Complications Of Inflammatory Bowel Disease
Long standing inflammatory bowel disease can lead to severe complications
Inflammatory bowel disease is a general term used for a group of chronic inflammatory disorders of unknown cause involving the digestive tract. Chronic inflammatory bowel disease may be divided into two major groups - chronic non-specific Ulcerative colitis and Crohn's disease. After years of repeated remissions and relapses, these disorders increase a person's risk of suffering from intestinal cancers, arthritis, liver damage, skin rashes and certain inflammatory diseases of the eye. The major complications of these diseases include the following :
Free air under right hemidiaphragm from perforation of intestines
In severe Ulcerative Colitis, extensive ulceration of the inner lining of large intestines may reduce the thickness and strength of the intestinal wall, and result in the formation of an opening or perforation. This causes discharge of intestinal contents into the abdominal cavity. This in turn, causes irritation to and inflammation of the peritoneal membrane lining the abdominal cavity, and results in acute peritonitis.
Toxic Megacolon - a severe dilatation commonly involving the transverse colon
2. Toxic Dilatation Of Colon
This complication may occur with Crohn's disease, but is more common in Ulcerative Colitis. The dilatation is thought to result from an effect of severe inflammation on the muscle tone of the intestinal wall. Injudicious use of hypomotility agents (medicines that reduce the intestinal movements) to treat diarrhea in the setting of acute colitis, can precipitate this complication. Reduced potassium levels in the body as a result of repititive episodes of diarrhea and vomiting, and use of cathartic preparations for Barium enema examination, may be the contributing factors. It presents as a severe colitis, with high fever, increased pulse rate, depletion of fluid volume, salt imbalance (reduced potassium, magnesium and other essential salts) and abdominal pain. The abdomen is tender to touch. Previously present diarrhea may actually decrease markedly owing to loss of tone of the intestinal wall, creating a false impression of improvement of colitis. Transverse colon is the most common site of dilatation. This condition represents a true medical emergency.
Extensive involvement increases the risk of complications
3. Increased risk of intestinal cancer
Inflammatory bowel disease increases the risk of cancer of intestines, especially when the disease is extensive and of a long duration. The cumulative risk of cancer begins to rise 10 years after the disease is diagnosed. In children, the risk of cancer appears to rise more sharply after the first 10 years of disease, perhaps because of the higher incidence of pancolitis in children. This risk is comparatively less with Crohn's disease in comparison with Ulcerative colitis, perhaps because less surface area of intestines is chronically involved with Crohn's disease than with Ulcerative colitis. The development of colon carcinoma in the setting of inflammatory bowel disease differs from that arising in the absence of colitis, in the following ways :
- Early warning signs of colon cancer (such as rectal bleeding and a change in bowel habits) are difficult to interpret in the settings of colitis.
- In individuals suffering from colitis, carcinomas are distributed more uniformly throughout the colon, than in non-colitic individuals, in whom most cancers occur in the rectosigmoid region, within reach of the sigmoidoscope.
- In individuals suffering from colitis, the tumors are more often multiple, flat and infiltrating, and appear to have a higher grade of malignancy. Also, the presence of irregularities in the intestinal lining, multiple ulcerations and pseudopolyps may pose difficulties in early detection of cancer.
4. Nutritional and Metabolic Complications
Recurrent bouts of diarrhea, vomiting and loss of appetite lead to weight loss, reduced muscle mass, and growth retardation in children. It is also accompanied by decreased level of electrolytes, such as potassium, calcium and magnesium. Inadequate nutrition and protein losing enteropathy (protein loss due to extensive ulceration of the inner lining of intestines) cause decreased levels of albumin in the body. Anemia occurs due to excessive blood loss, iron, folic acid and vitamin-B12 deficiency, and chronic disease process. Active disease involving the small intestines leads to steatorrhea (bulky stools) and fat soluble vitamin deficiency (of vitamins-A, D, E, and K). Increased absorption of oxalates from large intestines increases the risk of kidney stones. Loss of bile salts from the intestines increase the formation of gall stones.
5. Joint Manifestations
These range from joint pains to an acute arthritis, with painful and swollen joints. The non-deforming arthritis may involve one or more joints, and is often migratory. Knees, ankles and wrists are most commonly involved, but any joint may be affected. Typically the severity of arthritis varies with the activity of the underlying intestinal disease. Arthritis is more common with disease of large intestines, than with that affecting the small intestines. Ankylosing spondylitis, a severe form of arthritis that involves the spine and neck, is associated with, but unrelated to the severity of underlying intestinal disease. It may antedate the digestive symptoms by years, and persist after surgical or medical treatment of the disease. It presents as lower backache and stiffness, and eventual limitation of movements.
6. Skin Manifestations
These occur more commonly with disease involving large intestines. The severity of skin symptoms correlates with activity of the intestinal disease. The skin signs include Erythema nodosum, a red nodular eruption affecting extensor aspects of legs, less commonly the thighs and forearms. This eruption precedes the appearance of ulcerative colitis by a year or more. It often correlates with flare of disease, rather than its severity. Another signs is pyoderma gangrenosum, an ulcerating lesion often occurring on the trunk, is relatively painless, and may heal with scarring. This lesion may persist even after colectomy for ulcerative colitis. Apthous ulcers, another common skin symptom, resemble "canker sores" of the mouth.
7. Eye Signs
These include episcleritis (an inflammatory affection of the deep subconjunctival connective tissues, including the superficial layers of sclera or white of the eye); recurrent iritis (inflammation of iris, a free circular diaphragm, the aperture of which is the pupil); and uveitis (inflammation of uveal tract of the eyes). These represent a severe manifestation of the disease, and their activity parallels the course of the intestinal disease. They may respond dramatically when colectomy is done for other reasons.
8. Abnormalities in liver function
In severely ill, malnourished individuals, mild abnormalities of serum levels of liver enzymes (aminotransferases and alkaline phosphatase) represent nonspecific focal inflammation of liver or fatty infiltration. Factors that favor liver complications in severely ill individuals are poor nutrition, and concommitant steroid therapy. The condition is not progressive, and resolves with disease subsidence. Pericholangitis (inflammation of hepatic portal tract and bile duct), sclerosing cholangitis (a chronic inflammation of unknown cause, often involving bileducts and leading to biliary obstruction), cancer of biliary tract (bileduct and gall bladder) and autoimmune chronic active hepatitis, which may progress to cirrhosis of liver, are commonly associated with inflammatory bowel disorders.
9. Venous thrombosis and thromboembolism
Both Crohn's disease and ulcerative colitis are associated with clotting tendency of blood, that is further exaggerated by associated dehydration. Venous stasis (accumulation of blood in the veins) and deep vein thrombosis causing painful swellings in lower legs, and spread of clots via bloodstream into lungs (pulmonary embolism) leading to difficulty in breathing, are common complications.