Ulcerative

Colitis
Ulcerative colitis
• Ulcerative colitis (UC) is a
chronic inflammatory bowel
disease (IBD) that primarily
affects the colon (large
intestine) and rectum.

• The inflammation typically

begins in the rectum and
can extend continuously to
other parts of the colon.

• Ulcerative colitis is limited

to the colon.
Risk Factors
The cause of ulcerative colitis is unknown but an
overactive immune response, causes inflammation
and tissue damage.
Family History.

Age: Ulcerative colitis can develop at any age but is

most commonly diagnosed in people between the ages
of 15 and 30.

Diet: a diet high in fat, refined sugar, and low in fruits

and vegetables has been implicated in increasing the
risk of IBD.

Infections: past infections might trigger an abnormal

Risk Factors
Antibiotics: Frequent or long-term use of antibiotics
may alter gut microbiota (the balance of bacteria in the
gut), which could contribute to the development of
ulcerative colitis.

Smoking

Stress: While stress does not cause ulcerative colitis, it

can exacerbate symptoms and trigger flare-ups in
people with the condition.

Geography: UC is more common in Western countries,

particularly in urban areas, which may point to
environmental or lifestyle factors.
Types
Categorized based on the location of the
inflammation:
• Proctitis:
▫ Inflammation is limited to the rectum,
mildest form of UC.
▫ Symptoms may include rectal
bleeding, urgency, and tenesmus
(feeling of incomplete evacuation).
• Proctosigmoiditis:
▫ Inflammation involves the rectum and
the sigmoid colon (the lower end of
the colon).
▫ Symptoms are similar to ulcerative
proctitis but also include more
pronounced diarrhea, cramping, and
Types
• Left-sided Colitis (Distal Colitis):
▫ Inflammation extends from the rectum
up through the sigmoid and descending
colon (left side of the colon).
▫ Symptoms include bloody diarrhea,
abdominal cramping, and weight loss.

• Pancolitis:
▫ Inflammation affects the entire colon.
▫ More severe form of UC and can cause
severe symptoms, including bloody
diarrhea, abdominal pain, fatigue and
significant weight loss.
Types
• Extensive colitis
• Inflammation extends beyond the
left side of the colon, typically
affects the rectum, sigmoid colon,
descending colon, and may extend
into the transverse colon (the
middle section of the colon).

• Symptoms include frequent and

urgent bowel movements, bloody
diarrhea, abdominal pain, weight
loss, and fatigue
Symptoms
Ulcerative colitis symptoms can vary, depending
on the severity of inflammation and where it
occurs.
• Diarrhea, often with blood or pus.
• Rectal bleeding — passing small amount of
blood with stool
• Abdominal pain and cramping
• Rectal pain
• Urgency to defecate
• Inability to defecate despite urgency
• Weight loss, Fatigue, Fever
•
Diagnosis
1. History Taking and Physical Examination.
2. Lab Tests: Complete Blood Count (CBC), C-
Reactive Protein (CRP) and Erythrocyte
Sedimentation Rate (ESR)
3. Stool Tests
4. Imaging Studies: Abdominal X-ray, CT Scan or
MRI
5. Endoscopic Procedures: Sigmoidoscopy,
Colonoscopy
6. Endoscopic Ultrasound (EUS)
7. Histopathology
Management
• Medications for UC include:
• Aminosalicylates: prescribe sulfasalazine for
mild to moderate ulcerative colitis.
• Corticosteroids.
• Immunosuppressant: an immunosuppressant to
calm immune system. These medicines
include 6-mercaptopurine, azathioprine.
• Janus kinase (JAK) inhibitors (small molecule
drugs): Drugs like tofacitinib stop body’s
enzymes (chemicals) from triggering
inflammation.
Management
• Surgery:
▫Indications: Surgery is considered in cases of
severe complications (e.g., perforation, dysplasia or
cancer), or failure to respond to medical therapy.
▫Procedures: A colectomy (removal of the colon)
with ileac pouch-anal anastomosis (IPAA) is a
common procedure.
▫In some cases, a total proctocolectomy (removal of
the rectum and colon) with a permanent ileostomy
may be performed.
Definition

• Colorectal cancer
(CRC), also known
as bowel cancer, is
the development
of cancer from the
colon or rectum.
RISK FACTOR / CAUSES
• Increasing age.
• Previous colon cancer
• Smoking.
• History of gastrectomy.
Staging

• Stage 0: Cancer is confined to the inner lining

of the colon or rectum.
• Stage I: Cancer has grown into the wall of the
colon or rectum but has not spread outside.
• Stage II: Cancer has grown through the wall
but hasn't spread to nearby lymph nodes.
• Stage III: Cancer has spread to nearby lymph
nodes but not to distant organs.
• Stage IV: Cancer has spread to distant organs,
such as the liver or lungs (metastatic colorectal
cancer).
Clinical Features
• A change in bowel habits, such as diarrhea,
constipation.

• Rectal bleeding with bright red blood.

• Cramping or abdominal pain.

• Unintended weight loss.

• Rectal lesions and tenesmus.

Diagnostic Evaluation
• Abdominal and rectal examination.
• Sigmoidoscopy.
• Virtual colonoscopy.
TREATMENT

• Radiation therapy.
• Chemotherapy (5-flurouracil, capecitabine )
• Surgery: Abdominoperineal Resection.
• Radiofrequency Ablation.
Prevention
• Screening: Regular screening is the most
effective way to detect colorectal cancer early,
when it's most treatable.

• Lifestyle Modifications: Maintaining a

healthy diet, regular physical activity, limiting
alcohol, and avoiding tobacco can reduce the
risk.
Intestinal Obstruction
• Intestinal obstruction is a
partial or complete
blockage of the bowel that
results in the failure of the
intestinal contents to pass
through.

• This can occur in either the

small intestine or the large
intestine (colon).

• The obstruction can be

partial or complete and
may be caused by a variety
of factors.
ETIOLOGY/RISK FACTORS
1. Abdominal or pelvic
surgery.
2. Crohn’s disease
3. Cancer within abdomen.
4. Paralytic ileus (Pseudo
obstruction)
5. Twisting of the intestine
(Volvulus)
6. Diverticulitis
7. Impacted feces
8. Narrowing of the colon
9. Accidents
PATHOPHYSIOLOGY
Blockage in the intestine

Impairment of the passage of material through the

bowel

Blockage results in distention of the intestine

Necrosis and perforation of the bowel.

Activation of local and systemic inflammatory

responses and translocation of bacteria through
CLINICAL MANIFESTATION
 Abdominal Fullness, Gas
 Abdominal pain and cramping
 Breath odor
 Constipation
 Diarrhea
 Vomiting
 Fever
 Failure to pass stool in case of paralytic ileus.
 Absence of flatus.
 Fatigue.
DIAGNOSTIC EVALUATION
 A thorough history and physical examination
 Abdominal X-rays or CT scans
 Complete blood count and serum electrolyte
amylase and blood Urea, nitrogen
 Barium Enema
 Sigmoidoscopy/ Colonoscopy
MEDICAL MANAGEMENT
Collaborative Care:
• Treatment involves placing a nasogastric tube
through the nose into the stomach or intestine to
help relieve abdominal distention and vomiting
• Before surgery, IV infusions that contain normal
saline solution and potassium should be given to
maintain fluid and electrolyte balance.
• Sigmoidoscopy may successfully reduce a
sigmoid volvulus.
• Colon decompression catheters may be passed
through partially obstructed areas via
colonoscope to decompress the bowel before
SURGICAL MANAGEMENT
• If constricting bands are found, they are cut
and it may be necessary to resect the occluded
bowel and to anastomose the remaining
segments.

• Temporary colostomy is also done and later

when the patient is in better physical condition
a resection and anastomosis of the bowel may
be performed.
COMPLICATION

 Dehydration.
 Electrolyte imbalance.
 Infection.
 Jaundice.
 Perforation(hole) in the intestine.
 Peritonitis.
 Sepsis.
Anorectal abscess
• An anorectal
abscess is a
collection of pus in
the anal or rectal
region.

• It may be caused
by infection of an
anal fissure,
sexually
transmitted
Causes
1. A blocked gland
2. An infection of an anal fissures ( a tear or ulcer
in the lining of the anal canal)
3. A sexually transmitted disease (STI)
4. People with inflammatory bowel disease
5. People with DM
6. People with a weakened immune system.
Symptoms
1. Painful, hardened tissue around the anus.
2. Discharge of the pus.
3. A lump or nodule at the edge of anus
4. Tenderness at the edge of anus
5. Fever.
7. Pain associated with bowel movements.
8. Pain is usually constant, throbbing and worse
when sitting down and Fatigue
Diagnostic Evaluation
 A digital rectal examination is usually
sufficient for the diagnosis and the treatment
planning of anal abscesses and fistulae.

MRI scan: allows the assessment of: a) Location

of any fistular tracts. b) Location of the internal
and external opening(s) of any fistula. c)
Location of deep abscesses. d) Any damage to
the anal sphincter.

 Transperineal ultrasound may be a useful

adjunct.
Management
Prompt surgical drainage.
Medication for pain relief.
Antibiotics are usually not necessary unless
there is associated diabetes or
immunosuppressant.
Stool softeners may be used.
Management

• Surgery to drain the abscess which may be

done under LA or GA depending on the extent
& location of the abscess.
Hemorrhoids
• Hemorrhoids are
painful, swollen
veins in the lower
portion of the
rectum or anus.
Causes
• Straining during bowel movements.
• Constipation.
• Sitting for long periods of time
• Anal infections.
• Pregnancy.
• Obesity.
• Genetics.
• Low fiber diet.
• Certain diseases such as liver cirrhosis .
Types
• There are two types of
hemorrhoids i.e.

• Internal hemorrhoids occur

just inside the anus, at the
beginning of the rectum.

• External hemorrhoids occur

at the anal opening and
may hang outside the anus.
Sign and symptoms
• Anal itching
• Rectal pain
• One or more hard tender lumps near the anus
• Bleeding
Diagnosis
• Visual examination.
• Anoscopy.
• Endoscopic image.
• Sigmoidoscopy.
Management
Conservative Treatment
• Increase dietary fiber
• Oral fluids
• NSAID
• Sitz bath
• Rest
• Steroids ointments or creams
Management
• Fixative Procedures: The goal of nonsurgical procedures
used to treat hemorrhoids is called fixative procedures.
• It include cutting off blood flow to the hemorrhoids with a
rubber band using heat, Lasers , electric current.
•  Hemorrhoidectomy Surgical removal of hemorrhoid is
called hemorrhoidectomy.
Prevention
Drink plenty of water, at least eight glasses per
day.

Eat high fiber diet of fruits, vegetables, and

whole grains.

Empty bowels as soon as possible after the

urge occurs.

Regular exercise.
Anal Fistula and
Fissure

Anal Fissure

An unnatural crack or tear in the anus, usually

extending from the anal opening and located
posteriorly in the midline.
Etiology
• Most anal fissures are caused by stretching of
the anal mucosa beyond its capability.
• Various causes of this fissure include:
Straining to defecate, especially if the stool is
hard and dry
Severe and chronic constipation
Severe and chronic diarrhea
Crohn's disease and Ulcerative colitis.
Anal stretching
Insertion of foreign objects into the anus
Tight sphincter muscles
Clinical Manifestations
The symptoms of anal fissure include:
 Pain during, and even hours after, defecation.
 Visible tear in the anus.
 Blood on the stool or on toilet paper.
 Constipation.
 Burning, possibly painful, itchy.
Diagnosis
• A detailed medical history,
• physical examination
• digital rectal examination, and
• may include anoscopy to visualize the fissure.
Medical Management
• Most anal fissures are shallow or superficial .These
fissures self-heal within a couple of weeks.
• While waiting for the fissure to heal, topical or
suppository containing anti-inflammatory agents
and local anesthetic can be used.
Lidocaine ointments can numb the area and reduce
pain.
Nitroglycerin Ointment: Applied to the anal area, this
can help increase blood flow and promote healing
by relaxing the sphincter muscle.
Calcium Channel Blockers: Topical diltiazem or
nifedipine can help relax the anal sphincter and
reduce pain.
Management
Furthermore, treatment used for hemorrhoid
such as:
eating a high-fiber diet,
using stool softener,
avoiding straining,
taking pain killer and having a sitting bath.
Management

Surgical Options
• Lateral Internal Sphincterotomy (LIS): It
involves making a small incision in the anal
sphincter to reduce tension, which promotes
healing.
• Fissurectomy: In some cases, the fissure itself
may be surgically removed.
Anal Fistula
Abnormal opening on the cutaneous surface near the
anus.

Abnormal connection between the epithelialised surface

of the anal canal and (usually) the perianal skin

Usually this is from a local crypt abscess and also is

common in Crohns.
Causes
The primary cause of an anal fistula is usually
an anal abscess, which can result from:
Infection of Anal Glands
Crohn's Disease
Trauma or Surgery
Radiation Therapy
Sexually Transmitted Infections (STIs):
Certain infections can also lead to abscesses
and fistulas.
Symptoms

Anal fistulae can present with many different

symptoms:
• Pain
• Discharge - either bloody or purulent
• Pruritus ani – itching.
• Systemic symptoms if abscess becomes
infected.
Diagnostic Evaluation
• A thorough medical history,
• physical examination, and
• imaging studies such as an endoanal
ultrasound.
• MRI to assess the fistula's tract and surrounding
structures.
• Fistulogram: A contrast dye is injected into
the fistula to outline the tract on X-rays, helping
to visualize its path and any secondary
branches.
Management
• Managing an anal fistula typically involves
surgical intervention, as the fistula usually does
not heal on its own.
• Non-Surgical Management
▫Antibiotics: If there is an active infection,
antibiotics may be prescribed to control it.
▫Pain Management: Over-the-counter pain
relievers or prescription medications can help
manage discomfort.
Management
• Surgical Treatment
▫Fistulotomy: The most common procedure where
the fistula is cut open to allow it to heal from the
inside out.
▫Seton Placement: A seton (a piece of surgical
thread) is placed in the fistula tract to keep it
open, allowing it to drain and heal over time.
▫Fibrin Glue or Collagen Plug: Sometimes, a fibrin
glue or collagen plug is used to close the fistula
tract.
▫Endorectal Advancement Flap: For more
complex fistulas, this procedure uses a flap of
rectal mucosa to close the internal opening of
Pilonidal sinus

• A pilonidal sinus or pilonidal cyst is a small hole

or tunnel in the skin at the top of the buttocks,
near the tailbone (coccyx).

• It often contains hair, dirt, and debris, and can

become infected, forming an abscess.

• When this happens, it can cause pain, swelling,

and the discharge of pus or blood.
Causes
• The exact cause of a pilonidal sinus is not
entirely clear, but several factors contribute to
its development:
• Hair Ingress: Loose hairs can penetrate the
skin, causing an inflammatory reaction. This is
thought to be the primary cause of pilonidal
disease.
• Friction and Pressure
• Infection
• Hormonal Changes
• Obesity
Symptoms
• The symptoms of a pilonidal sinus or cyst can
vary depending on whether it is infected:
• Pain: A painful swelling or lump near the
tailbone
• Redness and Swelling
• Discharge: Pus or blood may drain from the
sinus
• Fever
• Recurrent Abscesses: Some people experience
recurrent abscesses that drain and then
reappear.
Diagnosis
• Clinical History
• Physical Examination
• Inspection of the Sacrococcygeal Area: The
primary diagnostic step involves visual
inspection of the area around the top of the
buttocks (near the tailbone).
• Imaging Studies: Ultrasound, MRI (Magnetic
Resonance Imaging), CT Scan (Computed
Tomography)
Management
• Non-Surgical Management
▫ Hygiene: Keeping the area clean and dry.
▫ Warm Compresses.
▫ Antibiotics: If the area becomes infected,
antibiotics may be prescribed to control the
infection.
• Surgical Treatment
▫ Incision and Drainage: The cyst is opened, and
the pus is drained, relieving pain and pressure.
▫ Marsupialization: After draining the cyst, the
edges of the skin are sewn to the wound edges,
forming a pouch that allows it to heal from the
inside out. This reduces the risk of recurrence.
Malabsorption
• Malabsorption refers to a condition where the
small intestine is unable to absorb nutrients,
vitamins, and minerals effectively from food.

• This can lead to various deficiencies and health

issues.
Causes
• Infections
▫ Giardiasis: A parasitic infection of the intestines.
• Chronic Diseases: Celiac Disease, Crohn's
Disease, Chronic Pancreatitis
• Enzyme Deficiencies: Lactase Deficiency,
Pancreatic Insufficiency
• Surgical Causes: Short Bowel Syndrome, Gastric
Bypass Surgery
• Others: Bile Acid Malabsorption, Radiation
Therapy.
signs and symptoms
Common symptoms include:
• Chronic Diarrhea: Frequent, loose, and watery
stools.
• Steatorrhea: Fatty, foul-smelling stools that may
float.
• Weight Loss
• Abdominal Pain and Bloating
• Nutritional Deficiencies
▫ Anemia: Due to iron, folate, or vitamin B12 deficiency.
▫ Osteoporosis: From calcium and vitamin D deficiency.
▫ Weakness and Fatigue: General tiredness and lack of
energy.
▫ Edema: Swelling due to protein malabsorption.
Diagnostic Evaluation
• Clinical History and Physical Examination
• Laboratory Tests
▫ Blood Tests: To check for anemia, vitamin and
mineral deficiencies, and markers of inflammation.
▫ Stool Tests: To evaluate and identify infectious
causes (e.g., stool culture, ova and parasite
examination).
▫ Breath Tests: For lactose intolerance or bacterial
overgrowth (e.g., hydrogen breath test).
• Imaging Studies: Abdominal Ultrasound, CT Scan
or MRI:
• Endoscopic Procedures: Upper Endoscopy with
Biopsy, Colonoscopy
Management
The management of malabsorption focuses on
treating the underlying cause, addressing
nutritional deficiencies, and managing symptoms:
• Nutritional Support
▫ Dietary Modifications: diet to avoid specific triggers
(e.g., gluten-free diet for celiac disease, lactose-free
diet for lactose intolerance).

▫ Nutrient Supplementation: Oral or parenteral

supplements of vitamins, minerals, and enzymes.

▫ Enteral or Parenteral Nutrition: In severe cases,

where oral intake is insufficient, tube feeding or
intravenous nutrition may be necessary.
Management
• Medications
▫ Antibiotics: For bacterial infections (e.g.,
giardiasis)
▫ Anti-inflammatory Drugs: For inflammatory bowel
diseases like Crohn’s disease.
▫ Corticosteroids: In certain cases, to reduce
inflammation.
DEFINITION
Colostomy is a surgically created open in the
colon for the purpose of evacuation of bowel.

Colostomy care is the maintenance of hygiene by

regular emptying of colostomy bag and
cleaning colostomy site.
TYPES
Ascending colostomy — is made from the ascending part of
the colon. The ascending colostomy is usually located in the
low to middle right side of the abdomen. The output is often
liquid to semiliquid, and gas is common.
Transverse colostomy — is made from the transverse part of
the colon. The transverse colostomy is usually located in the
centre of the abdomen above the navel. The output often is
liquid to pasty, and gas is common.
Descending colostomy — is made from the descending part of
the colon. The descending colostomy is typically located on the
lower left-hand side of the abdomen. The output may be pasty
to a formed consistency, and gas is common.
Sigmoid colostomy — is made from the sigmoid colon. The
sigmoid colostomy is usually located in the lower left-hand side
of the abdomen. The output is usually pasty to a formed
consistency, and gas is common.
PURPOSES
• To prevent leakage.
• To prevent excoriation of skin.
• To observe stoma and surrounding skin.
• To teach patient and relatives about care of
colostomy and collection bag.
ARTICLES
A clean tray containing:
Mackintosh with draw sheet,
Kidney tray
Pair of clean gloves
Colostomy bag
Normal saline / basin with warm tap water,
Gauze pieces,
Gauze pad / tissue paper
Skin barrier,
Stoma measuring guide,
Pen or pencil and scissors.
PROCEDURE
• Arrange the all necessary articles.
• Explain the procedure to the patient.
• Provide privacy and assist patient to a
comfortable position.
• Wash hands & wear gloves to prevent infection.
• Spread Mackintosh & draw sheet to protect linen
• Remove used pouch & skin barrier gently by
pushing the skin away from the barrier.
• Remove clamp and empty the contents into the
kidney tray.
• Ensures accuracy in determining correct pouch
size needed.
PROCEDURE
• Trace same circle behind the skin barrier, using
scissors, cut an opening 1/8th inch larger than
stoma before removing the wrapper over
adhesive part.
• Put skin barrier and pouch over the stoma, and
gently press on to the skin, for 1-2 minutes.
• To prevent irritation to skin.
• Use the pouch if it is drainable using a clamp or
clip
• Remove gloves and wash hands.
• Make the patient comfortable
• Clean the area and replace all articles.
PROCEDURE
• Rinse the pouch with tepid water or normal
saline to minimize the odor & growth of
microbes
• Discard the disposable pouch in paper bag
• Record the procedure with following details
(with date & time ).
• Amount,
• color,
• and consistency of the fecal matter in the
pouch.
SPECIAL CONSIDERATIONS
• Keep odor as free of odors as possible.
• Ostomy bag should be emptied frequently.
• Check the stoma regularly, the color should be
dark pink to red and moist.
• Pale color indicates anemia, Dark or purple blue
indicates compromised circulation.
SPECIAL CONSIDERATIONS
• Size of the stoma stabilizes 6-8 weeks.
• If dressing, check frequently for drainage and
bleeding.
• Keep the skin around the stoma (peristomal
area) site clean and dry.
• Intake and out put chart must be recorded for
every 4 hours.
• Encourage the patient to participate in care and
to look at the ostomy.
• Can help the patient by listening, explaining,
being available and supportive.
SPECIAL CONSIDERATIONS
• Encourage the patient to avoid fibre rich diets.
• Encourage the patient to drink fluids.
• Educate the patient about the various methods
of odour control measures.