Pocket Guide to Inflammatory Bowel Disease

by Sunanda V. Kane, Marla C. Dubinsky

Overview

Patients with Inflammatory Bowel Disease (IBD) present special challenges for practitioners, whether in the office, in the clinic, or on the telephone. This easy to read, easy to use pocket guide has been written by respected clinicians to help anyone who cares for IBD patients identify key problems and make decisions about treatment. Each chapter is devoted to a particular complaint or symptom and covers conditions to consider, questions to ask, and tests to order. The guide also contains valuable information on medications, complementary and alternative therapies, dealing with special populations, and long-term concerns such as non-adherence.

Product Details

ISBN-13:	9780521672399
Publisher:	Cambridge University Press
Publication date:	05/16/2005
Pages:	152
Product dimensions:	4.29(w) x 7.05(h) x 0.55(d)

About the Author

Sunanda V. Kane is an Assistant Professor of Medicine at the Inflammatory Bowel Disease Center, University of Chicago.

Marla C. Dubinsky is the Director of the Pediatric Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center in Los Angeles. In addition, she is an Assistant Professor of Pediatrics at the David Geffen School of Medicine, University of California, Los Angeles.

Read an Excerpt

Cambridge University Press
0521672392 - Pocket Guide to Inflammatory Bowel Disease - Edited by Sunanda V. Kane and Marla C. Dubinsky
Excerpt

CHAPTER 6

Fatigue

Fatigue is often the most troublesome symptom of IBD. It greatly limits work and social activities and often prevents patients from completing even basic daily routines. It is a major cause of depression in IBD patients. Fatigue stems from a variety of causes and treating each in turn can often make a big difference in a patient's quality of life.

1. CONDITIONS TO CONSIDER
   • Active IBD
   • Iron-deficiency anemia
   • B₁₂/folate deficiency
   • Malnutrition
   • Electrolyte abnormalities
   • Chronic pain
   • Depression
   • Undiagnosed malignancy
   • Drug reaction
   • Adrenal insufficiency
   • Unrelated viral infection
   • TPN line infection
   • Pregnancy
   • IBD-related arthritis
   • Hypothyroidism
2. QUESTIONS TO ASK
   1. How long has the fatigue been going on?
      • Several days to a week. May be due to increased disease activity, drug reaction, electrolyte abnormality, or line infection.
      • Several weeks to months. Worry about something more chronic such as iron/B₁₂/folate deficiency, malnutrition, pregnancy, adrenal insufficiency, IBD-related arthritis, hypothyroidism.
      • Several months to years. Harder to correct, but must be investigated. Consider chronic pain, depression, and malignancy.
   2. How severe is the fatigue?
      • Mild. Usually due to mild lab abnormality, anemia, mild flare, unrelated viral infection.
      • Moderate. Can be due to IBD flare, malnutrition, hypothyroidism, or adrenal insufficiency.
      • Severe. Must be immediately dealt with because it could indicate a life-threatening condition such as a malignancy, severe anemia, or sepsis.
   3. What are some of the associated symptoms?
      • Abdominal pain/diarrhea can indicate an IBD flare.
      • Weight loss can signal malnutrition, vitamin and mineral deficiencies, or a malignancy.
      • Bleeding can cause anemia.
      • Chronic pain, depression, inability to leave house. Need a consult with a pain specialist and/or a psychiatrist.
      • Dizziness/fainting/arthralgias can indicate adrenal insufficiency or can occur while prednisone is being tapered.
      • Fevers/arthritis/arthralgias. Serum sickness-like reaction to infliximab or autoimmune reaction to infliximab.
      • Nausea/vomiting could indicate pregnancy (get a urine or serum HCG) or an IBD flare.
   4. What else is going on in the patient's life?
      • Increased physical or work activity. Can easily cause fatigue in an already chronically ill individual.
      • Self-induced vomiting or limiting food intake due to an eating disorder. This is more common than you might think and contributes to malnutrition in certain IBD patients.
      • Nonadherence to medication such as iron, B₁₂, folate, or nutritional supplements. This contributes to anemia and malnutrition.
      • Nonadherence to IBD medications resulting in IBD flares.
      • OTC medications and certain herbal preparations can cause fatigue. Always examine carefully what the patient is taking. Patients should bring in pill bottles and all OTC medications to the office visit.
      • Menstrual cycles that cause some women to feel more fatigued around their periods and also to flare during menstruation.
   5. What is the patient's current IBD therapy regimen?
      • 6-MP/AZA can cause fatigue as a side effect.
      • Infliximab can cause fatigue through several mechanisms: Patients can develop an autoimmune reaction consisting of DNA. With long lapses between infusions, patients can also develop a serum sickness-like reaction consisting of fevers, arthralgias, and fatigue.
      • Prednisone. After taking prednisone for as few as 3 months, patients can develop adrenal insufficiency after the prednisone is tapered. Patients tapered to 10 mg or less should be tested by either an A. M. cortisol level or a cortisol stimulation test. In addition, the process of tapering prednisone itself can cause fatigue and arthralgias.
3. TESTS TO ORDER
   With fatigue that lasts more than a week, the patient should come in and be evaluated.
   • CBC, B12, folate, electrolyte levels, albumin, TSH. Will assess for anemia, infection, malnutrition, hypothyroidism, and electrolyte imbalances
   • A.M. cortisol level, cortisol stimulation tests in appropriate patients
   • Calorie counts. Consult with nutritionist in appropriate patients
   • Blood, urine, and stool cultures. In febrile patients or in immunosuppressed patients who are moderately to severely fatigued to rule out an occult infection
   • Urine or serum HCG. In women of childbearing age
   • ANA and anti-dsDNA. For patients on infliximab
   • Psychiatric evaluation. For patients with depression or eating disorders
   • Pain specialist evaluation. For patients with chronic pain
   • Physical exam. Look for tachycardia, hypotension, lymphadenopathy, thyromegaly, abdominal mass, blood on rectal exam
   • Back and spine ⅹ-rays. For certain patients with joint complaints.

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© Cambridge University Press

Table of Contents

Foreword; Preface; Part I. Basic Overviews: 1. Ulcerative colitis; 2. Crohn's disease; Part II. Patient Symptoms: 3. Abdominal pain; 4. Arthralgias; 5. Diarrhea; 6. Fatigue; 7. Fever; 8. Nausea; 9. Rash; 10. Rectal bleeding; 11. Red eye(s); Part III. Medications and Other Therapies: 12. Medication table; 13. Infliximab considerations; 14. Complementary and alternative therapies; Part IV. Special Populations: 15. The post-op patient; 16. The pediatric patient; 17. The pregnant patient; 18. The elderly patient; Part V. Special Considerations: 19. Colon cancer; 20. Nutritional issues; 21. Osteoporosis; 22. Non-adherence.

Editorial Reviews

Reviewer: Willem J de Villiers, MD, PhD, MHCM (University of Kentucky College of Medicine)
Description: This small pocket guide to inflammatory bowel disease is focused on direct patient care and aimed at busy healthcare providers in the clinic. The intent is to provide quick answers to common perplexing symptoms, and to help clinicians make decisions about treatment. Several short chapters deal specifically with special populations and considerations in IBD.
Purpose: The guide is aimed at practitioners, physician extenders, GI fellows and students who encounter IBD patients in the clinical setting. It wishes to provide succinct practical advice on approaches to common symptoms in IBD, special IBD populations, special considerations in IBD such as colorectal cancer, nutritional issues, osteoporosis and the nonadherent patient. Commonly used IBD medications are also discussed. Although these are worthy objectives, the superficial way in which the topics are covered detracts from the guide's utility.
Audience: Although the guide is purportedly aimed at practitioners, non-IBD GI subspecialists and GI fellows, it is written at a level more appropriate for medical students doing a GI rotation or physician extenders. The authors are well-known clinical IBD experts and authorities in the field.
Features: In very brief chapters the guide deals with common IBD patient symptoms such as abdominal pain, arthralgias, the vexing problem of fatigue, nausea, red eye, and skin rashes. Common IBD medications are then discussed, including complementary and alternative medicine. Special populations and considerations are briefly addressed such as postoperative management and IBD in children, pregnancy and the elderly. I particularly enjoyed the outlined approaches to the pediatric IBD patient and the discussion on nutritional issues. The individual chapters generally employed the same bullet-point features and format to enhance user-friendliness. Unfortunately, the chapters are too brief and superficial to be of much use to anyone other than the very occasional IBD care provider.
Assessment: This field is awash with many offerings on the provision of outstanding care to IBD patients. Unfortunately, this brief pocket guide falls short due to the superficial nature of the covered material. There are other much more useful guides, such as Lichtenstein's The Clinician's Guide to Inflammatory Bowel Disease Therapy (Slack, 2003).

Doody's Review Service

From the Foreword by Joseph B. Kirsner, MD, PhD..."This publication is highly recommended to all physicians involved in the study and management of IBD patients, including gastroenterology trainees, nurses, and advanced students who will learn much from this well-organized and authoritative contribution to the IBD literature."

From the Publisher