief. (2016). What is ileocolitis? Retrieved from https://www.ibdrelief.com/learn/what-is-ibd/what-is-crohns- disease/ileocolitis 22. Bayless, T., Hanauer, S. (2011). Advanced therapy of inflammatory bowel disease (3rd ed.), Volume 2. Shelton, CT: People’s Medical Publishing House USA 23. Crohn’s & Colitis Foundation of America. (2016). Types of Crohn’s disease and associated symptoms. Retrieved from http://www.ccfa.org/what-are-crohns-and-colitis/what-is-crohns- disease/types-of-crohns- disease.html?referrer=https://www.google.com/ 24. Menys, A., et al. (2013, Dec.). Small bowel strictures in Crohn’s disease: a quantitative investigation of intestinal motility using MR 84

nursece4less.com nursece4less.com nursece4less.com nursece4less.com enterography. Neurogastroenterology & Motility 25(12): 967- e775. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/nmo.12229/full 25. Bayless, T., Hanauer, S. (2011). Advanced therapy of inflammatory bowel disease (3rd ed.), Volume 2. Shelton, CT: People’s Medical Publishing House USA 26. Steckstor, M., Adam, B., Pech, O., Tannapfel, A., Riphaus, A. (2013, Jun.). Gastroduodenal Crohn’s disease. Video Journal and Encyclopedia of GI Endoscopy 1(1): 178-179. 27. Scheck, S., Ram, R., Loveday, B., Bhagvan, S., Beban, G. (2014, Dec.). Crohn’s disease presenting as gastric outlet obstruction. J Surg Case Rep. 2014(12): rju 128. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255135/ 28. Gore, R., Levine, M. (2015). Textbook of gastrointestinal radiology (4th ed.). Philadelphia, PA: Elsevier Saunders 29. Ji, X., Wang, L., Lu, D. (2014, Oct.). Pulmonary manifestations of inflammatory bowel disease. World Journal of Gastroenterology 20(37): 13501-13511. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4188901/ 30. Dyall-Smith, D. (2016). Orofacial Crohn disease. Retrieved from http://www.dermnetnz.org/topics/orofacial-crohn-disease/ 31. Zbar, A., Ben-Horin, S., Beer-Gabel, M., Eliakim, R. (2012, Mar.). Oral Crohn’s disease: Is it a separable disease from orofacial granulomatosis? A review. Journal of Crohn’s and Colitis 6(2): 135-142. 32. Hopkins Medicine. (2013). Collagenous and lymphocytic colitis: Introduction. Retrieved from http://www.hopkinsmedicine.org/gastroenterology_hepatology/_p dfs/small_large_intestine/collagenous_lymphocytic_colitis.pdf 33. Wickbom, A., Bohr, J., Eriksson, S., Udumyan, R., Phil, M., Nyhlin, N., Tysk, C. (2013, Oct.). Stable incidence of collagenous colitis and lymphocytic colitis in Orebro, Sweden, 1999-2008: A continuous epidemiologic study. Inflamm Bowel Dis. 19(11): 2387-2393. 34. National Institute of Diabetes and Digestive and Kidney Diseases. (2014, Jun.). Microscopic colitis. Retrieved from https://www.niddk.nih.gov/health-information/health- topics/digestive-diseases/microscopic-colitis/Pages/facts.aspx 35. Crohn’s & Colitis Foundation of America. (2012, Oct.). Microscopic colitis. Retrieved from http://www.ccfa.org/resources/microscopic- colitis.html?referrer=https://www.google.com/ 36. Kabir, S., Kabir, S., Richards, R., Ahmed, J., MacFie, J. (2014, Aug.). Pathophysiology, clinical presentation and management of 85

nursece4less.com nursece4less.com nursece4less.com nursece4less.com diversion colitis: A review of current literature. International Journal of Surgery. Retrieved from http://dx.doi.org/10.1016/j.ijsu.2014.08.350 37. Crohn’s Forum. (n.d.). Diversion colitis. Retrieved from http://www.crohnsforum.com/wiki/Diversion-Colitis 38. Harig, J., Soergel, K., Komorowski, R., Wood, C. (1989, Jan.). Treatment of diversion colitis with short-chain-fatty acid irrigation. N Engl J Med 1989; 320: 23-28. 39. 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.a sp 40. National Organization for Rare Disorders (NORD). (2015). Behçet’s syndrome. Retrieved from http://rarediseases.org/rarediseases/behcets-syndrome/ 41. Skef, W., Hamilton, M., Arayssi, T. (2015, Apr.). Gastrointestinal Behçet’s disease: A review. World J Gastroenterol. 21(13): 3801- 3812 42. IBD Relief. (2016). What is indeterminate colitis? Retrieved from https://www.ibdrelief.com/learn/what-is-ibd/what-is- indeterminate-colitis 43. Mahdi, B. (2012). A review of inflammatory bowel disease unclassified – Indeterminate colitis. Journal of Gastroenterology and Hepatology Research 1(10). Retrieved from http://www.ghrnet.org/index.php/joghr/article/view/214/395

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