Clinical
Practice Guideline
for
ULCERATIVE COLITIS
Developed
for the
Aerospace
Medical Association
by their
constituent organization
American
Society of Aerospace Medicine Specialists
Overview: Ulcerative colitis (UC) is a
chronic disease resulting in recurrent inflammation of the colon, often with an
unpredictable course. Symptoms vary from
abdominal tenderness and occasional semi-formed stools to severe abdominal
pain, liquid diarrhea with blood or pus, anemia, fever, and weight loss. If only the rectum is involved (ulcerative
proctitis), constipation and tenesmus may occur. Some patients will later develop definitive
signs of Crohn's disease and will need to be reclassified. As many as 3% of patients
may experience iritis. The course
of the disease tends to follow the anatomic location at initial diagnosis. Patients with proctitis or proctosigmoiditis
tend to have a benign course, while those with pancolitis usually have more
severe symptoms and frequent complications.
Those with left-sided colitis often have an intermediate course. Factors that are associated with progression
to more severe disease are onset at a young age, presence of joint symptoms,
and significant bleeding and toxicity when first diagnosed.
Aeromedical Concerns: The natural history of UC is highly
variable. There may be long periods of
remission. The majority of patients
suffer a relapse within one year of onset, however 20%
do not have a relapse for over ten years after the initial attack. Approximately 85% of patients with UC have
mild disease and do not require hospitalization. The other 15% with fulminant disease are at
risk of developing toxic dilation and perforation of the colon. Approximately 20-25% of patents require
colectomy in 10 years. For those who
have a colectomy with permanent ileostomy, the need for an ileostomy bag may be
incompatible for certain types of military flying, particularly in aircraft
that require the wear of extensive life support equipment or in high G
aircraft.
Epidemiological
studies have shown the relative risk (RR) for colorectal carcinoma to be not
significantly higher than the general population for patients with ulcerative
proctitis (RR 1.7; 95% confidence interval [CI], 0.8-3.2). Patients with disease distal to the splenic
flexure had a RR of 2.8 (95% CI, 1.6-4.4).
Those with pancolitis had a RR of 14.8 (95% CI, 11.4-18.9).
Treatment and Aeromedical
Disposition: The
individual should have a recent evaluation by internal medicine or
gastroenterology to determine the extent of disease. This evaluation should include sigmoidoscopy
or colonoscopy. For medical treatment,
corticosteroids or sulfasalizine are often preferred. Mesalamine, the unbound 5-aminosalicylate is
associated with lower incidences of side effects and is becoming more
popular. Corticosteroids can have some
profound side effects, so these aviators need to be evaluated closely before
returning to flying duties. Some studies
have shown that as many as 50% of patients with ulcerative colitis who are
treated medically will have continuous or intermittent symptoms.
The newer
drugs Embrel or Remicade
have been acceptable for use in civil airmen.
The FAA requires that the airman with this condition provide a status
report that explains the usual symptoms
the airman develops during an exacerbation, the extent of disease, whether
there have been any other organ involvement and the treatment. Obviously, the airman should not be granted
medical certification if they are experiencing an acute exacerbation and if
they are taking more than twenty milligram equivalent of prednisone.
Experience: Waiver is possible for mild cases
in remission at least one month. Medical
regimens that may be waiverable include oral and topical aminosalicylates and
topical steroids. The most frequently
cited side effects of sulfasalizine therapy include nausea, headache, and
dyspepsia. These effects are secondary
to the sulfa moiety and can be minimized with gradual titration of dose and use
of an enteric-coated preparation.
Allergic or toxic effects of the sulfapyridine moiety include
generalized hypersensitivity reactions, hemolytic anemia, bone marrow
suppression, hepatitis, and reversible oligospermia.
As of
November 2005 the FAA has currently issued 902 first-, 790 second-, and 1,857
third-class airmen with ulcerative colitis.
References:
Glickman
RM. Inflammatory bowel disease: Ulcerative colitis and Crohn’s disease. In:
Fauci AS, Braunwald E, Isselbacher KJ, et al. eds. Harrison’s Principles of
Internal Medicine, 14th edition.
Hanauer SB, Baert
F. Medical therapy of inflammatory bowel disease. Med Clin
N Am 1994; 78(6): 1413-26.
Katz J. The course of inflammatory bowel disease. Med Clin N Am 1994; 78(6): 1275-80.
Rayman,
Russell B, Clinical Aviation Medicine, 2nd edition,
Philadelphia, Lea & Febiger, 1990, p. 23.
December
14, 2005