ulcerative

Clinical Manifestations and Complications. The patient with ulcerative colitis suffers from attacks of bloody, mucoid diarrhea that are usually precipitated by physical or emotional stress. These acute attacks can last for days, weeks, or even months and are followed by periods of remission that can extend from a few weeks to several decades. Some patients experience relatively few attacks throughout their lifetime, while others have frequent, prolonged, and potentially serious attacks that predispose the colon to malignant changes. Both acute and chronic diarrhea can upset the fluid and electrolyte balance, interfere with normal nutrition, and produce fever, abdominal cramps, and weight loss.



A sudden and severe attack of the disease can lead to cessation of bowel function and toxic megacolon or dilatation of the colon. This can occur spontaneously, or it may be preceded by barium enema, hyperkalemia, or anticholinergic narcotics, or there may be bacterial overgrowth with production of exotoxin. Other complications include severe blood loss and anemia, systemic toxicity, and metabolic disturbances. A serious sequela of long-term chronic and continuous ulcerative colitis is carcinoma of the colon, which occurs in approximately 5% of people with ulcerative colitis. The risk of it is lower for persons who have infrequent relapses than for those who are symptomatic for years. Guidelines on screening for colon cancer have been developed by an expert panel and endorsed by numerous organizations concerned with the care of patients with GI diseases. They advise colonoscopy every one to two years for people who have had inflammatory bowel disease throughout the colon for at least 8 years or who have had it in the left colon for at least 15 years.

Patient Care. During acute attacks, the patient will most likely present problems related to fluid volume deficit, alteration in nutrition, loss of electrolytes, potential for skin breakdown in the anal region, disturbance of sleep and rest, and discomfort from abdominal cramps. Long-term problems are likely to be related to anxiety, alterations in self-concept, social isolation, and fear of malignancy.



The plan of care should include observation of the number and character of stools, periodic auscultation of bowel sounds, measurement of intake and output, daily weight, checking for signs of bleeding and anemia, and monitoring of blood gases, electrolytes, and pH for evidence of acid-base imbalance or abnormal electrolyte values. It also is important to be alert for signs of inflammatory changes in the joints or lesions on the skin.

When diagnostic procedures such as sigmoidoscopy, barium enema, and stool analyses are necessary, patients should have a satisfactory explanation of the purpose of these tests and what is expected of them before, during, and after each procedure.

Long-term goals of care should help the patient comply with the prescribed medical regimen, which usually consists of antidiarrheic agents, anticholinergic drugs to relieve abdominal cramps, mild sedatives, and a diet of low-residue, bland foods that have high caloric and protein content. Antibiotics are sometimes needed to control infections of the bowel.

Surgical intervention may be the only alternative when more conservative treatments fail. The surgery usually involves creation of a permanent ileostomy, which brings on a new set of problems.

There is no cure for ulcerative colitis, and it is a debilitating disorder that can create many physiologic, psychological, and social problems for the patient. The frequent bouts of severe diarrhea and discomfort can be embarrassing and depressing. Emotional support, empathetic listening, and cooperative problem solving are essential components of patient care. Further information may be obtained by writing The Crohn's and Colitis Foundation of America Inc., 386 Park Avenue South, 17th floor, New York, NY 10016-8804, calling them at 1-800-932-2423 or 1-212-685-3440, or consulting their web site at http://www.ccfa.org.