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Gastrointestinal Problems - Inflammation

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - I have Crohn's disease, curse my luck. It was diagnosed after I had a bad bout of pain and bleeding from the back passage which landed me in hospital. They had to cut some of my bowel away and put me on every type of medication they could to control it, none of which worked. So now I've ended up with a big scar and an ileostomy. Before all this I was a keen diver, but I've never felt up to trying it whilst all this was going on. Since the op I'm actually feeling much better and would love to dive again. So is it possible to dive with Crohn's and an ileostomy?

A - Crohn’s is one of the inflammatory bowel diseases, and it sounds like you’ve had it bad, poor you. The good news is that once the gut has settled down and you’re symptom-free, there’s no reason you can’t dive again. One or two of the medications that are used to control the disease have some potentially detrimental side effects, but in general they’re well tolerated. An “ostomy” (basically an artificial opening of the gut in the abdominal wall) is not a problem, as normally gas can escape from it so there’s no risk of expansion injury. (The odd case with a Koch pouch, which is airtight, would be a potential risk though.) A quick trip to your local dive doc for a medical should clear up these issues and with any luck you’ll be getting wet again soon.

Q - I was looking at the PADI medical questionnaire, and there is the question about "Bleeding or other blood disorders". I want to ask how I should answer this, and if I need to get a medical statement. I have in the past had some bleeding on defaecation due to internal piles. These episodes did not last for more then 2 or 3 days. I have seen a consultant about managing this, and he recommended no intervention other than topical cream for the moment if/when there is a recurrence. So how should I answer the question and do I need an RSTC statement?

A -
Apart from inventing psychiatry, the greatest contribution Sigmund Freud made to medicine, was that his name rhymed with hemorrhoid. Thanks, you Austrian mental manipulator, and all your rellies, Emma and Clement. Don't worry about your Siggys, they'll be fine. If your arse-surgeon has given them the all clear, then all should be fine underwater. Piles have 3 degrees of seriousness. Internal. Internal, come out but you can pop them back in. Or external. The latter would be an issue diving, as it would attract the bottom feeders, if your wetsuit came off in one of those sitcom sort of ways. But you are in the first 2 degrees for your doc to leave it, so no worries there.

So, answer "no" on the medical form. I think what that question aims at are problems like anaemia or blood clotting problems like haemophilia.

Q - I hope you can help me, you gave me some advice back in January following a vaginal hysterectomy and since then I have had what you can only describe as a run of bad luck.

I'll start at the beginning...I am a sufferer of CROHN'S although this has been in remission for some time now and doesn't cause me too much of a problem as I have been diagnosed with this now for 10 years. On Dec. 8th 2000 I had a vaginal hysterectomy which went very well no bleeding or any problems post op. On June 26th I was taken back into hospital as an emergency with an abscess on my umbilicus which left me with a large pustule of a tummy button, they did an incision and drainage everything seemed to be going well until the belly button then started to leak faeces. So on Aug 29th, back into hospital I go, to have a thorough examination of my large and small colon and I had a bowel resection where they removed approx 12in of large bowel. Touch wood every thing is OK now. Could you please tell me when I would be able to dive by as I am going to Tenerife for a holiday when I have the all clear from you.

A - Poor you. However I cannot offer you an exact date at this stage. Crohn's is an interesting problem for divers, as often the disease itself is not a problem but the medication used to treat it is. I assume that after this incident you may be taking some sort of high dose steroid medication or even immunosuppressive tablets. If this is the case then your return to the water will be delayed. Crohn's disease, where you get inflammation of the bowel is also associated with a whole range of other problems that have an effect on diving. It is easy to get anaemia with the consequent problems with tiredness on exertion. There are also problems with arthritis and this in the knees and hips will affect your finning abilities. Rarer but potentially devastating is a gas build up in the bowel which on ascent could expand enough to cause severe pain and threaten bowel perforation.

So you see there's a whole bunch of stuff going on with this illness and my advice is to sit down with a diving doctor for a thorough check up once you are off any medication that would bar you from the start. There is hope though, well controlled Crohn's in remission should be fine.

Q - I'm completing my medical form and need some advice
about question 16 (prescribed medication).

I take vitamin B12 in injection form once every three months after having a small bowel resection due to a bout of Crohns disease back in 1994 prior to becoming a sports diver.

I take no, 'other' medication and am in very good health

Would you class Vitamin B12 as prescribed medication for self certification purposes?

A - Not really. If you have been seen by a diving doctor and passed as fit for your Crohn's and since then all you have done is start taking B12 then all should be fine to self cert. However you do need a face to face diving medical if you get a flare up of the problem or suffer one of its consequences like anaemia. Likewise steroids can be used to treat this illness and if you take high dose prednisolone then it would also be pertinent to see a dive doctor before donning the wetsuit.

But a stable controlled medical condition like yours with only the B12 should be fine.

I would add one last point and that it is wise to stay away from "flatogenic" foods. Due to your problem you may have a weakened bowel wall and there have been cases in the past of divers on a diet of baked beans developing a gassy bowel at depth. Of course as they ascend if there is a weakness of the gut wall then as the gas expands you can imagine the rest.

Q - I am 37 years of age. I have been diving for about 6 years, 3 years as an instructor. 2 years ago I was diagnosed with Crohns disease and have not dived since. In hindsight I have had this disease for a many number of years. I have been diving without any apparent adverse effects.

I intend to go back to teaching sometime this year. As I can't find out very much from my G.P is there any advice or information you can pass on to me. This would be very much appreciated.

A - There is no absolute contraindication to diving if you have Crohns disease. However you should be aware of a few of things that can be caused by Crohns that can effect diving.

Firstly, anaemia can be a result of your condition. This will be a problem if you dive as your oxygen carrying capacity will be lowered making things more difficult if you have a hard counter current, surface dragging a tired buddy kind of dive. So if you are tired in yourself , short of breath and friends comment on how pale you look , don't dive but get a blood test before you go.

Secondly, one of the treatments for Crohns is high dose steroid tablets that keep the inflammation at bay.

Steroids have also been linked to cataract formation. These are opacities in the lenses of your eyes, most commonly found in the elderly. This is a rare side effect of steroid treatment, however another equally rare cause of cataract formation can be breathing higher concentrations of oxygen.

Now the concentrations in some higher O2 gas mixes shouldn't really cause this but if you are on steroids it's worth seeing an optician quickly if you feel your vision deteriorating.

Lastly, Crohn's disease can cause air trapping in your bowels, this is called intestinal obstruction and can be a danger with diving as the air can expand on ascent with obvious consequent problems. This though is a very intense pain and I doubt whether you would be in any condition even to contemplate a dive as it usually signifies a worsening of your condition which would need a visit to the hospital.

In all, stable Crohns is fine to dive with but just be aware of these other factors.

(other dive medical questions)


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