Inflammatory bowel disease is chronic, immune-mediated inflammation of the gastrointestinal tract that relapses and remits. It arises from an abnormal immune response to gut bacteria in a genetically susceptible person, influenced by environment (smoking, diet, antibiotics). The two main forms are Crohn disease (CD) and ulcerative colitis (UC).

Extraintestinal manifestations (occur in either form)

• Joints: peripheral arthritis, ankylosing spondylitis, sacroiliitis
• Skin: erythema nodosum, pyoderma gangrenosum
• Mouth: aphthous ulcers
• Eyes: uveitis, episcleritis
• Liver: primary sclerosing cholangitis (especially UC)
• Others: kidney stones, gallstones, venous thromboembolism, osteoporosis, anemia

• Stool frequency, consistency, blood, urgency, nocturnal stools; abdominal pain and distension
• Fever, fatigue, weight loss, growth delay in adolescents
• Hydration, orthostatic vital signs, electrolytes
• Perianal inspection in Crohn disease: fissures, fistulas, abscesses, skin tags
• Nutrition: weight trend, B12, iron, folate, vitamin D, albumin
• Psychosocial impact: body image, anxiety, depression, work and school disruption

Severity of UC (Truelove and Witts criteria): severe = 6 or more bloody stools per day plus at least one sign of systemic toxicity — heart rate over 90/min, temperature over 37.8 °C (100 °F), hemoglobin below 10.5 g/dL (105 g/L), or raised ESR/CRP. Daily stool count and blood are the key bedside measures.

Goals: induce remission, maintain remission, heal the mucosa, prevent complications, and maintain nutrition and quality of life.

Acute severe UC (hospital care)

• IV corticosteroids are first-line
• VTE prophylaxis with heparin — the clotting risk outweighs bleeding concerns in most clients
• Avoid opioids, anticholinergics, and antidiarrheals — they can precipitate toxic megacolon; avoid NSAIDs
• Fluids, electrolytes (especially potassium), transfusion as needed
• If no response in about 3 days: rescue therapy with infliximab or cyclosporine (cyclosporine: nephrotoxicity, hypertension, seizures — especially with low magnesium or cholesterol — and drug-level monitoring), or colectomy

Surgery

• UC: total proctocolectomy — with ileal pouch–anal anastomosis (IPAA, J-pouch) or end ileostomy — for refractory disease, dysplasia/cancer, perforation, massive bleeding, or toxic megacolon
• Crohn disease: bowel-sparing resection or strictureplasty for strictures, fistulas, abscesses; disease often recurs, so postoperative medical therapy continues. Early postoperative enteral nutrition supports healing and gut barrier function

Nutrition therapy

• No single diet prevents flares; avoid prolonged restrictive diets
• Low-residue (low-fiber) diet when strictures are present or during severe flares
• Exclusive enteral nutrition is first-line induction therapy for children with Crohn disease (avoids steroid effects on growth); in adults it is mainly supportive
• Replace iron (IV often better tolerated), B12, vitamin D, calcium; PN only when the gut cannot be used

Listed in priority order.

1. Detect life-threatening complications — monitor for toxic megacolon (abdominal distension, fever, tachycardia, sudden decrease in stool frequency, shock), perforation (sudden pain, rigidity), and massive bleeding; report immediately
2. Fluid, electrolyte, and blood balance — stool count and character, intake and output, daily weight, potassium and magnesium, hemoglobin; IV fluids and transfusion as ordered
3. VTE prevention — pharmacologic prophylaxis as ordered, mobility, monitor for DVT/PE signs
4. Infection prevention — immunosuppressed clients: hand hygiene, fever monitoring, screening before biologics
5. Pain and comfort — use non-opioid comfort measures; avoid opioids and antispasmodics (anticholinergics) in severe colitis; perianal skin care (gentle cleansing, barrier cream, sitz baths)
6. Nutrition — dietitian referral; small frequent meals; monitor weight and deficiency labs
7. Preoperative ostomy planning — referral to a wound, ostomy, and continence (WOC) nurse to mark the stoma site before surgery, avoiding skin folds, scars, the waistline, and bony prominences, where the client can see it
8. Psychosocial support — address body image, bathroom access anxiety, and depression; support groups

• Take maintenance medicine even when well — stopping causes flares
• Recognize a flare: more stools, blood, pain, fever, weight loss — call early
• Stop smoking (especially in Crohn disease)
• Avoid NSAIDs; use acetaminophen for pain
• Keep vaccinations current (inactivated influenza, pneumococcal, COVID-19, hepatitis B, recombinant zoster); avoid live vaccines while immunosuppressed
• On biologics: report fever, cough, or any infection promptly; annual skin checks
• Colonoscopy surveillance beginning about 8 years after diagnosis for colitis involving more than the rectum (sooner and yearly with PSC)
• Bone health: calcium, vitamin D, bone density testing with long-term steroids
• Plan pregnancy with the care team — most IBD drugs (5-ASA, thiopurines, anti-TNF and other biologics) continue safely, but methotrexate and JAK inhibitors (tofacitinib, upadacitinib) must be stopped before conception; use effective contraception while taking them

• Crohn: mouth to anus, skip lesions, transmural, granulomas, fistulas, terminal ileum → B12 deficiency
• UC: rectum upward, continuous, mucosal, bloody diarrhea, toxic megacolon; colectomy is curative
• UC severity: stools per day and blood (severe = 6 or more bloody stools plus systemic toxicity)
• Acute severe UC: IV corticosteroids, heparin VTE prophylaxis; avoid opioids, anticholinergics, antidiarrheals
• Extraintestinal: arthritis, oral ulcers, erythema nodosum, uveitis, PSC
• Mesalamine → watch kidney function; sulfasalazine → folate, sulfa allergy
• Before anti-TNF: screen for TB and hepatitis B; no live vaccines
• Steroids for flares only — taper
• Strictures → low-residue diet; children with Crohn → exclusive enteral nutrition
• Preoperative stoma site marking with a WOC nurse
• Smoking worsens Crohn disease