Inflammatory bowel disease is a general term encompassing three common disorders. Gareth Hurst explains the conditions and the underwriting implications
Inflammatory bowel diseases are disorders of the gastrointestinal (GI) tract. The GI tract covers all aspects of digestion, beginning at the mouth, encompassing the oesophagus, stomach, small intestine, large intestine, and ending at the anus. It is approximately 30ft in length from start to finish and a lot can go awry in the process of digestion. This article will focus on disorders of the small intestine and especially the large intestine (also known as the colon, or bowel).
Internationally, inflammatory bowel diseases are assumed to be more prevalent in developed countries, with people living in urban areas more likely to be affected than those in rural areas. Likewise, the cooler the climate, the higher the incidence rate. When assessing inflammatory bowel diseases as a group, the male-to-female ratio is generally equal. Those of Jewish descent are most likely to be afflicted, followed by non-Jewish Caucasian populations.
The most common inflammatory bowel disease is irritable bowel syndrome (IBS). Also the mildest of the disorders, IBS can still be a miserable illness to suffer, and is often associated with other conditions such as depression, anxiety and stress. IBS is more common in women than in men and affects 20% of the western population.
Symptoms experienced by IBS sufferers can include diarrhoea, constipation and stomach cramping. There is no bowel inflammation and no blood in the stools. Unfortunately for sufferers, the condition tends to be mild but chronic and relapsing. Most people diagnosed with IBS lead normal lives and are often advised to modify their diets. Medications are sometimes prescribed and can include anti-depressants. Recent studies have also shown that hypnotherapy can offer favourable results in alleviating symptoms.
Crohn's disease
Crohn's disease is one of the main illnesses known as inflammatory bowel disease; the other is ulcerative colitis. The symptoms of these two diseases are very similar - so similar, in fact, that it is estimated that approximately 10% of colitis cases (inflammation of the colon) cannot be entirely diagnosed as either Crohn's or ulcerative colitis.
Specifically, Crohn's disease can cause problems in any part of the GI tract, but most commonly affects the small intestine and the colon. The condition affects about one in 1,500 people and is most commonly diagnosed between the ages of 15 and 40. One in 10 of those diagnosed with the condition also have a close relative with a type of inflammatory bowel disease.
The cause of Crohn's disease is unknown, although it is considered that genetics, the immune system and environmental factors are important factors. It is thought that symptoms occur when the immune system reacts inappropriately, mistaking microbes - such as bacteria normally found in the intestines - as foreign or invading substances. The immune system defences are then triggered, sending disease-fighting white blood cells to the lining of the intestine, where they produce inflammation and generate harmful products that ultimately lead to ulcerations or injury to the bowel.
Symptoms themselves can be very unpleasant for sufferers, including persistent diarrhoea, abdominal cramping and rectal bleeding. Weight loss can occur, sometimes as a result of malabsorption, as can manifestations elsewhere in the body, such as the eyes, joints, skin and also the liver.
Aside from the symptoms previously described, complications can occur, making it an even more unpleasant condition to suffer. Notably, the inflammation of the intestine wall can result in the development of a fistula. Fistulae are 'tunnels' or 'tubes' that give rise to otherwise abnormal contact between internal organs, for example, the intestine to the bladder, the vagina, or the sufferer's skin.
Another complication is known as stricture. This is where the intestine becomes blocked. These blockages, typically caused by scar tissue, which is less flexible than the normal lining of the intestine, vary in severity. In the most severe cases, they can completely obstruct the passage through the intestine, and as the organ continues to contract to attempt to move the food along, the increased pressure can result in the perforation of the bowel wall. This event continues to worsen by causing severe infection in the abdominal cavity, causing abscesses and fistulas.
Treatment
Treatment of Crohn's disease varies, and despite the use of medication and even surgery, there is no absolute cure for the condition. Medical treatment is used to suppress the inflammatory response caused by the immune system, as well as fight infections caused by excess bacteria where fistulas or strictures have occurred. The use of steroids and immunosuppressive drugs are common and are employed to induce and then maintain periods of remission.
Surgical options are usually only considered when medical treatment has been attempted but has failed to adequately control the illness, or when complications that require intervention have occurred.
Surgical treatment includes options such as an ileostomy. This is where the entire colon is removed and an artificial opening, known as a stoma, is made in the abdomen. The ileum (the final section of the small intestine) is then connected to this opening and it acts as the exit for waste from the body.
In less severe cases, a procedure known as anastomosis can be performed. Used when only part of the colon is diseased and the rectum is also disease free, diseased sections of the colon are removed and the healthy ends are reattached to each other.
The symptoms and causes associated with ulcerative colitis are very similar to those of Crohn's disease. However, it only affects the colon, causing inflammation and sores, called ulcers, in the lining. Another differentiating characteristic is that this condition always commences in the rectum, and from here can spread throughout the colon, creating one large stretch of inflammation.
Ulcerative colitis rarely affects the small intestine, except for the end section, known as the terminal ileum. The classification of the disease depends on the extent of its activity throughout the bowel. These definitions look at the large intestine in reverse order, going back toward the small intestine, and are defined as follows:
Proctitis - where only the rectum itself is affected.
Proctosigmoiditis - where the rectum and the sigmoid colon is diseased.
Left-sided disease - extension in the whole of the descending colon.
Pancolitis - where the inflammation extends through all the above and also the transverse colon, or beyond further to the ascending colon.
Most often diagnosed between the ages of 15 and 35, and 55 and 75, ulcerative colitis affects around one in 1,000 people, making it more common than Crohn's disease.
While the complications relating to ulcerative colitis are common with those of Crohn's, severe attacks of colitis can be life threatening. A complication more common in ulcerative colitis, although still rare, is toxic megacolon. This is when gases collect in the colon and cause it to inflate, leading to the risk of perforation and septicaemia.
With ulcerative colitis, there is also an associated risk of bowel cancer, a complication that affects approximately 5% of sufferers. Risk increases with the length of time the condition has been present and how extensive the disease is. If the entire colon is involved, the risk of developing cancer may be as much as 32 times the normal rate. In contrast, however, if only the lower colon and rectum is involved, the risk is no higher than normal.
Treatment is similar to Crohn's disease, with surgery being introduced when medical treatment fails. About 25% to 40% of sufferers will require surgery due to complications of the disease.
Gareth Hurst is life and disability underwriter at Scottish Equitable Protect.
Underwriting implications
When assessing proposals where an applicant discloses an inflammatory bowel disorder, it is important to know what condition has been diagnosed, the extent (where applicable), and the current status of the disease (whether it is classed as active or is in remission).
When underwriting IBS, the underwriter will invariably accept this as standard rates for life and critical illness benefits from the application. With income protection, however, acceptance will depend on the amount of time taken off and if there are any associated conditions such as depression. If any exist, an exclusion of the condition may be given.
Insurance ratings for Crohn's disease depend on the aforementioned factors as well as the age of the proposer and the date of the last attack. Ratings can vary from 50% to 150% extra mortality, or could even be declined. If surgery has been involved, an underwriter may delay the case for six months following the operation and then apply a rating dependent on current symptoms.
Disability cover can be offered where the underlying condition is not classed as moderate or severe. As a guide, where the risks attract a loading of more than 150% for life cover, disability cover cannot be considered. But individual consideration may be given to disability benefits excluding the relevant condition.
Ratings for ulcerative colitis depend on where the disease is situated within the bowel area. They can vary depending on how long ago the last symptoms occurred. Surgery and disability benefits follow much the same pattern as Crohn's disease.
