Inflammatory Bowel Disease
Problem -- Crohn's Disease
The main difficulty divers would have is with a blockage or perforation and fistulas with air-trapping; this could lead to subsequent rupture due to the changes that take place in association with Boyle's law. Diving would be unwise during the active phase of the condition due to chronic diarrhea, abdominal pain, fever, anorexia and weight loss. Obstruction, fistulas and abscess formation are common complications of inflammation; intestinal bleeding, perforation, and small bowel cancer develop rarely.
No specific therapy is known. Anticholinergics and diphenoxylate 2.5 to 5 mg, loperamide 2 to 4 mg, deodorized opium tincture 0.5 to 0.75 mL (10 to 15 drops), or codeine 15 to 30 mg, given orally (ideally before meals) up to qid, may relieve cramps and diarrhea. These drugs can alter levels of consciousness and decrease decision making ability and are therefore adverse to diving.
to 1.5 gm/day has been shown to be beneficial in CD, especially in
colitis and has proved particularly useful for treating perianal
Neuropathy manifested chiefly by paresthesias is a common, potentially
serious side effect of long-term use and can cause confusion with the
neuropathic effects of a decompression accident.
is useful in the acute stages of CD. Aseptic hip necrosis
occur with long-term steroid administration and could be confused with
dysbaric osteonecrosis associated with diving.
are useful but the deadly combination of diminished immune
response and alien marine
must be taken into account with any decisions concerning diving with
patients on these drugs.
Crohn's patients are more prone to be taking
multiple drugs and
medicines, some of which have effects that are adverse to diving. These
should be listed and evaluated prior to allowing diving. See web page
Dive or not dive
Diving should be considered if the person is in good
physical condition, has quiescent disease, no
evidence of air-trapping and is off medications that are adverse to
Some consideration should be given to "need to dive" over riders; such as previously certified divers returning to diving, divemasters and instructors. Persons wanting to become certified should probably be discouraged from diving due to the long term course of Crohn's Disease.
The presence of an ileal pouch or continent ileostomy would prevent diving.
disease usually begins in the rectosigmoid area and may extend
eventually to involve the entire colon, or it may include most of
the large bowel at once. Crypt abscesses,
epithelial necrosis, and mucosal ulceration ultimately develop.
Systemic symptoms are mild or absent. If the process extends proximally,stools become looser and the patient may have 10 to 20 bowel movements/day, often with severe cramps and distressing urge to defecate, without respite at night. The stools may be watery and contain pus, blood, and mucus; they frequently consist almost entirely of blood and pus. Malaise, fever, anemia, anorexia, weight loss, leukocytosis, hypoalbuminemia, and elevated sedimentation rate may be present with extensive activecolitis. It should be apparent that diving would be contraindicated in the midst of an acute flare-up of this condition. In particular, it would not be good to be in a remote destination with this occurrence.
Hemorrhage is the most common local complication. In toxic colitis, a particularly severe local complication, transmural extension of the ulcerative process results in localized ileus and peritonitis. As the toxic colitis progresses, the colon loses muscular tone and within a matter of days or even hours begins to dilate. This is called toxic megacolon.
Risk of colon cancer is increased in patients with long-standing, extensive ulcerative colitis; such patients merit surveillance for early warning signs. Extracolonic complications include peripheral arthritis, ankylosing spondylitis, sacroiliitis, anterior uveitis, erythema nodosum, pyoderma gangrenosum, episcleritis, and, in children, severely retarded growth and development.
Anticholinergics or low doses of diphenoxylate, deodorized opium tincture, loperamide or codeine may be required for more intense diarrhea. All these antidiarrheal agents must be used with extreme caution in more severe cases, lest toxic dilation be precipitated. The effects of these drugs on the alertness of the diver would certainly be a consideration in disallowing diving in these individuals.
Azathioprine, 6-mercaptopurine, and cyclosporine have been used in the treatment of ulcerative colitis, but their long-term risk/benefit ratios have not been clearly established. Decreased immune response is hazardous to the diver in the alien marine bacterial environment.
colitis is a grave emergency. If intensive medical measures
do not produce definite improvement within 24 to 48 h, immediate
surgery is required or the patient may die from perforation and
Emergency colectomy is indicated for massive hemorrhage,
toxic colitis, or perforation. Subtotal colectomy with ileostomy and
mucous fistula is usually the procedure of choice, since total
with abdominoperineal resection is more than most critically
ill patients can tolerate. There is no contraindication to
in these situations after appropriate postoperative healing (3 months).
An ileostomy and a mucous fistula do not abrogate Boyle's Law and are
a risk for perforation.
Removal of the entire colon and rectum permanently cures chronic ulcerative colitis. Permanent ileostomy has been the traditional price of this cure, although various alternatives (eg, the continent ileostomy or especially endorectal "pull-through" procedures) are usually chosen. The cosmetic details of the surgery are less critical than the curative nature of colectomy in a disease as serious as ulcerative colitis. The continent ileostomy or ileal pouch are contraindications to diving due to the inability of gas in these structures to escape the effects of pressure changes. There is considerable risk of rupture of the pouch during ascent due to gas expansion. Clever divers have placed in-dwelling catheters in the pouch for equalization of the gas.
Ernest Campbell, MD, FACS All Rights Reserved.