Vesna LekaChibuzor Eronini

Alicia GuenetteCorinne Caissie

Regional Enteritis (Crohn’s Disease) ( Raymond-Senuik, 2010)● Most common in adolescence or young adults

● Most commonly occurs in the distal Ileum and ascending colon regions of the GI tract

● Seen more commonly in smokers

● What is regional enteritis?

o Subacute and chronic inflammation of the GI tract wall extending through all

layers

o Periods of remission and exacerbation

o At the beginning of the disease, there is edema and thickening of the mucosa

followed by the appearance of ulcers in the inflamed mucosa

o It affects multiple parts of the colon, with normal areas appearing within the

affected regions (Copstead & Banasik, 2013).

o The ulcers appear in clusters (“cobblestone appearance”)

o As the inflammation extends into the peritoneum, fistulas, fissures, and abscesses

appear. (50% of patients have granulomas)

o Advanced stages of the disease is evidenced by thickening of the bowel wall,

intestinal lumen narrowing, and the walls are fibrotic

● Clinical Manifestation (Raymond-Senuik, 2010).

o Pain in the right lower quadrant of the abdomen

● Perianal fissures, fistulas and abscesses. These may be the symptoms that lead

individuals to seek care (Copstead & Banasik, 2013).

o Diarrhea that is not relieved after defecation

● Diarrhea occurs due to disrupted absorption of the intestine

o Cramping occurs due to the inability for products to move through the narrow

lumen (caused by scar tissue and granulomas). With this, abdominal tenderness

and spasms are seen.

● To avoid cramping, patients reduce food intake and limit the variation of ingested food,

therefore, leading to malnutrition, weight loss, and secondary anemia.

o Occurrence of intra-abdominal and anal abscesses are the result of perforation of

inflamed intestine leading to fever and leukocytosis

o Chronic Symptoms:

● Diarrhea

● Abdominal pain

● Steatorrhea (excessive fat in feces)

● Anorexia

● Weight loss

● Nutritional deficiencies

o Manifestations beyond the GI tract

● Joint disorder ( such as arthritis)

● Skin lesions (erythema nodosum)

● ocular disorder (conjunctivitis)

● oral ulcers

● Diagnostic Tests (Raymond-Senuik, 2010)

o Proctosigmoidoscopy: used for ruling out inflammation of the rectosigmoid

region

o Stool examination: asses for steatorrhea and occult blood

o Barium study of upper GI tract: most conclusive diagnosis showing “string

sign” on an x-ray of the terminal ileum denoting narrowing of an intestinal

segment

o Endoscopy, colonoscopy, and intestinal biopsy are used to confirm diagnosis

o Barium enema: shows ulcerations , fissures, and fistulas

o CT Scan: depicts bowel wall thickening and fistula formation

o CBC: asses hematocrit and hemoglobin levels (decreased if disease is present);

white blood cell count (elevated due to inflammation component of the disease);

ESR (elevated); albumin and protein (decreased due to malnutrition)

● Complications (Raymond-Senuik,2010)

o Intestinal obstruction or stricture formation

o Perianal disease

o Fluid and electrolyte imbalance (due to diarrhea)

o Malnutrition from malabsorption

o Fistula and abscess formation

o Colon cancer

Relation to the Scenario

● Celine is hoping to get pregnant. According to the Crohn’s and colitis association of

Canada, a woman whose disease is in remission and is healthy is likely to get pregnant.

People with acute episodes of the disease may have trouble conceiving. Women with an

IPAA ( Ileal pouch with anal anastomosis) have reduced fertility rates due to internal

scarring around the fallopian tube. Having surgery to remove the part of the colon has no

effect on fertility (crohns and colitis.ca).

● Males who are experiencing acute episodes of the disease tend to have decreased sperm

counts. Sperm counts becomes normal when they are in remission

● Celine has had Crohn’s disease since the age of 16, has had 5 surgeries related to her

disease.

● Celine indicates she is starting to suffer from “extra-intestinal manifestations.” Some of

the common symptoms she experiences include: redness, swelling and pain at her joints

and dark red and purple colored bumps on her shins.

● Going into surgery, it was also found that she had a recto-vaginal fistula.

References

Copstead, L.E & Banasik, J (2013).Pathophysiology.(5th ed.). Elsevier.St. Louis.

Crohn’s & Colitis Canada (2014). Fertility, Pregnancy, Crohns disease & Ulcerative colitis.Retrieved from www.crohnsandcolitis.ca

Raymond-Senuik, C (2010). Management of Patients with Intestinal and Rectal Disorders. In R. A. Day, P. Paul, B. Williams, S. C. Smeltzer, & B. Bare. Brunner & Suddarth’stextbook of Canadian medical-surgical nursing. (2nd ed.).(pp 1157-1204). Philadelphia:Lippincott Williams & Wilkins.

Ulcerative ColitisEllen Palmer

What is it?● A disease of the colon and rectum

o Compared to disease processes occurring anywhere in the GI tract in Crohn’s Disease● Recurrent ulceration and inflammation of superficial (mucosal and sub-mucosal) layers

o Compared to all layers in Crohn’s Disease (Raymond-Seniuk, 2010; Sartin, 2013)

Pathophysiology

● Starts with inflammation at the bases of the crypts that line the mucosa → then leukocytes invade the crypts → this contributes to formation of abscesses → then multiple abscesses join together → this forms continuous ulcerso Compared to discontinuous lesions in Crohn’s Disease

● As time goes on, muscular hypertrophy and fat deposits cause the bowel to become narrower, shorter, and thicker

● Destructive processes lead to attempts to repair tissue → dysplasia can develop → increases risk of developing colon cancer (Raymond-Seniuk, 2010; Sartin, 2013)

Application to Scenario

Celine had an ileostomy created, but because Crohn’s Disease can occur anywhere in the GI tract, recurrence of disease processes at other locations is possible. Given the location of Ulcerative Colitis, a total colectomy with an ileostomy or ileal pouch anal anastomosis may need to be performed, depending on the disease severity. This essentially “cures” the patient (Raymond-Seniuk, 2010). Total colectomies can also be performed prophylactically in ulcerative colitis if extensive dysplasia is observed, given the high risk of colon cancer (Sartin, 2013).

Image: http://pharmafactz.com/pharmacology-of-inflammatory-bowel-disease /

Chris LambRisk Factors/Etiology: (Raymond-Seniuk, 2010, p. 1174)

The cause of ulcerative colitis is unknown. Previous family history is thought to be a risk factor. Prevalence is highest in whites and those of Ashkenazi Jewish descent.

Cassarah McLarty-Mueller

Clinical Manifestations/Signs and Symptoms: (Raymond-Seniuk, 2010, p. 1174)

● Times of exacerbations and remissions with the disease being either mild, severe or fulminant (suddenly or quick onset with severe effects (Merriam-Webster, 2015))

● Signs and Symptoms: diarrhea, lower left quadrant abdominal pain, intermittent tenesmus (feeling like you need to have a bowel movement, even though the bowel is already empty (Medlineplus, 2015)), rectal bleeding, anorexia, weight loss, fever, vomiting, dehydration, cramping, urge to defecate, passage of 10-20 liquid stools/day, hypocalcemia, rebound tenderness in right lower quadrant

○ Extraintestinal manifestations: skin lesions, eye lesions, joint abnormalities (arthritis), and liver disease

● Signs and symptoms due to rectal bleeding: pallor, anemia, fatigue○ Rectal bleeding may be mild or severe

● Complications: toxic megacolon, perforation, bleeding due to ulceration, vascular engorgement, highly vascular granulation tissue and osteoporotic fractures due to decreased bone mineral density

○ Toxic Megacolon: inflammation extends into the muscularis, which inhibits its ability to contract and results in colonic distention

■ Symptoms: fever, abdominal pain, distention, vomiting and fatigue

Annie LiuTreatment/Nursing Interventions Overview:

-goal: reducing inflammation, suppressing inappropriate immune responses, providing rest to allow healing, improving quality of life, preventing complications (Raymond-Seniuk, 2010, p.1174)-complex and ever-evolving-depends on disease location, severity, complications (Raymond-Seniuk, 2010, p.1174)-similar treatment in Crohn’s disease (Raymond-Seniuk, 2010, p.1174)

fluid and nutritional therapy (Raymond-Seniuk, 2010, p.1174)-meet nutritional deficits from malabsorption, diarrhea, anorexia-fluid and electrolytes to restore loss from diarrhea

restricting activity(Raymond-Seniuk, 2010, p.1177)-conserve energy demand and promoting rest during exacerbations of diarrhea, fever, bleeding

pharmacological therapy: (Raymond-Seniuk, 2010, p.1174-1175)-sedatives, antidiarrheals, and antipersistaltics to rest inflamed bowel-aminosalicylates for mild-moderate inflammation; long term use for prevention of recurrent-corticosteriods for acute exacerbations, but many systemic side effects limits its use-immunomodulators to dampen the immune response in severe cases when other therapies in effective-biologics-analgesics for pain-antibiotics for secondary infections due to immune suppression

surgical management: failure of nonsurgical measures to relieve symptoms, poor quality of life, complication, cancer (Raymond-Seniuk, 2010, p.1175)-25% patients have total colectomies with ileostomy; extra-intestinal manifestations subside with surgery

References:

MedlinePlus. (2015). Tenesmus. Retrieved fromhttp://www.nlm.nih.gov/medlineplus/ency/article/003131.htm

Merriam-Webster. (2015). Fulminant. Retrieved from http://www.merriamwebster.com/dictionary/fulminant

Raymond-Seniuk, C. (2010). Management of patients with intestinal and rectal disorders. In R.A. Day, P. Paul, B. Williams, S. C. Smeltzer, & B. Bare. Brunner & Suddarth’s textbookof Canadian medical- surgical nursing. (2nd ed.).(pp. 1173-1174). Philadelphia:Lippincott Williams & Wilkins.

Sartin, J. S. (2013). Gastrointestinal function. In L. E. Copstead, & J. Banasik. Pathophysiology.(5th ed.). (pp. 697-739). St Louis: Elsevier Saunders.

Herpes Zoster

David and Tracy

What is Herpes Zoster

● Herpes Zoster is an infection by the varicella-zoster virus, a DNA virus ● Herpes Zoster is also known as “The Shingles”● Indistinguishable from the virus that causes chicken pox● Infection is characterized by painful blisters on the skin that follow sensory neurons● Herpes Zoster is thought to be the reactivation of the chickenpox virus in adults● May be reactivated in times of immunosuppression

○ for example, taking immunosuppressive drugs (NHS,2013), stress or PTSD (Sinayobye, 2015)

● The latent virus lays dormant in nerve cells near the brain and spinal cord● About 10 % of adults get shingles in their lifetime, most cases in people >50 y/o● Also commonly appears in people with leukemias and lymphomas

Clinical Manifestations of Herpes Zoster

● Eruption of shingles is usually preceded by pain in the area supplied by the virus○ may also be preceded by malaise or GI disturbances

● Pain may be burning, lancinating, stabbing, or aching○ itching and tenderness may also occur.

● Red patches of skin with vesicles● Vesicles contain serum or purulence, may burst and crust over.● Follow band like configuration aligning with cranial nerves.● Clinical course of shingles is 1-3 weeks.● Ophthalmic nerve may be involved causing eye pain● On health adults the dormant virus is not a problem, but when activated may be disabling

Medical & Nursing Management of Herpes Zoster

● Herpes zoster is a virus, and so it can be treated with antiviral agents. Acyclovir (Avirax), valacyclovir (Valtrex), and famciclovir ( Famvir) are some of the antiviral agents that can be used.

○ If they are used within the first 24 hours of infection, it can stop the infection more easily.

● The main goals of managing shingles are to relieve pain and prevent further complications.

○ If shingles goes untreated, it can lead to infection, scarring, eye complications, and postherptic neuralgia.

● Corticosteroids, such as triamcinolone, help to speed up the healing process and help to reduce postherptic neuralgia.

● Ophthalmic herpes zoster can sometimes occur. It is a medical emergency and the patient should be referred to see an ophthalmologist as soon as possible.

○ If left untreated, it can lead to keratitis, uveitis, ulceration, and blindness.● As nurses, it is important that we inform the patient and their family about the importance

of taking the antiviral medications regularly. It is also our job to teach the patient how to perform wet dressings, and topical treatments of the lesion while using appropriate hand hygiene.

● Because the patient may suffer from mild-intense pain, it is important to teach the patient relaxation techniques and when they should take their analgesics.

● Home care may be required for those patients who cannot take care of themselves. Things to consider would be dressing changes, and nutrition of the patient.

references:

NHS, Crohn’s disease treatments (2013), Retrived from: http://www.nhs.uk/Conditions/Crohnsdisease/Pages/Treatment.aspx

Sinayobye, J. d., Hoover, D. R., Shi, Q., Mutimura, E., Cohen, H. W., & Anastos, K. (2015).Prevalence of shingles and its association with PTSD among HIV-infected women inRwanda. BMJ Open, 5(3), e005506. doi:10.1136/bmjopen-2014-005506

Stephen, T.C (2010). Management of patients with Dermatologic Disorders. In R. A. Day, P.Paul, B. Williams, S. C. Smeltzer, & B. Bare. Brunner & Suddarth’s textbook ofCanadian medical- surgical nursing. (2nd ed.).(pp. 1853-1855). Philadelphia: LippincottWilliams & Wilkins.