CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2
Desiree Lumaban
Inflammatory Bowel Disease (IBD)
Inflammatory Bowel Disease (IBD) is a term for
two conditions (Crohn’s Disease and Ulcerative
Colitis) that are characterized by chronic
inflammation of the gastrointestinal (GI) tract.
"The body's intestinal wall becomes swollen and
develops ulcers."
Crohn’s Disease (CD) Epidemiology
A transmural inflammation of the GI tract that can Inflammatory Bowel Disease is most prevalent in
affect any part, from the mouth to the anus. Western countries and in areas of northern latitude.
Rates of IBD are highest in North America, Northern
Affected Location Europe, and Great Britain.
The incidence of IBD is increasing worldwide,
Most often it affects the portion of the small intestine especially in Westernized and newly industrialized
before the large intestine/colon. countries.
Damaged Areas CD has an incidence of 6 to 15.5 cases per 100,000
persons per year and a prevalence of 3.6 to 214 per
Damaged areas appear in patches that are next to 100,000 people per year.
areas of a healthy tissue. The incidence of UC ranges from 1.2 to 20 cases per
100,000 persons per year with a prevalence of 7.6 to
Inflammation 246 per 100,000 persons per year.
Inflammation may reach through the multiple layers Both sexes are affected somewhat equally with IBD,
of the walls of the GI tract. although 20% to 30% more women are affected with
CD and slightly more males (60%) are affected with
Ulcerative Colitis (UC) UC.
Both UC and CD tend to have bimodal distributions
A mucosal inflammatory condition mainly on the in age of initial presentation. The peak incidence
rectum and colon. generally occurs in the second (CD) or third (UC)
decade of life, with a second peak occurring between
Affected Location 60 and 70 years of age.
Occurs in the large intestine (colon) and the rectum A higher incidence of IBD occurs in the Jewish
wherein it also affects the mucosal and the population, while black and Asian populations have a
submucosal layers. relatively similar, and possibly lower, incidence of
IBD.
Damaged Areas
Etiology
Damaged areas are continuous (not patchy) –
usually starting at the rectum and spreading further Three characteristics define the etiology of Inflammatory
into the colon. Bowel Disease (IBD):
Inflammation 1. Genetic predisposition - An increased chance or
likelihood of developing a particular disease based
Inflammation is present only in the innermost layer of on the presence of one or more genetic variants
the lining of the colon. and/or a family history suggestive of an increased
risk of the disease.
2. An altered, dysregulated immune response -
Occurs when the body can't control or restrain an
immune response. The body might underreact to
foreign invaders in which can cause infections to
spread quickly.
3. An altered response to gut microorganisms -
Microorganisms are proposed to be a major factor in
the initiation of inflammation in IBD. An alteration and
imbalance of these can cause chaos for digestion,
health, and overall wellbeing (Dysbiosis).
Pathophysiology Clinical Presentation of Ulcerative Colitis
Crohn's Disease
Transmural spread of inflammation leads to
lymphedema and thickening of the bowel wall and
mesentery. Mesenteric fat typically extends onto the
serosal surface of the bowel. Mesenteric lymph
nodes often enlarge.
Extensive inflammation may result in hypertrophy of
the muscularis mucosae, fibrosis, and stricture
formation, which can lead to bowel obstruction.
Noncaseating granulomas can occur in lymph nodes,
peritoneum, the liver, and all layers of the bowel wall.
Pathophysiology
Ulcerative Colitis
Management
The inflammation caused by ulcerative colitis affects
the mucosa and submucosa, and there is a sharp Nonpharmacologic Therapy
border between normal and affected tissue.
Only in severe disease is the muscularis involved. Nutritional Support - Treatment and prevention of
Early in the disease, the mucous membrane is malnutrition and treatment of active inflammation
erythematous, finely granular, and friable, with loss Supplements - Vitamin and mineral supplements
of the normal vascular pattern and often with can help with nutritional deficiencies.
scattered hemorrhagic areas. Surgery - May be necessary as the last resort which
Large mucosal ulcers with copious purulent exudate involes recetioning the segments of intestine that are
characterize severe disease. Islands of relatively affected
normal or hyperplastic inflammatory mucosa Exercise - May improve disease activity, quality of
(pseudopolyps) project above areas of ulcerated life, bone mineral density, and fatigue levels in
mucosa. patients with IBDs
Clinical Presentation of Crohn's Disease Pharmacologic Therapy
Anti-inflammatory medications – Mild ulcerative
colitis may be controlled with anti-inflammatory
medication such as Mesalazine, Mesalamine, and
Balsalazide
Immunosuppressive medications - Corticosteroids
(prednisolone or hydrocortisone) and Azathioprine or
Methotrexate to avoid the long-term effects of
corticosteroids
Biologics - Block a small protein that causes
inflammation in the intestine (Infliximab,
Adalimumab, and Golimumab
Prevention
Stop smoking.
Get recommended vaccinations.
Ask your doctor if you should be screened for
colorectal cancer.
If you are a woman with IBD, talk to your doctor
about how to prevent cervical cancer.
Talk with your doctor if you do not feel like yourself
and think that you might have depression or anxiety.
Ask your doctor if you need a bone density test. Low-impact/moderate exercises such as brisk
walking, bicycling, swimming, and yoga.
Case Study Corticosteroids – to decrease the inflammation
Immunomodulators – to decrease the autoimmune
Ms. Hale is a 19 year old female who presents to the
inflammatory response
Emergency Department (ED) reporting bloody diarrhea. She
reports that she has been told she has Irritable Bowel Antidiarrheals – to prevent large loss of fluids in stool
Syndrome (IBS) in the past, and sometimes has bloody
stools, but this is the first time she’s seen this much blood.
She has 5-10 bowel movements daily and she has had 3 Monitoring
already this morning. She reports she’s used to that,
especially if she eats greasy foods. She reports a weight loss Repeat colonoscopy to check for abnormalities of
of 10 lbs in the last 4 months. Her vital signs are stable. The the entire colon other than bleeding
provider found frank blood on a digital rectal exam. She Possible endoscopy to test for diseases and
received a colonoscopy, which showed a bleeding ulcer in her conditions that may be causing anemia, bleeding,
transverse colon. She returns to the ED 2 days later inflammation or diarrhea
complaining of bright red blood in her stools – two yesterday CT Scan to visualize nearly all parts of the body and
and five already today. She reports severe lower abdominal is used to diagnose disease or injury as well as to
pain, nausea and vomiting. plan medical, surgical or radiation treatment
Testing of CRP (C-Reactive Protein) and ESR
Findings:
(Erythrocyte Sedimentation Rate) to check for
19 y/o female patient inflammatory markers
Bloody diarrhea Repeat CBC (Complete Blood Count) due to
History of IBS further bleeding in order to detect possible anemia,
infections, dehydrations, and inflammations.
Sometimes has bloody stools
Usually has 5-10 bowel movements daily
Unhealthy eating habit (eats greasy foods)
Lost 10 lbs for the past 4 months
Stable vital signs
Blood on rectal exam
Colonoscopy showed a bleeding ulcer in the
transverse colon
Bright red blood in the stool
Severe lower abdominal pain, nausea, and vomiting
Assessment
She may actually have an inflammatory bowel
disease, not irritable bowel syndrome because of the
bleeding ulcers in her transverse colon
There is a possible exacerbation which is the
worsening of a disease or an increase in its
symptoms
Perform colonoscopy to evaluate the source of
bleeding
Perform CBC (Complete Blood Count) to assess the
severity of bleeding
Perform Digital Rectal Exam to look for possible
tumors or cancers inside the rectum, assess the
functioning of the anal sphincter, evaluate for
hemorrhoids or determine other causes of pain or
bleeding
Recommendations
Report increased bleeding/bloody stools or severe
abdominal pain
Drink plenty of water
Avoid foods that may increase stool output such as
fresh fruits and vegetables, prunes and caffeinated
beverages.
