ulcerative colitis nursing case study

Ulcerative Colitis Nursing Diagnosis and Nursing Care Plan

Last updated on May 18th, 2022 at 10:52 am

Ulcerative Colitis Nursing Care Plans Diagnosis and Interventions

Ulcerative colitis is a medical condition that involves the inflammation and ulcer formation in the lining of the colon (large intestine) and rectum.

Signs and Symptoms of Ulcerative Colitis

Children’s growth may also be affected by ulcerative colitis.

Types of Ulcerative Colitis

Causes and risk factors of ulcerative colitis.

Diet and stress are two risk factors that can make Ulcerative colitis worse, but not necessarily cause it.

This process sometimes fails due to certain factors, making the body attack its own cells. Cells in the digestive tract may be mistakenly attacked, causing ulcerative colitis.

Complications of Ulcerative Colitis

Further problems could develop if ulcerative colitis is left untreated.

Treatment of Ulcerative Colitis

There is a wide array of treatment options for patients with ulcerative colitis.

Anti-inflammatory drugs. These are the first line of treatment for people with ulcerative colitis.

Immune system suppressors. These drugs work by prohibiting inflammatory response through suppressing the immune system.

However, it is also the choice of drug when other treatments fail to work.

Other medications can be used to treat symptoms related to ulcerative colitis. Examples are anti-diarrheal drugs, pain relievers, antispasmodics, and iron supplements.

A more sophisticated procedure called ileoanal anastomosis can be done to prevent the patient from needing an external pouch to collect stool.

Limitations in dairy products can help manage diarrhea and abdominal pain.

Stress management

It has been established that stress does not cause ulcerative colitis but can aggravate its symptoms.

Nursing Diagnosis for Ulcerative Colitis

Nursing care plan for ulcerative colitis 1.

  Nursing Diagnosis: Diarrhea related to inflammation of bowel as evidenced by loose, watery stools, abdominal cramping and pain, increased urgency to defecate, tenesmus, and increased bowel sounds

Nursing Care Plan for Ulcerative Colitis 2

Desired Outcome : The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices.

More Nursing Diagnosis for Ulcerative Colitis

Quiz for ulcerative colitis 5 questions, #1. ulcerative colitis.

Ulcerative colitis It is a type of inflammatory bowel disease (IBD) that can have progressive symptoms over time and could be both debilitating and life-threatening if left uncontrolled.

#2. Ulcerative colitis affects

#3. what is pancolitis, #4. true or false: corticosteroids are commonly prescribed if other treatments cause no response..

Corticosteroids are commonly prescribed if other treatments cause no response.

#5. Limiting the following can help manage diarrhea and abdominal pain?

Nursing references.

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

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Primary care management of ulcerative colitis

Davis, Stephanie C. PhD, RN, FNP-BC; Robinson, Brittani L. MS, RN, FNP-C; Vess, Joy DNP, RN, ACNP-BC; Lebel, Joseph S. MD

Stephanie C. Davis is a graduate program coordinator and associate professor at Clemson University, School of Nursing, Clemson, S.C.

Brittani L. Robinson is a family NP at Carolina Nephrology, Greenville, S.C.

Joy Vess is an assistant professor at Medical University of South Carolina, College of Nursing, Charleston, S.C.

Joseph S. Lebel is a physician at Gastroenterology Associates, Greenville, S.C.; associate professor of internal medicine at University of South Carolina School of Medicine, Columbia, S.C.; and associate professor of internal medicine at Edward Via College of Medicine, Blacksburg, Va.

The authors have disclosed the following financial relationships related to this article: Allergan.

Ulcerative colitis (UC) is an inflammatory bowel disease marked by mucosal inflammation. UC has an impact on quality of life and places a financial burden on the healthcare system. This article focuses on the impact, presentation, diagnosis and classification, systemic manifestations, complications, management, and treatment associated with UC.

Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) marked by gastrointestinal (GI) mucosal inflammation due to altered microbiota, increased intestinal permeability, and immune system dysfunction. 1 UC is a chronic disease that causes inflammation and ulcerations in the lining of the large intestine, which includes the colon and rectum. 2 UC inflammation leads to small ulcers on the lining of the large intestines, which can lead to bleeding, pus, diarrhea, abdominal pain/cramping, nausea, and extreme fatigue. 3,4 (See Erythema and ulceration of the colon in UC .)

UC and Crohn disease have similar symptoms but are two distinct disease processes. UC affects the lining of the colon, whereas Crohn disease can affect the layers of the colon wall of the alimentary tract anywhere from the mouth to the anus and may even skip segments. At times, it is difficult to distinguish between UC or Crohn disease, and a diagnosis of intermediate colitis may be given. 3

Twenty-five to 40% of patients' disease manifestations may include symptoms related to the eyes, joints, skin, bones, kidneys, and liver. 3 The most common symptoms are abdominal discomfort and blood or pus in diarrhea. 4 UC is characterized by periods of relapse with debilitating symptoms and remission. The disease etiology is essentially unknown but thought to be influenced by genetic determinants, environmental factors, and microbiome in the intestinal tract. 5,6

UC has a profound impact on quality of life and places a financial burden on the healthcare system. The incidence of UC in the United States is 9 to 12 cases annually per 100,000 individuals, resulting in lost work days and steep hospital and medication costs. 7 Managing UC accounts for about 250,000 annual physician visits, 30,000 hospitalizations, and a loss of over one million work days per year. 8

The prevalence of UC in North America is 319 per 100,000 individuals. 9 It is estimated that up to 1.4 million individuals in the United States have been diagnosed with IBD. 10 UC appears to be more prevalent in the northern part of the world, especially among White individuals. 1

Reflecting the most recent comprehensive data, Nguyen and colleagues examined the rising hospitalization rates for IBD in the United States between 1998 and 2004. They found that an estimated 214,498 hospital admissions were related to UC, and the national cost for inpatient charges increased from $592 million to $945 million between 1998 and 2004. 11

Kappelman and colleagues examined the direct healthcare costs of UC in the United States through a cross-sectional study designed to analyze the medical, surgical, and pharmaceutical claims in a patient database. 12 Results revealed that the mean total cost for patients with UC was $7,948 per year, and the mean and median annual UC-associated costs were $5,066 and $17,928, respectively. They also found the largest portion of pharmaceutical expenses was related to oral/rectal aminosalicylates. Kappelman and colleagues estimated the annual direct costs of IBD at $5.3 billion and the annual cost for UC alone at $2.7 billion. 12

Diagnosis and severity classification

Typically, the diagnosis of UC is made based on history, physical exam, symptomatology, diagnostic testing, and endoscopy. History should include a recall of the number of bowel movements, bleeding episodes, and incidences of waking up at night from pain or diarrhea, fever, and joint aches. 3 The physical exam should include an oral exam, abdominal exam, anal/rectal exam, skin exam, and various diagnostic tests. Differential diagnoses to consider include Crohn disease, ischemic colitis, and Clostridium difficile infection. 3

According to the Crohn's and Colitis Foundation of America, diagnostic testing may include:

• blood and stool testing
• stool markers/cultures
• complete blood cell count
• erythrocyte sedimentation rate (ESR)
• C-reactive protein
• liver and kidney function panel
• electrolytes
• radiologic and diagnostic imaging
• barium enema
• computed tomography (CT) scan and CT enterography
• leukocyte scintigraphy
• magnetic resonance imaging and magnetic resonance enterography
• small bowel follow-through and small bowel enterocytes

The gold standard for diagnosis is endoscopy with biopsies. 3 Family history may be helpful because the number one risk factor for UC is a positive history in the immediate family. In addition to the above, fecal calprotectin has been found to be sensitive for detecting disease activity, although more so in UC than Crohn disease. 13 Genetic testing can help identify a patient's likelihood of developing symptoms and complications. 3

Classifying the severity of UC can be as daunting as the disease itself. There is great variation depending on which instruments or criteria are utilized for the classification of disease severity. According to Peyrin-Biroulet and colleagues, although existing algorithms begin with classifying patients according to disease severity, there is no formal validated or consensus definition as to what constitutes mild, moderate, or severe IBD. 14 Examples of criteria used to diagnose the severity of UC include the Montreal classification of inflammatory bowel disease (MCIBD), Truelove and Witts' severity index, American College of Gastroenterology (ACG) Guidelines, Mayo Score, and Simple Clinical Colitis Activity Index (SCCAI).

MCIBD . This classification was developed by the Working Party of the 2005 Montreal World Congress of Gastroenterology. It is stratified into three categories: E1 (ulcerative proctitis-limited to rectum), E2 (left-sided/distal UC), and E3 (extensive UC or pancolitis, has involvement that extends to the splenic flexure). 15

Truelove and Witts' severity index . This index was originally published in 1955 and was reproduced with permission by the National Institute for Health & Care Excellence in 2013. 16 It is stratified into three categories:

Mild: Fewer than four bowel movements/day, no more than small amounts of blood in the stool, afebrile, heart rate 90 beats/minute or less, no anemia, and ESR of 30 mm/h or below.

Moderate: Four to six bowel movements/day, mild-to-severe blood in stool, afebrile, heart rate 90 beats/minute or less, no anemia, and ESR of 30 mm/h or below.

Severe: Six or more bowel movements/day, visible blood in stool, plus one of the systemic markers (fever over 100.04°F [37.8° C], heart rate over 90 beats/minute, anemia present, ESR over 30 mm/h).

ACG Guidelines . These guidelines generally follow the Truelove and Witts' criteria with the addition of the “fulminant” category, in which the patient has more than 10 bowel movements daily, has continuous bleeding (which requires blood transfusion), and colonic dilatation on abdominal X-ray. 8,17

Mayo Score . This Likert-like scale looks at stool frequency, rectal bleeding, endoscopic findings, and physician's global assessment. 18 Stool frequency components include a normal number of stools for the patient; one or two stools/day more than normal; three to four stools more than normal; and over five stools more than normal. Rectal bleeding components include no blood, streaks of blood less than half the time, obvious blood with stool most of the time, or passing only blood. Endoscopic findings components are described as normal or inactive disease, mild, moderate, or severe disease. 18

SCCAI . This index scores bowel frequency during the day and night, urgency of defecation, blood in stool, general well-being, and extracolonic features. 19

Identifying severity of disease can vary based on which criteria are used. It is critical for NPs to decide which instrument best fits their practice and to consistently use the same instrument.

Systemic manifestations and complications

Individuals with UC are at higher risk for developing complications related to disease progression or complications of treatment. Sequelae may affect many body organs/systems.

Manolakis and Cash summarized the existing literature and identified many of the possible systemic manifestations associated with a diagnosis of UC. 20 The following is a summary of their findings:

O phthalmologic . Uveitis, episcleritis, keratopathy, keratoconjunctivitis sicca (dry eyes), and corticosteroid-induced cataracts or glaucoma (related to corticosteroid use for treatment).

Dermatologic . Some individual studies have demonstrated an increased risk for melanoma.

Bone health . Osteopenia and osteoporosis.

Gynecologic . Increased risk of abnormal Pap tests.

Psychological . Anxiety, depression.

Opportunistic infections . Increased risk due to treatment with corticosteroids, antimetabolites, and antitumor necrosis factor medications. 20

Additionally, patients with Crohn disease are at risk for complications, including stricturing, abscesses, and fistulae. Stricturing affects approximately 50% of patients with Crohn disease within 10 years of diagnosis. During this initial 10-year time frame, surgical resection is required in as many as 80% of patients with Crohn disease. 21

Colorectal cancer

The longer a patient has a diagnosis of UC, the higher the risk of developing colorectal cancer (CRC). After 10 years of UC, the risk of bowel cancer is 1 in 50; it increases to 1 in 12 after 20 years and 1 in 6 after 30 years. 22 Diagnosis of CRC may be missed because the symptoms of UC and CRC are similar; therefore, routine screening for CRC is critical. 22

Choi and colleagues completed a 40-year analysis of patients with UC through colonoscopic surveillance for neoplasia. They monitored 1,375 participants for a total of 15,234 patient-years. The authors found that 72 patients (5.2%) had positive detection of CRC. An additional 16 (1.2%) developed CRC after leaving surveillance. Fifty-four (61.4%) of the patients were male, and the median age at diagnosis was 55.5. 23

The average duration of UC when the CRC was diagnosed was 23.5 years. The cumulative incidence of neoplasia by UC duration was 4.1% at 10 years, 14.1% at 20 years, 28% at 30 years, and 38.9% at 40 years; however, the overall risk of CRC by disease duration was low, with only 10% developing cancer at 40 years of disease duration. 23

Psychological health

Patients with UC have periods of remission; however, they often have periods of relapse after enduring prolonged diarrhea, bloody stools, pain, fever, cramping, and other debilitating symptoms, which can cause profound psychological and emotional stress. The most recent ACG guidelines report anxiety in 19% of patients and depression in 21% of patients with no difference among inactive versus active disease. The benefits of treating depression were found to be significant, as there were noted to be less relapses and use of corticosteroids in the year following initiation of an antidepressant. Depression has also been an indicator for risk of nonadherence to the medication regimen. 24

Quality of life

Managing UC can be time-consuming, expensive, and life-altering. Dealing with the symptoms, lost days of work, adverse reactions of medications, and increased risks of complications can have effects on patients' physical well-being; their social and professional lives and overall quality of life may also suffer. 25

Two studies examined health-related quality of life (HRQOL) and both identified factors associated with lower HRQOL scores. The first study by Tabibian and colleagues examined HRQOL and adherence in 135 participants and found that lower HRQOL scores were associated with higher levels of perceived stress and numbers of relapses over the previous 2-year period. 25

In a study by Luo and colleagues, 214 patients were recruited to examine HRQOL through perceived stress and coping strategies. The authors found that better HRQOL was associated with regular follow-up, no use of corticosteroids, lower relapse and hospitalization rates, disease remission, an MCIBD score of E1, lower Mayo Score, and lower levels of perceived stress. 26

Many patients may experience disease symptoms for years before seeking medical care due to symptom embarrassment, fear of cancer, and associated costs. Primary care providers might diagnose the symptoms as another GI disease and not consider IBD. It is essential for primary care providers to include IBD in the differential diagnosis.

Treatment and goals

The ultimate goal for UC treatment is complete remission. Management of UC includes medical management, exercise, and dietary control.

Toronto Consensus Guidelines . The Toronto Consensus Guidelines committee was formed to review existing literature and develop recommendations for treatment of patients with mild-to-severe active UC. In brief, types of medications to treat UC include 5-aminosalicylates, corticosteroids, thiopurines, anti-tumor necrosis factor (anti-TNF) agents, and humanized monoclonal antibodies (see Summary of the Toronto Consensus Guidelines ). 27 The Toronto Consensus Guidelines committee reported that, at the time of the development of the guidelines, there were insufficient data to support the use of fecal microbial transplant, and the quality of studies examining probiotic use was insufficient to warrant supporting recommendations. 27

Exercise . Many experts have posited that exercise is beneficial in treating UC and obtaining complete remission. Liu and colleagues completed a study in mice designed to examine if prior (before disease) voluntary exercise would attenuate colonic inflammation and meliorate clinical symptoms. The authors hypothesized that exercise increases glucocorticoid production and upregulates peroxisome proliferator-activated receptor gamma (PPAR-γ) (involved in regulation of the inflammatory response) activity in the colon. 28 Results revealed that exercise significantly increased the expression of PPAR-γ and elevated corticosteroid levels in the colon and supported the hypothesis that exercise prior to active UC could be beneficial in suppressing inflammation. 28

Another study from 2015 found that among patients with Crohn disease in remission, exercise correlated with reduced risk of disease activity at 6 months. The same was true of patients with UC; however, the findings were not statistically significant among the population in this study. In addition to remission, exercise improves bone density. 29

Dietary control . Many experts believe that the increased consumption of fats and refined carbohydrates may increase risk of disease relapse. 6 The Western diet is typically abundant with carbohydrates, and digestion of these carbohydrates can vary naturally (even more so for patients with IBD). 30 The Western diet is also often high in carbohydrates, red meats, fats, starches, sugars, and low in fiber.

According to Uranga and colleagues, mucosal inflammation, increased permeability, and immune system dysfunction may be caused by several factors, including dietary habits. 1 The use of probiotics and prebiotics may be helpful in controlling symptoms and preventing relapse and is the focus of intense ongoing research; however, there is not currently enough evidence to support this. 1

Walton and colleagues completed a study on the adherence of patients with UC to healthy eating guidelines. Eighty-one participants completed a 24-hour diet recall designed to assess nutrient intake compared with national recommended intake values. The authors found that nutritional knowledge was limited, numerous food groups were largely avoided, and almost half of the participants avoided dairy products. 31

The authors also noted that fat intake was above and energy intake was significantly below the national recommendations. Not surprisingly, results also revealed that 12% of the participants had osteopenia, 6% osteoporosis, and 31% anemia, which may be indicative of nutrient deficiencies. 31

Vaccinations . It is essential to review the vaccination record of all patients diagnosed with UC. According to the 2017 ACG guidelines, all children, adolescents, and adults with IBD should receive vaccinations according to the current guidelines published by the CDC, the Advisory Committee on Immunization Practices, and the Infectious Disease Society of America. 24 Patients with IBD should receive nonlive vaccines regardless of immunosuppression status. 24 Before a live vaccine is considered, the immunosuppression status of the patient needs to evaluated and the prescribing label for the specific vaccine reviewed. The prescribing labels list specific contraindications for the live vaccine based on the immunosuppression status of the patient.

Special consideration should be given for international travel, military, or those who work in risk areas, as they may also require vaccines such as rabies, anthrax, or typhoid. 32 The CDC website provides immunization schedules for all age groups as well as vaccine-specific recommendations for travel and emergency situations. 32 Patients with IBD should be referred to a travel medicine or infectious disease specialist prior to travel. 24

The primary care provider is an integral part of the healthcare team for patients with UC (see Summary of Concert's Referral Points ). 33 Additional referrals should be considered for psychological, financial, and family/social support. Concert and colleagues state that patients with disease of more than 7-year duration should have annual colonoscopic surveillance. 33 Once the patient with UC is evaluated and stabilized by specialists, the primary care provider can resume the primary role for management. Collaboration between the provider and appropriate specialists should be ongoing as needed.

Implications for nursing research, practice, and education

A major implication for future research is the fact that there currently are no commonly agreed-upon criteria for defining the severity of UC. In addition, limited information exists as to etiology of IBD and more specifically, UC. Determining the genetic component of IBD is essential. While current research is focused on discovering medications to induce remission and prevent relapses of UC, treating a disease process is difficult when the pathology is essentially unknown. 3

Additional areas for research include discovering ways to minimize complications and better ways to predict/prevent UC in high-risk individuals. 3 Primary care providers must be educated on the identification of UC symptoms as well as best practice guidelines for acute and maintenance therapy. Remission is the treatment goal and can only be achieved if the proper maintenance treatment is initiated once the patient is in remission.

NPs must be aware that UC is a life-altering disease process that affects more than just the abdomen and GI tract. Patients should be assessed for anxiety and/or depression related to the daily process of managing UC, the adverse reactions of medications, and possible complications.

Healthcare providers play an essential role in educating patients regarding the natural progression of UC and the importance of adherence to long-term treatment. In addition to following evidence-based guidelines for medical management, partnering with patients through open communication and psychosocial support can improve patient treatment adherence. 34 Patient educational resources are available, including support groups, printed materials, computer and smartphone apps to track and manage disease symptoms, webcasts, and enrollment in clinical trials (see Patient and provider resources ).

Reaching remission

UC is a life-altering, possibly debilitating disease process, and much is still unknown about the etiology of the disease process. Existing literature supports efforts to decrease severity of disease and reduce the incidence of relapses through diet, exercise, and medical management. Screening, vaccinating, monitoring for complications/sequelae, and referral to specialists are critical to effective care of the patient with UC in order to achieve complete remission.

Patient and provider resources

American Gastroenterological Association

www.gastro.org

www.acg.gi.org

ACG Patient Education and Resource Center

http://patients.gi.org/topics/inflammatory-bowel-disease

Crohn's and Colitis Foundation

www.ccfa.org

National Institute of Diabetes and Digestive and Kidney Diseases

niddk.nih.gov

Society of Gastroenterology Nurses and Associates

www.sgna.org

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American College of Gastroenterology Guidelines; gastrointestinal mucosal inflammation; IBD; inflammatory bowel disease; Mayo Score; Montreal classification of inflammatory bowel disease; Simple Clinical Colitis Activity Index; Truelove and Witts' severity index; ulcerative colitis

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The following is a scenario of a patient with toxic megacolon:

Mary Cole, a 50-year-old female with a known history of ulcerative colitis (UC) and anemia, was driven to the emergency department (ED) by her daughter, Cindy, on April 11, 2019, just after 1000. The reason for her visit was due to complaints of severe abdominal pain/swelling and bloody diarrhea over the past four days.

Vital signs were taken in the ED showing a blood pressure (BP) of 96/50, heart rate (HR) 113 bpm, respiratory rate (RR) of 29, tympanic temperature of 38.9°C, oxygen saturation (O2 sat.) of 97% on room air, and a pain of 9/10 (using the verbal numeric pain scale) located in her left lower abdominal quadrant that is sharp, constant, and aggravated by movement. Mary states, “my stomach hurts so much I can barely take the pain”. She claims that she has been taking extra-strength Advil (ibuprofen 400mg) for the pain. Her vitals were reassessed after 20 minutes showing a decrease in BP to 85/47, HR 130, RR 29, tympanic temperature of 38.9°C, O2 sat. 96%, and pain still at 9/10.

Upon further assessment, Mrs. Cole appeared uncomfortable and was quietly crying and lying on her left side with her knees flexed and arms holding her abdomen. She was alert and oriented to person, place, time, and situation and was demonstrating appropriate responses and PERRLA. Her face was flushed and her skin felt warm and dry to touch. There was slight skin tenting at her clavicle and she admitted to not being able to “eat or drink very much over the past few days” due to her abdominal pain and discomfort. She claims to have been having diarrhea that “looks kind of bloody” and hasn’t been voiding as often as she “normally does”, approximately twice a day over these past few days. Her abdomen is visibly distended and tender/firm upon palpation. Upon auscultation, she has hypoactive bowel sounds in all four quadrants and her pain is noted to be in the left lower quadrant. She is tachycardic and has a clear S1S2 heartbeat with diminished pedal pulses;  tachypnea is noted, lung sounds are clear in all lobes. Her strengths in both upper and lower extremities are slightly weak and her daughter states that her mother has been “dizzy when getting up and has difficulty walking at times”.

While in the ED, the nurse inserted an 18-gauge intravenous (IV) to the left antecubital fossa (AC) and administered a 1 L normal saline (NS) bolus. Mary’s labs (CBC, CMP, cultures) were drawn, an x-ray and abdominal CT scan were performed, and a stool sample was ordered. She was administered 1 mg of morphine sulfate IV push at 1115 for her pain. In 15 minutes, her pain was reassessed and was reported as 8/10 using the numeric pain scale. She received an additional dose of 2 mg morphine sulfate IV push and reassessed after 15 minutes, stating a pain of 6/10; continuous pain assessment and management were performed. She was ordered NPO for bowel rest. The ED nurse administered 500 mg of metronidazole IV to prevent septic complications.

Mary’s labs revealed the following: elevated C-reactive protein of 16, positive antineutrophil cytoplasmic antibodies (ANCA), Hgb: 7.8, Hct: 23%, Platelets: 100,000, WBC: 13000, potassium: 3.3, sodium: 128, pH: 7.26, HCO3: 18, CO2: 31 (metabolic acidosis), lactic acid of 3.8, and the stool showed presence of blood and WBCs. Mary’s abdominal CT revealed colonic dilation of more than 6 cm in the transverse colon. Once results were in from the labs, x-ray, and CT scan, Mary was diagnosed with toxic megacolon resulting from a flare-up of UC and sent to the intensive care unit (ICU) for close observation and monitoring.

Once in the ICU, an NG tube was placed for gastric decompression due to the CT result of a 6 cm dilation of the colon. Her labs were closely monitored for electrolyte imbalance and further decline due to possible perforation of the colon (i.e. Hgb, Hct). Nursing priorities included focused assessments, monitoring for signs/symptoms of shock (perforation) such as rigid abdomen, severe abdominal pain, nausea/vomiting (N/V), fever, chills, and rectal bleeding. Mary was prescribed 400 mg of hydrocortisone IV to decrease inflammation and her pain was being monitored and managed with scheduled IV infusion of acetaminophen (Ofirmev) 1000 mg every 6 hours and 1 mg morphine sulfate IV push for breakthrough pain. Lactic acid was monitored every two hours until the levels fell below 2; she received Zosyn IV running at 25 mL/hr every four hours. Medical treatment was continued in cooperation with the gastroenterologist, intensivist, and surgeons to monitor for sepsis and the need for surgical intervention.

When Mary was stable, she was transferred to the direct observation unit (DOU) floor for observation and case management. On the floor, the patient was educated regarding toxic megacolon and taught about the need to continue her UC medication—Vedolizumab (Entyvio)—which, if taken correctly, should decrease the chance of  recurrence of UC flare-up and risk of toxic megacolon. Lastly, she met with case management and was educated on ulcerative colitis support groups and an appointment was schedule in May with her primary healthcare provider for follow-up.

Open-Ended Questions:

• Which areas of our nursing assessment should we closely monitor and what are we looking for?
• What are the major concerns with toxic megacolon related to bowel perforation?
• What other possible diagnoses should be considered and ruled out?
• What are the primary nursing diagnosis for Mrs. Cole?
• Areas of nursing assessment we want to closely monitor include a focused GI assessment, signs and symptoms of shock, and pain (related to dilation of colon).We would also monitor our lab values for any further indications that may show infection, fluid/electrolyte imbalances, and decrease in Hct/Hgb. It is important to remain cognizant of further deviations from the norm in order to prevent bowel perforation and/or treat the patient in a timely manner to reduce the chance of further complications (i.e. shock from perforation, sepsis).
• Biggest concern related to bowel perforation from toxic megacolon is infection from bacteria being released into abdomen; this places the patient at risk for septic shock.
• Other possible diagnosis that needed to be ruled out include: bowel obstruction peritonitis, pancreatitis, peptic ulcer, and kidney stones.
• Risk for infection
• Deficient fluid volume
• Risk for decreased cardiac tissue perfusion
• Dysfunctional gastrointestinal motility

Basson, M. D. (2018). Ulcerative colitis workup: approach considerations, serologic markers, other laboratory studies. Medscape . Retrieved from https://emedicine.medscape.com/article/183084-workup#showall Feuerstein, J. D., & Cheifetz, A. S. (2014). Ulcerative colitis: Epidemiology, diagnosis, and management. Mayo Clinic Proceedings, 89 (11), 1553-1563. http:dx.doi.org/10.1016/j.mayocp.2014.07.002

Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & suddarth’s textbook of medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

Unbound Medicine, Inc. (2014). Nursing Central (1.22) [Mobile application software]. Retrieved from <http://itunes.apple.com> Woodhouse, E. (2016). Toxic megacolon: A review for emergency department clinicians. Journal of Emergency Nursing, 42 (6), 481-486. https://doi.org/10.1016/j.jen2016.04.007

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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10 Inflammatory Bowel Disease (IBD) Nursing Care Plans

Use this nursing care plan and management guide to provide care for patients with inflammatory bowel disease (IBD). Enhance your understanding of nursing assessment , interventions, goals, and nursing diagnosis , all specifically tailored to address the unique needs of individuals with IBD.

Table of Contents

What is inflammatory bowel disease, nursing problem priorities, nursing assessment, nursing diagnosis, nursing goals, 1. enhancing bowel function and managing diarrhea, 2. preventing dehydration, 3. reducing anxiety and providing emotional support, 4. managing acute pain, 5. strengthening coping mechanisms, 6. providing adequate nutrition, 7. initiating patient education and health teachings, 8. administer medications and provide pharmacologic support, 9. monitoring results of diagnostic and laboratory procedures, 10. assessing and monitoring for potential complications.

Inflammatory bowel disease (IBD) is a group of chronic disorders that result in inflammation or ulceration (or both) of the bowel . IBD is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. It results from a complex interplay between genetic and environmental factors. Similarities involve (1) chronic inflammation of the alimentary tract and (2) periods of remission interspersed with episodes of acute inflammation. There is a genetic predisposition for IBD, and clients with this condition are more prone to the development of malignancy.

The two major types of inflammatory bowel disease are ulcerative colitis (UC) and Crohn disease (CD).

Ulcerative colitis (UC): A chronic condition of unknown cause usually starting in the rectum and distal portions of the colon and possibly spreading upward to involve the sigmoid and descending colon or the entire colon. It is usually intermittent (acute exacerbation with long remissions), but some individuals (30%–40%) have continuous symptoms. The cure is effected only by the total removal of the colon and rectum/rectal mucosa.

Regional enteritis (Crohn’s disease, ileocolitis): May be found in portions of the alimentary tract from the mouth to the anus but is most commonly found in the small intestine (terminal ileum). It is a slowly progressive chronic disease of unknown cause with intermittent acute episodes and no known cure. UC and regional enteritis share common symptoms but differ in the segment and layer of intestine involved and the degree of severity and complications. Therefore, separate databases are provided.

The manifestations of IBD generally depend on the area of the intestinal tract involved. Common symptoms may include abdominal cramping , irregular bowel habits, the passage of mucus without blood or pus, weight loss , fever and sweats, malaise and fatigue, arthralgias, growth retardation, and delayed sexual maturation in children, grossly bloody stools (typical of UC), and perianal diseases such as fistulas or abscesses.

Nursing Care Plans and Management

Nursing care management of clients with inflammatory bowel diseases (IBD) includes control of diarrhea and promoting optimal bowel function; minimizing or preventing complications; promoting optimal nutrition, and providing information about the disease process and treatment needs.

The following are the nursing priorities for patients with inflammatory bowel disease (IBD):

• Manage and reduce inflammation in the gastrointestinal tract.
• Alleviate symptoms such as abdominal pain , diarrhea , and rectal bleeding .
• Monitor disease activity and assess response to treatment.
• Prevent and manage complications, such as intestinal strictures or fistulas.
• Provide nutritional support and guidance to manage nutritional deficiencies.
• Administer appropriate medications to control inflammation and suppress the immune response.
• Educate patients on self-care measures and lifestyle modifications to manage symptoms.
• Offer support for emotional well-being and address the psychosocial impact of living with IBD.

Assess for the following subjective and objective data :

• See nursing assessment cues under Nursing Interventions and Actions.

Following a thorough assessment , a nursing diagnosis is formulated to specifically address the challenges associated with inflammatory bowel disease (IBD) based on the nurse ’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Goals and expected outcomes may include:

• The client will report a reduction in the frequency of stools and return to more normal stool consistency.
• The client will identify/avoid contributing factors.
• The client will maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor , and capillary refill; stable vital signs; balanced I&O with the urine of normal concentration/amount.
• The client will demonstrate behaviors to monitor and correct deficits, as indicated when the condition is chronic.
• The client will appear relaxed and report anxiety reduced to a manageable level.
• The client will verbalize awareness of feelings of anxiety and healthy ways to deal with them.
• The client will identify healthy ways to deal with and express anxiety.
• The client will use the support system effectively.
• The client will report pain is relieved/controlled.
• The client will appear relaxed and able to sleep /rest appropriately.
• The client will assess the current situation accurately.
• The client will identify ineffective coping behaviors and consequences.
• The client will acknowledge their own coping abilities.
• The client will demonstrate necessary lifestyle changes to limit/prevent recurrent episodes.
• The client will demonstrate stable weight or progressive gain toward the goal with normalization of laboratory values and the absence of signs of malnutrition .
• The client will verbalize understanding of disease processes, and possible complications.
• The client will identify stressful situations and specific action(s) to deal with them.
• The client will verbalize understanding of the therapeutic regimen.
• The client will participate in the treatment regimen.
• The client will initiate necessary lifestyle changes.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with inflammatory bowel disease (IBD) may include:

The intestinal immune system is key to the pathogenesis of inflammatory bowel disease (IBD). The intestinal epithelium prevents bacteria or antigen entry into the circulation by sealed intercellular junctions. In IBD, these junctions are defective from either a primary barrier function failure or as a result of severe inflammation (McDowell et al., 2022). During an IBD flare, the lining of the intestines becomes inflamed and cannot absorb all fluid. This results in stools being loose and watery, or even entirely liquid. The looser stool can also move more rapidly through the colon, causing more frequent bowel movements (Crohn’s and Colitis Canada, 2020).

Ascertain onset and pattern of diarrhea Ulcerative colitis most commonly presents as bloody diarrhea with or without mucus. According to the World Gastroenterology Organization, diarrhea may also occur at night and fecal incontinence is not uncommon (McDowell et al., 2022).

Observe and record stool frequency, characteristics, amount, and precipitating factors. This helps differentiate individual diseases and assesses the severity of episodes. Stools may be formed, but loose stools predominate if the colon or the terminal ileum is involved extensively. Constipation may be the primary symptom of ulcerative colitis when the disease is limited to the rectum; obstipation may occur and may proceed to bowel obstruction (Rowe & Anand, 2020).

Observe for the presence of associated factors, such as fever, chills, abdominal pain , cramping, bloody stools, emotional upset, physical exertion, and so forth. Grossly bloody stools, occasionally with tenesmus, although typical of ulcerative colitis, are less common in Crohn’s disease. Abdominal cramping and pain are commonly present in the right lower quadrant in Crohn’s disease. It can occur periumbilical or in the left lower quadrant in moderate to severe ulcerative colitis (Rowe & Anand, 2020).

Observe for fever, tachycardia, lethargy , leukocytosis, decreased serum protein, anxiety, and prostration. This may signify that toxic megacolon or perforation and peritonitis are imminent or have occurred, necessitating immediate medical intervention. Complications of ulcerative colitis include toxic megacolon, perforation, and bleeding as a result of ulceration, vascular engorgement, and highly vascular granulation tissue. In toxic megacolon, the inflammatory process extends into the muscularis, inhibiting its ability to contract and resulting in colonic distention.

Promote bedrest and provide bedside commode. Rest decreases intestinal motility and reduces the metabolic rate when infection or hemorrhage is a complication. The urge to defecate may occur without warning and be uncontrollable, increasing the risk of incontinence or falls if facilities are not close at hand. the nurse must provide ready access to a bathroom, commode, or bedpan and keep the environment clean and odor free. This protects the client’s safety, reduces stress, and enables the client to cope with diarrhea more effectively.

Remove stool promptly. Provide room deodorizers. Emptying the bedpan or commode promptly reduces noxious odors to avoid undue client embarrassment. This intervention will control odor and decrease the client’s anxiety and self-consciousness.

Identify and restrict foods and fluids that precipitate diarrhea (vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, and milk products). Avoiding intestinal irritants promotes intestinal rest and reduces intestinal workload. Raw vegetables and fruits, gas-forming foods, and alcohol can also precipitate diarrhea and cramping. When remission occurs, a less restricted diet can be tailored to the individual client, excluding foods known to precipitate symptoms. 

Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids. This provides colon rest by omitting or decreasing the stimulus of foods and fluids. Gradual resumption of liquids may prevent cramping and recurrence of diarrhea; however, cold fluids can increase intestinal motility. A liquid diet seemed superior to a regular diet for reducing inflammation. The problem with using enteral diets is that palatability limits the intake of adequate energy to meet client requirements (Rowe & Anand, 2020).

Provide an opportunity to vent frustrations related to the disease process. The presence of a disease with an unknown cause that is difficult to cure and that may require surgical intervention can lead to stress reactions that may aggravate the condition.

Eliminate or decrease the fat content in the diet. Fat can increase diarrhea in individuals with malabsorption syndrome. Consuming high-fat foods can also trigger symptoms such as abdominal pain, bloating, and diarrhea because they take longer to digest, stimulating the bowel to contract. Additionally, fat can increase the secretion of bile and pancreatic enzymes, contributing to diarrhea and other digestive issues.

Administer cholestyramine as indicated. In clients with Crohn’s disease who have a significant ileal disease or who have had an ileal resection, diarrhea may sometimes occur due to bile salt malabsorption. In such clients, treatment with bile-binding resins, such as cholestyramine, may be helpful in managing diarrhea (Rowe & Anand, 2020).

Administer topical corticosteroids or aminosalicylate preparations as prescribed. These agents reduce mucosal inflammation in clients with mild disease limited to the rectum and sigmoid colon. In clients with acute moderate to severe disease and with more extensive (pan colonic) disease, oral or intravenous corticosteroid therapy is initiated. In clients not responding to steroids or aminosalicylates, immunosuppressive immunomodulatory therapy may be initiated to reduce inflammation.

Administer antibiotics as indicated. The antibiotics metronidazole and ciprofloxacin are the most commonly used antibiotics in persons with IBD. Antibiotics are used only sparingly in persons with ulcerative colitis because of limited treatment efficacy and efficacy. In persons with Crohn’s disease, antibiotics are used for various indications, most commonly for perianal disease, fistulas, and intra-abdominal inflammatory masses (Rowe & Anand, 2020).

Administer probiotics or fish oil. Probiotics are beneficial bacteria that restore balance to the intestinal environment, with a resulting reduction in inflammation. Omega-3 fatty acids found in fish oil appear to benefit clients with active UC by decreasing inflammation; they must be taken in large quantities.

Clients diagnosed with IBD may have difficulty absorbing nutrients, including water, from the food they consume. This can lead to dehydration over time, as the body may not be able to absorb enough water to meet its requirements. Additionally, diarrhea is a common manifestation of both UC and Crohn’s disease, which involves frequent loose bowel movements, predisposing the client to further deficit in fluid volume. Preventing dehydration is an important aspect of managing inflammatory bowel disease (IBD) as it helps maintain overall health and supports the proper functioning of the gastrointestinal tract.

  Note possible conditions or processes that may lead to deficits such as fluid loss , limited intake, fluid shifts, and environmental factors. Fluid loss may be an effect of diarrhea or vomiting . Clients who suffer from acute gastroenteritis have been presented with a raised risk of growing IBD. A study also disclosed pathogenic bacteria that can cause gastroenteritis diseases such as Campylobacter and Salmonella that possibly play an essential role in the IBD etiology (Seyedian et al., 2019).

Monitor I&O. Note the number, character, and amount of stools; estimate insensible fluid losses (diaphoresis). Measure urine specific gravity; observe for oliguria. This provides information about overall fluid balance , renal function, and bowel disease control, as well as guidelines for fluid replacement. To detect fluid volume deficit , the nurse keeps an accurate record of I&O.  Systemic symptoms are common in IBD and include sweats, malaise, and arthralgias (Rowe & Anand, 2020).

Assess vital signs ( BP , pulse, temperature). Hypotension (including postural), tachycardia, and fever can indicate a response to fluid loss . A low-grade fever may be the first warning sign of a flare. Clients with toxic megacolon may appear septic; have a high fever, lethargy , chills, and tachycardia; and have increasing abdominal pain, tenderness, and distension (Rowe & Anand, 2020).

Observe for excessively dry skin and mucous membranes decreased skin turgor and slowed capillary refill. These signs may indicate excessive fluid loss or resultant dehydration . The extent of fluid loss may not be readily evident with diarrhea, particularly if the person uses the bathroom without assistance. Systemic manifestations of fluid volume deficit may be the first indicators of the problem.

Weigh daily and record. Rapid weight loss (over days to a week) usually indicates fluid loss, whereas weight loss over weeks to months may indicate malnutrition. Weight loss is observed more commonly in Crohn’s disease than in ulcerative colitis because the malabsorption associated with small bowel disease, or small bowel disease may act as an appetite deterrent. Additionally, the client may reduce their food intake in an effort to control their symptoms (Rowe & Anand, 2020).

Observe for overt bleeding and test stool daily for occult blood. An inadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation, potentiating the risk of hemorrhage . Observe stools for obvious blood and test for occult blood as indicated. Report grossly bloody stools or hematochezia, which may indicate hemorrhage and necessitate emergency surgery .

Note generalized muscle weakness or cardiac dysrhythmias. Excessive intestinal loss may lead to electrolyte imbalance , e.g., potassium , which is necessary for proper skeletal and cardiac muscle function. Minor alterations in serum levels can result in profound or life-threatening symptoms.

Monitor laboratory studies such as complete blood count , electrolytes (especially potassium , and magnesium ), and ABGs ( acid-base balance ). This determines the replacement needs and effectiveness of therapy. Hypokalemia is common because of prolonged diarrhea. Prolonged anemia may result in decreased hematocrit, hemoglobin , and RBCs. Anemia is common and may be either anemia of chronic disease or iron deficiency anemia . Anemia may result from acute or chronic blood loss , or malabsorption, or may reflect the chronic disease state (Rowe & Anand, 2020).

Maintain oral restrictions, and bedrest; avoid exertion. The colon is placed at rest for healing and to decrease intestinal fluid losses. Bowel rest during acute exacerbation of IBD promotes healing and reduces diarrhea and other manifestations.

Provide a bland, high-protein, high-calorie, low-residue diet as prescribed, when the client resumes oral intake. Nutritional management varies with the client’s condition. In severely ill clients, total parenteral nutrition ( TPN ) along with NPO status is prescribed to replace nutritional deficits while allowing complete bowel rest and improving nutritional status before surgery . A bland, high-protein, high-calorie, low-residue diet with vitamin and mineral supplements and excluding raw fruits and vegetables provide good nutrition and decrease diarrhea.

Assess tolerance to the diet and modify the diet plan accordingly. Cramping, diarrhea, and flatulence are signs that the client is not tolerating the diet. The use of elemental diets is being investigated for effectiveness as a primary therapy as an alternative to steroids and bowel rest in treating clients with acute Crohn’s disease. Elemental diets are free of bulk and residue, low in fat, and digested in the upper jejunum providing good nutrition with low fecal volume to enable bowel rest in selected clients.

Administer parenteral fluids, and blood transfusions as indicated. Maintenance of bowel rest requires alternative fluid replacement to correct losses and anemia. These measures maintain the acutely ill client and are guided by laboratory test results. Administering blood products and iron will help correct existing anemia and losses caused by hemorrhage.

The prevalence of anxiety and depression is higher in clients with chronic diseases compared to the general population and having a long-term illness is a risk factor for depression. Research on clients with both chronic disease and IBD reveals that the presence of anxiety or depressive disorder is associated with poor treatment compliance . Provision of treatment for mental disorders may improve long-term outcomes, and it is, therefore, important to identify clients at the greatest risk of anxiety and depression so that they can be offered the appropriate treatment and support. (Byrne et al., 2017)

Review physiological factors, such as active medical conditions; recent or ongoing stressors. These factors can cause or exacerbate anxiety or anxiety disorders . IBD clients with anxiety and depression are more likely to report problematic symptoms, even in the absence of significant inflammation. The development of anxiety and depression in these clients may potentiate disease flares or complications and can reduce the likelihood of therapeutic success (Navabi et al., 2018).

Observe and note behavioral clues (restlessness, irritability, withdrawal , lack of eye contact, demanding behavior). Indicators of the degree of anxiety or stress (the client may feel out of control at home or at work managing personal problems). Stress may develop as a result of physical symptoms of the condition and the reaction of others. A study showed that IBD clients dealing with anxiety and depression also experience more disease-related complications and more often engage in counterproductive behaviors and utilize medical therapies with problematic side effects. Specifically, it was revealed that they are more likely to manifest extra-intestinal manifestations of IBD, and they carry a significantly more severe symptom burden (Navabi et al., 2018).

Encourage verbalization of feelings. Provide feedback. This establishes a therapeutic relationship and assists the client and caregiver in identifying problems causing stress. The client with severe diarrhea may hesitate to ask for help for fear of becoming a burden to the staff.  Rapport can be established by being attentive and displaying a calm, confident manner. The nurse should allow time for the client to ask questions and express feelings.

Acknowledge that the anxiety and problems are similar to those expressed by others. Active-listen to the client’s concerns. Validation that feelings are normal can help reduce stress, isolation , and the belief that “I am the only one.” Careful listening and sensitivity to nonverbal indicators of anxiety, such as restlessness and tense facial expressions, are helpful. The client may be emotionally labile because of the consequences of the disease and the uncertainty of exacerbations with complications.

Provide accurate, concrete information about what is being done (reason for bed rest , restriction of oral intake, and procedures). Involving the client in the plan of care provides a sense of control and helps decrease anxiety. The nurse should tailor the information about possible impending surgery to the client’s level of understanding and desire for detail. If surgery is planned, pictures, illustrations, websites, and blogs help explain the surgical procedure and help the client visualize what a stoma looks like.

Provide a calm, restful environment. Removing the client from outside stressors promotes relaxation and helps reduce anxiety.  Acute stress, such as that experienced during examinations and events, produces a stress response that may become maladaptive if continuously activated, potentially resulting in immunosuppression , autonomic and enteric nervous system alterations, intestinal permeability, and other inflammatory changes that may ultimately lead to chronic disease (Wynne et al., 2019). 

Encourage staff and caregivers to project a caring concerned attitude. A supportive manner can help the client feel less stressed, allowing energy to be directed toward healing or recovery. Be empathetic and nonjudgemental in dealing with the client and family. Family relationships are disrupted; financial, lifestyle, and role changes make this a difficult time for those involved with the client, and they may react in many different ways.

Help the client identify and initiate positive coping behaviors used in the past. Successful behaviors can be fostered in dealing with current problems and stress, enhancing the client’s sense of self-control. Positive coping styles are associated with less illness uncertainty and better outcomes. A study described cognitive strategies for managing emotions as particularly helpful when undergoing procedures, and hence might be especially effective at decreasing mental health effects from medical trauma (Easterlin et al., 2020).

Assist the client to learn new coping mechanisms through stress management techniques, organizational skills, etc. Learning new ways to cope can be helpful in reducing stress and anxiety, and enhancing disease control. Several treatments are available for reducing psychological dysfunction, including stress, in clinical practice , and these interventions have been systematically and critically reviewed in IBD clients. They include educational programs, simple stress management, and relaxation strategies, hypnotherapy, mindfulness-based stress reduction, and cognitive behavioral therapy (Wynne et al., 2019).

Assist the client in identifying cognitive and behavioral strategies for managing emotions. Many families described facing serious stress and pain with IV placement before learning behavioral techniques, such as the use of topical anesthetics, pre-hydration, breathing exercises, and distraction. The families in a study also described coping strategies that are cognitive behavioral therapy techniques, such as reframing, optimism, and focusing on benefits. Although families develop a variety of helpful behaviors over time, this process could be expedited if healthcare teams routinely incorporated these strategies into their practice (Easterlin et al., 2020).

Provide information for and encourage social support. Connecting families to others with IBD might further provide anticipatory information and social support. Child Life Specialists are also an important source of education and coping skills and could assist the client and their families. Parents rely on spouses and family members for support. Families also rely on information from others affected by IBD and educational support, such as tutors. Clients and caregivers also report that they drew strength from their relationships with the care team (Easterlin et al., 2020).

Chronic abdominal pain is a major complaint in individuals with IBD. Nevertheless, it is an under-recognized and undertreated problem with a negative impact on the quality of life. The IBD inflammation-related factors may include ongoing sub-clinical inflammation, central and visceral post-inflammatory sensitization, small intestinal bacterial overgrowth, strictures, stenosis and adhesions, food intolerances, and bowel dysmotility. Recognizing client-reported outcomes such as pain is integral to improving the client’s quality of life (Norton et al., 2017).

Assess reports of abdominal cramping or pain, noting location, duration, and intensity (0–10 scale). Investigate and report changes in pain characteristics Colicky intermittent pain occurs with Crohn’s disease. Pain is a frequently reported symptom in active IBD, with the expectation that in the majority of clients, it will resolve when the disease is controlled. A survey conducted in the UK found that up to 50% of clients with Crohn’s disease and 37% of those with ulcerative colitis reported pain, irrespective of whether IBD was in relapse or in remission. Of those reporting pain, a high level of pain (>7/10) was scored by 54% of clients with Crohn’s disease (Norton et al., 2017).

Note nonverbal cues (restlessness, reluctance to move, abdominal guarding, withdrawal, and depression). Investigate discrepancies between verbal and nonverbal cues. Body language or nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine the extent and severity of the problem. Reducing abdominal pain is a key therapeutic target for IBD therapy; however, pain severity does not always correlate with endoscopic and clinical biomarkers, and a significant proportion of clients report ongoing pain during periods of remission. Bodily pain, cramps, and extra-intestinal manifestations of IBD such as arthralgia are also reported by clients (Sweeney et al., 2018).

Review factors that aggravate or alleviate pain. This may pinpoint precipitating or aggravating factors (such as stressful events, and food intolerance) or identify developing complications. Pain may be modulated by central factors such as psychological symptoms (stress, anxiety, depression, or poor coping), sleep disturbance, and medications, and could arise from other medical conditions (Norton et al., 2017).

Observe and record abdominal distension, increased temperature, and decreased BP . This may indicate developing intestinal obstruction from inflammation, edema , and scarring. Toxic megacolon is a medical emergency. Clients appear septic; have a high fever, lethargy , chills, and tachycardia; and have increasing abdominal pain, tenderness, and distention (Rowe & Anand, 2020).

Assess for the presence of anxiety or depression. Negative emotional arousal may exacerbate pain in IBD directly through the amplification of descending pain signals in higher-order processing or by exacerbating inflammation via the production of cortisol. Findings indicate that higher levels of depression and anxiety were associated with greater pain severity or intensity. A recent systematic review identified prevalence rates of 15% and 20% for depression and anxiety in over 150,000 IBD clients. Prospective studies with IBD clients have demonstrated that depression and anxiety are associated with symptom exacerbation and the onset of active disease (Sweeney et al., 2018).

Observe for ischiorectal and perianal fistulas. Fistulas may develop from erosion and weakening of the intestinal bowel wall. Recurrence of perianal fistulas after medical or surgical treatment is common. In one study, one year after surgery for Crohn disease, 20 to 37% of clients had symptoms suggestive of clinical recurrence, and endoscopic evidence of recurrent inflammation was in the new terminal ileum in 48 to 93% of clients (Rowe & Anand, 2020).

Encourage the client to report pain. The client may try to tolerate pain rather than request analgesics. The possible underrecognition of the symptom of pain by clinicians, combined with clients not seeking help as they believe that “nothing can be done” leads to pain being underdiagnosed and not effectively managed. Additionally, inconsistencies and considerable variation in how pain is assessed in IBD may further contribute to its underrecognition and underreporting (Norton et al., 2017).

Encourage the client to assume a position of comfort (knees flexed). This reduces abdominal tension and promotes a sense of control. Because abdominal pain can cause varying levels of distress, the client may experience extremes in comfort and positioning .  Position changes, local application of heat, diversional activities, and prevention of fatigue are helpful in reducing pain.

Provide comfort measures (back rub, repositioning) and diversional activities. This promotes relaxation , refocuses attention, and may enhance coping abilities. Deep, slow breathing may help decrease perception or response to pain. These measures also provide a sense of having some control over the situation and an increase in a positive attitude.

Cleanse the rectal area with mild soap and water or wipes after each stool and provide skin care (A&D ointment, Sween ointment, Karaya gel, Desitin, petroleum jelly). Provide regular perineal care . This protects the skin from bowel acids, preventing excoriation. The nurse should examine the skin frequently, especially the perianal area. Perineal care , including the use of a skin barrier, is important after each bowel movement . The nurse should give immediate attention to reddened or irritated areas over bony prominences and use pressure-relieving devices to prevent skin breakdown.

Provide sitz bath as appropriate. This enhances cleanliness and comfort in the presence of perianal irritation or fissures. A sitz bath is a relatively easy procedure that involves filling a bathtub with warm water. An additive, such as salt, may be used occasionally. The healthcare provider usually orders a sitz bath to be done one to four times a day, plus after defecation. Generally, the client is instructed to immerse their perineum and lower pelvis in a tub of warm water with or without additives for 20 to 30 minutes (Lang et al., 2011).

Keep the client on nothing by mouth (NPO) as indicated. Complete bowel rest can reduce pain, and cramping. Unlike clients with UC, diet can influence inflammatory activity in persons with Crohn disease. NPO can hasten the reduction of inflammation, as may the use of a liquid or predigested formula for enteral feeding .

Promote dietary modifications that may reduce pain. Although diet has been well demonstrated to have little or no influence on inflammatory activity in persons with ulcerative colitis (UC), it may influence symptoms. For this reason, clients are often advised to make a variety of dietary modifications, especially adaptation of a low-residue diet as beneficial in the treatment of UC. Such a diet, however, might decrease the frequency of bowel movements (Rowe & Anand, 2020).

Promote physical rest by scheduling rest periods, sleep , and daily activities. Generally, clients do not need to limit activity when IBD is quiescent. During disease flares, physical activity is limited only by the extent of fatigue and the abdominal pain or diarrhea the client is experiencing. Moderate to vigorous physical activity for as long as 12 weeks has been shown to improve symptom scores and many specific quality-of-life dimensions, including energy, sleep , emotion, and physical functioning (Rowe & Anand, 2020). 

Provide information about alternative interventions or therapies to reduce pain. There is some previous research on cognitive, emotional, and behavioral factors associated with pain severity in IBD. A review found a number of psychological interventions: both self-directed and therapist-led stress management interventions resulted in reduced abdominal pain and a 10-week manualized program examining cognitions, emotions, stress, and behaviors led to less reported pain. Integrating disease-specific concerns into cognitive behavioral treatment also had beneficial effects in reducing pain as well as anxiety (Norton et al., 2017).

Administer immune modifiers as prescribed. The concept of deep mucosal healing, particularly in Crohn’s disease, is becoming routine care. There are several studies, primarily involving anti-TNF agents; that have shown that the elimination of inflammation results in a decrease in the rate of surgery, the use of corticosteroids, and the rate of hospitalization (Rowe & Anand, 2020).

Administer corticosteroids as indicated. Corticosteroids are rapid-acting anti-inflammatory agents used in the treatment of IBD. These drugs are indicated for acute flares of disease only and have no role in the maintenance of remission. For a flare of moderate severity, a dose of prednisone 20 to 40 mg/day or equivalent is often sufficient to treat the flares. Once symptoms are controlled, a dedicated tapering of the steroid dose follows (Rowe & Anand, 2020).

Coping is an important construct in the context of chronic illness and refers to an individual’s efforts to tolerate and resolve stressors that exceed his or her resources. Because the client may feel isolated, helpless, and out of control, understanding and emotional support are essential. The client may respond to stress in a variety of ways that may alienate others. Negotiating meaning over stressful life circumstances can enhance coping and lead to better outcomes (Sweeney et al., 2018,).

Assess the client’s and caregiver’s understanding and previous methods of dealing with the disease process. This enables the nurse to deal more realistically with current problems. Anxiety and other problems may have interfered with previous health teaching and client learning . In a study, for most clients, one of the main challenges was not being “normal”. These clients expressed frustrations with needing to prioritize their health, which sometimes meant missing social events. A few clients hid their diagnosis from friends because they feared being “viewed as a disease” (Easterlin et al., 2020).

Determine outside stressors (family, relationships, social or work environment). Stress can alter the autonomic nervous response, affecting the immune system and contributing to the exacerbation of the disease. Even the goal of independence in the dependent client can be an added stressor. The nurse needs to recognize that the client’s behavior may be affected by a number of factors. Any client suffering from the discomforts of frequent bowel movements and rectal soreness is anxious , discouraged, and unhappy.

Provide an opportunity for the client to discuss how illness has affected relationships, including sexual concerns. Stressors of illness affect all areas of life, and the client may have difficulty coping with feelings of fatigue and pain in relation to relationships and sexual needs. Clients struggled with the unpredictable nature of the disease, while parents worried about treatment decisions, managing social relationships, and transitions from childhood to adulthood. Most clients may be open, but they may acknowledge that, because the symptoms involve bowel habits and manifestations are not outwardly obvious, it can be difficult to initiate conversations about their disease (Easterlin et al., 2020).

Help the client identify individually effective coping skills. The use of previously successful behaviors can help the client deal with the current situation and plan for the future. Positive coping styles are associated with less illness uncertainty and better outcomes. Similar to adapting to the diagnosis of IBD, clients in a study described a process by which they came to accept their diagnosis. Ultimately, most clients came to accept the diagnosis with symptom control, as clients felt they had achieved a “new normal” (Easterlin et al., 2020).

Active-listen in a nonjudgmental manner; maintain nonjudgmental body language when caring for the client; and assign the same staff as much as possible. This aids in communication and understanding the client’s viewpoints and adds to the client’s feelings of self-worth. This also prevents reinforcing the client’s feelings of being a burden, (frequent need to empty bedpan or commode). Additionally, this provides a more therapeutic environment and lessens the stress of constant adjustments. It is important to communicate that the client’s feelings are understood by encouraging the client to talk and express their feelings and to discuss any concerns.

Provide emotional support and encourage social support. Families draw strength from relationships. Children rely on parents to navigate the diagnosis of IBD and repeated IV placement. Parents rely on spouses and family members for support. Families also rely on information from others affected by IBD and educational support, such as tutors. Moreover, clients and their families highlight the strength they draw from relationships with the healthcare team (Easterlin et al., 2020).

Provide uninterrupted sleep and rest periods. Exhaustion brought on by the disease tends to magnify problems, interfering with the ability to cope. The nurse should recommend intermittent rest periods during the day and schedule or restricts activities to conserve energy and reduce metabolic rate. Activity restrictions should be modified as needed on a day-to-day basis.

Encourage the use of stress management skills, ( relaxation techniques, visualization, guided imagery, deep-breathing exercises). This refocuses attention, promotes relaxation, and enhances coping abilities. Stress reduction measures that may be used include relaxation techniques, visualization, breathing exercises, and biofeedback. Many families described facing serious stress and pain with IV placement before learning behavioral techniques, such as the use of topical anesthetics, pre-hydration, breathing exercises, and distraction. Although families developed a variety of helpful behaviors over time, this process could be expedited if healthcare teams routinely incorporated these strategies into practice (Easterlin et al., 2020).

Include the client and family in team conferences to develop an individualized program. This promotes continuity of care and enables the client and family members to feel a part of the plan, imparting a sense of control and increasing cooperation with the therapeutic regimen. Healthcare delivery systems that build social relationships, maintain normalcy, and consider the needs of the whole family may further facilitate coping. Healthcare delivery systems that are multidisciplinary, incorporate flexible hours (evenings, weekends), and are family-oriented (offer child care and integrated mental healthcare for family members) may facilitate relationship-building, decrease logistical costs, and improve mental health and coping for the entire family (Easterlin et al., 2020).

Refer to resources as indicated (local support group, social worker, psychiatric clinical nurse specialist, spiritual advisor). Additional support and counseling can assist the client and family members in dealing with specific stress and problem areas. Professional counseling may be needed to help the client and family manage issues associated with chronic illness and resulting disability. Connecting families to others with IBD might provide further anticipatory information and social support (Easterlin et al., 2020).

Assist the client in managing emotions and reducing anxiety. The healthcare team might also support coping by helping clients identify cognitive and behavioral strategies for managing emotions. The team might provide anticipatory guidance to decrease anxiety related to the unknown, both in living with a chronic illness and preparing for medical procedures. For IBD, this might include introductory information about the condition, stories from other clients and parents, and detailed information about the infusion procedures (Easterlin et al., 2020).  

Provide information about positive coping mechanisms. The families in a study described coping strategies that are cognitive behavioral techniques, such as reframing, optimism, and focusing on benefits. These clients dealt with negative emotions about the infusion process by focusing on the benefits of the treatment and the opportunities the appointment afforded to interact with the healthcare team. These coping skills may be shared with other clients who may find them useful and incorporated into their routines.

Educate the client about behaviors that contribute to dysfunctional coping. A number of studies examined coping strategies in relation to pain levels. Greater use of behaviors such as self-distraction, behavioral disengagement, denial , venting, and self-blame and less use of active coping and planning were related to increased pain severity in IBD (Sweeney et al., 2018).

Promote the strengthening of the client’s locus of control. An internal locus of control, namely the perception that one’s behavior can control events and outcomes associated with better pain-related quality of life. Perceived controllability of stressful life events has been investigated in individuals with functional gastrointestinal disorders and has demonstrated that developing skills of coping flexibility, in particular learning to identify and respond adaptively to controllable vs uncontrollable stressors, may be a useful tool for clients with more complex symptoms (Sweeney et al., 2018).

Among environmental factors, accumulating evidence suggests that dietary nutrients contribute to the pathogenesis of IBD. Specifically, diets rich in fat and protein, have been identified as risk factors for the development of IBD. Hence, nutritional intervention, which aims to reduce the intake of potential nutritional hazards, is a treatment option for IBD that induces and extends disease remission. Additionally, some dietary nutrients can potentiate the host’s immune system and intestinal barrier function, which in turn protect the host from disease. Therefore, providing beneficial nutrients, while limiting nutritional hazards, is a key strategy for successful dietary therapies designed for the treatment of IBD (Sugihara et al., 2019).

Weigh daily. This provides information about dietary needs and the effectiveness of therapy. Weight loss is observed more commonly in Crohn’s disease than in ulcerative colitis because the malabsorption associated with small bowel disease, or small bowel disease may act as an appetite deterrent. In addition, clients may reduce their food intake in an effort to control their symptoms (Rowe & Anand, 2020).

Inspect oral mucosa. This may reveal ulcerations and/or provide information about the integrity of the entire GI tract, affecting the ability to eat and absorb nutrients. Oral manifestations are observed in 8 to 10% of clients and may be considered specific or unspecific. These manifestations include cobblestoned oral mucosa, granular gingival swelling of hyperplastic aspect, labial swelling accompanied by vertical fissures, and deep and linear ulcers associated with hyperplastic mucosa folds on the vestibule folds (Munerato & Barcelos, 2016).

Evaluate the client’s appetite. Appetite may be suppressed because of altered taste , early satiety, meal-related cramping, diarrhea, or a combination of these factors. Additionally, ulceration in the oral mucosa may be painful during eating and lead to the client avoiding meal times to avoid the pain.

Record intake and changes in symptomatology. This is useful in identifying specific deficiencies and determining GI response to foods. Clients with IBD may experience GI symptoms even during remission without underlying inflammation. Recent studies have demonstrated that the restriction of several groups of fermentable carbohydrates is effective in the management of functional symptoms (Sugihara et al., 2019).

Monitor laboratory studies, including hemoglobin and hematocrit, serum electrolytes , and total serum protein and albumin levels. These studies provide an indicator of nutritional status. Anemia is common and may be either anemia of chronic disease or iron deficiency anemia. Anemia may result from acute or chronic blood loss, or malabsorption, or may reflect the chronic disease state. Vitamin B12 deficiency can occur in clients with Crohn’s disease who have significant terminal ileum disease or in clients who have had terminal ileum resection. Nutritional status can also be assessed by serum albumin, prealbumin, and transferrin levels. Hypoalbuminemia may reflect malnutrition because of poor oral intake or because of protein-losing enteropathy that can coexist with active IBD (Rowe & Anand, 2020).

Encourage bed rest and limited activity during the acute phase of illness. Decreasing metabolic needs aids in preventing caloric depletion and conserves energy. During disease flares, physical activity is limited only by the extent of fatigue and the abdominal pain or diarrhea the client is experiencing. In most instances, diarrhea limits activity primarily because of the lack of immediate access to toilet facilities in many locations and/or occupations (Rowe & Anand, 2020).

Recommend rest before meals. This quiets peristalsis and increases available energy for eating. Bowel rest during an acute exacerbation of IBD promotes healing and reduces diarrhea and other manifestations.

Provide oral hygiene . A clean mouth can enhance the taste of food. An aqueous solution of clobetasol propionate in combination with nystatin as a mouthwash may be prescribed to be used by the client three times a day for seven days (Munerato & Barcelos, 2016).

Serve foods in well-ventilated, pleasant surroundings, with an unhurried atmosphere, and congenial company. A pleasant environment aids in reducing stress and is more conducive to eating. Appetite and food preferences are influenced by a variety of factors, including mood, emotions, and surroundings. Research suggests that by eating in a pleasant environment where the client is comfortable and there is good lighting, people are more likely to enjoy their meal and feel satisfied. This can lead to an increase in appetite and a desire to eat more.

Avoid or limit foods that might cause or exacerbate abdominal cramping, and flatulence (milk products, foods high in fiber or fat, alcohol, caffeinated beverages, chocolate, peppermint, tomatoes, and orange juice). Individual tolerance varies, depending on the stage of disease and the area of the bowel affected. Lactose intolerance is common in persons with Crohn’s disease or ulcerative colitis and can mimic symptoms of IBD (Rowe & Anand, 2020). High alcohol consumption was associated with an increased risk of relapse. Dietary fats are associated with an increase or decrease in IBD, depending on the type of fat. A high intake of dietary polyunsaturated fatty acids was associated with a reduced risk of ulcerative colitis. In contrast, a high intake of trans-unsaturated fats was associated with an increased risk of the same disease (Sugihara et al., 2019).

Promote client and family participation in dietary planning as possible. This provides a sense of control for the client and family and the opportunity to select foods desired, which may increase intake. Families, especially the primary food preparer, can reinforce teaching and help the client maintain required restrictions or kilojoule intake.

Encourage the client to verbalize feelings concerning the resumption of diet. Hesitation to eat may be the result of fear that food will cause exacerbation of symptoms. Crohn’s disease can significantly alter the bowel’s ability to absorb nutrients. In both forms of IBD, blood and protein-rich fluid may be lost in diarrheal stools. With malabsorption and continuing nutrient losses, multiple nutrient deficits can develop, affecting growth and development, healing, muscle mass, bone density, and electrolyte balances.

Keep the client NPO as indicated. Resting the bowel decreases peristalsis and diarrhea, limiting malabsorption and loss of nutrients. Unlike clients with ulcerative colitis, diet can influence inflammatory activity in persons with Crohn’s disease. NPO can hasten the reduction of inflammation, as may the use of a liquid or predigested formula for enteral feeding (Rowe & Anand, 2020).

Resume or advance diet as indicated (clear liquids progressing to the bland, low residue; then high-protein, high-calorie, caffeine-free, nonspicy, and low-fiber as indicated). This allows the intestinal tract to readjust to the digestive process. Protein is necessary for tissue healing integrity. Low bulk decreases peristaltic response to meals. Note: Dietary measures depend on the client’s condition (if the disease is mild, the client may do well on a low-residue, low-fat diet high in protein and calories with lactose restriction). In moderate disease, elemental enteral products may be given to provide nutrition without overstimulating the bowel. The client with toxic colitis is NPO and placed on parenteral nutrition.

Administer elemental enteral nutrition as indicated. In a prospective study of 56 clients with quiescent Crohn’s disease on maintenance infliximab therapy, a study found that concomitant enteral nutrition did not significantly improve the maintenance rate of clinical remission in clients with Crohn’s disease. Although a meta-analysis demonstrated that steroids were superior to a liquid diet alone, a liquid diet seemed superior to a regular diet for reducing inflammation (Rowe & Anand, 2020).

Provide multivitamin supplementation as prescribed. Multivitamin supplementation is recommended in clients with IBD. for clients with vitamin B12 or vitamin D deficiency, supplementation of these vitamins should be given. The results of two studies suggest the link between vitamin D and IBD may be of particular importance. Clients receiving steroid therapy should receive vitamin D and calcium supplementation. Parenteral iron ( IM weekly or IV) may be used in clients with chronic iron-deficiency anemia who are unable to tolerate the oral formulation (Rowe & Anand, 2020).

Educate the client to avoid food additives and emulsifiers. High animal or dairy fat, animal protein, wheat, emulsifiers, and thickeners appear to top the list of candidate foods associated with intestinal inflammation in animal models. Emulsifiers may affect the microbiome as well as the host. Emulsifiers appear to affect compositional changes associated with inflammation (Levine et al., 2018).

Because IBD is a chronic, often lifelong disease that is frequently diagnosed in young adulthood, increasing client knowledge improves medical compliance and assists in the management of symptoms (Rowe & Anand, 2020). Additionally, IBD is a chronic condition for which the client provides daily self-management. For this reason, teaching is a vital component of care. Initiating patient education and health teachings in patients with inflammatory bowel disease (IBD) is essential for empowering individuals to actively participate in the management of their condition and improve their overall well-being.

Determine the client’s perception of the disease process. The nurse should assess the client’s understanding of the disease process and their need for additional information about medical management and surgical interventions. This establishes a knowledge base and provides some insight into individual learning needs.

Review the disease process, cause and effect relationship of factors that precipitate symptoms, and identify ways to reduce contributing factors. Encourage questions. Precipitating or aggravating factors are individual; therefore, the client needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. The accurate knowledge base provides an opportunity for the client to make informed decisions and choices about the future and control of the chronic disease. Although most clients know about their own disease process, they may have outdated information or misconceptions.

Review medications, purpose, frequency, dosage , and possible side effects. This promotes understanding and may enhance cooperation with the regimen. It is also important to explain the rationale for the use of medications, such as corticosteroids and anti-inflammatory, antibacterial, and anti-diarrheal agents. The nurse should emphasize the importance of taking medications as prescribed and not abruptly discontinuing them (especially corticosteroids) to avoid the development of serious medical problems.

Remind the client to observe for side effects if steroids are given on a long-term basis (ulcers, facial edema , muscle weakness ). Steroids may be used to control inflammation and to effect a remission of the disease; however, drugs may lower resistance to infection and cause fluid retention. The potential complications of corticosteroid use include fluid and electrolyte abnormalities, osteoporosis , avascular bone necrosis, peptic ulcers, cataracts , glaucoma, neurologic and endocrine dysfunctions, infectious complications, and occasional psychiatric disorders including psychosis (Rowe & Anand, 2020).

Stress the importance of good skin care (proper handwashing techniques and perineal skincare). This reduces the spread of bacteria and the risk of skin irritation or breakdown, and infection. Perianal care, including the use of a skin barrier, is important after each bowel movement . The nurse should also emphasize giving immediate attention to reddened or irritated areas over bony prominences and uses pressure-relieving devices to prevent skin breakdown.

Recommend cessation of smoking. Smoking can increase intestinal motility, aggravating symptoms. Tobacco use has been linked to increases in the number and severity of flares of Crohn’s disease, and smoking cessation can help achieve remission in clients with Crohn’s disease. However, current smoking protects against ulcerative colitis, whereas former smoking increases the risk of ulcerative colitis (Rowe & Anand, 2020).

Emphasize the need for long-term follow-up and periodic reevaluation. Clients with IBD are at increased risk for colon or rectal cancer , and regular diagnostic evaluations may be required. An interventional radiologist may be consulted when percutaneous drainage of an abscess is desired. Specialty consultation is best for managing extracolonic manifestations. Also consider arranging consultations for clients with a registered dietitian and a stoma nurse, if indicated (Rowe & Anand, 2020).

Educate the client about the effects of IBD on reproduction, pregnancy, and breastfeeding . In women with IBD, fertility is normal or only minimally impaired. The prescribing information for medications in clients who are attempting to conceive, are pregnant, or are breastfeeding must be reviewed.  All of the aminosalicylates and corticosteroids appear to be safe in women in all phases of fertility, pregnancy, and lactation. Men should avoid sulfasalazine during periods when they and their mates are attempting to become pregnant. Sulfasalazine can decrease sperm counts and sperm motility, causing functional azoospermia. The sperm effects are reversible by discontinuing sulfasalazine (Rowe & Anand, 2020).

Caution for women with Crohn’s disease about using contraceptives. Advise women who have Crohn’s disease with small bowel disease and malabsorption that oral contraception may have reduced effectiveness. Additional contraception is recommended for women on combined hormonal contraception who are also receiving antibiotic regimens for less than three weeks, as well as for seven weeks following cessation of the antibiotic. Note that certain medications prescribed for rectal or genital use may adversely affect the efficacy of condoms (Rowe & Anand, 2020).

Emphasize the importance of adhering to the prescribed diet after discharge. The nurse should reinforce the importance of nutritional management at home: a bland, low-residue, high-protein, high-calorie, and high-vitamin diet relieves symptoms and decreases diarrhea. Dietary modifications can control but do not cure the disease. It is important to encourage the client to keep a record of the foods that irritate the bowel to avoid them and to drink at least eight glasses of water each day (Rowe & Anand, 2020).

Encourage strengthening client and family support. The prolonged nature of the disease has an impact on the client and often strains their family life and financial resources. Family support is vital; however, some family members may be resentful or feel guilty, tired, and unable to cope with the emotional demands of the illness and the physical demands of providing care. Some clients with IBD do not socialize for fear of being embarrassed. These clients need time to express their fears and frustrations.

Medications play a significant role in managing symptoms, reducing inflammation, and maintaining remission in individuals with IBD. However, a specific medication regimen for an individual with IBD will depend on several factors, including the type and severity of the disease, response to previous treatments, and the patient’s overall health. The use of medications in IBD requires careful monitoring by healthcare providers to assess effectiveness, manage potential side effects, and adjust treatment plans accordingly.

1. Aminosalicylates (5- ASA ) These medications, such as mesalamine and sulfasalazine, are used to reduce inflammation in the gastrointestinal tract and maintain remission in mild to moderate cases of IBD.

2. Corticosteroids Prednisone and budesonide are examples of corticosteroids used to suppress inflammation and control symptoms during flare-ups of IBD. They are typically prescribed for short-term use due to their potential side effects.

3. Immunomodulators Azathioprine , mercaptopurine , and methotrexate are immunomodulatory medications that suppress the immune system and reduce inflammation. They are used to induce and maintain remission in moderate to severe cases of IBD or as steroid-sparing agents.

4. Biologic Therapies Biologic agents, such as anti- tumor necrosis factor (TNF) medications like infliximab, adalimumab, and certolizumab pegol, are used for moderate to severe IBD that does not respond to other treatments. They target specific proteins involved in the inflammatory process to reduce inflammation and promote healing.

5. Integrin Receptor Antagonists Vedolizumab and natalizumab are integrin receptor antagonists that selectively target certain immune cells involved in the inflammation of IBD. They are used in moderate to severe cases of IBD when other treatments have not been effective.

6. Janus Kinase (JAK) Inhibitors Tofacitinib is a JAK inhibitor that works by modulating the immune response. It is used in moderate to severe ulcerative colitis when other treatments have not been successful or well-tolerated.

7. Antibiotics In some cases, antibiotics such as metronidazole or ciprofloxacin may be prescribed to control bacterial overgrowth or treat complications associated with IBD, such as abscesses or fistulas.

8. Anti-diarrheal Medications Medications such as loperamide (Imodium) may be used to manage acute episodes of diarrhea associated with IBD. However, they should be used cautiously and under medical supervision to prevent potential complications.

Monitoring the results of diagnostic and laboratory procedures is an integral part of managing inflammatory bowel disease (IBD) in patients. Regular monitoring helps healthcare providers assess disease activity, evaluate treatment effectiveness, detect complications, and make informed decisions regarding patient care . By closely monitoring the results of diagnostic and laboratory procedures, healthcare providers can assess disease activity, track treatment response, detect complications, and provide timely interventions to optimize the management of inflammatory bowel disease.

1. Blood Tests Blood tests are frequently used to assess various aspects of IBD, including inflammation markers, nutritional status, and autoimmune markers. Some commonly ordered blood tests for IBD include:

• Complete blood count (CBC) to evaluate for anemia, infection, or inflammation.
• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to measure inflammation levels.
• Liver function tests to assess liver health and detect any associated complications.
• Albumin and other nutritional markers to evaluate nutritional status and identify deficiencies.
• Anti-Saccharomyces cerevisiae antibodies (ASCA) and other antibodies to help differentiate between Crohn’s disease and ulcerative colitis.

2. Stool Tests Stool tests are performed to assess for infectious causes of gastrointestinal symptoms and to evaluate the presence of inflammation. Common stool tests in IBD may include:

• Stool culture to identify bacterial, viral, or parasitic infections.
• Fecal calprotectin , a marker of inflammation in the intestines.
• Stool examination for the presence of blood or mucus.

3. Colonoscopy and Endoscopy Colonoscopy and endoscopy procedures involve the use of a flexible tube with a camera to visualize and evaluate the colon and the lining of the gastrointestinal tract. These procedures allow for direct visualization of the intestines and can aid in diagnosing and monitoring the extent and severity of IBD. Biopsies can also be taken during these procedures for further analysis.

4. Imaging Studies Various imaging modalities may be used to assess the gastrointestinal tract and identify abnormalities in patients with IBD. Common imaging studies include:

• Abdominal ultrasound to evaluate the presence of complications such as abscesses or strictures.
• Computed tomography (CT) scan to assess the extent of inflammation, detect complications, or evaluate the small intestine.
• Magnetic resonance imaging (MRI) to provide detailed images of the gastrointestinal tract, useful for assessing inflammation and complications.

5. Capsule Endoscopy Capsule endoscopy involves swallowing a small capsule containing a camera that captures images as it passes through the digestive system . It can provide detailed visualization of the small intestine, which is difficult to assess with conventional endoscopy or imaging techniques.

6. Histopathology Biopsy samples obtained during endoscopy or colonoscopy procedures are sent for histopathological examination. These microscopic evaluations of tissue samples can help confirm the diagnosis of IBD, distinguish between Crohn’s disease and ulcerative colitis, and assess the severity of inflammation.

7. Genetic Testing Genetic testing may be performed to identify specific gene variants associated with an increased risk of developing IBD. While not commonly used for diagnosis, genetic testing can provide additional information in certain cases and help guide treatment decisions.

Complications can arise from the chronic inflammation and altered immune response associated with IBD. Regular assessment and monitoring allow healthcare providers to identify and address complications promptly.

1. Assess patient’s vital signs regularly. Monitoring vital signs, including temperature, pulse rate , blood pressure , and respiratory rate, helps identify early signs of infection or systemic inflammation, which can be indicators of potential complications in patients with IBD.

2. Assess patient’s abdomen regularly. Regular assessment of the abdomen can help detect changes in bowel sounds, tenderness, distention, or signs of peritonitis , which may indicate complications such as abscesses, perforation, or obstruction.

3. Observe patient’s stool. Observing the characteristics of stools, including consistency, color, presence of blood, mucus, or changes in bowel habits, can provide valuable information about disease activity and the presence of complications, such as active inflammation, bleeding, or infection.

4. Assess patient’s pain level. Monitoring pain levels using standardized pain assessment tools allows for the early identification of worsening pain, which may be indicative of complications such as strictures, abscesses, or fistulas.

5. Evaluate patient’s nutritional status. Regular assessment of nutritional status helps identify malnutrition or nutritional deficiencies, which are common in patients with IBD. Monitoring weight, body mass index (BMI), and assessing dietary intake and tolerance can guide appropriate interventions to optimize nutrition and prevent complications related to nutritional deficiencies.

6. Monitor laboratory values. Regular monitoring of laboratory values, including complete blood count (CBC), inflammatory markers (such as C-reactive protein and erythrocyte sedimentation rate), albumin, electrolytes, and liver function tests, can provide insights into disease activity, nutritional status, and the presence of potential complications or medication -related side effects.

7. Assess patient’s medication adherence. Assessing medication adherence helps ensure that patients are taking their prescribed medications as instructed. Poor adherence to medication regimens can lead to disease exacerbation, increased risk of complications, and decreased treatment effectiveness.

8. Provide comprehensive patient education. Providing comprehensive patient education on potential complications associated with IBD and the importance of self-monitoring and reporting symptoms enables patients to actively participate in their care. Educating patients about the signs and symptoms of complications empowers them to seek timely medical attention and facilitates early intervention and management.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

More nursing care plans related to gastrointestinal disorders:

• Appendectomy
• Bowel Incontinence (Fecal Incontinence)
• Cholecystectomy
• Constipation
• Diarrhea Nursing Care Plan and Management
• Cholecystitis and Cholelithiasis
• Gastroenteritis
• Gastroesophageal Reflux Disease (GERD)
• Hemorrhoids
• Ileostomy & Colostomy
• Inflammatory Bowel Disease (IBD)
• Intussusception
• Liver Cirrhosis
• Nausea & Vomiting
• Pancreatitis
• Peritonitis
• Peptic Ulcer Disease
• Subtotal Gastrectomy

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Ulcerative Colitis Clinical Presentation

• Author: Marc D Basson, MD, PhD, MBA, FACS; Chief Editor: BS Anand, MD  more...
• Sections Ulcerative Colitis
• Practice Essentials
• Pathophysiology
• Epidemiology
• Physical Examination
• Approach Considerations
• Serologic Markers
• Other Laboratory Studies
• Endoscopy and Biopsy
• Histologic Findings
• Radiologic Assessment of Ulcerative Colitis
• Treatment of Mild Disease
• Treatment of Acute, Severe Disease
• Indications for Surgery
• Maintenance Therapy
• Complications
• Long-Term Monitoring
• Preventive Care
• Guidelines Summary
• European Crohn's and Colitis Organisation (2022)
• Ulcerative Colitis Clinical Practice Guidelines (ASCRS, 2021)
• WSES-AAST Inflammatory Bowel Disease Emergency Management Clinical Practice Guidelines (2021)
• ECCO Clinical Practice Guidelines on Infections in Inflammatory Bowel Disease (2021)
• American Gastroenterological Association Guidelines (2020)
• American Gastroenterological Association Guidelines (2019)
• American College of Gastroenterology Guidelines (2019)
• British Society of Gastroenterology Guidelines (2019)
• Medication Summary
• 5-aminosalicylic Acid Derivative
• Tumor Necrosis Factor Inhibitors
• Immunosuppressant Agents
• Corticosteroids
• Alpha 4 Integrin Inhibitors
• JAK Inhibitors
• Gastrointestinal, Interleukin Inhibitors
• Sphingosine 1-Phosphate Receptor Modulators
• Antimicrobials
• Antidiarrheal
• Questions & Answers
• Media Gallery

Patients with ulcerative colitis (UC) predominantly complain of rectal bleeding, with frequent stools and mucous discharge from the rectum. [ 31 ] Some patients also describe tenesmus. The onset is typically insidious. In severe cases, purulent rectal discharge causes lower abdominal pain and severe dehydration, especially in the elderly population.

Ulcerative colitis manifests as an intense inflammatory reaction in the large intestine. Rarely, patients have persistence of small intestinal inflammation following proctocolectomy and pull-through. [ 32 , 33 ] Constipation may be the main symptom when the inflammation is limited to the rectum (proctitis). [ 4 ]

Fulminant disease

In some cases, ulcerative colitis has a fulminant course marked by severe diarrhea and cramps, fever, leukocytosis, and abdominal distention. Fulminant disease occurs more often in children than in adults. [ 34 ] An estimated 15% of patients present with an attack severe enough to require hospitalization and steroid therapy. [ 35 , 36 ] Children may also present with systemic complaints, including fatigue, arthritis , failure to gain weight, and delayed puberty. The differential diagnosis of these symptoms in the pediatric population includes many entities, and definitive diagnosis may be delayed.

Extracolonic manifestations

Extraintestinal manifestations of inflammatory bowel disease include the following [ 4 ] :

• Musculoskeletal conditions: Peripheral or axial arthropathy
• Cutaneous conditions: Erythema nodosum, pyoderma gangrenosum
• Ocular conditions: Scleritis, episcleritis uveitis
• Hepatobiliary conditions: Primary sclerosing cholangitis (PSC)

Ulcerative colitis is associated with various extracolonic manifestations. These include uveitis, pyoderma gangrenosum, pleuritis, erythema nodosum, ankylosing spondylitis, and spondyloarthropathies. Reportedly, 6.2% of patients with inflammatory bowel disease have a major extraintestinal manifestation. Uveitis is the most common, with an incidence of 3.8%, followed by PSC at 3%, ankylosing spondylitis at 2.7%, erythema nodosum at 1.9%, and pyoderma gangrenosum at 1.2%. [ 37 ] However, reports vary, and some have stated that the incidence of ankylosing spondylitis is as high as 10%. Arthropathies occur in as many as 39% of patients with inflammatory bowel disease. About 30% of such patients have inflammatory back pain , 10% have synovitis, and as many as 40% have radiologic findings of sacroiliitis. [ 38 ]

Primary sclerosing cholangitis

PSC is a potentially serious condition associated with ulcerative colitis, often resulting in cholestatic jaundice and liver failure that requires liver transplantation. Of patients with PSC, 75% have inflammatory bowel disease. Of patients with ulcerative colitis, 5% have cholestatic liver disease, and 40% of those have PSC. One interesting hypothesis about the etiology of PSC in patients with ulcerative colitis involves the release of proinflammatory agents in the colon and their absorption into the enterohepatic circulation; they are then concentrated in the biliary system, leading to bile duct damage. [ 39 , 40 ]

Additional manifestations of disease

Anecdotal reports of recurrent subcutaneous abscesses unrelated to pyoderma gangrenosum exist, [ 1 ] and multiple sclerosis also has been weakly associated with ulcerative colitis. [ 2 ]

Immunobullous disease of the skin has been associated with ulcerative colitis. One theory regarding this association is the concept of epitope spread. Colonic inflammation leads to mucosal damage, which exposes otherwise hidden antigens. Antibodies to these antigens are then formed; these most likely are cell adhesion molecules, which cross-react with similar antigens in other tissues. [ 3 ]

Findings from abdominal examination are usually unremarkable in ulcerative colitis (UC). Physical findings are typically normal in mild disease, except for mild tenderness in the lower left abdominal quadrant (tenderness or cramps are generally present in moderate to severe disease [ 4 ] ). The extent and/or the severity of the disease may be reflected by abdominal tenderness, and digital rectal examination may yield mucus and bloody stools. [ 10 ]

Patients with severe disease can have signs of volume depletion and toxicity, including the following:

Tachycardia

Significant abdominal tenderness

Weight loss

The severity of ulcerative colitis can be graded as follows:

Mild: Bleeding per rectum and fewer than four bowel motions per day

Moderate: Bleeding per rectum with more than four bowel motions per day

Severe: Bleeding per rectum, more than four bowel motions per day, and a systemic illness with hypoalbuminemia (< 30 g/L)

Murata I, Satoh K, Yoshikawa I, Masumoto A, Sasaki E, Otsuki M. Recurrent subcutaneous abscess of the sternal region in ulcerative colitis. Am J Gastroenterol . 1999 Mar. 94(3):844-5. [QxMD MEDLINE Link] .

Kimura K, Hunter SF, Thollander MS, et al. Concurrence of inflammatory bowel disease and multiple sclerosis. Mayo Clin Proc . 2000 Aug. 75(8):802-6. [QxMD MEDLINE Link] .

Egan CA, Meadows KP, Zone JJ. Ulcerative colitis and immunobullous disease cured by colectomy. Arch Dermatol . 1999 Feb. 135(2):214-5. [QxMD MEDLINE Link] .

[Guideline] Bernstein CN, Eliakim A, Fedail S, et al. World Gastroenterology Organisation global guidelines: inflammatory bowel disease: update August 2015. J Clin Gastroenterol . 2016 Nov/Dec. 50(10):803-8. [QxMD MEDLINE Link] . [Full Text] .

Esteve M, Gisbert JP. Severe ulcerative colitis: at what point should we define resistance to steroids?. World J Gastroenterol . 2008 Sep 28. 14(36):5504-7. [QxMD MEDLINE Link] . [Full Text] .

Shen B. Crohn's disease of the ileal pouch: reality, diagnosis, and management. Inflamm Bowel Dis . 2009 Feb. 15(2):284-94. [QxMD MEDLINE Link] .

Van Assche G, Vermeire S, Rutgeerts P. Treatment of severe steroid refractory ulcerative colitis. World J Gastroenterol . 2008 Sep 28. 14(36):5508-11. [QxMD MEDLINE Link] . [Full Text] .

Heuschen UA, Hinz U, Allemeyer EH, et al. Backwash ileitis is strongly associated with colorectal carcinoma in ulcerative colitis. Gastroenterology . 2001 Mar. 120(4):841-7. [QxMD MEDLINE Link] .

Kaufman SS, Vanderhoof JA, Young R, Perry D, Raynor SC, Mack DR. Gastroenteric inflammation in children with ulcerative colitis. Am J Gastroenterol . 1997 Jul. 92(7):1209-12. [QxMD MEDLINE Link] .

[Guideline] Matsuoka K, Kobayashi T, Ueno F, et al. Evidence-based clinical practice guidelines for inflammatory bowel disease. J Gastroenterol . 2018 Mar. 53(3):305-53. [QxMD MEDLINE Link] . [Full Text] .

Himmel ME, Hardenberg G, Piccirillo CA, Steiner TS, Levings MK. The role of T-regulatory cells and Toll-like receptors in the pathogenesis of human inflammatory bowel disease. Immunology . 2008 Oct. 125(2):145-53. [QxMD MEDLINE Link] .

Kuenzig ME, Lee SM, Eksteen B, et al. Smoking influences the need for surgery in patients with the inflammatory bowel diseases: a systematic review and meta-analysis incorporating disease duration. BMC Gastroenterol . 2016 Dec 21. 16(1):143. [QxMD MEDLINE Link] .

Xavier RJ, Podolsky DK. Unravelling the pathogenesis of inflammatory bowel disease. Nature . 2007 Jul 26. 448(7152):427-34. [QxMD MEDLINE Link] .

Lindberg E, Magnusson KE, Tysk C, Jarnerot G. Antibody (IgG, IgA, and IgM) to baker's yeast (Saccharomyces cerevisiae), yeast mannan, gliadin, ovalbumin and betalactoglobulin in monozygotic twins with inflammatory bowel disease. Gut . 1992 Jul. 33(7):909-13. [QxMD MEDLINE Link] . [Full Text] .

Barrett JC, Lee JC, Lees CW, et al. Genome-wide association study of ulcerative colitis identifies three new susceptibility loci, including the HNF4A region. Nat Genet . 2009 Dec. 41(12):1330-4. [QxMD MEDLINE Link] . [Full Text] .

Vasiliauskas E. Serum immune markers in inflammatory bowel disease. Gastroenterology and Endoscopy News. Available at https://www.gastroendonews.com . October 1997;

Peeters M, Joossens S, Vermeire S, Vlietinck R, Bossuyt X, Rutgeerts P. Diagnostic value of anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic autoantibodies in inflammatory bowel disease. Am J Gastroenterol . 2001 Mar. 96(3):730-4. [QxMD MEDLINE Link] .

Dubinsky MC, Ofman JJ, Urman M, Targan SR, Seidman EG. Clinical utility of serodiagnostic testing in suspected pediatric inflammatory bowel disease. Am J Gastroenterol . 2001 Mar. 96(3):758-65. [QxMD MEDLINE Link] .

Hoffenberg EJ, Fidanza S, Sauaia A. Serologic testing for inflammatory bowel disease. J Pediatr . 1999 Apr. 134(4):447-52. [QxMD MEDLINE Link] .

Kaditis AG, Perrault J, Sandborn WJ, Landers CJ, Zinsmeister AR, Targan SR. Antineutrophil cytoplasmic antibody subtypes in children and adolescents after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr . 1998 Apr. 26(4):386-92. [QxMD MEDLINE Link] .

Duggan AE, Usmani I, Neal KR, Logan RF. Appendicectomy, childhood hygiene, Helicobacter pylori status, and risk of inflammatory bowel disease: a case control study. Gut . 1998 Oct. 43(4):494-8. [QxMD MEDLINE Link] . [Full Text] .

Andersson RE, Olaison G, Tysk C, Ekbom A. Appendectomy and protection against ulcerative colitis. N Engl J Med . 2001 Mar 15. 344(11):808-14. [QxMD MEDLINE Link] .

Levenstein S, Prantera C, Varvo V, et al. Stress and exacerbation in ulcerative colitis: a prospective study of patients enrolled in remission. Am J Gastroenterol . 2000 May. 95(5):1213-20. [QxMD MEDLINE Link] .

Almeida MG, Kiss DR, Zilberstein B, Quintanilha AG, Teixeira MG, Habr-Gama A. Intestinal mucosa-associated microflora in ulcerative colitis patients before and after restorative proctocolectomy with an ileoanal pouch. Dis Colon Rectum . 2008 Jul. 51(7):1113-9. [QxMD MEDLINE Link] .

Felder JB, Korelitz BI, Rajapakse R, Schwarz S, Horatagis AP, Gleim G. Effects of nonsteroidal antiinflammatory drugs on inflammatory bowel disease: a case-control study. Am J Gastroenterol . 2000 Aug. 95(8):1949-54. [QxMD MEDLINE Link] .

Bousvaros A, Zurakowski D, Duggan C, et al. Vitamins A and E serum levels in children and young adults with inflammatory bowel disease: effect of disease activity. J Pediatr Gastroenterol Nutr . 1998 Feb. 26(2):129-35. [QxMD MEDLINE Link] .

Garland CF, Lilienfeld AM, Mendeloff AI, Markowitz JA, Terrell KB, Garland FC. Incidence rates of ulcerative colitis and Crohn's disease in fifteen areas of the United States. Gastroenterology . 1981 Dec. 81(6):1115-24. [QxMD MEDLINE Link] .

Cotran RS, Collins T, Robbins SL, Kumar V. Pathologic Basis of Disease . Philadelphia, Pa: WB Saunders; 1998.

Jang ES, Lee DH, Kim J, et al. Age as a clinical predictor of relapse after induction therapy in ulcerative colitis. Hepatogastroenterology . 2009 Sep-Oct. 56(94-95):1304-9. [QxMD MEDLINE Link] .

Narula N, Alshahrani AA, Yuan Y, Reinisch W, Colombel JF. Patient-reported outcomes and endoscopic appearance of ulcerative colitis-a systematic review and meta-analysis. Clin Gastroenterol Hepatol . 2019 Feb. 17(3):411-418.e3. [QxMD MEDLINE Link] .

[Guideline] Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol . 2010 Mar. 105(3):501-23; quiz 524. [QxMD MEDLINE Link] .

Gooding IR, Springall R, Talbot IC, Silk DB. Idiopathic small-intestinal inflammation after colectomy for ulcerative colitis. Clin Gastroenterol Hepatol . 2008 Jun. 6(6):707-9. [QxMD MEDLINE Link] .

Slatter C, Girgis S, Huynh H, El-Matary W. Pre-pouch ileitis after colectomy in paediatric ulcerative colitis. Acta Paediatr . 2008 Mar. 97(3):381-3. [QxMD MEDLINE Link] .

Falcone RA Jr, Lewis LG, Warner BW. Predicting the need for colectomy in pediatric patients with ulcerative colitis. J Gastrointest Surg . 2000 Mar-Apr. 4(2):201-6. [QxMD MEDLINE Link] .

Lichtiger S, Present DH, Kornbluth A, et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med . 1994 Jun 30. 330(26):1841-5. [QxMD MEDLINE Link] .

Rowe FA, Walker JH, Karp LC, Vasiliauskas EA, Plevy SE, Targan SR. Factors predictive of response to cyclosporin treatment for severe, steroid-resistant ulcerative colitis. Am J Gastroenterol . 2000 Aug. 95(8):2000-8. [QxMD MEDLINE Link] .

Bernstein CN, Blanchard JF, Rawsthorne P, Yu N. The prevalence of extraintestinal diseases in inflammatory bowel disease: a population-based study. Am J Gastroenterol . 2001 Apr. 96(4):1116-22. [QxMD MEDLINE Link] .

de Vlam K, Mielants H, Cuvelier C, De Keyser F, Veys EM, De Vos M. Spondyloarthropathy is underestimated in inflammatory bowel disease: prevalence and HLA association. J Rheumatol . 2000 Dec. 27(12):2860-5. [QxMD MEDLINE Link] .

Cox KL, Cox KM. Oral vancomycin: treatment of primary sclerosing cholangitis in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr . 1998 Nov. 27(5):580-3. [QxMD MEDLINE Link] .

Marchesa P, Lashner BA, Lavery IC, et al. The risk of cancer and dysplasia among ulcerative colitis patients with primary sclerosing cholangitis. Am J Gastroenterol . 1997 Aug. 92(8):1285-8. [QxMD MEDLINE Link] .

Kim B, Barnett JL, Kleer CG, Appelman HD. Endoscopic and histological patchiness in treated ulcerative colitis. Am J Gastroenterol . 1999 Nov. 94(11):3258-62. [QxMD MEDLINE Link] .

Calabrese C, Fabbri A, Gionchetti P, et al. Controlled study using wireless capsule endoscopy for the evaluation of the small intestine in chronic refractory pouchitis. Aliment Pharmacol Ther . 2007 Jun 1. 25(11):1311-6. [QxMD MEDLINE Link] .

Bernstein CN, Fried M, Krabshuis JH, et al. World Gastroenterology Organization Practice Guidelines for the diagnosis and management of IBD in 2010. Inflamm Bowel Dis . 2010 Jan. 16(1):112-24. [QxMD MEDLINE Link] .

McNamara D. New IBD guidelines aim to simplify care. Medscape Medical News. February 20, 2018. Available at https://www.medscape.com/viewarticle/892853 . Accessed: June 6, 2018.

Carucci LR, Levine MS. Radiographic imaging of inflammatory bowel disease. Gastroenterol Clin North Am . 2002 Mar. 31(1):93-117, ix. [QxMD MEDLINE Link] .

Eisenberg RL. Gastrointestinal Radiology: A Pattern Approach . Philadelphia, Pa: Lippincott-Raven; 1998. 602-8.

Wiesner W, Steinbrich W. [Imaging diagnosis of inflammatory bowel disease]. Ther Umsch . 2003 Mar. 60(3):137-44. [QxMD MEDLINE Link] .

van den Broek FJ, Fockens P, Dekker E. Review article: New developments in colonic imaging. Aliment Pharmacol Ther . 2007 Dec. 26 Suppl 2:91-9. [QxMD MEDLINE Link] .

Deutsch DE, Olson AD. Colonoscopy or sigmoidoscopy as the initial evaluation of pediatric patients with colitis: a survey of physician behavior and a cost analysis. J Pediatr Gastroenterol Nutr . 1997 Jul. 25(1):26-31. [QxMD MEDLINE Link] .

Matsumoto T, Nakamura S, Jin-No Y, et al. Role of granuloma in the immunopathogenesis of Crohn's disease. Digestion . 2001. 63 Suppl 1:43-7. [QxMD MEDLINE Link] .

Basson MD, Etter L, Panzini LA. Rates of colonoscopic perforation in current practice. Gastroenterology . 1998 May. 114(5):1115. [QxMD MEDLINE Link] .

Polter DE. Risk of colon perforation during colonoscopy at Baylor University Medical Center. Proc (Bayl Univ Med Cent) . 2015 Jan. 28(1):3-6. [QxMD MEDLINE Link] .

Makkar R, Bo S. Colonoscopic perforation in inflammatory bowel disease. Gastroenterol Hepatol (N Y) . 2013 Sep. 9(9):573-83. [QxMD MEDLINE Link] .

[Guideline] Shergill AK, Lightdale JR, Bruining DH, et al, for the Standards of Practice Committee. The role of endoscopy in inflammatory bowel disease. Gastrointest Endosc . 2015 May. 81(5):1101-21.e1-13. [QxMD MEDLINE Link] . [Full Text] .

Boal Carvalho P, Cotter J. Mucosal healing in ulcerative colitis: a comprehensive review. Drugs . 2017 Feb. 77(2):159-73. [QxMD MEDLINE Link] .

Ford AC, Achkar JP, Khan KJ, et al. Efficacy of 5-aminosalicylates in ulcerative colitis: systematic review and meta-analysis. Am J Gastroenterol . 2011 Apr. 106(4):601-16. [QxMD MEDLINE Link] .

Lichtenstein GR, Ramsey D, Rubin DT. Randomised clinical trial: delayed-release oral mesalazine 4.8 g/day vs. 2.4 g/day in endoscopic mucosal healing--ASCEND I and II combined analysis. Aliment Pharmacol Ther . 2011 Mar. 33(6):672-8. [QxMD MEDLINE Link] .

Hanauer SB, Sandborn WJ, Dallaire C, et al. Delayed-release oral mesalamine 4.8 g/day (800 mg tablets) compared to 2.4 g/day (400 mg tablets) for the treatment of mildly to moderately active ulcerative colitis: The ASCEND I trial. Can J Gastroenterol . 2007 Dec. 21(12):827-34. [QxMD MEDLINE Link] .

Sandborn WJ, Regula J, Feagan BG, et al. Delayed-release oral mesalamine 4.8 g/day (800-mg tablet) is effective for patients with moderately active ulcerative colitis. Gastroenterology . 2009 Dec. 137(6):1934-43.e1-3. [QxMD MEDLINE Link] .

Ford AC, Khan KJ, Sandborn WJ, Kane SV, Moayyedi P. Once-daily dosing vs. conventional dosing schedule of mesalamine and relapse of quiescent ulcerative colitis: systematic review and meta-analysis. Am J Gastroenterol . 2011 Dec. 106(12):2070-7; quiz 2078. [QxMD MEDLINE Link] .

D'Haens G, Sandborn WJ, Barrett K, Hodgson I, Streck P. Once-daily MMX(®) mesalamine for endoscopic maintenance of remission of ulcerative colitis. Am J Gastroenterol . 2012 Jul. 107(7):1064-77. [QxMD MEDLINE Link] .

Barber J Jr. FDA approves Uceris for ulcerative colitis. Medscape Medical News. Jan 18, 2013. Available at https://www.medscape.com/viewarticle/777917 . Accessed: January 28, 2013.

Sandborn WJ, Danese S, D'Haens G, et al. Induction of clinical and colonoscopic remission of mild-to-moderate ulcerative colitis with budesonide MMX 9 mg: pooled analysis of two phase 3 studies. Aliment Pharmacol Ther . 2015 Mar. 41(5):409-18. [QxMD MEDLINE Link] .

Uceris (budesonide) rectal foam [package insert]. Bridgewater, NJ 08807: Distributed by Salix Pharmaceuticals (a division of Valeant Pharmaceuticals North America LLC). Rev September 2016. Available at [Full Text] .

Ford AC, Bernstein CN, Khan KJ, et al. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol . 2011 Apr. 106(4):590-9. [QxMD MEDLINE Link] .

Ford AC, Sandborn WJ, Khan KJ, et al. Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol . 2011 Apr. 106(4):644-59, quiz 660. [QxMD MEDLINE Link] .

Singh S, George J, Boland BS, Vande Casteele N, Sandborn WJ. Primary non-response to tumor necrosis factor antagonists is associated with inferior response to second-line biologics in patients with inflammatory bowel diseases: a systematic review and meta-analysis. J Crohns Colitis . 2018 May 25. 12(6):635-43. [QxMD MEDLINE Link] .

Sandborn WJ, Rutgeerts P, Feagan BG, et al. Colectomy rate comparison after treatment of ulcerative colitis with placebo or infliximab. Gastroenterology . 2009 Oct. 137(4):1250-60; quiz 1520. [QxMD MEDLINE Link] .

Hindryckx P, Novak G, Vande Casteele N, et al. Review article: dose optimisation of infliximab for acute severe ulcerative colitis. Aliment Pharmacol Ther . 2017 Mar. 45(5):617-30. [QxMD MEDLINE Link] .

Kevans D, Murthy S, Mould DR, Silverberg MS. Accelerated clearance of infliximab is associated with treatment failure in patients with corticosteroid-refractory acute ulcerative colitis. J Crohns Colitis . 2018 May 25. 12(6):662-9. [QxMD MEDLINE Link] .

Reinisch W, Sandborn WJ, Hommes DW, et al. Adalimumab for induction of clinical remission in moderately to severely active ulcerative colitis: results of a randomised controlled trial. Gut . 2011 Jun. 60(6):780-7. [QxMD MEDLINE Link] .

Sandborn WJ, van Assche G, Reinisch W, et al. Adalimumab induces and maintains clinical remission in patients with moderate-to-severe ulcerative colitis. Gastroenterology . 2012 Feb. 142(2):257-65.e1-3. [QxMD MEDLINE Link] .

Sandborn WJ, Feagan BG, Marano CW, et al. A phase 2/3 randomized, placebo-controlled, double-blind study to evaluate the safety and efficacy of subcutaneous golimumab induction therapy in patients with moderately to severely active ulcerative colitis (UC): Pursuit SC [abstract #943d]. Presented at: Digestive Disease Week; San Diego, California; May 21, 2012.

US Food and Drug Administration. FDA approves new treatment for moderately to severely active ulcerative colitis [news release]. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm609225.htm . May 30, 2018; Accessed: May 31, 2018.

Sandborn WJ, Su C, Sands BE, et al, for the OCTAVE Induction 1, OCTAVE Induction 2, et al. Tofacitinib as induction and maintenance therapy for ulcerative colitis. N Engl J Med . 2017 May 4. 376(18):1723-36. [QxMD MEDLINE Link] . [Full Text] .

Eli Lilly and Company. FDA approves Lilly's Omvoh (mirikizumab-mrkz), a first-in-class treatment for adults with moderately to severely active ulcerative colitis. Available at https://investor.lilly.com/news-releases/news-release-details/fda-approves-lillys-omvohtm-mirikizumab-mrkz-first-class . October 26, 2023; Accessed: October 31, 2023.

D'Haens G, Dubinsky M, Kobayashi T, and the, LUCENT Study Group. Mirikizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med . 2023 Jun 29. 388 (26):2444-55. [QxMD MEDLINE Link] .

Sands BE, Sandborn WJ, Panaccione R, et al, for the UNIFI Study Group. Ustekinumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med . 2019 Sep 26. 381(13):1201-14. [QxMD MEDLINE Link] . [Full Text] .

Bristol Myers Squibb. Bristol Myers Squibb receives European Commission approval of Zeposia (ozanimod) for use in adults with moderately to severely active ulcerative colitis [press release]. Available at https://news.bms.com/news/corporate-financial/2021/Bristol-Myers-Squibb-Receives-European-Commission-Approval-of-Zeposia-ozanimod-for-use-in-Adults-with-Moderately-to-Severely-Active-Ulcerative-Colitis/default.aspx# . November 23, 2021; Accessed: November 28, 2021.

Sandborn WJ, Feagan BG, D'Haens G, and the True North Study Group. Ozanimod as induction and maintenance therapy for ulcerative colitis. N Engl J Med . 2021 Sep 30. 385 (14):1280-91. [QxMD MEDLINE Link] . [Full Text] .

Feagan BG, Rutgeerts P, Sands BE, et al. Vedolizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med . 2013 Aug 22. 369(8):699-710. [QxMD MEDLINE Link] .

Leblanc S, Allez M, Seksik P, et al. Successive treatment with cyclosporine and infliximab in steroid-refractory ulcerative colitis. Am J Gastroenterol . 2011 Apr. 106(4):771-7. [QxMD MEDLINE Link] .

Khan KJ, Ullman TA, Ford AC, et al. Antibiotic therapy in inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol . 2011 Apr. 106(4):661-73. [QxMD MEDLINE Link] .

Sakuraba A, Sato T, Naganuma M, et al. A pilot open-labeled prospective randomized study between weekly and intensive treatment of granulocyte and monocyte adsorption apheresis for active ulcerative colitis. J Gastroenterol . 2008. 43(1):51-6. [QxMD MEDLINE Link] .

Miki C, Okita Y, Yoshiyama S, Araki T, Uchida K, Kusunoki M. Early postoperative application of extracorporeal leukocyte apheresis in ulcerative colitis patients: results of a pilot trial to prevent postoperative septic complications. J Gastroenterol . 2007 Jun. 42(6):508-9. [QxMD MEDLINE Link] .

Emmrich J, Petermann S, Nowak D, et al. Leukocytapheresis (LCAP) in the management of chronic active ulcerative colitis--results of a randomized pilot trial. Dig Dis Sci . 2007 Sep. 52(9):2044-53. [QxMD MEDLINE Link] .

Ruuska T, Lahdeaho ML, Sutas Y, Ashorn M, Gronlund J. Leucocyte apheresis in the treatment of paediatric ulcerative colitis. Scand J Gastroenterol . 2007 Nov. 42(11):1390-1. [QxMD MEDLINE Link] .

Domenech E, Panes J, Hinojosa J, et al, for the ATTICA Study Group by the Grupo Espanol de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa. Addition of granulocyte/monocyte apheresis to oral prednisone for steroid-dependent ulcerative colitis: a randomized multicentre clinical trial. J Crohns Colitis . 2018 May 25. 12(6):687-94. [QxMD MEDLINE Link] .

Zittan E, Ma GW, Wong-Chong N, et al. Ileal pouch-anal anastomosis for ulcerative colitis: a Canadian institution's experience. Int J Colorectal Dis . 2017 Feb. 32(2):281-5. [QxMD MEDLINE Link] .

Sandborn WJ, Vermeire S, Peyrin-Biroulet L, et al. Etrasimod as induction and maintenance therapy for ulcerative colitis (ELEVATE): two randomised, double-blind, placebo-controlled, phase 3 studies. Lancet . 2023 Apr 8. 401 (10383):1159-71. [QxMD MEDLINE Link] . [Full Text] .

Pfizer Inc. U.S. FDA approves Pfizer’s VELSIPITY for adults with moderately to severely active ulcerative colitis (UC). October 13, 2023. Available at https://www.pfizer.com/news/press-release/press-release-detail/us-fda-approves-pfizers-velsipitytm-adults-moderately .

Sandborn WJ, et al. A phase III randomized, placebo-controlled, double-blind study to evaluate the safety and efficacy of subcutaneous golimumab maintenance therapy in patients with moderately to severely active ulcerative colitis: PURSUIT-Maintenance. Presented at the American College of Gastroenterology, October 22, 2012 Las Vegas, NV.

Sandborn WJ, Travis S, Moro L, et al. Once-daily budesonide MMX® extended-release tablets induce remission in patients with mild to moderate ulcerative colitis: results from the CORE I study. Gastroenterology . 2012 Nov. 143(5):1218-26.e1-2. [QxMD MEDLINE Link] .

Rembacken BJ, Snelling AM, Hawkey PM, Chalmers DM, Axon AT. Non-pathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis: a randomised trial. Lancet . 1999 Aug 21. 354(9179):635-9. [QxMD MEDLINE Link] .

Tsuda Y, Yoshimatsu Y, Aoki H, et al. Clinical effectiveness of probiotics therapy (BIO-THREE) in patients with ulcerative colitis refractory to conventional therapy. Scand J Gastroenterol . 2007 Nov. 42(11):1306-11. [QxMD MEDLINE Link] .

Simchuk EJ, Thirlby RC. Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg . 2000 Jul. 24(7):851-6. [QxMD MEDLINE Link] .

Farouk R, Dozois RR, Pemberton JH, Larson D. Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum . 1998 Oct. 41(10):1239-43. [QxMD MEDLINE Link] .

Shamberger RC, Hergrueter CA, Lillehei CW. Use of a gracilis muscle flap to facilitate delayed ileal pouch-anal anastomosis. Dis Colon Rectum . 2000 Nov. 43(11):1628-31. [QxMD MEDLINE Link] .

Karlbom U, Raab Y, Ejerblad S, Graf W, Thorn M, Pahlman L. Factors influencing the functional outcome of restorative proctocolectomy in ulcerative colitis. Br J Surg . 2000 Oct. 87(10):1401-8. [QxMD MEDLINE Link] .

Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg . 1998 Jun. 85(6):800-3. [QxMD MEDLINE Link] .

Ogilvie JW Jr, Goetz L, Baxter NN, Park J, Minami S, Madoff RD. Female sexual dysfunction after ileal pouch-anal anastomosis. Br J Surg . 2008 Jul. 95(7):887-92. [QxMD MEDLINE Link] .

Cornish JA, Tan E, Teare J, et al. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review. Dis Colon Rectum . 2007 Aug. 50(8):1128-38. [QxMD MEDLINE Link] .

Shen BO, Jiang ZD, Fazio VW, et al. Clostridium difficile infection in patients with ileal pouch-anal anastomosis. Clin Gastroenterol Hepatol . 2008 Jul. 6(7):782-8. [QxMD MEDLINE Link] .

Falk A, Olsson C, Ahrne S, Molin G, Adawi D, Jeppsson B. Ileal pelvic pouch microbiota from two former ulcerative colitis patients, analysed by DNA-based methods, were unstable over time and showed the presence of Clostridium perfringens. Scand J Gastroenterol . 2007 Aug. 42(8):973-85. [QxMD MEDLINE Link] .

Chia CS, Chew MH, Chau YP, Eu KW, Ho KS. Adenocarcinoma of the anal transitional zone after double stapled ileal pouch-anal anastomosis for ulcerative colitis. Colorectal Dis . 2008 Jul. 10(6):621-3. [QxMD MEDLINE Link] .

Arias MT, Vande Casteele N, Vermeire S, et al. A panel to predict long-term outcome of infliximab therapy for patients with ulcerative colitis. Clin Gastroenterol Hepatol . 2015 Mar. 13(3):531-8. [QxMD MEDLINE Link] .

Sarigol S, Wyllie R, Gramlich T, et al. Incidence of dysplasia in pelvic pouches in pediatric patients after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr . 1999 Apr. 28(4):429-34. [QxMD MEDLINE Link] .

Pekow JR, Hetzel JT, Rothe JA, et al. Outcome after surveillance of low-grade and indefinite dysplasia in patients with ulcerative colitis. Inflamm Bowel Dis . 2010 Aug. 16(8):1352-6. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Farraye FA, Melmed GY, Lichtenstein GR, Kane SV. ACG clinical guideline: preventive care in inflammatory bowel disease. Am J Gastroenterol . 2017 Feb. 112(2):241-58. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Raine T, Bonovas S, Burisch J, et al. ECCO Guidelines on therapeutics in ulcerative colitis: medical treatment. J Crohns Colitis . 2022 Jan 28. 16 (1):2-17. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Spinelli A, Bonovas S, Burisch J, et al. ECCO Guidelines on therapeutics in ulcerative colitis: surgical treatment. J Crohns Colitis . 2022 Feb 23. 16 (2):179-89. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Holubar SD, Lightner AL, Poylin V, et al, on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical practice guidelines for the surgical management of ulcerative colitis. Dis Colon Rectum . 2021 Jul 1. 64(7):783-804. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] De Simone B, Davies J, Chouillard E, et al. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg . 2021 May 11. 16(1):23. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Kucharzik T, Ellul P, Greuter T, et al. ECCO guidelines on the prevention, diagnosis, and management of infections in inflammatory bowel disease. J Crohns Colitis . 2021 Jun 22. 15(6):879-913. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Feuerstein JD, Isaacs KL, Schneider Y, et al, for the AGA Institute Clinical Guidelines Committee. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology . 2020 Apr. 158(5):1450-61. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Ko CW, Singh S, Feuerstein JD, et al, for the American Gastroenterological Association Institute Clinical Guidelines Committee. AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis. Gastroenterology . 2019 Feb. 156(3):748-64. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG clinical guideline: ulcerative colitis in adults. Am J Gastroenterol . 2019 Mar. 114(3):384-413. [QxMD MEDLINE Link] .

Swift D. Updated UC guideline adds mucosal healing to treatment goal. Medscape Medical News. March 4, 2019. Available at https://www.medscape.com/viewarticle/909801 . Accessed: March 20, 2019.

[Guideline] Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut . 2019 Dec. 68(Suppl 3):s1-s106. [QxMD MEDLINE Link] . [Full Text] .

American Gastroenterological Association. New guideline provides recommendations for the treatment of mild-to-moderate ulcerative colitis. January 9, 2019. Available at https://www.gastro.org/press-release/new-guideline-provides-recommendations-for-the-treatment-of-mild-to-moderate-ulcerative-colitis . Accessed: March 20, 2019.

Parente F, Molteni M, Marino B, et al. Are colonoscopy and bowel ultrasound useful for assessing response to short-term therapy and predicting disease outcome of moderate-to-severe forms of ulcerative colitis?: a prospective study. Am J Gastroenterol . 2010 May. 105(5):1150-7. [QxMD MEDLINE Link] .

Moran CP, Neary B, Doherty GA. Endoscopic evaluation in diagnosis and management of inflammatory bowel disease. World J Gastrointest Endosc . 2016 Dec 16. 8(20):723-32. [QxMD MEDLINE Link] .

Andersson T, Lunde OC, Johnson E, Moum T, Nesbakken A. Long-term functional outcome and quality of life after restorative proctocolectomy with ileo-anal anastomosis for colitis. Colorectal Dis . 2011 Apr. 13(4):431-7. [QxMD MEDLINE Link] .

Brooks M. FDA approves new indication for Simponi. Medscape Medical News . May 15, 2013. [Full Text] .

Charron M, del Rosario JF, Kocoshis S. Use of technetium-tagged white blood cells in patients with Crohn's disease and ulcerative colitis: is differential diagnosis possible?. Pediatr Radiol . 1998 Nov. 28(11):871-7. [QxMD MEDLINE Link] .

Choi JS, Potenti F, Wexner SD, et al. Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique: is there a relation to tissue type?. Dis Colon Rectum . 2000 Oct. 43(10):1398-404. [QxMD MEDLINE Link] .

Cottliar A, Fundia A, Boerr L, et al. High frequencies of telomeric associations, chromosome aberrations, and sister chromatid exchanges in ulcerative colitis. Am J Gastroenterol . 2000 Sep. 95(9):2301-7. [QxMD MEDLINE Link] .

Cucchiara S, Celentano L, de Magistris TM, Montisci A, Iula VD, Fecarotta S. Colonoscopy and technetium-99m white cell scan in children with suspected inflammatory bowel disease. J Pediatr . 1999 Dec. 135(6):727-32. [QxMD MEDLINE Link] .

da Luz Moreira A, Kiran RP, Lavery I. Clinical outcomes of ileorectal anastomosis for ulcerative colitis. Br J Surg . 2010 Jan. 97(1):65-9. [QxMD MEDLINE Link] .

Durno C, Sherman P, Harris K, et al. Outcome after ileoanal anastomosis in pediatric patients with ulcerative colitis. J Pediatr Gastroenterol Nutr . 1998 Nov. 27(5):501-7. [QxMD MEDLINE Link] .

Ekbom A, Helmick C, Zack M, Adami HO. Ulcerative colitis and colorectal cancer. A population-based study. N Engl J Med . 1990 Nov 1. 323(18):1228-33. [QxMD MEDLINE Link] .

Fonkalsrud EW, Bustorff-Silva J. Reconstruction for chronic dysfunction of ileoanal pouches. Ann Surg . 1999 Feb. 229(2):197-204. [QxMD MEDLINE Link] . [Full Text] .

Fonkalsrud EW, Thakur A, Roof L. Comparison of loop versus end ileostomy for fecal diversion after restorative proctocolectomy for ulcerative colitis. J Am Coll Surg . 2000 Apr. 190(4):418-22. [QxMD MEDLINE Link] .

Gorfine SR, Bauer JJ, Harris MT, Kreel I. Dysplasia complicating chronic ulcerative colitis: is immediate colectomy warranted?. Dis Colon Rectum . 2000 Nov. 43(11):1575-81. [QxMD MEDLINE Link] .

Hunt LE, Eichenberger MR, Petras R, Galandiuk S. Use of a microsatellite marker in predicting dysplasia in ulcerative colitis. Arch Surg . 2000 May. 135(5):582-5. [QxMD MEDLINE Link] .

Metcalf DR, Nivatvongs S, Sullivan TM, Suwanthanma W. A technique of extending small-bowel mesentery for ileal pouch-anal anastomosis: report of a case. Dis Colon Rectum . 2008 Mar. 51(3):363-4. [QxMD MEDLINE Link] .

Rutter MD, Saunders BP, Wilkinson KH, et al. Thirty-year analysis of a colonoscopic surveillance program for neoplasia in ulcerative colitis. Gastroenterology . 2006 Apr. 130(4):1030-8. [QxMD MEDLINE Link] .

Shamberger RC, Masek BJ, Leichtner AM, Winter HS, Lillehei CW. Quality-of-life assessment after ileoanal pull-through for ulcerative colitis and familial adenomatous polyposis. J Pediatr Surg . 1999 Jan. 34(1):163-6. [QxMD MEDLINE Link] .

Treem WR, Cohen J, Davis PM, Justinich CJ, Hyams JS. Cyclosporine for the treatment of fulminant ulcerative colitis in children. Immediate response, long-term results, and impact on surgery. Dis Colon Rectum . 1995 May. 38(5):474-9. [QxMD MEDLINE Link] .

Bezzio C, Festa S, Saibeni S, Papi C. Chemoprevention of colorectal cancer in ulcerative colitis: digging deep in current evidence. Expert Rev Gastroenterol Hepatol . 2017 Apr. 11(4):339-347. [QxMD MEDLINE Link] .

[Guideline] Feuerstein JD, Nguyen GC, Kupfer SS, Falck-Ytter Y, Singh S, for the American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on therapeutic drug monitoring in inflammatory bowel disease. Gastroenterology . 2017 Sep. 153(3):827-34. [QxMD MEDLINE Link] . [Full Text] .

Dharmaraj R, Dasgupta M, Simpson P, Noe J. Predictors of pouchitis after ileal pouch-anal anastomosis in children. J Pediatr Gastroenterol Nutr . 2016 Dec. 63(6):e210-1. [QxMD MEDLINE Link] .

Rinawi F, Assa A, Eliakim R, et al. Predictors of pouchitis after ileal pouch-anal anastomosis in pediatric-onset ulcerative colitis. Eur J Gastroenterol Hepatol . 2017 Sep. 29(9):1079-85. [QxMD MEDLINE Link] .

• Ulcerative Colitis. Increased postrectal space is a known feature of ulcerative colitis.
• Ulcerative Colitis. Plain abdominal radiograph from a patient with known ulcerative colitis who presented with an acute exacerbation of his symptoms. The image shows thumbprinting in the region of the splenic flexure of the colon.
• Ulcerative Colitis. Double-contrast barium enema study shows pseudopolyposis of the descending colon.
• Ulcerative Colitis. Single-contrast enema study in a patient with known ulcerative colitis in remission shows a benign stricture of the sigmoid colon.
• Ulcerative Colitis. Plain abdominal radiograph in a 26-year-old with a 10-year history of ulcerative colitis shows a long stricture/spasm of the ascending colon/cecum. Note the pseudopolyposis in the descending colon.
• Ulcerative Colitis. Single-contrast enema study in a patient with total colitis shows mucosal ulcers with a variety of shapes, including collar-button ulcers (yellow arrow), in which undermining of the ulcers occurs, and double-tracking ulcers (red arrow), in which the ulcers are longitudinally orientated.
• Ulcerative Colitis. Double-contrast barium enema study shows total colitis. Note the granular mucosa in the cecum/ascending colon and multiple strictures in the transverse and descending colon in a patient with a more than a 20-year history of ulcerative colitis.
• Ulcerative Colitis. Single-contrast barium enema study shows burnt-out ulcerative colitis.
• Ulcerative Colitis. Intravenous urogram in the same patient as in Image 11 shows features of ankylosing spondylitis.
• Ulcerative Colitis. Lateral radiograph of the lumbar spine in the same patient as in Images 10-11 shows a bamboo spine.
• Ulcerative Colitis. Single-contrast barium enema study in a patient with Shigella colitis.
• Ulcerative Colitis. Postevacuation image obtained after a single-contrast barium enema study shows extensive mucosal ulceration resulting from Shigella colitis.
• Ulcerative Colitis. Double-contrast barium enema studies show granular mucosa associated with Campylobacter colitis.
• Ulcerative Colitis. Ulcerative colitis as visualized with a colonoscope.
• Ulcerative Colitis. Inflamed colonic mucosa demonstrating pseudopolyps.
• Table 1. Distinguishing Ulcerative Colitis from Crohn Disease

Contributor Information and Disclosures

Marc D Basson, MD, PhD, MBA, FACS Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha , American College of Surgeons , American Gastroenterological Association , Phi Beta Kappa , Sigma Xi, The Scientific Research Honor Society Disclosure: Nothing to disclose.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases , American College of Gastroenterology , American Gastroenterological Association , American Society for Gastrointestinal Endoscopy Disclosure: Nothing to disclose.

Burt Cagir, MD, FACS Associate Regional Dean and Professor of Surgery, Geisinger Commonwealth School of Medicine; Director, General Surgery Residency Program, Executive Director, Donald Guthrie Foundation for Research and Education, Guthrie Robert Packer Hospital; Medical Director, Guthrie/RPH Skills and Simulation Lab; Associate in Surgery, Guthrie Robert Packer Hospital and Corning Hospital Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons , Association of Program Directors in Surgery , Society for Surgery of the Alimentary Tract Disclosure: Nothing to disclose.

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons , Society of Thoracic Surgeons , and Society of University Surgeons

Disclosure: Nothing to disclose.

Alex Jacocks, MD Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Tri H Le, MD Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center

Tri H Le, MD is a member of the following medical societies: American College of Gastroenterology , American Gastroenterological Association , American Society of Gastrointestinal Endoscopy , and Crohns and Colitis Foundation of America

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Emergency Physicians , and Society for Academic Emergency Medicine

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center; Clinical Professor, University of Mississippi School of Pharmacy

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS is a member of the following medical societies: American Academy of Clinical Toxicology , American Association for the Study of Liver Diseases , American College of Forensic Examiners , American College of Gastroenterology , American College of Physicians , American Federation for Clinical Research, American Gastroenterological Association , and American Society of Gastrointestinal Endoscopy

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

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Attachment and perceived stress in patients with ulcerative colitis, a case-control study

Affiliations.

• 1 Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
• 2 Department of Psychology, University of Bologna, Bologna, Italy.
• 3 IBD Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
• PMID: 27624586
• DOI: 10.1111/jpm.12331

WHAT IS KNOWN ON THE SUBJECT?: Ulcerative colitis (UC) is a chronic inflammatory disorder associated with high perceived psychological stress. The attachment theory provides a psychodynamic perspective to investigate the relationship between close interpersonal relationships and stress in UC. Researchers have hypothesized that the chronic illness might affect personality trait as the attachment style of patients. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: UC patients exhibit a more pronounced attachment insecurity that, in turn, resulted as a determinant of psychological stress. This study suggests that UC could determine a shift towards insecurity in the attachment style that, in turn, promotes psychological stress and increases the risk of psychopathologies. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The more accurate knowledge of attachment insecurity in patients with chronic disorders such as UC may help the nurses to face with often dysfunctional patients' styles of manifesting distress, patterns of help seeking and expectations of health professionals. The knowledge of psychopathological mechanisms in patients with UC could improve the prevention and treatment of psychological disorders in affected patients.

Abstract: Introduction Ulcerative colitis (UC) is a chronic disorder characterized by recurrent intestinal symptoms. The attachment theory provides a psychodynamic perspective to investigate the relationship between interpersonal relationships and stress in UC. Aim The aim of this study was to compare the attachment dimensions between UC patients and controls and to evaluate the impact of these dimensions on perceived stress in patients. Method In all, 101 patients with UC completed the attachment style questionnaire and the perceived stress questionnaire (PSQ). Clinical and psychometric parameters were added as predictor variables in a regression with the PSQ score as dependent variable. One hundred and five healthy subjects took part in the study as controls. Results Compared to controls, UC patients exhibited greater scores in relationships as secondary, need for approval and preoccupation with relationships. In UC, disease activity, confidence and preoccupation with relationships resulted predictors of perceived stress. Discussion Compared to healthy controls, UC patients exhibited more pronounced attachment insecurity that, in turn, was a significant predictor of the perceived stress. Implications for practice The knowledge of attachment insecurity may help the nurses and all health care providers to face with dysfunctional patients' styles of manifesting distress, help seeking and expectations of health professionals.

Keywords: attachment anxiety; attachment avoidance; attachment style; inflammatory bowel disease; psychological stress; ulcerative colitis.

© 2016 John Wiley & Sons Ltd.

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Case Report

Ulcerative colitis: a case of steroid refractory disease, lennard lee.

1 Milton Keynes NHS Foundation Trust, Milton Keynes, UK

Mohammed Majid Akhtar

2 Department of Cardiology, Royal London Hospital, London, UK

Anjum Gardezisanjliajk

George macfaul.

A 21-year-old lady was admitted to a hospital with an 8-week history of bloody diarrhoea. She had been diagnosed with ulcerative colitis 2 years previously and had remained in remission until the gradual onset of bloody diarrhoea. Her bowel frequency was 20 times per day and associated with significant abdominal pain and weight loss. She was started on intravenous steroids, topical therapy and anti-tumour necrosis factor therapy; however, this failed to achieve symptom control. Histology of tissue obtained from flexible sigmoidoscopy eventually demonstrated cytomegalovirus (CMV)-associated colitis. Intravenous anti-viral valganciclovir was initiated and the patient made a rapid recovery. This case discusses the differentials for steroid-refractory ulcerative colitis, including the common pitfall of inflammatory bowel disease management and CMV infection. This case also discusses CMV pathophysiology including histological features, appropriate investigations and current management guidelines.

This case is important for a number of reasons.

With the advent of guidelines and objective scoring systems such as the ‘Oxford Criteria’, the management of ulcerative colitis is being increasingly standardised. However, there are a number of different reasons why a patient may be having worsening of their symptoms and this may not necessarily be due to an established underlying disease process. In this case, the patient nearly had a colectomy for refractory severe ulcerative colitis when the actual diagnosis was of cytomegalovirus (CMV)-related colitis.

Second, this study revisits one of the common pitfalls of inflammatory bowel disease (IBD) management and the issue of CMV infection. CMV infection is a relatively rare, but important, cause of a chronic worsening of gastrointestinal symptoms in IBD patients. Early recognition can lead to rapid symptom control. This case not only is a revision on the characteristic histological findings but also gives recommendation on the latest treatment guidelines.

Case presentation

A 21-year-old woman was electively admitted to hospital with an 8-week history of bloody diarrhoea. She had been diagnosed with ulcerative colitis 2  years previously and had remained in remission until the gradual onset of bloody diarrhoea. Her bowel frequency was 20 times per day, associated with significant abdominal pain and weight loss of 4 kg. Over the previous 8 weeks, she had remained on mesalazine 4.8 g daily, steroid enemas, azathioprine 120 mg and high-dose prednisolone (40 mg), but noticed no improvement in her symptoms.

Investigations

She had a pulse of 92/min and a blood pressure of 142/65 mm Hg, and clinical examination revealed cushingoid appearances. Laboratory investigations revealed haemoglobin 6.2 g/dl, C-reactive protein (CRP) 175 mg/l, white cell count (WCC) 6.1×10 9 /l and albumin 21 g/l. All other bloods were unremarkable, including her thiopurine methyltransferase (TPMT) levels. A flexible sigmoidoscopy was performed and this demonstrated severe ulceration from the rectosigmoid junction extending beyond the limit of endoscopy.

Differential diagnosis

A majority of patients with ulcerative have steroid-responsive disease; however, a small proportion have steroid-dependent or steroid-refractory disease.

Steroid dependence is defined as an inability to taper the steroid dose to less than 10 mg/day. Steroid refractory disease is defined as a lack of clinical response to high-dose prednisolone.

The differential diagnosis for steroid-refractory disease includes:

• Severe phenotype ulcerative colitis
• Poor compliance with medications
• Non-response to medications, in particular hypermethylators of azathioprine.
• Secondary concurrent pathology. This may include extra-gastrointestinal pathology (endocrine disorders, diet or drugs) or gastrointestinal causes (infections, ischaemic, neoplastic or infiltrative).

After admission, she was started on IV hydrocortisone 100 mg four times a day and nutrition was optimised. There was no clinical response by day 3 of admission, and based on the ‘Oxford Criteria’, infliximab was initiated and a surgical opinion was sought. At day 5, her bowels were still opening 8 times per day and the surgical consort strongly advocated a surgery.

However, at day 5, the histology from the flexible sigmoidoscopy also returned showing not only severe colitis but also ‘inclusion bodies’. Furthermore, the CMV PCR returned confirming a high viral load.

Outcome and follow-up

Intravenous Valganciclovir was initiated, and within 48 h her bowel frequency returned to twice a day and patient felt symptomatically better.

CMV is a member of the Herpes virus family, and patients with both ulcerative colitis and Crohn's disease are at increased risk of CMV reactivation and colitis. The virus is transmitted through close personal contact; in the general adult population, 40–70% has evidence of prior infection. In normal individuals, CMV infection is rarely symptomatic and usually self-limited. However, in the context of IBD, the pro-inflammatory cytokines and iatrogenic immunosuppression increase the risk of CMV-harbouring monocytes reactivating and differentiating into active macrophages. A number of cohort studies have been performed; while the incidence of CMV disease has not been clearly demonstrated to be associated with anti-tumour necrosis factor or thiopurine therapy, patients who are on long-term steroids have at least a 10-fold increased risk of developing the condition. 1 The majority of the patients with CMV colitis treated promptly with intravenous antiviral therapy are able to go into disease remission, although it remains controversial whether an episode of CMV colitis changes the course of ulcerative colitis in terms of colectomy rates or disease prognosis. 2 The gold standard for diagnosing the condition is the histological examination of diseased colon as CMV PCR levels correlate poorly with disease activity. On histological examination, CMV-infected cells are typically 2–4-fold larger than the surrounding cells and demonstrate a thickened nuclear membrane and granular intracytoplasmic inclusions. The characteristic ‘owl's eyes’ appearances indicate active CMV-replicating nucleoprotein cores. Front line therapy for CMV remains ganciclovir or valganciclovir, but viral resistance has been documented, and second line therapies include foscarnet, cidofovir and leflunomide. The decision whether immunosuppressants such as infliximab/thiopurines/steroids be withdrawn during a course of antiviral therapy remains extremely contentious and remains an evidence-free area.

Learning points

• Patients with uncontrolled gastrointestinal symptoms should have their treatment escalated at day 3 based on the ‘Oxford Criteria’.
• Cytomegalovirus is a very important differential to exclude in patients with a flare of their IBD. This may be done by either serology or histology.
• Compared to patients with Crohn's disease, ulcerative colitis patients have a modest to absent CRP response. 3 During a flare of ulcerative colitis, the average CRP from the clinical trials was only 15 and rarely above 54. 3 4

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

Inflammatory Bowel Disease Case Study (45 min)

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What further history questions would you ask Ms. Hale?

• Normal” bowel habits – how many times a day, color, consistency
• Previous experiences with bleeding?
• Diet and lifestyle habits
• Other medical conditions and medication history

Ms. Hale reports she has 5-10 bowel movements daily, she has had 3 already this morning. She reports she’s used to that, especially if she eats greasy foods. She says “I had just accepted that I would never poop normally, but I’ve never seen that amount of blood before. It was crazy!”. She reports a weight loss of 10 lbs in the last 4 months.

What additional nursing assessments need to be performed?

• Full set of vital signs
• Full abdominal assessment
• Assess any bowel movements
• Assess skin and pulses for signs of anemia or poor perfusion due to bleeding

What diagnostic tests would you expect the provider to order? Why?

• CBC – to assess for severity of bleeding (keep in mind that the H/H may take some time to ‘catch up’ to the blood loss)
• Colonoscopy – to evaluate for a source of bleeding
• Digital Rectal Exam and fecal occult blood test

Ms. Hale’s vital signs are stable. The provider found frank blood on a digital rectal exam. Ms. Hale received a colonoscopy, which showed a bleeding ulcer in her transverse colon, which was cauterized, but no other signs of bleeding.  The provider believes this may have been an isolated incident due to irritation caused by the patients greasy food diet and IBS. He orders for her to be discharged home.

What discharge instructions should be included for Ms. Hale?

• Avoid foods that are irritating to the bowels
• Report increased bleeding/bloody stools or severe abdominal pain
• Drink plenty of water
• Eat bland foods for 2-3 days to avoid irritation to the ulcer that was cauterized

Ms. Hale returns to the ED 2 days later complaining of bright red blood in her stools – two yesterday and five already today. She reports severe lower abdominal pain, nausea and vomiting. 

What further diagnostic testing should be done at this time?

• Repeat colonoscopy, possible endoscopy, CT scan
• Labs – check CRP and ESR for inflammatory markers
• Re-check CBC due to further bleeding

The nurse notes open sores in Ms. Hale’s mouth and Ms. Hale also begins reporting epigastric pain.

An endoscopy, repeat colonoscopy, and CT scan show severe thickening of the mucosa in the small and large intestine, with some ulcerations in the duodenum and ileocecal junction, in addition to the previous one seen in the transverse colon.

What do you believe might be the issue for Ms. Hale?

• She may actually have an inflammatory bowel disease, NOT irritable bowel syndrome.
• If that’s the case, she’s obviously having a significant exacerbation at this time.

Is Ms. Hale presenting with signs of Ulcerative Colitis or Crohn’s Disease? Explain.

• Ms. Hale is presenting with signs of Crohn’s Disease – the telltale sign is that there are ulcerations and thickening of the mucosa in places OTHER than the large intestine. Ulcerative Colitis ONLY affects the colon.
• Ms. Hale has ulcerations in her mouth and small intestine.
• Although Ulcerative colitis tends to have bloody stools more often than Crohn’s, bloody stools are also possible during Crohn’s exacerbations

A Gastroenterology specialist officially diagnoses Ms. Hale with Inflammatory Bowel Disease, and explains that these symptoms can sometimes be misdiagnosed until they become severe.  Specifically, he diagnoses her with Crohn’s Disease and explains how it affects the entire GI tract. He will write for new medications and discharge her home tomorrow, as long as she is stable.

What medications would you expect Ms. Hale to be discharged with? Why?

• Corticosteroids – to decrease the inflammation
• Immunomodulators – to decrease the autoimmune inflammatory response
• Antidiarrheals – to prevent large loss of fluids in stool

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