INFLAMMATORY BOWEL DISEASES: CHARACTERISTICS, EVOLUTION, AND QUALITY OF LIFE

ABSTRACT - BACKGROUND: Inflammatory bowel diseases present progressive and potentially debilitating characteristics with an impact on health-related quality of life (QoL) throughout the course of the disease, and this parameter may even be used as a method of evaluating response to treatment. AIM: The aim of this study was to analyze epidemiological data, medications in use, previous surgeries, and hospitalizations in patients with inflammatory bowel diseases, and to determine the impairment in QoL of these patients. METHODS: This is a prospective, cross-sectional, observational study in patients with inflammatory bowel disease followed up in a tertiary hospital in São Paulo-SP, Brazil. General and disease-related, evolution, and quality-of-life data were analyzed using a validated quality-of-life questionnaire, namely, Inflammatory Bowel Disease Questionnaire (IBDQ). RESULTS: Fifty-six individuals were evaluated, with an equal number of patients with Crohn’s disease and ulcerative colitis. A higher prevalence of previous surgeries (p=0.001) and hospitalizations (p=0.003) for clinical-surgical complications was observed in patients with Crohn’s disease. In addition, the impairment of QoL also occurred more significantly in these patients (p=0.022), and there was a greater impact on females in both forms of inflammatory bowel disease (p=0.005). CONCLUSIONS: Patients with Crohn’s disease are more commonly submitted to surgeries and hospitalizations. Patients affected by both forms of inflammatory bowel disease present impairments in QoL, which are mainly related to intestinal symptoms, and females are more affected than men.


A QUEDA DA PRESSÃO PORTAL APÓS DESVASCULARIZAÇÃO ESOFAGOGÁSTRICA E ESPLENECTOMIA INFLUENCIA A VARIAÇÃO DO CALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO NA ESQUISTOSSOMOSE NO SEGUIMENTO EM LONGO PRAZO?
Does the drop in portal pressure after esophagogastric devascularization and splenectomy variation of variceal calibers and the rebleeding rates in schistosomiasis in late follow-up?
Walter de Biase SILVA-NETO 1 , Claudemiro QUIRESE 1 , Eduardo Guimarães Horneaux de MOURA 2 , Fabricio Ferreira COELHO 3 , Paulo HERMAN 3 ABSTRACT -Background: The treatment of choice for patients with schistosomiasis with previous episode of varices is bleeding esophagogastric devascularization and splenectomy (EGDS) in association with postoperative endoscopic therapy.However, studies have shown varices recurrence especially after long-term follow-up.Aim: To assess the impact on behavior of esophageal varices and bleeding recurrence after post-operative endoscopic treatment of patients submitted to EGDS.Methods: Thirty-six patients submitted to EGDS portal pressure drop, more or less than 30%, and compared with the behavior of esophageal varices and the rate of bleeding recurrence.Results late post-operative varices caliber when compared the pre-operative data was observed despite an increase in diameter during follow-up that was controlled by endoscopic therapy.

Conclusion
variceal calibers when comparing pre-operative and early or late post-operative diameters.
The comparison between the portal pressure drop and the rebleeding rates was also not

Perspectives
This study emphasizes the necessary appreciation of the quality of life in patients with inflammatory bowel disease, looking for a better assistance to these chronic patients.

Central message
Patients with Crohn's disease are more commonly submitted to surgeries and hospitalizations with a greater impairment of quality of life -notably in females -among patients with inflammatory bowel disease.The score of the answers was presented through multiple choice with seven alternatives (Likert scale), with each question ranging from 1 (representing a "worst" aspect) to 7 (representing a "best" aspect), so that the total IBDQ score is between 32 and 224; the lower the score, the greater the impact on QoL 3,21,26 .
The author provided the informed consent form and then the questionnaire to the participant.If the participant had any doubts, the interviewer repeated the wording of each question to reinforce the understanding of the interviewee.The study was evaluated and approved by the Faculty of Medicine Santa Marcelina's Research Orientation Committee (COPE-FASM: opinion number P010/2019), by Plataforma Brasil, and the consubstantiated opinion of the ROC (number: 3.574.576).
Statistical analyses were performed using the IBM SPSS Statistics version 20 software for Windows, and Pearson's correlation analysis was used with a power of 95% and alpha probability fixed at 5%.The scatter diagram was used to verify the relationship between various aspects and total score.
The differences between the total IBDQ of comparative groups of CD and UC were combined using the Student's t-test.The verification of homogeneity or heterogeneity of variances was carried out by one-tailed F test.For the stratification of data related to sex, the dummy binary variable was created.The dispersion diagram with the curve plot for a trend line and ANOVA was used to indicate which of the symptoms best fit the IBDQ score (Crohn's alpha coefficient for intestinal, systemic, emotional, social, and total with 95%), and for all analyses, a value of p=0.05 was considered.

RESULTS
Fifty-six patients with IBD were evaluated, with equal number of patients with CD and UC, and the demographic characteristics are summarized in Table 1.
Figure 1 shows the prevalence of IBD and of the CD and UC forms in relation to the time of disease, where it can be seen that in most of the study patients the prevalence of disease was found between 1 and 10 years.

INTRODUCTION
Inflammatory bowel disease (IBD) refers to a group of diseases [Crohn's disease (CD) and ulcerative colitis (UC)] that are autoimmune, chronic, and of unknown etiology 25,27 .Moreover, it presents progressive and potentially debilitating characteristics 24 .
The study of health-related quality of life (HRQoL) in these patients is relevant, as it can lead to changes in the social, psychological, and social-professional spheres and, during the course of the disease, several factors that interact and combine can cause different impacts on the degree of life satisfaction of these individuals and can even be used as a method to evaluate the treatment 2,18 .
Symptoms such as profuse chronic diarrhea, abdominal pain, and hyporexia affect HRQoL. 3Therapeutic measures, whether conservative (adverse drug effects) or surgical (resections, definitive ostomies) , result in frequent adverse effects in the long term 14,24 , affecting the life of patient mentally, emotionally, physiologically, socially, and physically 4 .
The objective was to cross-sectionally analyze epidemiological data, medications in use, previous surgeries, and hospitalizations in patients with IBDs at the Coloproctology Unit of the Department of General Surgery of Santa Marcelina Hospital and determine the impairment of QoL of these patients and the aspects involved in this impairment.

METHODS
This is a prospective, cross-sectional, observational study involving patients with IBD (CD and UC) followed at the Coloproctology Unit of the Department of General Surgery of Santa Marcelina Hospital, from March 2019 to February 2020.
Patients over 18 years of age, with physical and mental capacity to participate in the study and agree with the term of consent and participation in the work, were included.Pregnant women and patients with an indication for emergency hospitalization were excluded.
The following items were analyzed:     3 stratifies the surgeries according to the length of disease, where it is possible to verify that most surgical procedures occurred in both diseases between 5 and 10 years of diagnosis, notably in patients with CD (p=0.003).
Table 4 presents the results of analysis of the IBDQ domains in IBD, CD, and UC using Student's t-test, where one can observe     5 stratifies the values of IBDQ questionnaire in IBD, CD, and UC and correlates them with gender using Student's t-test, where we observed a higher score in males.Table 6 stratifies the domains in CD and UC and shows comparison between genders.
The scatter diagram (Figure 2) was used to verify the relationship between the various aspects and the total score where a higher R² value corresponds to a more accurate adjustment.It can be seen that for the population with IBD, the characteristic that best explained the total IBDQ score was that of intestinal symptoms and the one that explained the least was that of social aspects.

DISCUSSION
This was a prospective study assessed in a sample of patients with IBD who were followed up in a specialized tertiary hospital in São Paulo, Brazil.We analyzed a number of patients consistent with some studies in the literature on the subject and also the distribution of the two forms of the disease 16,17 .
Regarding demographic data, we observed an overall mean age similar to the literature 1,16,19,20 ; likewise, the mean duration of disease in this study was similar to the studies surveyed 13,15,17 for a period of more than 5 years.
According to the literature 17,18,20 , we observed a higher percentage of surgeries among patients with CD (p=0.001);however, with more frequent abdominal surgeries reported in different studies, orificial procedures were notably observed 22,28 .Moreover, hospitalizations related to morbidity were also numerous in these patients (p=0.003), which was consistent with the literature 5,7,10,17,18,20 .
Regarding drug therapy, it was noted that among patients with UC, mainly aminosalicylates were used, while biological drugs were mainly used in treating patients with Crohn's disease, matching the literature surveys 5,9,11,16 .
Table 7 compares previous studies with this study and we can observe an acceptable number of patients for the analysis of the impact of IBD on QoL.In addition, it can be seen that the gut and systemic symptom scores of this study are close to those reported by Han et al. 13 and Pallis et al. 17 Although the scores for the social and emotional aspects differ from those found in these publications, it is noticeable that the total IBDQ score of this study falls between the ranges 13,17 .Van der Eijk et al. 23 showed that psychological stress, including anxiety, depression, and stressful life events, has a negative impact on the QoL of patients with IBD.
In this study, female patients with IBD, CD, and UC had lower IBDQ scores when compared to males (p=0.0005,0.004, and 0.05, respectively), inferring that they have a greater impairment in QoL, which is consistent with the study by Magalhães et al. 16 who showed that women with CD presented significantly lower IBDQ score than men (p=0.023).However, the results of same study differ from ours in patients with UC, as we also observed a greater impact on QoL in females (p=0.05),whereas in the cited work, we did not observe a significant impact on QoL (p=0.061).
It was also observed in the present study that the total IBDQ score is more affected in patients with Crohn's disease (p=0.022), which is consistent with the literature 6,12 ; however, it differs from the studies of some authors which do not show statistical difference 8,16,20 .
As a limitation of the study, one can think of the relatively small number of patients; however, a prospective collection performed by a single researcher in a university health center is another limitation.Moreover, this study emphasizes the necessary appreciation of the QoL in patients with IBD, looking for a better assistance to these patients with chronic disease.

Figure 1 .
Figure 1.Prevalence of IBD and CD and UC forms in relation to the time of disease.

Figure 1 -
Figure 1 -Prevalence of IBD and CD and UC forms in relation to the time of disease.

Figure 2 -
Figure 2 -Scatter diagram showing the relationship between various aspects and total score.

Table 1 -
General data on the prevalence of IBD, CD, and UC regarding marital status, education, gender, color, smoking, comorbidities, duration of disease, BMI, and age of the patients.

Table 2 -
Prevalence data of CD and UC regarding previous surgeries and hospitalization for clinical-surgical complication.

Table
INFLAMMATORY BOWEL DISEASES: CHARACTERISTICS, EVOLUTION, AND QUALITY OF LIFE ABCD Arq Bras Cir Dig 2022;35:e1653

Table 3 -
Prevalence of previous surgeries in relation to the length of disease.

Table 4 -
Domains of the global IBDQ in IBD, CD, and UC

Table 5 -
IBDQ index score in IBD, CD, and UC comparing genders

Table 6 -
Stratification of IBDQ domains in CD and UC and comparison between genders.

Table 7 -
Comparison between IBDQ scores among studies