Impact of Inflammatory Bowel Disease on the Patient

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Inflammatory bowel disease constitutes a group of diseases of unknown cause. The symptoms produced depend on the location, extent, and acuteness of the inflammatory lesions. The common presenting features are fever, anorexia, weight loss, abdominal discomfort,

*For example, dermatitis herpetiformis, a blistering disease predominantly on the buttocks, shoulders, elbows, and knees.

diarrhea, rectal urgency, and rectal bleeding. It is a chronic, potentially disabling illness, often resulting in the need for multiple surgeries, in fistula formation, and in cancer.

Inflammatory bowel disease may lead to long absences from school or work, disruption of family life, malabsorption, malnutrition, and multiple hospitalizations. A patient can have 10 to 30 watery or bloody bowel movements each day. As a consequence, patients with inflammatory bowel disease can have many psychologic problems, particularly when they are young adults. Because of malabsorption, the prevalence of osteopenia in patients with inflammatory bowel disease ranges from 40% to 50%;osteoporosis is present in 5% to 30% of all patients. Fractures of the hip, spine, and distal radius occur. One study revealed that the incidence of fractures among persons with inflammatory bowel disease is 40% greater than in the general population.

Sexual development may be delayed as a result of malnutrition. Social development is also delayed. The necessity of constantly having to remain near a bathroom inhibits patients' abilities to develop normal dating patterns. Many of these patients are socially immature, and social introversion is common. By necessity, they remain at home. Their lives revolve around their bowel habits.

In most cases, there is a positive correlation between the severity of the physical disease and the extent of emotional disturbance. Dependency is the most reported characteristic of patients with inflammatory bowel disease. Repressed rage, suppression of feelings, and anxieties are also common. It is reported that many patients have a constant desire to rid themselves of events in their lives. This characteristic can be acted out through the diarrhea. Another characteristic of these patients is to be obsessive-compulsive. The marked obsessive character becomes even more obvious when the patient is ill. It is typical for patients to worry incessantly about what is happening in their bowels. The patients are intelligent, often having read much literature, including medical textbooks, about their disease.

Denial is usually not a prominent symptom. In contrast, these patients concentrate obsessively on the details of their bowel habits.

Sexual problems are common. Interest and participation in sexual activity tend to be at a low level. Many of these individuals prefer to be fondled like a child and largely reject any genital contact. Patients are prone to regard sexual activity in anal terms, such as ''dirty,'' ''unclean,'' or ''soiling.'' They are squeamish about body contact, odors, and secretions. The loss of libido and decreased sexual drive may be related to their fear of bowel action during intercourse, of perineal pain, or that sexual intercourse may in some way further damage the bowel.

The frequent hospitalizations cause anxiety and depression, which exacerbate the disease. The fear of cancer may be the basis of depression, which is a common response to the disease. It is well established that emotional factors are important in maintaining and prolonging an existing attack. Schoolwork deteriorates as young patients are forced to miss more and more school, further increasing their anxiety.

An often unappreciated major complication of inflammatory bowel disease is substance abuse. As a result of chronic pain, as much as 5% of patients with inflammatory bowel disease are physically addicted to oral narcotics. Many more are psychologically dependent on their pain medication.

Many patients with ulcerative colitis require an ileostomy. The fear of disfigurement, the loss of self-confidence, the potential lack of cleanliness, and the dread of unexpected spillage are common.

Time for listening and an interest in a patient's problem are important in gaining the patient's confidence. Listening may reveal and help unravel the emotional problems that may be the source of the exacerbation of the bowel disease. Talking with the patient may be more efficacious than prescribing anti-inflammatory agents or tranquilizers. Careful and thoughtful discussion of the illness strengthens the doctor-patient relationship and produces immeasurable therapeutic benefits.

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