Crohn’s Disease: Intermittent Distress and FMLA
by Presley Reed, M.D.
Crohn's disease is a chronic inflammatory bowel disease that intermittently debilitates a small percentage of the US workforce.
The disease usually occurs in younger employees which sometimes makes it difficult for employers and coworkersto understand the individual.s need for intermittent leave.
Because Crohn's disease is a permanent condition with symptoms that flare upintermittently, the employer must remain receptive and responsive to requests for intermittent FMLA leave for the duration of the individual.s employment.
Not only do the symptoms present intermittently, but their intensity also varies greatlybetween episodes for any patient. Consequently, physicians may be hardpressed to establish specific estimates for reasonable periods of leave. Only rough estimates pertain which makes FMLA administration more difficult. Some individuals will need extended leave, particularly when the individual's condition requires surgical treatment or when complications arise, such as severe arthritis.
The Medical Disability: Workplace Guidelines for Disability Duration, FourthEdition (MDA) serves as an educational tool that may help FMLA administrators understand the significance and unpredictability of crohn's disease. The MDAcouples general descriptions of medical conditions with specific workplace related information, with the result that those managing disability cases and/or administering FMLA leave can make educated decisions. According to the MDA, crohn's disease shares the following symptoms and characteristics. Crohn’s disease produces areas of patchy inflammation primarily in the smallintestine, but can also produce inflammation in any part of the digestive tract, including the mouth, esophagus, stomach, and colon.
Where inflammation exists, it extends into all the tissue layers. This results in abdominal pain, diarrhea, gastrointestinal bleeding, and poor absorption (malabsorption) of nutrients fromfood. The disease affects men and women equally and typically develops before theage of 30 years. Although the disease is chronic, usually lasting a lifetime, itproduces inflammation intermittently and can be in remission for long periods of time. The cause of Crohn’s disease is unknown, but an immune system abnormality may play a role.
Because the disease seems to run in families, there may be agenetic element to its development. Crohn’s disease is found in 0.1% of the US. population and is most common in white and Jewish individuals. Stress is believed to aggravate the disease.Symptoms vary according to the severity of the disease, the location of the inflammation, and whether intestinal complications have developed.
Typically an individual experiences intermittent periods of fever, diarrhea, pain in the lower right abdomen, fatigue, and weight loss. Sometimes, symptoms develop outside of the digestive tract. Joint pain, swelling,and tenderness are common extra intestinal symptoms.
Crohn’s disease increases the risk of colon cancer, a development that significantly influences theseverity of the disease.
Long-term use of corticosteroids may causeosteoporosis, cataracts, diabetes, hypertension, and aseptic necrosis of the hip. Crohn’s disease cannot be cured, but its symptoms can be controlled throughnutrition and diet modifications, medication, and sometimes surgery. A brief discussion of each of these responses will help us better understand thes eriousness of the diagnoses and the personal discomfort of the individual.
Not only the discomfort associated with pain but of not knowing whether to expect remission or recurrence. Nutrition is important in this disease, so a diet adequate in calories, vitamins, and protein is recommended.
Diet modifications vary according to the symptoms ofthe disease. During periods of diarrhea, a low-fat, high-fiber diet should befollowed. In contrast, early in the relapse of the disease or if symptoms of obstruction are present, a low-fiber diet is needed. During an acute stage of the disease, no food should be taken by mouth in order to rest the colon. Sometimes, especially with advanced disease, nutritional supplementation is needed.
Nutrients may be placed directly into the stomach or intestine through a tube (enteral therapy) or into the bloodstream intravenously (total parenteral nutrition, or TPN). Anti-inflammatory drugs of the 5-amino salicylic acid group are given to reduce inflammation. Corticosteroids reduce inflammation during an acute attack, but aregiven for only a few months at a time because they may cause significant long term adverse effects.
Immuno suppressive drugs are given to help relieves ymptoms in individuals with severe progressive disease who have no tresponded to other treatments. Iron may be needed to treat anemia, and vitamin B12 injections may be neededdue to malabsorption, particularly if there is advanced disease of the smallintestine. When abscesses are present, antibiotics are given to fight the infection. Bile salt binding agents or other antidiarrheal medications may be helpful during episodes of diarrhea. These, however, should be used with caution. Many individuals gain significant relief from surgery in which a portion of theintestine is removed (resection). In severe disease, the entire colon may beremoved (colectomy). Depending on how much of the intestine is removed, atemporary or permanent passageway may need to be created through which waste materials can be emptied.
Surgery may also be needed to remove a fistula (fistulectomy) or open an obstructed portion of intestine (stricturoplasty). As with any chronic disease, living with Crohn’s disease is challenging. Psychotherapy or participation in a support group may help an individual cope with the particular difficulties associated with Crohn’s disease and the general difficulties of living with chronic disease. Serious as it is, crohn's disease need not stop individual productivity. With medical and surgical management, individuals with Crohn’s disease can be fullyfunctioning throughout a long life. The disease will have periods of exacerbationand periods of remission, but typically does not lead to death. Some workplace adjustments may be necessary.
Flexible and private lavatoryaccess may be needed, particularly during periods of exacerbation. For example,the individual suffering from crohn's disease will not be able to continue at workif only two 15-minute breaks can be provided throughout the workday. Federal FMLA regulations mandate that the individual be allowed as much time as necessary, within the 12-week limit, to seek relief on an intermittent basis and for unpaid job protection. Severe attacks may require a lighter work assignment or time off for recovery orhospitalization.
If surgery is performed, individuals may need to be restricted from heavy lifting for a short period.The length and frequency of disability will depend on several factors: the degreeof inflammation, the amount of bleeding, the individual’s nutritional state, and theextent to which an individual’s disease can be controlled through diet andmedication. If abscesses, obstruction, or fistulas are present, surgery may beneeded.
Although surgery results in immediate disability, the potential for greatersymptomatic relief may decrease future disability absence. The cause of crohn's disease is unknown, but there are documentable effects onthe individual who suffers with this chronic condition. Discounting the severity ofthe symptoms or disregarding requests for FMLA leave may only serve toproduce a negative impact on workplace productivity. This may be especially relevant because stress apparently aggravates the condition. Crohn's disease is without question a "serious health condition" that meets the FMLA criteria for job protection. The difficult aspect of administering leave related to crohn's disease is the chronic, yet unpredictable, nature of its debilitating-symptoms. When the employee’s specific medical condition is known to the administrator (e.g., when FMLA is administered in concurrence with short-term disability or employee illness banks), the employer may then be able to make thebest of a difficult situation. Administering FMLA leave to the mutual benefit of the individual and the company.
PS. I pulled this from a PDF (located here) so there were some spaceing issues