Ulcerative Colitis: Causes Symptoms Diagnosis Treatment Complications Nursing Assessment Diagnosis Intervention by Nurses Note

  Ulcerative Colitis

Ulcerative colitis is a chronic, idiopathic, diffuse inflammatory disease of the mucosa and, less frequently, the submucosa of the colon and rectum. If only the rectum is involved, it may be called ulcerative proctitis. 

Pathophysiology and Causes of Ulcerative Colitis

1. The exact cause of ulcerative colitis is unknown. Possible theories include: 

• a. Genetic predisposition. 
• b. Environmental factors (viral or bacterial pathogens, dietary). 
• c. Immunologic imbalance or disturbances. 
• d. Defect in intestinal barrier causing hypersensitive mucosa and increased permeability.
•  e. Defect in repair of mucosal injury, which may develop into a chronic condition. 

2. Multiple crypt abscesses develop in intestinal mucosa that may become necrotic and lead to ulceration and perforation 

3. May manifest as a systemic disease with inflammatory changes of connective tissue. Most common in young adulthood and middle age, peak incidence at ages 20 to 40. 

4. Incidence greatest in whites of Jewish descent. 

Clinical Manifestations and Symptoms of Ulcerative Colitis

1. Bloody diarrhoea is a key symptom. 

2. Tenesmus (painful straining), sense of urgency, and frequency. 

3. Increased bowel sounds; abdomen may appear flat, but, as the condition continues, the abdomen may appear distended. 

4. There often is weight loss, fever, dehydration, hypokalemia, anorexia, nausea and vomiting, iron-deficiency anaemia, and cachexia (general lack of nutrition and wasting with chronic disease). 

5. Crampy abdominal pain. 

6. The disease usually begins in the rectum and sigmoid and spreads proximally, at times, involving the entire colon. The anal area may be irritated and reddened; left lower abdomen may be tender on palpation. 7. There is a tendency for the patient to experience remissions and exacerbations. 

8. Increased risk of developing colorectal cancer. 

9. May exhibit extracolonic manifestations of eye (iritis, uveitis), joint (polyarthritis), and skin complaints (erythema nodosum, pyoderma gangrenosum). 

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Diagnostic Evaluation of Ulcerative Colitis

Diagnosis is based on a combination of laboratory, radiologic, endoscopic, and histologic findings.

 Laboratory Tests 

1. Stool examination to rule out enteral pathogens; faecal analysis positive for blood during active disease. 

2. CBC—haemoglobin and hematocrit may be low due to bleeding; WBC may be increased. 

3. Elevated erythrocyte sedimentation rate (ESR). 

4. Decreased serum levels of potassium, magnesium, and albumin may be present.

Other Diagnostic Tests 

 1. Barium enema to assess extent of disease and detect pseudopolyps, carcinoma, and strictures. May show absence of haustral markings; narrow, lead-pipe appearance; superficial ulcerations. 

 2. Flexible proctosigmoidoscopy/colonoscopy findings reveal mucosal erythema and oedema, ulcers, inflammation that begins distally in the rectum and spreads proximally for variable distances. Pseudopolyps and friable tissue may be present. 

 3. Histological findings from biopsies of the colon include changes in crypt height, loss of crypts, and neutrophils infiltrates in the crypts. 

 4. CT scan can identify complications such as toxic megacolon. 5. Rectal biopsy—differentiates from other inflammatory diseases or cancer.

Management of Ulcerative Colitis

 General Measures 

 1. Bed rest, IV fluid replacement, clear liquid diet. 

 2. For patients with severe dehydration and excessive diarrhea, TPN may be recommended to rest the intestinal tract and restore nitrogen balance. 

 3. Treatment of anemia—iron supplements for chronic bleeding, blood replacement for massive bleeding. 

Drug Therapy 

 1. Sulfasalazine—mainstay drug for acute and maintenance therapy. Given orally and is systemically absorbed. Dose-related adverse effects include vomiting, anorexia, headache, skin discolouration, dyspepsia, and lowered sperm count. 

 2. Oral salicylates, such as mesalamine, olsalazine—appear to be as effective as sulfasalazine but are not systemically absorbed and are used when patients are allergic to sulfa. 

 3. Mesalamine enema available for proctosigmoiditis; suppository for proctitis. 

 4. Corticosteroids—primary agent used in the management of inflammatory disease. Should be treated concomitantly with 5-aminosalicylic acid preparations to benefit from their  potential steroid-sparing effects. Enema available for proctitis and left-sided colitis. 

 5. Immunosuppressive drugs—purine analogues, azathioprine, 6-mercaptopurine may be indicated when the patient is refractory or dependent on corticosteroids. 6. Antidiarrheal medications may be prescribed to control diarrhoea, rectal urgency and cramping, abdominal pain; not routinely ordered—treat with caution.

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Surgical Measures 

 1. Surgery is recommended when patients fail to respond to medical therapy, if clinical status is worsening, for uncontrollable adverse effects of medications, severe haemorrhage, perforation, toxic megacolon, dysplasia, or cancer. 

 2. Noncurative approaches (possible curative, reconstructive procedure at later date): a. Temporary loop colostomy for decompression if toxic megacolon present without perforation. b. Subtotal colectomy, ileostomy, and Hartmann’s pouch. c. Colectomy with ileorectal anastomosis. 

 3. Reconstructive procedures—curative: 

• a. Total proctocolectomy with permanent end-ileostomy.
•  b. Total proctocolectomy with continent ileostomy (Kock or BCIR). 
• c. Total colectomy with ileal reservoir—anal (or ileal reservoir–distal rectal) anastomosis—procedure of choice. Multiple reservoir shapes can be surgically created; however, the J-shaped pouch (reservoir) is the easiest to construct.
• d. The ultimate surgical goal is to remove the entire colon and rectum to cure patient of ulcerative colitis.

Complications of Ulcerative Colitis

 1. Perforation, haemorrhage. 

 2. Toxic megacolon (life-threatening)—fever, tachycardia, abdominal distention, peritonitis, leukocytosis, dilated colon on abdominal x-ray. 

 3. Abscess formation, stricture, anal fistula. 

 4. Malnutrition, anaemia, electrolyte imbalance. 

 5. Skin lesions (erythema nodosum, pyoderma gangrenosum). 

 6. Arthritis, ankylosing spondylitis. 

 7. Colon malignancy. 

 8. Liver disease (sclerosing cholangitis). 

 9. Eye lesions (uveitis, conjunctivitis). 

 10. Growth retardation in prepubertal children. 

 11. Possible infertility in females. 

Nursing Assessment of Ulcerative Colitis

 1. Review nursing history for patterns of fatigue and overwork, tension, family problems that may exacerbate symptoms. 

 2. Assess food habits and use of any dietary or herbal supplements used as alternative therapies that may have a bearing on triggering symptoms (milk intake may be a problem). Many patients use vitamins, herbs, and homoeopathic remedies without realizing the effect on bowel function.

 3. Determine number and consistency of bowel movements, any rectal bleeding present. 4. Listen for hyperactive bowel sounds; assess weight. 

Nursing Diagnosis of Ulcerative Colitis

1. Chronic Pain related to the disease process.
2. Imbalanced Nutrition: Less Than Body Requirements related to diarrhoea, nausea, and vomiting.
3. Deficient Fluid Volume related to diarrhoea and loss of fluid and electrolytes. 
4. Risk for Infection related to disease process, surgical procedures. 
5. Ineffective Coping related to fatigue, feeling of helplessness, and lack of support system.

Nursing Interventions of Ulcerative Colitis

1. Promoting Comfort
2. Achieving Nutritional Requirements
3. Maintaining Fluid Balance
4. Minimizing Infection and Complications