AUSTRALIAN
ASSOCIATION Inc.
Questions and Answers about Complications
1. Question: What are complications of Crohn's disease and ulcerative colitis?
Answer: Complications in general can be defined as
events that make a simple matter more complex. Uncomplicated
inflammatory bowel disease involves inflammation of portions of
the intestinal tract, of large or small intestine, or both. In
uncomplicated disease one would expect improvement especially
with appropriate treatment. Lack of improvement, advancement of
the disease, or its extension beyond the intestinal tract can be
seen as complications.
2. Question: How common are complications of Crohn's disease and ulcerative colitis?
Answer: Complications are by no means inevitable or
even frequent, especially in appropriately treated patients.
However, they are sufficiently common and cover such a wide range
of manifestations, that it is important for patients and
physicians to be acquainted with them. Early recognition often
means effective treatment.
3. Question: What are some of the more important local complications of ulcerative colitis?
Answer: You may be familiar with the complications of
peptic ulcers (ulcers of the stomach and duodenum). The same
complications can occur in patients with ulcerative colitis.
There may be profuse bleeding, perforation (rupture) of the
bowel, obstruction (blockage), or simply failure of the patient
to respond to the usual medical treatments.
4. Question: What is the approximate percentage of patients with ulcerative colitis who would be expected to develop one of the above complications?
Answer: The complication rate in ulcerative colitis is
somewhere in the 10-20% range. About 80-90% of patients respond
satisfactorily to medical treatment and never develop any
complications.
5. Question: What does distension (bloating) of the abdomen mean in a patient with ulcerative colitis?
Answer: A mild degree of abdominal distension is common
in individuals without any intestinal disease and is somewhat
more common in patients with ulcerative colitis. If the
distension is severe or of sudden onset, and associated with
fever and loss of appetite, one would have to suspect a serious
complication of colitis, the so-called toxic megacolon. This is
fortunately a rare complication. It is produced by severe
inflammation of the entire thickness of the colon and weakening
and ballooning out of its wall. This can be compared to the
weakening and threatened rupture of a tyre. Treatment is aimed at
controlling the inflammatory reaction, restoring losses of fluid,
salts and blood. If there is no rapid improvement, surgery may
become necessary to avoid rupture of the bowel.
6. Question: What is meant by systemic complications of inflammatory bowel disease?
Answer: These refer to those problems which affect the
patient as a whole rather than the bowel locally. Fever is
perhaps the most common, and is a reaction of the body to
inflammation in general. Severe blood loss can lead to rapid
heart action, a drop in blood pressure, and other responses of
the circulatory system. At times, other organs of the body which
are not part of the intestinal tube, can show abnormalities.
These are called extra-intestinal manifestations.
7. Question: What are extra-intestinal manifestations?
Answer: A small percentage of patients with
inflammatory bowel disease suffer from inflammation of the distal
joints (small joints of fingers, hands, feet, ankles, and knees)
or of the central joints (spine and sacroiliac joints). A small
percentage of patients suffer from a painful inflammation of the
eye called iritis and a small percentage of patients may suffer
from erythema nodosum which is a type of skin lesion that is red,
swollen and painful. Another skin problem that may affect some
patients is pyoderma gangrenosum (punched-out ulcerations).
8. Question: What causes these extra-intestinal manifestations?
Answer: The cause is not known but is believed that all
of these manifestations represent disturbances in the immunologic
system (the body's defence system against the inflammatory
process or against abnormal products of intestinal metabolism).
9. Question: Can the liver be affected in inflammatory bowel disease?
Answer: A small number of patients have disturbances in
liver functions and structure. It is believed that these liver
problems also represent disturbances in the body's immunologic or
defence systems and are not fully understood.
10. Question: Can these extra-intestinal manifestations be treated?
Answer: Most of them respond to treatment directed at
the inflammatory bowel disease. For instance, arthritis of the
distal joints usually subsides when the intestinal disease is
effectively treated with anti-inflammatory drugs, or rarely, by
means of surgical removal of the inflamed bowel.
11. Question: When the patient has arthritis or inflammation of the joints, how can the doctor tell that this problem is connected with the intestinal condition?
Answer: This is not always easy, particularly in
patients who have severe inflammation of the joints and mild or
even absent intestinal symptoms. In most instances, the presence
of diarrhoea, or any other symptoms of inflammatory bowel
disease, is the most important clue to the correct identification
of the joint problem. Also, the joints in this case are usually
not as severely affected as they are in rheumatoid arthritis and
do not undergo destructive changes. It is usually possible to
make sure what type of inflammation one is dealing with in any
given patient.
12. Question: We have been mostly discussing ulcerative colitis. How does Crohn's disease differ from ulcerative colitis in its various complications?
Answer: Much of what has been said above applies to
both ulcerative colitis and Crohn's disease. Because Crohn's
disease can affect any portion of the intestinal tube, and
because as a rule the entire thickness of the intestinal wall of
the involved segments is diseased, additional problems may arise,
such as fistulas.
13. Question: What are fistulas?
Answer: A fistula is an abnormal passage such as from
one loop of intestine to another. Such passages may also lead to
other internal organs or to the skin. Fistulas are relatively
common in Crohn's disease and rare in ulcerative colitis. Because
inflammatory process involves the full thickness of the intestine
in Crohn's disease, the usually smooth outside surface of the
intestinal loops becomes rough and sticky and adheres to
neighbouring structures. The inflammation may spill over into
adjacent areas and lead to the production of abnormal passages or
fistulas. Fistulas may lead to abscesses (collections of pus). In
many instances this calls for a surgical incision and drainage
and other appropriate measures. If the fistula is small, medical
treatment alone may be sufficient to control it and bring about
its closure and healing.
14. Question: Since the small intestine is involved in the absorption of foods, can Crohn's disease of the small intestine cause malnutrition?
Answer: This depends on the extent and severity of the
disease. If the small segment of intestine is involved and
treated promptly and appropriately, malnutrition should not
develop. If the disease is extensive and of long duration,
malnutrition of varying degrees can develop.
15. Question: What can be done to combat malnutrition?
Answer: A combined approach of medical treatment and,
if necessary, surgical treatment of the inflammation, together
with replacement of nutrients is usually indicated. If patients
are deficient in vitamin B12, this vitamin
can be given by injection. If there is a deficiency in iron, this
mineral can be given in tablet, or liquid form or by injection.
Nutritional supplements can be given in the form of concentrated
nutrient solutions. Hospitalised patients can be given
intravenous fluids, sometimes in the form of Total Parenteral
Nutrition (TPN) where all nutrients are supplied by the
intravenous route.
16. Question: What are the most common intestinal complications of Crohn's disease?
Answer: Partial obstruction of the intestine is
probably the most common complication. Affected patients may
complain of severe crampy pain in the mid-abdomen. They may note
that the abdomen gets distended or bloated at the same time.
Vomiting occurs with severe obstruction.
17. Question: Does partial obstruction as described above always lead to surgery?
Answer: No. Only in severely obstructed patients is
surgery necessary. In many less severely obstructed patients,
medical treatment alone will reverse the partial obstruction,
relieve the symptoms, and permit the patient to eat normally
again.
18. Question: Are there complications in inflammatory bowel disease that specially affect children and adolescents?
Answer: Yes. When inflammatory bowel disease affects
children or adolescents, growth may be retarded or there may be a
delay in the onset of puberty. It is important to recognise the
correct cause of delayed growth and development because proper
treatment of the inflammatory bowel disease will usually restore
growth and maturation patterns.
19. Question: Are the systemic manifestations of inflammatory bowel disease the same in children as in adults?
Answer: They tend to be the same ones but for unknown
reasons the extra-intestinal or systemic manifestations may
predominate in children and even overshadow the intestinal
symptoms, thus making diagnosis more difficult. It is therefore
of greater importance to keep close watch on youngsters who fail
to grow or thrive, feel sick, have fever, and complain of general
malaise and weakness, for these may be systemic manifestations of
inflammatory bowel disease.
20. Question: When a youngster develops inflammatory bowel disease and suffers from diarrhoea, bleeding, fever, etc. doesn't it affect his or her emotional state?
Answer: It frequently does, as does any serious illness
that may affect any person, but youngsters may be less able to
cope with serious illness.
21. Question: Can inflammatory bowel disease lead to cancer?
Answer: Cancer is very rare in Crohn's disease. In long
standing ulcerative colitis involving most or all of the colon,
there is an increased frequency of developing cancer compared to
the normal population. However, the increased frequency is still
relatively low and patients can be identified who are higher
risk. If the risk of cancer is considered high, surgical
resection can be recommended.
22. Question: There have been so many complications described. Once again, what is the overall frequency of complications in inflammatory bowel disease?
Answer: With proper treatment now available in the form
of anti-inflammatory drugs such as sulfasalazine or with
corticosteroids, and in some situations, immunosuppressant drugs,
the majority of patients do well and do not develop any serious
complications. Early recognition, proper treatment, good
nutrition and a positive outlook are the most important
deterrents to the complications of inflammatory bowel disease.