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Pocket Guide to Inflammatory Bowel Disease
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Details

  • 4 tables
  • Page extent: 152 pages
  • Size: 178 x 108 mm
  • Weight: 0.122 kg

Library of Congress

  • Dewey number: 616.3/44
  • Dewey version: 22
  • LC Classification: RC862.I53 P63 2005
  • LC Subject headings:
    • Inflammatory bowel diseases--Handbooks, manuals, etc
    • Inflammatory Bowel Diseases--Handbooks

Library of Congress Record

Paperback

 (ISBN-13: 9780521672399 | ISBN-10: 0521672392)




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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