I've been remiss in posting. I know. I'm sure all 5 of my readers are seriously bummed by this. I've been on the lower GI service this month. Which is pretty much colorectal surgery . . . but for us at my hospital we are the IBD (irritable bowel disease) specialists. The vast, vast majority of our service is made up of patients with ulcerative colitis or chron's disease. For those of you that didn't go to med school these are disease that affect the bowel causing cyclic waves of diarrhea and constipation. They can be painful, uncomfortable and life altering. But, they don't kill you. Well, they might be a contributing factor to your death. But your life expectancy isn't much altered as long as you have close medical/surgical care.
A little back story on chron's vs ulcerative colitis. Ulcerative colitis is by far the more benign of these two disease processes. As the name implies UC is limited just to the colon. Which means that by removing the colon you can cure the patient. Of course this means the potential of a life long ostomy and serious changes in your diet and bowel habits. Not to mention possible post-operative complications that could require more hospitalizations. But, yes the course is much better than Chron's.
I'm not really sure the exact reason why they call it Chron's. It's probably named after some old doc somewhere who first described it. That's how most things get there name, but I think that Chron's is an apt name for this disease. Because it turns young people into bitter old people long before they should be. The thing with Chron's is it's not limited to the colon it can actually affect the entire intestine and even extra-digestive organs. It goes through the full thickness of the bowel wall so you're more likely to get fistulas. It's also a granulumatous disease. But the kicker is that every time you go into someone with Chron's all you can do is a stop-gap repair. Because this person's bowel is not normal and every manipulation causes a secondary problem. But, it's not like we can just leave it alone because all those fistulas and abscesses and granulomas have to be dealt with.
So, now all of you out there are thinking that you'd rather have ulcerative colitis, and maybe you are right. I think I would. But I don't want you thinking that UC is an easy disease. Post-op complications like fistulas and abscesses can occur any time you manipulate the bowel. And these can become more of a problem then the original colitis. And either way, whichever process you are battling you are no longer able to poop normally. And with that comes a certain amount of psychosis. I'm not kidding about or exaggerating this fact. Not being able to poo regularly or at convenient times or just into a toilet makes you crazy. I want you to pause and think about having to be in a place that allows you to go to the bathroom 10-15 times a day. Or living with near constant nausea, even vomiting secondary to the need to poo or constipation. Or having your fecal matter hanging in a bag off your abdomen. Now that you've thought about that I think you can imagine why you wouldn't be quite right in the head.
These patients have astronomic levels of anxiety, they are often paranoid, co-dependent, ritualistic. Not to mention the fact that most of them are bitter and often times mistrusting of those in white coats. But, I think the saddest thing is that most of these symptoms onset while people are still in middle and high school which means that their child hood is destroyed. It's really hard to make friends when you're in and out of the hospital. Or if you're the kid that's always running to the bathroom. And what if one day you can't control your bowels and you have an accident? Try living that one down.
So, when doctors talk about the "sick role," we are talking about patients exactly like this. They've gotten used so used to being sick that they just can't figure out how not be. For them being in the hospital is actually a comfort. They know that they are going to be taken care of, that there symptoms are understood, that they can get medications that instantaneously makes them feel better. IV drugs will do that. And so we see people malingering and we have patients freaking out about not getting there dilaudid exactly ever 2 hours. These patients have such a large psychiatric component to their illness that often times you are treating that more than there actual bowel complaints.
It's hard as a surgeon to wrap your head around that sometimes. We can't cut out psychosis. We can't take a biopsy of crazy and send it to pathology to have it staged. Psych meds aren't something we are used to prescribing either. Most of us read the sex chapter in our psych books for laughs and giggles and then ignored the rest. I was always a little more interested in it and even toyed with the idea of going in to psych. For a fleeting moment only. Because the inability to fix people would have driven me crazier than my patients.
One of my favorite ladies on the service a woman with long-standing chron's who is on IV fluids at home because her ostomy puts out so much that she can't keep herself hydrated. She also does a little cocaine in her spare time. Which means that when she comes to the ED, which happens monthly, it's always a special treat. She's also always sick. Her electrolytes are usually out of wack. Her kidney numbers are usually sky high and she'll get admitted. Then, when she is in the hospital she does the crazies. Pouring food/liquids into her ostomy bag. Hoarding food off her trays and piling it up in the shower, which she doesn't use. Visiting with other patients and recommending medical therapies that have worked on her before. She exhibits ritualistic behaviour in her room when she doesn't realise she's being watched.
And she's really just the beginning. You have the woman who swears carrots came out of her vagina the day after we took down her rectovaginal fistula. The 19 year old girl with a gastric tube, a nasal tube, an ostomy who somehow managed to retain 2.3 liters of urine in her bladder, all with her belly ring in place. A lady who was taking enough pain medications to tranq an elephant and wouldn't drink water because the fish poop in it. And our fine gentleman who had his own name tatooed around his ostomy site. The woman who came to the OR with a note taped to her belly saying "make it quick, Obama needs my vote in 2012." Yup, they are all crazy. They are all so used to being sick they can't function without it. But, honestly, they are my favorite patients so far.
Also, a little treat for you . . . the poo song from scrubs. http://www.youtube.com/watch?v=pnIk0npINiE . . . this isn't strictly true in all other aspects of medicine but on GI medicine we spend a lot of time worrying about poop so I've been humming this a lot lately.
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