J. Coloproctol. (Rio J.) vol.37 número4

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

Quality

of

life

of

patients

with

inflammatory

bowel

disease

Thais

Karla

Vivan

,

Bianca

Mariz

Santos

,

Carlos

Henrique

Marques

dos

Santos

a_{HospitalRegionaldoMatoGrossodoSul,CampoGrande,MS,Brazil}

b_{ColégioBrasileirodeColoproctologia,CampoGrande,MS,Brazil}

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Articlehistory:

Received13February2017 Accepted19June2017

Availableonline9September2017

Keywords:

Inflammatoryboweldiseases Crohn’sdisease

Ulcerativecolitis Colitis

Qualityoflife

a

b

s

t

r

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c

t

Rationale:Crohn’sdiseaseandnon-specificulcerativecolitisarepartofinflammatorybowel diseases.Theyhaveachronicevolution,leadingtoimportantrepercussionsonpatients’ qualityoflife.Measuringthissubjectiveparameterrequiresanevaluationtoolinclinical trialsandhealthprograms.The“InflammatoryBowelDiseaseQuestionnaire”isanAmerican instrumentofMcMasterUniversity,whichhaditsreproducibilityandvaliditydetermined instudiesinothercountriesasameasureofthequalityoflifeinIBD.

Objective:Toevaluatethequalityoflifeofpatientswithinflammatoryboweldiseasethrough theInflammatoryBowelDiseaseQuestionnaire,andtocorrelatetheresultswith sociode-mographicdataofthepatients.

Methods:This is a prospective cross-sectional study carried out with 58 patients; the patients’follow-upwasconductedattheoutpatientclinicofColoproctology.

Results:Amongthe58patientsevaluated,70.1%hadDC,62.1%werewomen,themeanage was46.08years,96.6%werenon-smokers,and24.1%weresubmittedtosurgeryforthe underlyingdisease.43%wereinacombinationtherapyscheme,44%inmonotherapy,and 12%werenotusingmedication.Significantchangeinqualityoflifewasobservedinpatients takingprednisone.

Conclusion: Thepatientswithbetterqualityoflifearethosewhoweretakingprednisone. Therewasnoothercorrelationwithsignificanceinthepatients’qualityoflife.

©2017SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Qualidade

de

vida

dos

pacientes

com

doenc¸a

inflamatória

intestinal

Palavras-chave:

Doenc¸ainflamatóriaintestinal Doenc¸adeCrohn

Coliteulcerativa

r

e

s

u

m

o

Racional: Fazpartedasdoenc¸asinflamatóriasintestinaisadoenc¸adeCrohneaRetocolite UlcerativaInespecíficaPossuemevoluc¸ãocrônica,gerandorepercussões importantesna qualidadedevidadosdoentes.Mediresseparâmetrosubjetivorequeruminstrumentode avaliac¸ãoemensaiosclínicosedeprogramasdesaúde.O“InflammatoryBowelDisease

∗ _{Correspondingauthor.}

E-mail:thais.vivan@hotmail.com(T.K.Vivan). http://dx.doi.org/10.1016/j.jcol.2017.06.009

Colite

Qualidadedevida

Questionnaire”éuminstrumentonorte-americanodaMcMasterUniversity,quetevesua reprodutibilidadeevalidadedeterminadaemestudosemoutrospaíses,comomedidada qualidadedevidaemdoenc¸asinflamatóriasintestinais.

Objetivo: Avaliaraqualidadede vidadospacientescomdoenc¸ainflamatória intestinal atravésdoquestionário“InflammatoryBowelDiseaseQuestionnaire”,ecorrelacionaros resultadoscomdadossociodemográficosdospacientes.

Método: Estudoprospectivotransversal,realizadocom58pacientes,acompanhamentono ambulatóriodeColoproctologia.

Resultados: Dentreos58pacientesavaliados,70,1%possuíamDC,62,1%mulheres,idade médiade46,08anos,96,6%nãotabagistas,24,1%submetidosàcirurgiapeladoenc¸adebase. Estavamemusodeterapiacombinada43%,monoterapia44%esemusodemedicamento 12%.Foiobservadaalterac¸ãosignificativadaqualidadedevidanospacientesemusode prednisona.

Conclusão: Ospacientescommelhorqualidadedevida sãoosqueestavamemusode prednisona.Nãohouveoutracorrelac¸ãocomsignificâncianaqualidadedevida.

©2017SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction

Crohn’s disease (CD) and idiopathic ulcerative rectocolitis (IUR) are the forms of inflammatory bowel diseases (IBD), beingcharacterizedbyachronicinflammationoftheintestine. ThecauseofIBDisstillunknownandthereissome interac-tionbetweengenetic,environmentalandimmunefactors.1,2

Thesediseasesaffectyoungandoldpeople,withno predilec-tionasforraceandgender.3,4

AccordingtoOrdinanceNo.483ofApril1,2014mofthe BrazilianMinistryofHealth,chronicdiseasesarethose disor-derswithagradualonset,withalongoruncertainduration, and which, ingeneral,present multiplecauses and whose treatmentinvolveschangesofthepatient styleoflife,ina processofcontinuouscarethatusuallydoesnotleadtoone’s healing.

Theconceptofqualityoflife(QoL)referstohowwellpeople performtheirfunctionsindailylifeandthepersonal assess-mentoftheirwell-being,andtheformsofinflammatorybowel disease,bothIURandCD,haveimportantrepercussionsonthe QoLofthecarriers.5

ThemeasurementofQoLisanimportantparameterwhen oneassessestheimpactofchronicdiseases,sincethe physi-ologicalchanges,despiteprovidingimportantinformationfor theclinician,cancausevariouseffectsbothforpatientsand theirfamilies,astheyinfluencefunctionalcapacityand well-being–criticalaspectsforthepatient.6,7

InordertoevaluatetheQoLofpatientswithinflammatory bowel disease,the “Inflammatory Bowel Disease Question-naire”questionnaire,alreadyvalidatedinBrazil,wasapplied andsubsequentlywecorrelatedtheIBDQdatawith sociode-mographicandmorbiditydataavailable.

Methods

Thisisacross-sectional,prospectivestudy,withnoconflictof interest,andcostswillbebornebytheresearchers.Thestudy

wasconductedfromAugust2016toJanuary2017,andinvolved patientswithIBDregisteredintheexceptionalmedicine pro-gramoftheHealthDepartmentoftheStateofMatoGrosso doSul(MS),aftertheirevaluationbyanauditorphysicianand withthe Ordinancecriteria beingfulfilled.Patientswithan undeterminedcauseofcolitisandpatientsundergoing diag-nosticinvestigationwereexcluded.

ToevaluatetheQoL,theNorthAmericanformof McMas-ter University, “Inflammatory Bowel Disease Questionnaire (IBDQ)”, a questionnaire translated and validated in Por-tuguese, was the instrument applied, along with a small formonmorbidityandsociodemographiccharacteristics.The IBDQconsistsof32itemscoveringfour domains:intestinal symptoms,systemicsymptoms,socialaspects,andemotional aspects,andtheresponseoptionsarepresentedintheform ofmultiplechoice,withsevenalternatives.Thescores1and 7mean,respectively,theworseandthebetterstateofQoL.5,6

Thevolunteerpatientsansweredthequestionnaires with-out any externalhelp; oncecompleted, the questionnaires wereconfidentiallydepositedinabox.

After the data collection, the IBDQ results were cross-checked with the questionnaire on socio-demographic characteristics, as follows: age, gender, disease, diagnosis time,surgeryresultingfromthedisease,medicationinuse, smoking,anddiseaseactivity.TheresultsoftheIBDQwere submittedtostatisticaltreatmentwiththeuseofSPSS (ver-sion23)andGraphPadPrism(version6.01)programs,cluster analysis, and the chi-squaredtest, withsignificance estab-lishedasp<0.05.

Results

Descriptiveanalysis

Ageandgender

37,9%

62,1%

Male Female

Total = 58

Fig.1–Distributionofthepatientsstudiedbygender.

15,5%

19,0% 15,5%

5,2%

15,5% 25,9%

Total = 58

10 - 19 years 20 - 29 years 30 - 39 years 40 - 49 years 50 - 59 years 60 - 69 years 70 - 79 years 3,4%

Fig.2–Distributionofthepatientsstudiedbyagegroup.

100

90

80

70

60

50

40

30

20

10

0

Male Female

70 years and over 60 - 69 years 50 - 59 years 40 - 49 years 30 - 39 years 20 - 29 years 10 - 19 years

Relativ

e frequency (%)

Fig.3–Distributionofthepatientsstudiedbyagegroup

andgender.

42.5±17.3 years; forwomen(n=36,62.1% of the total)the meanagewas48.3±13.4years.

Fig.1illustratesthedistributionbetweengenders,while Figs.2and3listtheagegroupsoftheparticipants.

Onlytwo(3.4%)patientsweresmokers(onewithCDand onewithURC)and56(96.6%)didnotsmoke.Only14(24.1%) patientsunderwentsurgeryduetoaninflammatorydisease; ofthesepatients,13hadadiagnosisofCDandonlyonepatient hadURC.

Regardingtreatment,sevenpatients(12.06%)werenoton medication,25(43.01%)werebeingtreatedwithcombination

Table1–DrugsinusebypatientssufferingIBD.

Druginuse Numberofpatients(%)

None 7(12.06%)

Salicylate,oral 13(22.41%)

Salicylate,suppository/enema 6(10.34%)

Methotrexate 1(1.7%)

Prednisone 12(20.68%)

Azathioprine 24(41.37%)

AntiTNF 22(37.93%)

Table2–Diagnosistimeandnumberofpatients.

Diagnosistime Numberofpatients(%)

Lessthan1year 10(17.2%)

1–2years 7(12%)

2–3years 13(22.4%)

Morethan5years 28(48.2%)

Table3–Distributionofdiseasefrequenciesaccordingto gender.

Gender Total

Male Female

Crohn’sdisease 16(27.6%) 25(43.1%) 41(70.7%) Ulcerativerectocolitis 6(10.3%) 11(19.0%) 17(29.3%)

Total 22(37.9%) 36(62.1%) 58(100.0%)

therapy,and26(44.08%)wereonmonotherapy.Table1lists thedrugsinuse.

Whenaskedaboutdiseaseactivity,31patientsthoughtthe diseasewasactive,13believedthatthediseasewasnotactive, and14didnotknowaboutit.Table2liststhediagnosistimes.

Disease

Table3showsthefrequencydistributionofdiseases, accord-ing to gender, while Table 4 shows the same distribution accordingtoagegroup.

QoL

Thesumofthescoresofeachdomainwasdividedbythe num-berofquestionsthat composedthedomain,andthesame procedurewasdoneforthetotalscore.Thesevaluesare pre-sentedinTables5–7,withrespecttogender,agegroup,and disease,respectively.

Inferentialanalysisofthedependentvariable“QoL”.

QoLversusgender. TheD’AgostinoandPearson normal-itytest,appliedtothetotalvaluesofQoL,revealedthatwe were facedwithaparametric sampling distribution, which authorizedustousetheStudent’sttesttotrytofindsignificant differencesbetweenthegroups.

The“t”testrevealednosignificantdifferencesbetweenthe groupstested(p=0.2374),indicatingthatthegenderdidnot influencetheQoLofthepatient.Fig.4illustratesthisfinding.

Table4–Distributionofdiseasefrequenciesaccordingtoagegroup.

Agegroup(years) Total

10–19 20–29 30–39 40–49 50–59 60–69 70–79

Crohn’sdisease 2(4.9%) 9(15.5%) 8(13.8%) 5(8.6%) 8(13.8%) 7(12.1%) 2(3.4%) 41(70.7%) Ulcerativerectocolitis 0(0.0%) 0(0.0%) 3(5.2%) 4(6.9%) 7(12.1%) 2(3.4%) 1(1.7%) 17(29.3%) Total 2(3.4%) 9(15.5%) 11(19.0%) 9(15.5%) 15(25.9%) 9(15.5%) 3(5.2%) 58(100.0%)

Table5–Meanandstandarddeviationofcorrectedscores,accordingtodomainsandgender.

Gender Domains

Bowel Systemic Social Emotional Total

Male 4.90±1.66 4.45±1.55 5.10±1.83 4.32±1.91 153±50

Female 4.54±1.49 3.96±1.67 4.58±1.75 4.33±1.55 137±46

Total 4.68±1.55 4.14±1.63 4.78±1.78 4.33±1.68 143.3±47.7

Table6–Meanandstandarddeviationofcorrectedscores,accordingtodomainsandagegroup.

Agegroup Domains Total

Bowel Systemic Social Emotional

10–19years 4.90±1.98 4.20±1.98 4.70±1.56 4.50±1.65 145±47

20–29years 5.68±0.90 4.84±1.04 6.22±1.25 5.15±0.77 175±23

30–39years 4.12±1.71 3.84±1.51 4.31±1.88 4.39±1.51 130±53

40–49years 4.04±1.58 3.18±1.53 3.53±1.87 2.81±1.65 114±52

50–59years 4.35±1.51 4.01±1.97 4.55±1.67 4.29±1.60 141±46

60–69years 5.08±1.56 4.53±1.56 5.29±1.60 4.78±2.09 149±49

70–79years 5.87±1.27 5.47±1.10 5.60±1.25 4.89±2.01 179±35

Total 4.68±1.55 4.14±1.63 4.78±1.78 4.33±1.68 143.3±47.7

Table7–Meanandstandarddeviationofcorrectedscores,accordingtodomainsanddisease.

Disease Domains

Bowel Systemic Social Emotional Total

Crohn’sdisease 4.77±1.53 4.22±1.66 4.91±1.77 4.28±1.70 145±48

Ulcerativerectocolitis 4.45±1.63 3.95±1.57 4.47±1.82 4.43±1.67 138±48

Total 4.68±1.55 4.14±1.63 4.78±1.78 4.33±1.68 143.3±47.7

Male Female

Qua

lity of lif

e

210

180

150

120

90

60

30

0

Fig.4–Qualityoflifeaccordingtogender.

Theanalysisofvariancerevealednosignificantdifferences betweenthegroupstested(p=0.1122),indicatingthattheage groupdidnotexertinfluenceinthelifeofthepatient.Fig.5 illustratesthisfinding.

QoLversus domain. TheD’Agostino andPearson’s nor-malitytest,appliedtothecorrectedvaluesofthedifferent

250

200

150

100

50

10-19 years

Quality of lif

e

20-29 years

30-39 years

50-59 years

60-69 years

70-79 years 40-49

years 0

Fig.5–Qualityoflifeaccordingtoagegroup.

7

6

5

4

3

2

1

0

Corrected score

Bowel factors

Systemic factors

Social factors

Emotional factors

Fig.6–Qualityoflifeaccordingtodomain.

Model summary

Algorithm Twostep

4

2

-1,0 -0,5

Silhouette measure of cohesion and separation Poor Fair Good

0,0 0,5 1,0

Inputs

Clusters

Cluster quality

Fig.7–Clusteranalysisappliedtostudydomains.

Silhouetteindex_=0.6.

Table8–Contingencetableforqualityoflifeaccording toprednisoneuse.

Useofprednisone Betterquality oflife

Poorerquality oflife

Total

No 19(32.7%) 27(46.6%) 46(79.3%)

Yes 11(19.0%) 1(1.7%) 12(20.7%)

Total 30(51.7%) 28(48.3%) 58(100.0%)

Theone-way ANOVA test revealed no significant differ-ences amongthe values of the domains tested (p=0.157), indicatingthatnoneofthedomainshaveagreaterimportance intheQoLofthepatient.Fig.6illustratesthisfinding.

Domainsversusmedication. Theclusteranalysisapplied tothedomainsbytheTwoStepalgorithmrevealsthepresence oftwodistinctgroups,asshowninFigs.7and8.

Basedonthisdistributionofpatientsintwodistinctgroups, analyseswereperformedbasedonchi-squaredtests,inorder todeterminesignificantcorrelationsbetweenQoLandthe var-ioussociodemographicfactors,amongthemthemedication usedbythepatientsinthesample.

It was found that the use of prednisone significantly increasespatients’QoL(p=0.0026),asshowninTable8.

Clusters

Cluster

Label Higher quality of life Lower quality of life

Description

Size

51,7% (30)

48,3% (28)

Inputs

Systemic factors 2,85

Social factors 3,40

Bowel factors 3,50

Emotional factors 3,19

Emotional factors 5,55 Bowel factors

5,94 Social factors

6,26

Systemic factors 5,53

1 2

lnput (Predictor) Importance

1,0 0,8 0,6 0,4 0,2 0,0

Fig.8–Theimportanceofeachdomaininthepredictionof

qualityoflife.

Discussion

IBDscanpermanentlyaltertheQoLofpatients’lives, espe-ciallywhenthedisordergoesthroughaperiodofexacerbation. The symptoms presentedby patients with IBD can gener-atechangesthathaveagreatimpactonattitudes,behaviors, andproductivity,aswellasinphysical,emotional,andsocial aspects.

In this study, wecan observe the occurrence ofa peak incidenceofIBDbetween50and59yearsofage.The predom-inanceofCDinwomenandthebimodalpresentation(20and 50years)iscompatiblewithfindingsintheliterature.However, contrarytowhathasbeenobservedinsomestudies,IUGRwas predominantlyinwomen,notinmen.6

Smokingdidnotinfluencethisstudysincethenumberof patients(n=2)wasnotrelevant.

When scores taking into account the diagnoses were assessedseparately,nostatisticallysignificantdifferencewas observedforCDversusIUGR,andthisresultwassimilarto thatfoundinastudyconductedinSpain.8_{Also,nostatistical}

relevancewasobservedwhentheIBDQscorewascorrelated withsociodemographicdata.

Conclusion

Therewasno statisticalsignificanceofthe QoLofpatients withIBDwhencomparedwithsociodemographicvariables. Onthe other hand,the clusteranalysisdemonstrated that thesystemicdomainofIBDQcanbeconsideredagood pre-dictorofQoLandthat,inaddition,patientswhoweretaking prednisonehadbetterscoresforQoL.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Appendix

A.

Supplementary

data

Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,atdoi:10.1016/j.jcol.2017.06.009.

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