ulcerative colitis and crohn's disease a conference …...volume 26, no. 2 summer 1994...

VOLUME 26, NO. 2 SUMMER 1994 ULCERATIVE COLITIS

ULCERATIVE COLITIS AND CROHN’S DISEASEA CONFERENCE ON MORBIDITY AND MORTALITY OF

INFLAMMATORY BOWEL DISEASE

IVAN T. BECK, MD, PHD, FRCP(C), FACP, FACGEmeritus Professor of Medicine and of Physiology Queen’s University

Gastrointestinal Disease Research UnitHotel Dieu HospitalQueen’s University

Kingston, Ontario, Canada

Introduction. Before discussing the findings of the Con-ference on Morbidity and Mortality of InflammatoryBowel Disease 0BD), a short review is indicated of thetwo conditions, which are referred to under the term ofIBD: ulcerative colitis and Crohn’s disease. Ulcerativecolitis (UC) is a mucosal disease. It is a continuousinflammation which is restricted to the colon. Crohn’sdisease involves the deeper layers of the bowel. It mayaffect any part of the gastrointestinal tract from mouthto anus. The inflammation is almost always segmental.Inflammatory bowel disease can be diagnosed onlyonce the etiology of inflammation remains unknownafter all other recognizable causes of injury such asinfection, radiation, ischemic colitis, gay bowl syn-drome, etc. have been excluded. In most instances, ul-cerative colitis and Crohn’s disease can be easilyseparated and appear to be the manifestations of twoseparate diseases. There is, however, some evidencethat suggests that UC and CD may represent two ex-tremes of the same disease. This concept is based on theobservation that occasionally patients present with anintermediary form in which the two conditions cannotbe clearly separated on clinical or pathologic grounds.There is also genetic evidence to support this concept:often in the same famil~ or even between identicaltwins, one individual may suffer from Crohn’s diseasewhile the other from ulcerative colitis.1 Furthermore,the extraintestinal complications of the two diseases aresimilar.

Ulcerative colitis (UC) usually starts at the most distalpart of the colon and may manifest as a simple proctitisinvolving only the rectum. Other patients may sufferfrom proctosigmoiditis, left-sided colitis involving thedescending colon, subtotal colitis (up to the hepaticflexure) or total involvement of the large intestine.2

Proctitis was considered by some as separate conditionfrom UC but it is now becoming evident that in aconsiderable number of patients with proctitis the in-flammation progresses to the proximal colon and insome to the entire large intestine.3 Histological findings

in ulcerative colitis show superficial ulceration of thesurface epithelium, intense inflammatory infiltration ofthe mucosa with pus in the crypts with typical cryptabscesses. There is distortion and destruction of theglandular structure of the colon. These findings how-ever, are not pathognomic for UC, because they occurin the presence of any severe chronic mucosal disease.As the disease becomes chronic, ulcerations may healwith flattened mucosa and the intervening normal mu-cosa may appear as "pseudopolyps.’’2

Complications of ulcerative colitis are shown in Table 1.

Bleeding used to be a life-threatening complication, butwith better transfusion facilities, monitoring and earliersurger~ this ceased to be a major problem. Severe tox-icity and dilatation of the colon, often leads to perfora-tion. Again early and safer surgery has overcome theprevious mortality associated with this complication.Healing may occur with stricture formation, but this isless common in UC than in CD. There is evidence thatmalignancy of the colon is more common in ,P2a.tientswith ulcerative colitis than in the normal bowel. How-ever, the incidence of patients with ulcerative colitisdeveloping malignancy has been overrated in the pastand recent evidence indicates that the incidence is muchlower than previously believed.3 Extraintestinal com-plications may involve the liver, biliary tract, joints, skinand the eyes. Because of malnutrition, fatty liver is notuncommon. Hepatitis may be due to blood transfusionsand autoimmune hepatitis may accompany UC. Someof these become chronic and prolonged inflammatorychanges may lead to cirrhosis. The classic biliary com-plication is sclerosing cholangitis with multiple intra-hepatic and extra_hepatic strictures of the bile ducts.Rarely this may lead to choleangiocarcinoma. Periph-eral arthritis classically involves large joints in asym-metrical manner but small joints may also be involved.Development or exacerbation of this type of arthritisusually parallels intestinal disease activity, while anky-losing spondylitis and sacro-ileitis are unrelated to dis-

JOURNAL OF INSURANCE MEDICINE VOLUME 26, No. 2 SUMMER 1994

ease activity and may precede the development of ul-cerative colitis. Several skin lesions have been observedin patients with ulcerative colitis, such as oral aphthousulcerations, erythema nodosum, arteritis, pyodermagangrenosum, epidermolysis bullosa, etc. Eye lesionsobserved in inflammatory bowel disease are episcleritisand uveitis.2

Crohn’s disease (CD) may affect any part of the alimen-tary tract. One third of the cases are restricted to thesmall bowel (regional enteritis). The terminal ileum ismost commonly involved. Almost half of all patientswith CD have both the small and large bowel involved,and ileocolitis is the most common manifestation. Colo-nic Crohn’s without small bowel disease occurs in ap-proximately 20% of the cases. One of the commonmanifestations is perianal involvement with fistulasand perianal abscesses. This may occur in about 30% of

patients .4,5

The earliest visible lesions are superficial roundaphthous ulcerations. These ulcers, are deeper thanthose in ulcerative colitis and they progress quickly totransmural inflammation. Non-caseating granulomasare often found and are considered pathognomic forCrohn’s disease. However, granulomas are not alwayspresent or at least are so rare that they are not found inevery biopsy. Because of the depth of the lesions, athickening of the bowel wall is common and this maylead to strictures. Transmural inflammation is mani-fested by the presence of lymphoid nodules which arefound at the junction of the muscularis externae and theserosa and may extend to the mesenteric side of thebowel. The presence of these nodes on the mesentei~and the multiple strictures are the classic findings ofCrohn’s disease at operation.6

The complications of Crohn’s disease5 are shown inTable 2. Because of the nature of the disease, obstructionis more common than in UC. Because of the depth of theinvolvement, periintestinal abscesses are often found.Fistulas originating in the intestine may lead blindlyinto the mesentery and are the source of these ab-scesses.Fistulas may also connect several bowel loops.Entero-vesical and entero-cutaneous fistulas can alsooccur. Others may be the cause of perirectal disease.Because of the slow progression of the disease across thebowel wall, mesentery and omentum tends to adhere tothe fistulas. Therefore, abscesses are common but frankperforation or massive bleeding is rare. Malignancy hasbeen reported in long-standing Crohn’s disease, and thefrequency of this complication is probably less thanpreviously believed.7 Because of involvement of thesmall bowel and f~luent resection of different sectionsof the small intestine, malabsorption is common.8 As in

other situations with intestinal malabsorption, there isincreased incidence of cholelithiasis and urolithiasis. Ifthe disease is long-standing, after several years of pu-rulent fistulas and abscesses, amyloidosis may develop.Because of the presence of chronic disease, hematologiccomplications, such as anemia of chronic disease oranemia due to bleeding is not uncommon.8 Extraintesti-nal manifestations of Crohn’s disease are similar tothose in UC.

Organization of the Conference. With this backgroundin mind, it is now appropriate to discuss the reasons forthe Conference on Morbidity and Mortality of Inflam-matory Bowel Disease held in Quebec City in 1992. TheCrohn’s and Colitis Foundation of Canada (previouslythe Canadian Foundation for Ileitis and Colitis) sup-ports medical research; education of physicians andpatients; and recently it became involved in advocatingfor the specific needs of patients with inflammatorybowel disease (Table 3). The Foundation has a Lay Boardand a Medical Advisory Board (MAB). There is closecooperation between the two boards. The Lay Board isinvolved in organizing charitable donations and theadministration of finances. The MAB has three majorcommittees, the Research Committee, the EducationCommittee and the Patient Advocacy Committee. TheResearch Committee reviews research applications andadvises on the distribution of funds to support research.The Education Committee provides educational mate-rial for patients and physicians and the Patient Advo-cacy Committee deals with specific needs for patientssuch as approaching government to obtain support forthe inclusion of nutrient substances into the medicationlist for patients with inflammatory bowel disease. Forthe last several years, the Lay Board received manycomplaints from patients about the difficulties they hadobtaining insurance. Dr. Suzanne Lemire, chairman ofthe Patient Advocacy Committee, reported to the MABabout the medical aspects of obtaining insurance. Shefound that the last generally accepted text on life riskwas that of "Brackenridge" which was published in1985.9 A book written in 1985 could have includedmorbidity and mortality data published after 1982. Anyreport published in 1982 would deal with cases thatwere collected during the 1970’s. Because of the manyrecent advances in the 1980’s, the MAB of the CCFCassumed that the mortality and morbidity figures musthave improved since the publication of Brackenridge’stext. The major advances related to improved diagnos-tic techniques (Table 4), improved medical therapy (Table5) and safer and less complex surgery (Table 6). Theintroduction of ultrasound and CT scan made it easierto differentiate an abscess from a swollen edematousinflamed bowel. The better differential diagnosis of theclassic finding of a right lower quadrant mass allowed

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VOLUME 26, No. 2 SUMMER 1994 ULCERATIVE COLITIS

for more appropriate therapy.10 Colonoscop:~ espe-dally because of the improved pathological recognitionof dysplasia11 allowed to carry out surgery before can-cers have developed. Table 4 indicates that the poten-tially more toxic drug Sulfasalazine can now bereplaced by 5-amino-salicylic acid preparations. Theconventional steroids are being replaced with steroidswith first-pass kinetics. Cydosporin and other new im-munosuppressive agents have been added to Imuranand 6MP,, and metranidazole has been found to be veryeffective, especially in perianal Crohn’s disease.12 In thepast there was very little interest in nutritional supportand many patients were starved on "bowel rest." Intro-duction of enteral nutrition and total parenteral nutri-tion has not only helped to induce remissions, but alsoallows vatients to enter surgery in a better nutritionalstate.13"a4 As shown in Table 5, surgery has become saferand much less complex.15’16 Avoiding exclusion of dis-eased bowel in blind loops resulted in a diminishedincidence of small intestinal bacterial overgrowth and alesser incidence of cancer developing in blind loops. Inthe past, partial colectomy was performed in Crohn’sdisease and this led to multiple reoperations. Presentlyin most centers, total colectomy is carried out even ifonly a segment of the colon is involved. Multiple stric-tures are corrected by stricturoplasty rather than byresection of large chunks of the small intestine. Betterbowel preparation diminishes the chance of peritonitis.

Abscesses, if possible are evacuated by radialogic meth-ods rather than by surgery. Post-operative surgical ther-apy has improved with better antibiotics andnutritional support. All these advances suggested thatthe morbidity and mortality must have improved dur-ing the last decade.

On the basis of these assumptions, the MAB of theCrohn and Colitis Foundation of Canada, with the sup-port of the Lay Board, decided to organize a conferencereviewing the recent data on the morbidity and mortal-ity of inflammatory bowel disease. An organizing com-mittee (Table 7) was established. In addition to the abovecommittee, the advice of Dr. Guy Tremblay, PastPresident, Canadian Life hsurance Medical OfficersAssociation, was obtained on the first meeting of thiscommittee. Anumber of speakers were invited to speakon several aspects of the conference (Table 8). In additionto the speakers 19 Canadian gastroenterologists andsurgeons were invited to participate in the conference.The total number of participants was 30. The invitedguests represented a broad spectrum of individualswith specific interests, a good scattering of age and ofgeographic location. There was a mix of academic andnon-academic physicians and surgeons. Two of the in-

vited practicing gastroenterologists were also insurancemedical officers.

The organizing committee decided that before embark-ing on the conference, it was necessary to ascertainwhether the impression of the Lay Board of the CCFCwas correct in assuming that patients with inflamma-tory bowel disease have difficulties in obtaining insur-ance. Dr. Suthefland was charged to obtain data on thisand to report to the conference on his findings. Theconference lasted one day. In the morning lectures weregiven by Dr. Lloyd Sutherland on the results of thepatients’ survey on insurance, by Dr. Guy Tremblay onthe process by which life insurance applications areevaluated, by Dr. Richard Farmer on the human cost ofinflammatory bowel disease, by Mr. Rod Riley on theCanadian Experience of the morbidity and mortality ofIBD. Dr. Goran Hellers reviewed the morbidity andmortality of Crohn’s disease and Dr. Vibeke Binder thatof ulcerative colitis. In the afternoon three group ses-sions were organized, each consisting of approximatelyten participants. One group chaired by Dr. DesmondLeddin was charged to discuss the morbidity and mor-tality If ulcerative colitis and to propose recommenda-tions which would help to improve the insurability ofpatients with UC. Dr. Lloyd Sutherland chaired a groupthat dealt with the same issues an Crohn’s disease be-fore surgery and a group chaired by Dr. Alan Thomsondiscussed Crohn’s disease after surgery. The summaryof the discussions of these small groups were reportedto the reassembled plenary session by their chairmen.These were further discussed and final conclusions andrecommendations were drawn.

The Meeting. The first lecture was by Dr. Lloyd Suther-land on the results of the patient survey on insurabil-ity.17 Drs. Beck, Leddin, Prokipchuk, Thomson andSutherland sent questionnaires to 50 cases each, and Dr.Lemire; whose cases represented the experience of theFrench-Canadian population sent questionnaire to 70patients with IBD. A total of 320 questionnaires weresent out and 206 responded providing a 66% responserate. The results for straight life insurance are shown inFigure I indicating a high rejection rate for both disease.Rejection and special rating for disability insuranceshowed similar results. Interestingly, group life wasrefused in 35% of patients with ulcerative colitis and17% of patients with Crohn’s disease.

Thus there appears to be reasonable evidence indicatingthat patients with IBD has considerable difficulties inobtaining insurance.

The next and most exciting lecture was given by Dr. GuyTremblay on the process by which life insurance appli-

288


c~tions are evaluated/rated.18 He explained how insur-ance companies work. Most clinicians were unaware ofthe fact that for the first 7 to 8 years after obtaining aninsurance, the life expectancy of the insured populationis half to one-third lower than that of the general popu-lation. This is because individuals who have recogniz-able diseases have been already excluded. Because theinsurance business is competitive and companies wantto sell insurance, patients with IBD have a better chanceto obtain insurance at a lower additional rate if theyshop around among several insurance companies. Hepointed out that the insurability of patients improvesafter periods of good health and suggested that weshould encourage patients to reapply after periods ofremission. He pointed out that patients will do better ifa clinician helps the medical director to evaluate therisk. Dr. Tremblay advised that clinicians should writea letter, rather than just fill out a form, and that ifapplicable, clinicians should mention the period of re-mission, the fact that the patient is reliable and is underongoing follow-up. Medications used should be men-tioned, especially if the patient is not on steroids orimmunosuppressive agents. An important factor is thepatient’ s ability to function, i.e. if he/she is back to workand has held the same job for a certain length of time.He also suggested that patients have group insurancecoverage at their work, should be advised not to changetheir jobs.

Dr. Richard Farmer, previously physician in chief of theDivision of Medicine and director of the Department ofGastroenterology at the Cleveland Clinic, reviewed thehuman cost of inflammatory bowel disease}9 He inves-tigated 164 patients with IBD whose disease onsetstarted around the age of 20. Only those patients wereincluded in the study whose follow-up was over 10years. A questionnaire was designed to assess their (a)ability to function, 09) social and recreational activities,(c) attitude towards life and health and their (d) medicalstatus. The findings of the study indicates that ulcera-tive colitis patients have a better quality of life thanpatients with Crohn’s disease and patients with bothdiseases enjoy a better quality of life before than aftersurgery. Most importantly, IBD patients have a dose tonormal life-style, with 44% functioning well and beingable to work, 50% functioning 11 well but sub-optimally,the majority of whom still can work and only 6% hadsevere disabling symptoms.

A review of the Canadian morbidity and mortality databased on hospital discharges between 1971 and 1989was presented by Rod Rile3a MA from the CanadianCenter of Health Information, Statistics Canada.20 Dis-charge diagnosis are filled out in every Canadian hos-pital. These forms are submitted to the Provincial

Ministries of Health and then forwarded annually to theCanadian Center for Health Information. As patientsmay be admitted several times a year, the statisticspresented by Mr. Riley do not provide incidence forprevalence. They are, however, useful to assess the gen-eral trends and provide accurate mortality statistics.The data indicated that between 1971 and 1989, in Can-ada, similar to the observations in other Western coun-tries, Crohn’s disease was on the rise, while the rate ofdischarge for ulcerative colitis remained unchanged(Figure 2). There was a greater increase in the numbersof hospitalizations of the elderly patients with IBD.Unfortunatel~ it is impossible to tell how many of theolder patients with atherosclerotic vessels suffered fromischemic bowel disease rather than IBD. The mortalityrate was steadily decreasing since 1971 and in 1989,mortality due to ulcerative colitis was 1.5/million andfor Crohn’s disease 2/million (Figure 3). Mortality wasextremely low in the young and somewhat higher in theelderly. Some patients of the later group may have hadmultisystem diseases and may not be suffering fromIBD but from ischemic or other types of bowel disease.

The literature on the morbidity and mor talityTo, f Crohn’sdisease was reviewed by Dr. Goran Hellers. Mortalityrate in early studies was considerably higher than theexpected mortality rate of the general population (Fig-ure 4)21 but was equal to the expected in the study of Dr.Vibeke Binder22 which included patients up to the yearof 1985 (Figure 5). Dr. Heller also reported on standardincidence ratio of cancer in Crohn’s disease. There ap-pears to be an increased excess mortality due to cancerin younger patients but not in the older population.After the age of 30, the ratio falls to 1.5 and this is notsignificantly different from that of the general popula-tion.

Dr. Vibeke Binder reported on the morbidity and mor-tality of ulcerative colitis, in Copenhagen County be-tween 1962 and 1987.3 The median observation timewas 11.7 years (range 1 to 25 years). Dr. Binder foundthat in the first year after diagnosis, there was a slightincrease in mortali~, but once the patient survived thefirst year of illness, the mortality rate became that of thebackground population. To study the incidence of can-cer, she selected only those patients who were followedfor over 7 years. She found that the calculated lifetimecancer risk of the Danish population was 3.7%, whilethat for ulcerative colitis was 3.6%. Thus in the Copen-hagen stud)4 it appears that patients with ulcerativecolitis do not have an increased risk of malignancy. Shealso studied the quality of life of patients with ulcerativecolitis and found that their working capaci~, profes-sional life, private, family and sexual adjustment wassimilar of that of the general population.

289


Group Discussions. With this background information,the Conference broke up into three groups of 10 partici-pants. Each group was requested to review the litera-ture on morbidity and mortality of the area designatedto them. They were also asked to come up with recom-mendations to the CCFC and the profession to educatepatients and physicians on the workings of insurancecompanies. The chairman of each session summarizedthe discussion and reported to the general sessionwhich reconvened immediately after the small groupsfinished their sessions.

Dr. Leddin reported on ulcerative colitis. The groupreviewed the appropriate section of the volume "Medi-cal Selection of Life Risks, A Comprehensive Guide toLife Expectancy for Underwriters and Clinicians" by R.D. C. Brackenridge, 1985.9 They agreed with the classi-fication and the approach used in "Brackenridge" todivide ulcerative colitis into mild, moderate and severe.However, according to their opinion, the data were outof date on mortality. This group like the other two cameup with important suggestions regarding the patient’sand physician’s approach to insurance companies. Therecommendations of this group will be incorporatedbelow with those of the two other groups.

The second group discussed Crohn’s disease beforesurgery. Dr. Sutherland summarized the data. Sincemost patients eventually go to surger~ the group foundthat there is very little known about the morbidity andmortality of those patients with Crohn’s disease who donot end up with an operation. Nor did they find anyspecific predictors as to when patients will have surgery.Dr. Don Daly, a gastroenterologist, who is also a medicalofficer of Prudential of England, brought with him thetext "M & G Underwriting." They reviewed the criteriaused by Prudential of England to assess insurability ofpatients with CD. Apparently, the highest premium waspaid by patients with ileocecal involvement.Astonishingly, patients with jejunitis were rejected irre-spective of the severity of the disease. The group won-dered whether the involvement of the jejunum withCrohn’s disease was confused with the more severecondition "ulcerative jejunitis." Interestingly, the type oftherapy had no effect on rating. This group like the othertwo came up with recommendations to the CCFC andthe Canadian Association of Gastroenterology (CAG).

The third group dealt with Crohn’s disease after sur-gery. This section was chaired by Dr. A.B.R. Thomson.Dr. Goran Hellers was a member of this group provid-ing surgical expertise. Dr. Thomson reported that evi-dence exists that, morbidity and mortality after surgeryin Crohn’s disease has recently improved. This is due to

the modem surgical and post surgical techniques, re-viewed in Table 6, and because of the excellent surgicalresults patients are sent earlier and in a better conditionto surgery. Dr. Heller stated that the operation forCrohn’s disease is not more risky than an operation forany other cause and that there is no additional surgicalmortality related to Crohn’s disease. The reoperationrate is 4% per year.

Accordingly, previous surgery should not be a consid-eration for extra rating for life insurance. However,based on the report by Dr. Farmer and personal experi-ence of the group indicated that previous surgery maybe a factor in disability insurance. This group’s recom-mendations to the CCFC and GAG are incorporatedwith those of the other two groups and is discussedbelow.

Recommendations. All three groups indicated that theCCFC should develop an educational booklet for pa-tients. This pamphlet should explain how insurancecompanies rate applicants. Patients should be encour-aged to reapply after a period of remission. Most impor-tantly, patients should understand that they should tryto stay in the same job to maintain their group insur-ance. Patients should be advised that if they maintaintheir regular follow-up, they may get better insuranceratings. It was felt that the CCFC should develop a formproviding the information that is important to conveyto the insurance companies in order to obtain a morefavorable rating. When a patient applies for insurance,they could take this form to their physician as a guide-line. It was also suggested that the CCFC should iden-tify insurance brokers in different communities whohave an understanding of IBD.

The recommendations to the Canadian Association ofGastroenterology suggested that this organizationshould embark on an educational campaign to physi-cians to enlighten them about insurance companies andtheir method of ratings. Specificall~ it was felt thatclinicians should be more open in their interaction withthe medical officers of insurance companies, and mayeven communicate directly with them. Rather than fill-ing out a form, physicians should be encouraged towrite a letter about their patients and, if applicable, theyshould point out that the patient has lost little time fromwork, has constant careful follow-up, is on maintenancetherapy, has no jejunal disease, is not sufficiently ill torequire TPN or long-term steroid therapy. Since jejunitisis a cause for complete rejection by at least one insuranceunderwriting text, it would be of interest to investigatewhy jejunal disease is considered so deleterious that itexcludes patients from insurance.

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JOURNAL OF INSURANCE MEDICINE VOLUME 26, NO. 2 SUMMER 1994

Conclusion. Patients with IBD have considerable diffi-culty in obtaining straight life and disability insurance.This, in spite of the fact that the quality of life of mostpatients with IBD is not very different from that of thegeneral population and the mortality rate of patientswith IBD is decreasing and presently is not differentfrom that of the general population. However, membersof the Conference learned from representatives of theinsurance industry that the mortality rate of generalpopulation is higher during the first seven years thanthat of insured population. Members of the Conferencelearned that patients with IBD had a better chance toobtain insurance if there is a close cooperation betweenthe treating physician and the medical officer of theinsurance compan)~

REFERENCES

1. Pena SA, Crusius JB, Pool MO, et al. Genetics and epidemiologymay contribute to understanding the pathogenesis of IBD - a newapproach is now indicated. Can J Gastroentero11993;7:71-74.

2. Farmer RG, Easley KA, Rankin GB. Clinical patterns, naturalhistory, and a progression of ulcerative colitis. A long term follow-upof 1116 patients. Dig Dis Sci 1993;38:1137-1146.

3. Binder V. Overview of morbidity and mortality in ulcerativecolitis. Can JGastroenterol (in print).

4. Farmer RG, Whelan G, Fazio V-W. Long term follow-up ofpatients with Crohn’s disease. Relationship between the clinical pat-tern and prognosis. Gastroen terology 1985;88:1818-25.

5. Depew WT, Medeiros J, Beck IT, et al. Clinical presentation andcourse of Crohn’s disease in southeastern Ontario. Can J Gastroenterol1968;2:107-116.

6. Lewin KJ, Riddell RH, Weinstein WM. Gastrointestinal Pathologyand Its Clinical Implications, Vol. II. New York, Tokyo, Igaku-Shoin,199Z841-856, 862-904.

7. Hellers G. Morbidity and mortality of Crohn’s disease. Can JGastroenterol (in print).

8. Beck IT. Laboratory assessment of inflammatory bowel disease.Dig Dis Sci 1987;32:26.8-41.8.

9. Brackenridge RDC. Medical Selection of Life Risks, a Comprehen-sive Guide to Life Expectancy for Underwriters and Clinicians. New York,H.L. Press, 1985.

10. Sleisenger MH, Fordtran J, Seharschmidt BF, et al. Gastrointes-tinal Disease, Pathop_hj/siology, Diagnosis, Management. Philadelphia,London, Toronto, Montreal, Sydney, Tokyo, W.B. Saunders Co.,1993:1281-1284.

11. Riddell RH, Goldman H, Ransohoff DE et al. Dysplasia ininflammatory bowel disease: Standardized classification with provi-sional clinical applications. Hum Path 1983;14:931-968.

12: Peppercorn MA. Advances in drug therapy for inflammatorybowel disease. Annals Int Med 1990;112:50-60.

13. Williams CH. Special issues in nutritional therapy of inflam-matory bowel disease. Can J Gastroen tero11993;7:196199.

14. Rigaud D. Enteral feeding with elemental and non-elementaldiets in Crolm’s disease. Can J Gastroentero11993;7:200-207.

15. Tjandra ~, Fazio VW. Crohn’s disease: The benefits of minimalsurger~ Can J Gastroentero11993;7:254-257.

16. Longo WE, Ballantyne GH, Cahow CE. Treatment of Crohn’scolitis. Segmental or total colectomy? Arch Surg 1988;123:588-590.

17. Sutherland LR. Results of patient’s survey on insurability. CanJ Gastroenterol (in print).

.18. Tremblay G. Process by which life insurance applications areevaluated/rated. Can J Gastroenterol (in print).

19. Farmer RG. Human cost of inflammatory bowel disease. Can JGastroenterol (in print).

20. Riley R. Crohn’s disease and ulcerative colitis - Morbidity andmortality, the Canadian experience. Can J Gastroenterol (in print).

21. Hellers G. Crohn’s disease in Stockholm county 1955-74. Astudy of epidemiology, results of surgical treatment and long-termprognosis. Acta Chit Sband 1979;490(S):184-

22. Binder V, Hendriksen C, Kreiner S. Prognosis in Crohn’sdisease-based on the results from a regional patient group from thecounty of Copenhagen. Gut 1985;26:146-150.

TABLE 1.Complications of Ulcerative Colitis

Gastrointestinal

BleedingToxic Megacolon PerforationStrictureMalignancy

Extra Intestinal

Liver Disease:Biliary Trace.Arthritis :Skin Lesions:Eye Lesions:

Fatty Liver, Hepatitis, CirrhosisSclerosing Cholangitis, CholangiocarcinomaPeripheral, Ankylosing Spondylitis, Sacro-ileitisErythema nodosum, Arteritis, Pyoderma GangrenosumEpiscleritis, Uveitis

291


TABLE 2Complications of Crohn’s Disease

Gastrointestin01

- IntestinalObstruction AbscessFistulas

- Enteric- Mesenterico Perirectal- Vesica]- Cutaneous

Perforation (Rare)Bleeding (Rare)

- MetabolicMalabsorption - (Cholelithiasis, Urolithiasis)AmyloidosisHematologic

Extra Intestinal

- Liver and Biliary Tract Disease - Same as in ulcerative colitis- Joint, Skin and Eye Lesions - Same as in ulcerative colitis

TABLE 3.Crohn’s and Colitis Foundation Of Canada*

Supports Medical ResearchProvides EducationSupports Specific Needs of Patient with IBD

Lay Board -- Medical Advisory Board

MAB CommitteesResearch CommitteeEducation CommitteePatient Advocacy Committee

*Canadian Foundation for Ileitis and Colitis

TABLE 4.Improved Diagnostic Methods

UltrasoundCT ScanColonoscopyImproved Pathologic Interpretations -- Dysplasia

292


TABLE 5.Improved Medical Therapy

Therapy available in the 1970’s Recent useful additions

DrugsSulfasalazineSteroids (Conventional)Imuran - 6MP

5-ASAWith First-Pass KineticsCyclosporineMetronidazole

NutritionLittle InterestBowel Rest

Enteral NutritionTotal Parenteral Nutrition

TABLE 6.Safer and Less Complex Surgery

Avoidance of Blind LoopsAvoidance of Partial Colectomy for Crohn’s Disease StricturoplastyBetter Bowel PreparationInvasive RadiologyBetter Post-Surgical CareBetter AntibioticsNutritional Support

TABLE 7.Organizing Committee of the Conference

Ivan T. Beck, Kingston (Chair)Desmond D. Leddin, HalifaxSuzanne E. Lemire, QuebecEldon A. Shaffer, CalgaryLloyd R. Sutherland, CalgaryAlan B. R. Thomson, EdmontonRaymond J. Van Berkel, Toronto

TABLE 8.Guest Speakers of the Conference

Guy Trembla~ Quebec, Quebec ..Past President/Canadian Life Insurance Medical Officers Association

Richard G. Farmer, Washington, D. C.Medical Advisor, Agency for International Development

Rod Rile~ OttawaCanadian Center for Health Information Statistics Canada

Goran Hellers, Huddinge, SwedenDepartment of Surger~ Karolinska Institute

Vibeke Binder, Copenhagen, DenmarkDepartment of Gastroenterology, Helev Hospital

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FIGURE 1.Straight Life Insurance

Percent acceptance, rating and rejection for straight life insurance of Canadian patients with IBD

Crohn’s Disease:50_

Per 100,00 Population

40.

3130.

20.

10.

0.

36 33% Accepted

% Rated

% Rejected

Ulcerative Colitis:

50_Per 100,00 Population

40_

30_

2o _ 18

10_

0-

4438

% Accepted

% Rated

% Rejected

294


FIGURE 2.Hospital Discharge Rates

Changes in Canadian hospital discharge rates with patients with IBD between 1971 and 1989(reproduced from ref.20)

50-45-40--35--30-25-20-15-10-5 --0

1971

Ulcerative ColitisPer 100,00 Population

I I I I I I I I I I I I I I I I

1973 1975 1977 1979 1981 1983 1985 1987 1989

Males -- -- Females

50--45--40--35--30--25--20--15"-10--5 -0 -

1971

Crohn’s DiseasePer 100,00 Population

I I I I I I I I I I i I I I I I I

1973 1975 1977 1979 1981 1983 1985 1987 1989

Males -- -- Females

295


FIGURE 3.Mortality Rates

Changes in Canadian mortality rates of IBD patients between 1971 and 1989 (reproduced from ref.20)

m

2.5---2 ---15--

0

Crohn’s DiseasePer 100,00 Population

I I I

1971-74 1975-78 1979-82 1983-86 1987-89

Males -- -- Females

32.5

0

mm

m

m

n

Ulcerative ColitisPer 100,00 Population

i I i I1971-74 1975-78 1979-82 1983-86 1987-89

Males -- -- Females

296

JOURNAL OF INSURANCE MEDICINE VOLUME 26, NO. 2 SUMMER 1994

FIGURE 4.Mortality in Crohn’s Disease -- Early Studies

The expected and observed (continuous line) mortality in studies from different time periods (The Mayo Clinic1919-52, Leiden 1937-71, Oxford 1938-70, and Stockholm 1955-74). Early studies on mortality in Crohn’s disease

(reproduced from ref. 7 and 21)

100 100

90 90

80 80

Leiden70 70 1937-71

5 10 15 5 10 15

80 -

70 -

.... ObservedExpected

Stockholm1955-74

5 10 15

100

9O

8O

70Oxford1935-70

5 10 15

297


FIGURE 5.Later Study

Survival, Crohn’s Disease - Males and Females

Survival of patients with Crohn’s disease compared with the age- and sex-matched background population.A later study on mortality in Crohn’s disease (reproduced from ref. 22)

BINDER ET ALGUT 1985

D 1 2 3 4 5 6 7 8 9 10

Years after diagnosis

ulcerative colitis and crohn's disease a conference …...volume 26, no. 2 summer 1994...

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