Crohn's Disease and Ulcerative Colitis

Crohn's Disease and Ulcerative Colitis
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Crohn's Disease andUlcerative

 

?What is crohn's disease

Crohn's disease is a chronicinflammatory process primarily involving the intestinal tract. Although it mayinvolve any part of the digestive tract from the mouth to the anus ,it mostcommonly affects the last part of the small intestine(ileum) and /or the largeintestine ::colon and rectum

Crohn's disease is a chroniccondition and may recur at various times over a lifetime. Some people have longperiods of remission, sometimes for years, when they are free of symptoms.there is no way to predict when a remission may occur or when symptoms willreturn

 ? What are the Symptoms of Crohn's disease

Because Crohn's disease can affectany part of the intestine, symptoms may vary greatly from patient to patient.Common symptoms include cramping ,abdominal pain,diarrhea ,fever, weight loss,and bloating.Not all patients experience all of these symptoms ,and some mayexperience none of them .Other symptoms, may include

.((anal pain or drainage,skin lesions, rectal abscess ,fissure ,and joint pain (arthritis)

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  ?Who does it  affect

Any age group may be affected ,butthe majority of patients are young adults between 16 and 40 years old. Crohn'sdisease occurs most commonly in people living in northern climates. It affectsmen and women equally and appears to be common in some families. About 20percent of people with Crohn's disease have a relative ,most often a brother orsister ,and sometimes a parent or child ,with some form of inflammatory boweldisease

Crohn's disease and a similarcondition called ulcerative colitis are often grouped together as inflammatorybowel disease .The two diseases afflict an estimated two million individuals inthe U.S

 ? What causesCrohn's disease

The exact cause is not known .However ,current theories center on an immunologic

(The body's defense system) and/orbacterial cause. Crohn's disease is not contagious ,but it does have a slightgenetic (inherited) tendency .An X-ray study of the small intestine may be usedto diagnose Crohn's disease.

  ?How is Crohn's disease treated

Initial treatment is almost alwayswith medication .There is no "cure" for  Crohn's disease ,butmedical therapy with one or more drugs provides a means to treat early Crohn'sdisease and relieve its symptoms .The most common drugs prescribed arecorticosteroids ,such as prednisone and methylprednisolone and various anti-inflammatory agents.

Other drugs occasionally usedinclude 6 - mercaptopurine and azathioprine, which are immunosuppressive.Metronidazole, an antibiotic with immune system effects ,is frequently helpfulin patients with anal disease.

In more advanced or complicatedcases of Crohn's disease, surgery may be

Recommended . Emergency surgery issometimes necessary when complications ,such :

As a perforation of the intestine,obstruction(blockage)of the bowel ,or significant bleeding occur with Crohn'sdisease .Other less urgent indications for surgery may include abscessformation, fistulas(abnormal communications from the intestine),severe analdisease or persistence of the disease despite appropriate drug treatment.

Not all patients with these or othercomplications require surgery. This decision is best reached throughconsultation with your gastroenterologist and your colon and rectal surgeon

  ?Shouldn'tsurgery for Cohn's disease be avoided at all costs

While it is true that medicaltreatment is preferred as the initial form of therapy ,it is important torealize that surgery is eventually required in up to three-fourths of allpatients with Crohn's .Many patients have suffered unnecessarily due to amistaken belief that it inevitably leads to complications.

Surgery is not "curative,"although many patients never require additional operations. Aconservative approach is frequently taken, with a limited resection ofintestine (removal of the diseased portion of the bowel) being the most commonprocedure.

Surgery often provides effectivelong - term relief of symptoms and frequently limits or eliminates the need forongoing use of prescribed medications. Surgical therapy is best conducted by aphysician skilled and experienced in the management of Crohn's disease.

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"Surgery often Provides effective long - term relief ofsymptoms and frequently limits or eliminates the need for ongoing use ofprescribed medications."

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  Surgery inCrohn's Disease 

?When does surgeriesbecome necessary in Crohn's disease

Because two-thirds to three-quartersof patients with Crohn's disease will need surgery at some time during theirlives, it is important to understand why an operation might the indicated. Someoperations are required for serious complications, other are performed forelective indications. Complications requiring urgent surgery include excessivebleeding, perforation of the bowel, intestinal obstruction, abscess formation,or toxic megacolon (dilatation and loss of muscle tone in the colon).If one ofthese complications occurs, a decision to operate must be made quickly.

Elective Surgery in Crohn's diseasemay be indicated because medical treatments have failed to control symptomssuch as pain ,weight loose ,fever ,or extreme fatigue ,or because the sideeffects of these treatments may be intolerable. In consideration of electivesurgery it is essential to consult your gastroenterologist and surgeon aboutwhether surgery at this time will change the course of your disease, whichoperations are available to you ,and what you can expect after surgery .Surgeryis part of the continuum of care in patients with Crohn's disease. It is not acure for the disease .It can alleviate the complications of the disease. Thegoal of surgery is to conserver bowel and return the patient to the bestpossible quality of life .When a patient with Crohn's disease is going to havesurgery ,it is important that the physicians involved be aware of the variousmedications that the person  is taking .The care of the patient is a teameffort including the surgeon , anesthesiologist ,and the primary treatingphysician .For example, the patient taking steroids must continue to receivethem intravenously during the perioperative period. The surgeon and thegastroenterologist,must determine who will monitor the tapering of the steroidspostoperatively.

  ?What is therole of nutrition in the surgical patient with Crohn's disease

Nutrition plays an important role.The inflammation associated with Crohn's disease can cause diarrhea andmalabsorption .If proper nutrition is not provided, significant weight loss andmalnutrition may result .It is very important to bolster the patient'snutritional status prior to elective surgery. Among the benefits of thisstrategy is an improvement in the immune status of the patient, which lessensthe likelihood of complications such as infection and even lessens the time torecovery .while in an emergency situation the restoration of nutrition may not bepossible, proper nutrition can be provided prior to an elective operation suchas for a partial intestinal obstruction that is still causing discomfort.Nutrition can frequently be provided as an elemental formula taken orally or,If need be, by total parenteral nutrition ,which provides total bowel rest.Medication to reduce the inflammation of Crohn's disease may also be helpfulprior to surgery, including steroids ,metronidazol ,6-mercaptopurine or one ofthe other immunosuppressive agents, or one of the 5-aminosalicylic acidmedications.

                 

 ? Whatare the most commonly performed operation for Crohn's disease

The objective of a surgicalprocedure in Crohn's disease is to remove the portion or segment of diseasedintestine that is causing symptoms or, if it is a smaller segment with astricture ( a narrowed area ) ,to perform a strictureplasty . Surgicalremoval of a diseased portion of intestine is called a resection; rejoiningtogether the remaining ends of the bowel to restore intestinal continuity iscalled anastomsis.

This type of surgery dose not resultin an ostomy .The various names for surgical resections depended on which partof the intestine is removed and then anastomosed together. For example ,when aportion of the ileum (small intestine) is removed along with the cecum(apportion of the large intestine),the procedure is called an ileocolic resectionwith ileoascending colon anastomosis(referring to the parts of the small andlarge intestine that are joined together).When all of the colon is removed forCrohn's colitis and the ileum is joined to the nondiseased rectum, theprocedure is called a total abdominal colectomy with ileorectal anastomosis.

When the small intestine is involvedwith Crohn's disease, it may have areas of diseased bowel interposed with areasof normal bowel. These "skip" areas are a classic sign of Crohn'sdisease. The areas with active disease may narrow and ultimately not permit thepassage of the intestinal contents. The normal bowel compensates by pushingagainst this "strictured area,"causing the terrible crampy painassociated with an intestinal obstruction .It is inadvisable to remove longsegments of small intestine because of the severe nutritional deficiencies thatcan occur. Therefore, in order to conserve the intestine and improve thequality of life for patients with this form of Crohn's disease,stricurtureplasty has evolved. This procedure widens the strictured areawithout removing any segments of the small intestine by opening the small bowelalong the area of the stricture and then closing the incision transversely.There have been many reported cases of dilating the stricture with a ballooncatheter, but the effect of this method may be only temporary .The use ofstrictureplasty in colonic Crohn's disease is not advised at this time.

The use of conservative surgery incolonic Crohn's disease may be an alternative approach, however. Limitedcolonic resection can improve a patient's lifestyle without an ostomy. Thistype of resection has a high recurrence rate but is still a good option toconsider 

In approximately 15 percent ofpatients with Crohn's disease only the colon is involved. Removal of the colonand rectum (proctocolectomy) with an ileostomy is performed in some patients.When the rectum and anus are diseased with fistulas and abscesses, the analsphincter can be damaged causing incontinence. Some patients have enduredrepeated frustrations from the failure of medical and localized surgicaltherapies and would rather live with an ileostomy. Ostomates(patients withostomies)can have very active and normal lives.

  ?How abscessesand fistulas are surgically treated

Approximately 25 percent of adultpatients with  Crohn's disease have fistulas or abscesses. They are lesscommon in children .This complication is caused by a perforation of the bowelforming a collection of pus, intestinal bacteria, and fluids. If thiscollection forms a channel or a track to another loop of bowel or organ (forexample, the bladder, vagina or skin),it is called a fistula. This complicationis caused by a perforation of the bowel forming a collection of pus ,intestinalbacteria, and fluids. If this collection forms a channel or a track to anotherloop of bowel or organ (for example, the bladder, vagina or skin),it is calleda fistula. This complication can occur in the abdomen, the pelvis, or the softtissue surrounding the anorectum .If an abscess perforates into the abdominalcavity, the infection spreads rapidly causing sever pain, fever, shock ,andgeneralized sepsis(bacteria in the blood).This becomes a surgical emergency,and an immediate abdominal exploration must be performed in order to drain theabscess and wash out the abdominal cavity. A bowel resection and a temporaryostomy may also be required. If the abscess is confined or Walled off, theinfection spreads more slowly causing intermittent fevers and chills, generalizedweakness,or localized abdominal tenderness.This type of abscess can be drainedby a long needle through the skin with direct guidance of a CT- Scanner, aprocedure that will temporarily control the infection and allow a more electivesurgical intervention involving bowel resection without need of a temporaryostomy.

Abscesses and fistulas involving theanorectum must be treated surgically with a great deal of care in order toprevent damage to the anal sphincter .If the sphincter is damaged, analincontinence may occur .Some abscesses and fistulas may be treated medicallywith antibiotics and immunomodulators.

  ?Are there newersurgical techniques for Crohn's Disease

The use of microinvasive orlaparoscopic surgery has recently been advocated because of less postoperativepain, shorter hospital stays, and less scarring. This type of microinvasivesurgery in Crohn's Disease has been utilized for both elective and urgentoperation. Not recommended for emergency surgery, it is still a new techniquethat requires further evaluation .

?What are the chancesthat Crohn's Disease will recur after surgery

In adults, recurrence of symptomaticCrohn's Disease with pain ,fever, weight loss, diarrhea is 20 percent at twoyears after surgical resection,30 percent at three years, and approximately 50percent at five years when the disease recurs, it is usually at five years.When the disease recurs, it is usually at the site of the anastomosis orileostomy .it is important to remember that each person with Crohn's Disease isdifferent .Theses are only statistics and should not be interpreted asprediction of recurrence.The use of newer medication such as the 5-ASA agentsand the immunomodulators may possibly reduce the likelihood of recurrence. Also,recurrence rate varies with the original resection site. After proctocolectomywith ileostomy ,this rate is less than 20 percent. There are limited data aboutrecurrence rate in children.

?If there is arecurrence, will I need a second or third operation

Most recurrent Crohn's diseaseresponds favorably to medical treatment, In fact only 40 to 50 percent of thosewith recurrent symptoms after their first operation will need a secondoperation. Those that need a third operation range from 10 to 30 percent .

Surgery is not the end of the linebut is a part of the continuing care of a patient .The combination of medicaland surgical therapy is designed to offer a better and productive quality oflife to patients with the illness.

Surgery in UlcerativeColitis

 ?When dose surgery become necessary inulcerative colitis

Over the past decade, Surgery inUlcerative Colitis has evolved to a degree that offers a patient severalalternative to achieve both a better quality of life and a cure for his or herdisease. Approximately 25 to 40 percent of patients with Ulcerative Colitiswill require surgery at some time during their illness.

Emergency indications for surgeryinclude perforation of the colon, massive colonic bleeding ,fulminant (suddensever) Ulcerative Colitis, and toxic megacolon. Any of these conditions requirea prompt decision and prompt intervention .The type of surgical procedure willvary with the condition of the patient and also the experience  of thesurgeon performing the procedure. We will discuss the types of surgicalprocedures later on.

Elective indications for surgery inpatients with Ulcerative Colitis include chronic sever symptoms ,failure ofmedical therapy, and a high risk of developing colon cancer. Because of thelatter risk, colonoscopy is recommended in patients with longstanding disease.During the colonoscopy, random biopsies of  the colon are taken. Biopsiesare examined under the microscope for the presence of dysplasia

Patient with high-grade dysplasiashould undergo removal of the colon and rectum with construction of an ileoanalpouch anastomosis or an ileostomy .Some patients with low -grade dysplasiashould also undergo colectomy or more frequent screening.

The risk of developing cancer beginsto increase after ten years of disease. For this reason children, whose diseasebegan in early childhood, do not need surveillance until adolescence. Coloncancer is extremely rare in the pediatric population.

   Any patient beingevaluated for surgery for ulcerative colitis should inform the involvedphysicians(including the anesthesiologist)of the medications that he or she isreceiving. The surgeon and the gastroenterologist should decide prior tosurgery how steroids will be managed.

?Is nutrition importantin the surgical patient with Ulcerative Colitis

Unlike Crohn's disease in whichpatients can have severe protein and calorie malnutrition, Ulcerative Colitis,with the exception of very severe cases, usually does not present as a diseaseof severe malnutrition.

Nutrition is extremely important,however, in those patients about to undergo surgical therapy for UlcerativeColitis. The patient must go into the operation well nourished, unless it is anemergency situation .This may be accomplished by oral supplements before theoperation. Some patients may require intravenous feeding consisting of totalparenteral nutrition (TPN).

 ?What is the mostcommonly performed operation for Ulcerative Colitis

The most recommended procedure is proctocolectomy(removal of the colon and rectum),which includes salvaging the anal muscleswith construction of a neorectom (new rectum ) out of a portion of the smallbowel (making a reservoir or pouch),attaching the pouch to the anus, andconstructing a temporary loop ilestomy. The loop ileostomy is then closed sixto eight weeks later. The more common name for this operation is  theileoanal pouch anastomosis. This operation has replaced the classicproctocolectomy and permanent ileostomy as the operation of choice .It can beperformed in patients of all ages from five to seventy .Every case is different,and the patients,wishes and desires must be appreciated andconsidered.  

  The operation is usuallyperformed in two stages, the second being less traumatic than the first. Thefirst is removal of the colon and rectum to the level of the anal muscles. Theileum (the very end of the small bowel) is then fashioned into a reservoir (using about twenty centimeters of bowel),pulled down to the anus, and anastomosedto it will either sutures or surgical staples. The pouch is allowed to heal byconstructing a temporary loop ileostomy in order to prevent stool from passingto the healing pouch .Then ,at the second stage of surgery six to eight weekslater, the ileostomy is closed thus restoring gastrointestinal continuity andallowing the patient can have this operation done in one stage, but they mustbe highly selected individuals.

After the operations, patientsaverage six bowel movement per day .The consistency of the stool varies but ismostly soft, almost "putty-kike."As with any operation ,there areshort-them and long -term complications. The two most common longtermcomplications are small bowel obstruction and pouchitis (a nonspecific inflammationof the pouch ).The bowel obstruction causes crampy abdominal pain with nauseaand vomiting. This is managed with bowel rest and intravenous fluids inapproximately two - thirds of the patients. But the remaining patients requiresurgery to release the bowel from the source of obstruction (an adhesion) . Theobstruction is usually scart issue that forms in the abdominal cavity after anytype of surgery .

Pouchitis was originally describedin cases featuring the condition that occurs in 30 percent of pouch patients ,pouchitis  causes mild or sever symptoms and may be acute or chronic. Itcan cause diarrhea and crampy abdominal pain with increased frequency of stool,and also systemic effects including fever, dehydration ,and arthralgias (jointpain) .It can be managed with an antibiotic, metronidazole (Flagyl R)orciprofloxacin (Cipro R), for three to six weeks. In a small percentage ofpatients, however,poucitis becomes chronic and requires long-term antibiotics.

The incidence of pouch failure isapproximately 8 to 10 percent, Failure requires removal of the pouch andconversion to a permanent ileostomy .Although the ileonal pouch anastomosis isthe most commonly recommended type of surgery, it should be performed bysurgeons who have experience with the procedure and the aftercare of thepatient.

  ?What isproctocolectomy and ileostomy?

Proctocolectomy and ileostomy wasthe "gold standard" for the surgical treatment and cure of ulcerativecolitis until the advent of the ileoanal pouch anastomosis operation,widly usedand recommended for som patients with ulcerative colitis.The procedure involvesremoval of the entire colon and rectum with construction of a permanentileostomy ( the end of the small bowel is brought through the abdominal wallallowing the drainage of intestinal waste) .It is usually performed in onestage but can be performed in two, depending on the experience of the surgeonand the condition of the patient. If at the time of a total abdominal colectomywith ileostomy the rectum is left in place, a second operation would berequired to convert the patient to an ileoanal pouch anastomosis or to removethe remaining rectum and leave the patient with a permanent ileostomy .Theindications for proctocolectomy and ileostomy are the same as for the ileoanalpouch anastomosis. The complication rate is lower, but the patient is left witha permanent ileostomy.

  What is lifewith an ileostomy like?

Before a person has an ileostomy(permanent or temporary) ,the surgeon and the enterostomal therapist shouldspeak with him about the ileostomy, its location ,and the person's lifestyle.

The patients should be given anopportunity to speak to people who already have an ileostomy to have a completeunderstanding of its implications on lifestyle. The usual site for an ileostomyis the right lower abdomen just below the belt line to the right of theumbilicus. This allows for easy care and access and placement of the ostomyappliance(pouch)so that there is minima  interference with normallifestyle.

An individual can live a long,active, and productive life with an ileostomy.The psychological implications ofa change in body image can be a problem.

Support from family, theenterostomal therapist,and support groups is important .The local chapter ofthe Crohn's & Colitis Foundation of America has access to excellent supportgroups and should be consulted.

  ?What othertypes of surgical procedures can be performed

Theough there are other surgicalprocedures for ulcerative colitis, they are seldom performed today .In rareinstances the entire colon can be removed and the small bowel anastomsed to theremaining rectum in patients with " rectal sparing disease", butthese patientsprobably have Crohn's disease not ulcerative colitis. Thefunctional results of attaching the ileum to the rectum of patients withulcerative colitis is not very good .The use of the continent ileostomy (theKock Pouch) ,which was an operation with some promise befor the illeoanal pouchanastomosis ,is not a good primary operation for patients with ulcerativecoltis.The clinical studies on the continent ileostomy are conflicting .Theoperation may be an alternative approach to patients who already have anestablished ileostomy, but it is a highly technical operation and the surgeonmust have a large experience with the technique to decrease the highreoperation rate and overall failure rate of the procedure. Limited colonicresection in patients with ulcerative colitis is not recommended because of thehigh recurrence rate .

?What is the role oflaparascopic surgery in ulcerative colitis

The two main operation forulcerative colitis,the ileonal pouch anastomosis and the proctocoecto my withpermanent ileostomy can be performed  through laparoscopic ( microinvasive) techoniquse.The short - and long - term complications should be the same asfor the open technique.The use of laparoscopic colon resectionin the presenceof cancer is not recommended. This is a newer surgical approach and should beperformed by surgeons who are experienced with it . The operation may takelonger , but less postoperative pain and shortened overall recovery time areits main advantages.

  ?Which operationshould a patient choose

When people are confronted with theneed for surgery, all available resources must be utilized to allow the personto make the correct decision .With support from the surgeon andgastroenterologist, a beneficial operation can be planned .The individual shouldspeak to people who have already undergone an operation .Once a patient hascompete information on each operation , an appropriate decision can be reachedas to which operation will result in the best quality of life.

?What is crohn'sdisease

Crohn's disease is a chronicinflammatory process primarily involving the intestinal tract . Although it mayinvolve any part of the digestive tract from the mouth to the anus , it mostcommonly affects the last part of the small intestine (ileum) and /or the largeintestine(colon and rectum).

Crohn's disease is a chroniccondition and may recur at various times over a lifetime. Some people have longperiods of remission, sometimes for years, when they are free of symptoms.there is no way to predict when a remission may occur or when symptoms willreturn .

Understanding Crohn'sDisease and Ulcerative Colitis

  It would be wonderful if allyoung people could enjoy consistently good health and smooth adjustment duringtheir elementary and high school years. Crohn's disease and Ulcerative Colitisare chronic intestinal illnesses that can make it difficult for affectedchildren to enjoy, and thrive in, the school experience .The good that comesfrom the support and encouragement of teachers who understand Crohn's diseaseand Ulcerative Colitis cannot be overstated. It is in this spirit that thisbrochure has been prepared.

 

Facts about theDiseases

Crohn's disease is a condition inwhich the walls of a portion of the gastrointestinal tract have become irritated,inflamed, and swollen. The lower portion of the small intestine, termed theileum, and the large intestine (the colon) are most often affected. Crohn'sdisease is referred to as ileitis when the ileum is affected, colitis when thecolon is involved ,and ileocolitis when both regions are diseased.Occasionally, other part of the gastrointestinal tract such as the stomach areinvolved.

Ulcerative Colitis causesinflammation exclusively in the large intestine; other regions of thegastrointestinal tract are generally not involved. In both conditions,abdominal pain and diarrhea, with or without bleeding, are the most commonsymptoms. The cramps can be severe and are likely to be exacerbated when thereis a need to use the toilet .This urgency may be so great as to result inincontinence (accidental stooling ) if there is any delay in reaching toiletfacilities. Occasionally, some young people with inflammatory bowel diseaseexperience pain coming from outside of the intestinal tract proper, for example,the knee and ankle joints.

Because of the similarity betweenCrohn's disease and Ulcerative Colitis, the term inflammatory bowel disease (IBD,for short) has been used in reference to both diseases.

Crohn's disease and UlcerativeColitis may occur in children of any age, but are especially common in childrenover the age of ten .Males and females are affected equally. It is emphasizedthat this disease should not be confused with "spastic colon" or"irritable bowel syndrome", far less serious and unrelatedconditions.

Crohn's disease and UlcerativeColitis are not caused by emotional stress or diet. Symptoms of the diseasestend to worsen or "flare up" in an unpredictable fashion, oftenfollowing viral infections. Conversely ,symptoms of these diseases tend to remit in an equally unpredictable way for varying lengths of time. It isespecially during the flare-ups, however, that the support of teachers, as wellas family and friends, is so important in helping the affected student to cope.

Crohn's disease and UlcerativeColitis are lifelong illnesses. Although surgical removal of the entire colonmay be curative, it is often not the end of the child's problems. Medicationscan alleviate inflammation and discomfort but are not, in and of themselves,cures for the diseases. In addition, medications may be  associated withunpleasant side effects. Crohn's disease and Ulcerative Colitis are not contagious.

Researchers believe that thediseases may be caused by an overactive immune system. This is in sharpcontrast with some intestinal disorders that are caused by an underactive ordeficient immune system.

 Inflammatory Bowel Diseases

   From the Perspective of the Child

Leaving the classroom

"sometimes, when I have toleave the classroom, teachers give me a hard time and I have to explain infront of everybody"

Young people with these illnessestell that their need to use the toilet frequently and unpredictably. Attacks ofpain and diarrhea often occur suddenly and with no warning what so ever.Children with Crohn's disease and Ulcerative Colitis must be able to leave theclassroom quickly while attracting minimal attention.

Questions about the need to use thetoilet in front of classmates will only cause further embarrassment and shame.This short delay may cause a humiliating stooling accident. Actually, whentreated like adults, most young person's will respond maturely and will notabuse the privilege of leaving the classroom. In some schools, bathrooms arelocked for long periods for security reasons, similarly, in some schools,toilet stalls may not have doors. Any accommodation a school can provide thatreduces the anxiety associated with the need to find a toilet quickly will beof incalculable benefit.

Providing a private bathroom in thenurse's or faculty's area is ofthen beneficial.

Coping

"The hardest thing for me todeal with is the fact that I am different from everybody else. Deep down, Idon't want to be different  ."

Young Crohn's disease and UlcerativeColitis must cope with attacks of abdominal pain and diarrhea. They may beunable to eat, because eating elicits even more diarrhea and pain. poor dietaryintake often slows growth , which may make affected students look younger andsmaller than their class mates. These problems often cause them to withdraw andbecome depressed or angry, especially during the preadolescent or adolescentyears.Treatment can cause problems, too, cortisone - type drugs such asprednisone are effective in controlling ,but not curing ,inflammation caused byCrohn's disease and Ulcerative Colitis.These drugs, however ,typically causepeople to gain weight, to develop a rounded , puffy

Appearance (moon face),to haveworsening of acne, and to become moody and restless. This change in appearancemay isolate children and teenagers from their classmates who may not be awareof the illness and who may ridicule them .To minimize the disfiguring effectsof cortisone-type drugs, intake of salty and high -caloric foods should becurtailed. This, in turn, may further isolate children who can no longer snackon salty foods, such as French fries and potato chips, along with theirfriends.

Taking medicationduring school hours

Students with IBD often need to takemedications during the school day to help control their diarrhea, pain, andother symptoms .

Schools generally require that thesemedications be dispensed by the school nurse. It is very desirable thatarrangements be made ,if necessary ,to facilitate timely dispensing of drugs toan affected student .In this manner, he or she will not be late for class andstand out, yet again, as being different .

Absence from school

"My teachersdon't think I look sick"

Not all young people with Crohn'sdisease and Ulcerative Colitis are small or have side effects of medication.They may appear to be well superficially ,but may actually feel ill. Manyyoung people with inflammatory bowel diseases may require hospitalization fromtime to time, sometimes for several weeks. Surgery may be necessary to removeirreversibly diseased intestine or to alleviate a particular complication, suchas the accumulation of an abscess cavity (pus pocket) within the abdomen. Whilein the hospital, children typically appreciate hearing from classmates andteachers and are often able to keep up with school work. Teachers can helpenormously by communicating with their pupil's physician or office nurse.

Participation in sport

Young people with these illnessesshould participate in sports unless they are in an active state of theirdisease.

Admittedly, some strenuous sportsmay cause fatigue or aggravate abdominal and joint pains.

While a modified gym program may bethe answer in some circumstances, it is very desirable that the affected childmaintains at least some physical activity and not become a "couchpotato".

Communication withParents and

HealthcareProfessionals

Teachers often get to know theirstudents very well. Thus, it is not surprising that teachers may be the firstto recognize when a child may be experiencing a "flare" of his or herdisease. This might well be indicated by more frequent trips to the toilet,decreases in intake during lunch ,declines in school performance as a result ofthese factors, and ,perhaps, the distraction caused by worsening abdominal painor medication, Similarly, teachers may be the first to notice signs of abreakdown in coping mechanisms. The development of discipline problems orindication of social isolation from peers might suggest such breakdowns. Earlyintervention when problems develop is important in treating inflammatory boweldisease. Thus, timely communication with parents, who alert healthcareprofessionals, can be extremely useful in identifying fare-ups or othercomplications before they progress too far. additional interventions canthen  be initiated.

Direct communication with medicalpersonnel is always valuable.

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