The epidemiologic and demographic characteristics of inflammatory bowel disease: an analysis of a computerized file of 1400 patients

Racial differences in disease extent and severity in patients with ulcerative colitis: a retrospective cohort study

INTRODUCTION

Ulcerative colitis (UC) is increasing in African-Americans (AA). The objectives of this study were to assess disease extent and severity in UC by race.

METHODS

Disease extent and severity was assessed in UC outpatients evaluated at the University of Maryland and Baltimore VA from 1997 to 2005.

RESULTS

About 197 patients were identified; 47 were AA (23%). Of AA, 23% had proctitis, 23% had left-sided colitis, and 53% had extensive colitis compared to 10%, 31%, and 59% of Caucasians, respectively (P = 0.056). African-Americans were less likely to ever receive steroids (45% versus 62%; P = 0.065), be treated with > or = 2 courses of steroids (54% versus 68%; P = 0.242) or be steroid dependant (33% versus 46%; P = 0.304). After adjustment, only female gender (OR 0.32, [0.16-0.66]) and age at diagnosis (OR 2.50, [1.28-4.90]) were associated with extensive colitis. Being seen at UMMS (OR 5.10, [2.60-10.10]) was associated with steroid use.

CONCLUSION

Race was not associated with extent of colitis or disease severity in UC.

Infectious gastroenteritis and risk of developing inflammatory bowel disease

BACKGROUND & AIMS

Infectious gastroenteritis (IGE) is known to exacerbate previously diagnosed inflammatory bowel disease (IBD). However, limited data are available describing a causal link between IGE and incident IBD.

METHODS

By using a medical encounter data repository of active duty military personnel, a study was conducted to assess IBD risk in subjects with an antecedent case of IGE.

RESULTS

Between 1999 and 2006, there were 3019 incident IBD cases and 11,646 matched controls who were evaluated in a conditional logistic regression model. To control for potential misclassification, IGE episodes within 6 months of IBD diagnosis were excluded as exposures. After adjusting for potential confounders, an episode of IGE increased the risk of IBD (odds ratio, 1.40; 95% confidence interval, 1.19-1.66). The risk was slightly higher for Crohn's disease compared with ulcerative colitis. In addition, there was an approximate 5-fold increase in IBD risk for persons with a previous irritable bowel syndrome diagnosis.

CONCLUSIONS

These data support theories that the initiation of IBD is a multifactorial process that might include the disruption of normal gut homeostatic mechanisms. Further studies are warranted to evaluate the pathogen-specific risks, identify susceptible populations, and better understand the pathophysiologic relationship between IGE and IBD.

College adjustment in University of Michigan students with Crohn's and colitis

BACKGROUND

Adjustment to college is critical for academic success. Poor college adjustment correlates with poor academic performance, low graduation rates, and poor success later in life. Limited data are available on the effects of inflammatory bowel disease (IBD) on college adjustment. We hypothesize that disease activity negatively impacts on QOL, and adversely affects college adjustment.

METHODS

Undergraduate students (6 Crohn's disease [CD], 12 ulcerative colitis [UC], 19 healthy controls) completed a standardized college adjustment survey (SACQ) and QOL instrument (SF-12). Where appropriate, disease specific activity and QOL indices were obtained (HBI, SCCAI, SIBDQ).

RESULTS

There was an inverse correlation between disease activity and college adjustment in CD and UC (R = -0.6554, p = 0.0032). IBD students had lower physical QOL (SF-12) than controls (p = 0.0009). Emotional domain of college adjustment correlated best with SIBDQ (R = 0.8228, p < 0.0001), and correlated better in CD (R = 0.8619) than UC (R = 0.7946). Mental QOL (SF-12) was worse in CD than UC (p = 0.0211), but neither differed from controls (p = 0.4, p = 0.6).

CONCLUSIONS

Students with active Crohn's and colitis adjust less well to college life. Physical and emotional factors likely contribute. More aggressive medical therapy and better emotional support before and during college may result in happier and healthier college students, leading to higher graduation rates and future success. Interventions resulting in better disease control and support systems may improve college performance and provide long-term benefits to young adults with IBD.

Inflammatory bowel disease and African Americans: a systematic review

BACKGROUND

Inflammatory bowel disease (IBD) is comprised of Crohn's disease (CD) and ulcerative colitis (UC). There are conflicting reports on whether African Americans have a more severe disease course, presentation, and more frequent extraintestinal manifestations (EIM). We examined the precise nature of this relationship by conducting a systematic review.

METHODS

Using predefined inclusion criteria we searched multiple healthcare databases and Grey literature. Eight reports met the inclusion criteria. Using the parameters as defined in the Montreal classification and the presence or absence of EIM, we compared IBD in African Americans and Caucasians.

RESULTS

Over 2000 IBD cases were pooled from 8 reports with African Americans comprising 17%. African Americans and Caucasians had similar distribution of types of IBD, with CD being more common than UC in both groups (CD 76% versus 68% and UC 24% versus 32%, respectively). With respect to CD, both groups presented with nonstricturing and nonpenetrating disease behavior (55% versus 41%) more frequently and had similar rates of ileocolonic disease location (42% versus 38%), and presence of perianal disease (26% versus 29%). In UC patients, proctitis was the most frequent initial presentation in both races. Joint complications were the most frequent EIM in both African Americans (52%) and Caucasians (60%).

CONCLUSIONS

This study dispels the commonly held views that African Americans with IBD generally have more colonic disease, more severe disease behavior, and more perianal disease than Caucasians. African Americans also have similar variety and frequency of EIMs as compared to Caucasians.

Disparities in the use of immunomodulators and biologics for the treatment of inflammatory bowel disease: a retrospective cohort study

BACKGROUND

Treatment disparities between African Americans (AA) and Caucasians exist in multiple diseases. There are limited studies in inflammatory bowel disease (IBD). Our objectives were to assess differences in IBD therapies between AA and Caucasians, controlling for disease severity.

METHODS

We identified outpatients with ulcerative colitis (UC) or Crohn's disease (CD) evaluated at the University of Maryland and the Baltimore Veterans Affairs Medical Center from 1997-2005. We assessed medications used and the presence of covariates by race.

RESULTS

We identified 406 patients; 102 were AA (25%). AA were less likely to receive steroids (56% versus 68%; P = 0.02), mercaptopurine/azathioprine (6-MP/AZA) (28% versus 40%; P = 0.03), infliximab (IFX) (10% versus 20%; P = 0.03), or either 6-MP/AZA or IFX (28% versus 44%; P = 0.005). Age at diagnosis <40 (odds ratio [OR] 2.22, 95% confidence interval [CI] 1.06-4.54), steroid use (OR 4.75, 95% CI 1.93-11.7), and CD (OR 6.25, 95% CI 3.22-12.5) were positively associated with IFX use, while AA (OR 0.50, 95% CI 0.23-1.08) was negatively associated with IFX use. Age at diagnosis <40 (OR 1.84, 95% CI 1.12-3.23), steroid use (OR 10.2, 95% CI 5.37-19.2), and CD (OR 2.32, 95% CI 1.43-3.20) were positively associated with either 6-MP/AZA or IFX use, while AA (OR 0.57, 95% CI 0.32-1.01) was negatively associated with 6-MP/AZA or IFX use.

CONCLUSIONS

There were trends toward lower odds of treatment with IFX or either 6-MP/AZA or IFX in AA when compared with Caucasians. Further studies are needed to determine if these differences are due to less severe disease in AA patients or due to disparities in care.

Diagnostics of inflammatory bowel disease

The diagnosis of inflammatory bowel disease (IBD) with its 2 main subforms, Crohn's disease and ulcerative colitis, is based on clinical, endoscopic, radiologic, and histologic criteria. This paradigm remains unchanged despite the advent of new molecular technologies for the examination of serum proteins and genetic sequences, respectively. The main innovations in diagnostic technologies include the development of more sophisticated endoscopic and noninvasive imaging techniques with the aim of improving the identification of complications, in particular malignant diseases associated with IBD. The future will see further progress in the identification of genetic susceptibility factors and of protein biomarkers and their use to describe the molecular epidemiology of IBD. It can be expected that future diagnostic algorithms will include molecular parameters to detect early disease or guide therapies by predicting the individual course of disease.

Changes in pulmonary function in patients with ulcerative colitis

OBJECTIVES

Information on the occurrence and frequency of pulmonary involvement in patients with ulcerative colitis (UC) is inconsistent. Some authors reported pulmonary impairment with UC by standard pulmonary function tests (PFTs) and documented a reduced diffusing capacity for carbon monoxide (DLCO) especially in patients with active disease, whereas others could not detect differences in routine PFTs between UC patients and controls.

AIM

The aim of this prospective study was to determine the frequency and type of pulmonary dysfunction in patients with UC with respect to disease activity. Furthermore, to evaluate the influence of smoking, nutritional status, sputum cytology and sulphasalazine therapy on PFT parameters.

PATIENTS AND METHODS

Twenty-six patients with UC (20 with active disease, 6 inactive) and 16 age and sex matched healthy controls were investigated with respect to the following pulmonary function tests, forced vital capacity (FVC), forced expiratory volume in the 1s (FEV(1)%) and their ratio (FEV(1)/FVC) and forced expiratory flow 25-75% (FEF25-75%) as well as oxygen saturation. For UC patients, colonoscopy and biopsy were done. Disease activity was assessed by Truelove index for UC. Induced sputum was sampled for cytology. Smoking habit, body mass index (BMI) and medications were recorded.

RESULTS

Fifteen out of 26 patients with UC (57.6%) exhibited at least one pathological pulmonary function test (<80% of predicted value). Small airway obstruction was reported in the 15 patients, restrictive dysfunction in 30.7% and obstructive dysfunction in 11.5%. The impairment of PFTs was significant and more pronounced in patients with active disease, FVC (-14% of predicted), FEV(1) (-9% of predicted) and FEF25-75% (-32% of predicted), P<0.01, 0.05 and 0.01, respectively. There was no significant influence of smoking and medications on PFTs.

CONCLUSIONS

UC patients show significantly decreased lung function tests in comparison to healthy controls. The impairment in active disease exceeded that during the remission. Early recognition is important, as they can be strikingly steroid responsive.

Case report: Fatal acute exacerbation of usual interstitial pneumonia in ulcerative colitis

Pulmonary involvement in ulcerative colitis may manifest as a variety of disorders. Ulcerative colitis-related interstitial lung disease is exceedingly rare and has been reported to be steroid-responsive. We describe the first case of a patient with acute exacerbation of ulcerative colitis-induced usual interstitial pneumonia, who did not respond to corticosteroid therapy and died 12 weeks after the onset of pulmonary symptoms. Early recognition of pulmonary disease in patients with ulcerative colitis is necessary to initiate further diagnostic work-up and may aid treatment decisions.

Defects in mucosal immunity leading to Crohn's disease

Crohn's disease (CD) is characterized by patchy transmural inflammation involving any part of the intestinal tract. Animal models have provided a great deal of insight into the pathogenesis of CD, but no animal model has recapitulated the full spectrum of manifestations witnessed in human disease. The defects in mucosal immunity in CD can be divided into those that involve the epithelial barrier, those that involve the innate immune response, and finally, defects in the adaptive immune response. Defects in the epithelial barrier in CD include an increase in intestinal permeability, increased adherence of bacteria, and decreased expression of defensins. Murine and human studies have demonstrated an increased expression of T-helper 1 (Th1) cytokines by lamina propria lymphocytes. This increased Th1 cytokine expression is driven by interleukin-12 (IL-12)/IL-23 and tumor necrosis factor-like 1A (TL1A) production by antigen-presenting cells, resulting in Tbet expression by CD4+ T cells. Another dimension of the inappropriate immune response in CD is T-cell and B-cell reactivity to luminal microbes. With the identification of the nucleotide-binding oligomerization domain 2 (NOD2) gene as a susceptibility gene, defects in the innate immune response are beginning to be explored. One may consider a model in which defective innate immune clearance of pathogens or commensal bacteria in CD leads to an inappropriate adaptive immune response to the commensal flora.

Comparative phenotypic and CARD15 mutational analysis among African American, Hispanic, and White children with Crohn's disease

BACKGROUND

Despite a large body of literature on the subject of Crohn's disease (CD), very little information is available on racial/ethnic differences related to disease presentation, clinical course, and genetics. The first identified CD susceptibility gene, CARD15, seems to be present in up to 40% of white children with CD. However, the frequency of this gene among patients with CD of other racial/ethnic groups in the United States is not known.

METHODS

We conducted a multicenter study on African American and Hispanic children with CD to describe the phenotypic and genotypic (CARD15) features in comparison with white children with CD. We also analyzed the frequency of CARD15 mutations in large control samples from white, African American, and Hispanic children.

RESULTS

The disease location and behavior were similar among all 3 groups, with inflammatory behavior and the ileocolonic location being the most frequent phenotype. However, significantly lower frequencies of CARD15 mutations were seen in African American (P < 0.0001) and Hispanic (P < 0.0001) children with CD compared with white children with CD. This lower CARD15 frequency among African American patients with CD was also mirrored in the general population.

CONCLUSIONS

Phenotypic features of CD are similar among African American and Hispanic children compared with white children. CARD15 mutations are not increased among African American and Hispanic children with CD. CARD15 mutational frequencies among African American and Hispanic children within the general population are lower compared with white children within the general population. Future genetics studies will be required to determine the relationships between genotype and CD phenotype in various ethnic and racial groups.

Crohn's disease: presentation and severity compared between black patients and white patients

PURPOSE

Common belief based on clinical experience suggests that Crohn's disease is more severe among black patients, although little data exists on the effect of race on Crohn's disease. We compared multiple variables among black patients with Crohn's disease requiring surgery to those of white patients presenting to a university colorectal surgery unit during a five-year period.

METHODS

A total of 345 patients required surgery for Crohn's disease between June 1998 and September 2003. The following data were abstracted from patient charts and a prospectively maintained database: age at diagnosis; age at first Crohn's disease surgery; presenting symptoms; incidence, number and location of fistulas at presentation; number of Crohn's disease operations; and family history of inflammatory bowel disease. Data regarding medical insurance coverage also were obtained. Complete data were evaluable on 178 patients. Patient variables were analyzed using the chi-squared, Fisher exact, and Student t-tests.

RESULTS

Mean age at diagnosis was 28 years for white males, 20 years for black males, 30 years for white females, and 28 years for black females (all p > 0.05). Thirty-seven percent of white females presented with obstructive symptoms vs. 12 percent of black females. (P = 0.011). Sixty-five percent of black females presented with inflammatory symptoms compared with 28 percent of white females (P = 0.001). Of females presenting with fistulas, 15 percent of black patients had a rectovaginal fistula compared with 5 percent of white patients. Seventeen percent of black males and 21 percent of white males had intra-abdominal fistulas. None of these differences were statistically significant. The incidence of fistulas at presentation, mean number of fistulas, total number of operations, and family history of inflammatory bowel disease did not differ.

CONCLUSIONS

Contrary to expectations, Crohn's disease does not seem to be more severe among black patients, who had an earlier age of diagnosis, although this was not statistically significant. Overall, there was no difference in disease presentation. White females were more likely to present with obstructive symptoms compared with black females, who more often presented with inflammatory symptoms. Among patients with fistulas, the incidence of rectovaginal fistulas was higher in black females compared with white females, and white males were somewhat more likely to have intra-abdominal fistulas than black males. Although there was no demonstrated difference in incidence and mean number of fistulas at presentation, the number of operations for Crohn's disease, or family history of inflammatory bowel disease among blacks and whites, there are differences in presenting symptoms among these populations.

The education and employment status of patients with inflammatory bowel diseases

Inflammatory bowel disease (IBD) has the propensity to affect patients who are in their late teens and early 20s, an age when most people decide on their educational and career directions. This review describes the effects that IBD has on the continuum of education and employment. Patients with Crohn's disease and ulcerative colitis attain a similar level of education as that of the general population. The quality of life of such patients in school, as measured by both patients' and teachers' perceptions, indicates that, despite the difficulties that students face in terms of missed school time and physical inconveniences, teachers are generally perceived by students to have favorable attitudes toward helping them. Even though earlier work in the area of employment has suggested that the occurrence of IBD is clustered among people in white-collar positions, recent data have suggested that certain environmental risks for IBD (i.e., sedentary or indoor jobs) may be associated with jobs classified as being white-collar, and therefore having a white-collar job may in itself not be a risk factor for the development of IBD. Patients with IBD have a higher rate of nonparticipation in the labor force, and the participation rate seems to maintain steady levels over time. A majority of patients with IBD continue in the same employment positions over a period of years. Patients with IBD, especially those who have undergone surgery, took more sick leave than their counterparts without IBD. A majority of patients with IBD favored the disclosure of their diagnosis to their employers and perceived little discrimination in the workplace. Furthermore, most employers were perceived by their employees with IBD as having fair attitudes toward the compensation provided for their employees with IBD.

Cigarette smoking and age at diagnosis of inflammatory bowel disease

OBJECTIVES

The incidence and age of onset of inflammatory bowel disease (IBD) appear to be changing. The aim of this study was to determine whether the prevalence of cigarette smoking differs among patients with Crohn's disease (CD) or ulcerative colitis (UC) at the time of diagnosis compared with the general population and whether smoking history is related to the type and age of IBD onset.

METHODS

Prevalence rates of smoking at the time of IBD diagnosis were compared between patients with CD and UC from the IBD Center at the University of Pittsburgh Medical Center versus age-, gender-, and time period-adjusted rates in the Pennsylvania general population. Analyses also were stratified by gender and diagnoses before and after 40 years of age, i.e., early and late onset.

RESULTS

There were 263 IBD patients (144 UC patients and 119 CD patients) seen in the IBD center between August 2000 and December 2002. The prevalence of active smoking was significantly higher at diagnosis in CD patients compared with the Pennsylvania general population (33% versus 24%, P = 0.04), particularly in those with CD onset at 40 years of age or later (47% versus 27%, P = 0.005). In contrast, smoking prevalence was significantly lower in UC patients than the general population (9% versus 28%, P < 0.0001), particularly among those with UC onset before the age of 40 years (6% versus 27%, P < 0.0001). Smoking cessation was associated with an approximate, but nonsignificant, 3-fold higher likelihood of late-onset UC compared with CD.

CONCLUSIONS

Cigarette smoking is associated with the development of late-onset CD and is protective against developing UC at any age, particularly early onset. Former smoking is associated with a high likelihood of developing late-onset UC, but not CD.

Inflammatory bowel disease in African Americans

Ulcerative colitis (UC) and Crohn's disease (CD) are idiopathic inflammatory disorders of the gastrointestinal tract. The two disorders encompass a wide spectrum of clinical presentations and are diagnosed on the basis of their clinical, endoscopic, radiologic, and histologic features. Combined, the two disorders affect approximately 800,000 patients in the United States. An assessment of the epidemiology of these disorders is complicated by a wide range of factors including the absence of population based registries in ethnically diverse regions, the use of retrospective data, and highly variable clinical presentations which may delay or obscure the diagnosis. In this paper we review the available data regarding the epidemiology, clinical presentation, and clinical course of inflammatory bowel disease in African Americans.

Inflammatory bowel disease and environmental influences

Some environmental factors have been established firmly as influences on the development of IBD, such as smoking and appendectomy. Other behaviors, such as oral contraceptive use and sugar intake, have been suggested as risk factors, but he data conflict sharply. The importance of other behaviors, such as breast-feeding, is even murkier with sharply divergent data. Some issues studied may not be factors in themselves but rather markers for other unidentified influences. The conflicting evidence in many of these studies may be clarified as specific genes are identified and the interplay between these environmental factors and genetic subtypes is investigated.

Clinical aspects and pathophysiology of inflammatory bowel disease

The chronic inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis, are recognized as important causes of gastrointestinal disease in children and adults. In this review we delineate the clinical manifestations and diagnostic features of IBD. In addition, we summarize important recent advances in our understanding of the immune mediators of intestinal inflammation. This information has led to new therapeutic approaches in IBD. Further, we discuss the considerable data that point to the significance of genetic factors in the development of IBD and the genetic loci which have been implicated through genome-wide searches. The commensal bacterial flora also appears to be a critical element, particularly in regards to Crohn's disease, although the precise role of the bacteria in the disease manifestations remains unclear. Current investigations promise to yield fresh insights in these areas.

Early bronchopulmonary involvement in Crohn disease: a case report

BACKGROUND

Bronchopulmonary manifestations of Crohn disease have been rarely described in children, including both subclinical pulmonary involvement and severe lung disease.

CASE PRESENTATION

A 6.5-year-old girl is described with early recurrent bronchopulmonary symptoms both at presentation and in the quiescent phase of Crohn disease. Pulmonary function tests (lung volumes and flows, bronchial reactivity and carbon monoxide diffusing capacity) were normal. Bronchoalveolar cytology showed increased (30%) lymphocyte counts and bronchial biopsy revealed thickening of basal membrane and active chronic inflammation.

CONCLUSIONS

Clinical and histological findings in our young patient suggest involvement of both distal and central airways in an early phase of lung disease. The pathogenesis of Crohn disease-associated lung disorders is discussed with reference to the available literature. A low threshold for pulmonary evaluation seems to be advisable in all children with CD.

Granulomatous lung masses in an elderly patient with inactive Crohn's disease

This is a case report of a 77-year-old female with Crohn's disease manifested by recurrent bowel obstructions, who required surgical resections on two occasions but no further medical treatment. She presented 2 years later with pulmonary infiltrates, hilar adenopathy, and multiple lung masses. Biopsies of the masses demonstrated noncaseating granulomatous inflammation and fibrosis similar to the pathology from her bowel resection. Six months later, these pulmonary lesions partially resolved without therapy. This case illustrates significant pulmonary manifestations of Crohn's disease in the absence of active gastrointestinal disease.

The relationship between inflammatory bowel disease and socioeconomic variables

OBJECTIVES

Inflammatory bowel diseases (IBD) are chronic diseases associated with considerable morbidity. This morbidity may have an impact on the ability of patients to remain employed, on their marital status, and on their ability to complete a course of higher education. It has long been held that IBD patients are of a higher socioeconomic status and more educated than the general population. Our aim was to determine the relationship between IBD and employment, income, disability, education, and marital status in two population-based data sets based in the province of Manitoba, Canada.

METHODS

Two studies are reported here. In study A, we surveyed persons with IBD, using the population-based University of Manitoba IBD Database, created in 1995-1996. We compared these IBD patients to the general population with respect to employment, education, and marital status using data from the 1996 National Population Health Survey. IBD patients were queried as to their socioeconomic status as of the time of diagnosis and also at the time of the survey (1995-1996). In study B, we used a database that linked health care and census variables to determine differences in employment, income, occupation, and marital status among individuals who met the administrative definition of IBD (created in forming the University of Manitoba IBD Database, based on ICD-9-CM codes 555 for Crohn's disease and 556 for ulcerative colitis) compared with the rest of working-age population.

RESULTS

In study A we found that, compared with the general population, patients with IBD were more likely to be unemployed. Crohn's disease appeared to affect employment more than ulcerative colitis. IBD patients, however, had a low rate of reporting themselves as disabled (1.3%). Among those married when diagnosed with IBD, approximately 10% of men and up to 20% of women were no longer married 5 yr later. More patients with IBD were married in 1995 compared with the general population; however, more were also divorced. Fewer patients with IBD achieved postsecondary education. In study B, we found that individuals with IBD were twice as likely to be out of the labor force as were controls. Sedentary occupations were twice as likely to be associated with IBD. The income, education level, and marital status of IBD patients were not significantly different from those of controls.

CONCLUSIONS

Individuals with IBD at some time in the course of their illness are more likely not to be working than are those in the general population. Based on employment status and job classification, as well as income and education, IBD patients are not of a higher socioeconomic status as previously reported. IBD patients are at least as likely as the general population to be married.

Occupational mortality from inflammatory bowel disease in the United States 1991-1996

OBJECTIVE

The occupational distribution of inflammatory bowel disease (IBD) may help to shed light on its yet unknown etiology. The U.S. vital statistics offer the opportunity to study cause of death by occupation and industry.

METHODS

The numbers of deaths from Crohn's disease and ulcerative colitis were retrieved from the computerized 1991-1996 data files of the National Center for Health Statistics. Deaths were grouped by gender, ethnicity, disease type, occupation, and industry. Mortality by occupation and industry were expressed as proportional mortality ratio (PMR), adjusted for gender and ethnicity.

RESULTS

Between 1991 and 1996, 2399 subjects died from Crohn's disease and 2419 subjects died from ulcerative colitis. Significant correlations were found between the PMR values of ulcerative colitis and Crohn's disease regarding their distribution by occupation, r = 0.36 and p < 0.05, as well as by industry, r = 0.37, p < 0.01. IBD mortality by occupation was significantly reduced among farmers (PMR: 70, 95% confidence interval [CI]: 42-97), mining machine operators (31, 95% CI: 0-74), and laborers (71. 95% CI: 45-98). A nonsignificant increase was found among sales persons (117, 95% CI: 95-139) and secretaries (122, 95% CI: 83-161). IBD mortality by industry was significantly reduced in agricultural production of livestock (39, 95% CI: 1-78), mining (46, 95% CI: 9-83), grocery stores (55, 95% CI: 17-94), and work in private households (64, 95% CI: 30-97). A nonsignificant increase was found in food production (128, 95% CI: 74-182), investment and insurance business (137, 95% CI: 77-198), and administration (122, 95% CI: 81-163).

CONCLUSIONS

IBD mortality is low in occupations associated with manual work and farming and relatively high in sedentary occupations associated with indoor work. Crohn's disease and ulcerative colitis show a similar distribution.

Changes in the incidence of inflammatory bowel disease: what does it mean?

A sharp rise in the incidence of inflammatory bowel disease (IBD) has been observed in the western world since the early 1950s. The increase in the incidence of ulcerative colitis preceded the increase in the incidence of Crohn's disease by about 10-15 years. In high-incidence areas, a female preponderance at a young age (20-40 years) is observed in Crohn's disease, whereas in ulcerative colitis male incidence is still high at older ages. IBD is more common in the developed world than in the developing world and, in both the United States and Europe, a north-south incidence gradient has been reported, with IBD more common in the north than in the south. There are also indications that, in typically low-incidence areas, more cases are being seen lately. At present, IBD is rather common in western Europe, affecting 0.5-1.0% of the population during their lifetime. It will be interesting to follow these temporal trends in the coming years, as they may teach us more about the role of environmental factors in the pathogenesis of IBD.

Crohn's disease: does race matter? The Mid-Atlantic Crohn's Disease Study Group

OBJECTIVE

The severity of Crohn's disease (CD) has been reported to be greater in blacks than in whites. This possible disparity may be due, in part, to differences between these groups in health care utilization and accessibility. To explore these issues, we conducted a multicenter survey of patients with CD.

METHODS

One-hundred and forty-five blacks with CD, recruited from four teaching hospitals and five private practices, and identified by medical record review or ICD-9 code, were enrolled and matched to 407 whites with CD (by age, gender, and practice type [teaching vs. private practice setting]). Participants were interviewed regarding medical history, health status, personal health care practices during the preceding 5 yr, and beliefs regarding health care in the general population.

RESULTS

Blacks and whites were similar with respect to age of CD onset, lag in time to diagnosis, and number of gastrointestinal (GI)-related hospitalizations and surgeries. Medication usage patterns were also similar in the two groups. Quality of life, measured by SF-36, was lower in all categories for blacks, compared with whites. Blacks were more likely to have had to stop work (p<0.01) and have lost more work days (p<0.01) than were whites. Whites were more likely to have health insurance and be able to identify a regular provider than were blacks. Blacks were more likely to report the following: receiving Medicaid; difficulty affording health care; delaying appointments due to financial concerns; difficulty traveling to their provider's office; and experiencing unreasonable delays at their provider's office. After adjusting for potential confounding variables, we found no differences between the groups, except for the number of days of work lost because of CD.

CONCLUSIONS

These data suggest that black and white patients have similar reported disease presentations and course, and contrast with prior reports suggesting a more severe disease course among black patients. Although the disease itself appears similar, there were numerous reported differences between the races in health care utilization practices and in disease impact upon daily activities. We suggest that apparent disparities in CD according to race are actually due to social and economic factors, and not to the disease itself.

Granulomatous cheilitis and Crohn's disease in a 3-year-old boy

Granulomatous cheilitis and Crohn's disease are disorders of unknown etiology. There are case reports describing their coincidence and pointing out the necessity of ruling out systemic disorders once the diagnosis of granulomatous cheilitis is made. However, such reports are few and the causal association of both diseases is controversial in the literature. We report the youngest patient so far, a 3-year-old boy, who had granulomatous cheilitis and Crohn's disease simultaneously. This coincidence so early in life strongly suggests that both represent manifestations of the same disease.

Military history of patients with inflammatory bowel disease: an epidemiological study among U.S. veterans

OBJECTIVES

The military history of patients with inflammatory bowel disease (IBD) contains types of exposure that are not available through other sources and may provide clues about the as-yet unknown etiology of IBD. We therefore sought to describe the epidemiology of IBD among veterans, with particular emphasis on their military history.

METHODS

A case-control study compared 10,544 IBD patients and 42,026 controls with respect to age, gender, ethnicity, time period of military service, military duty in Vietnam, status as prisoner of war, and exposure to Agent Orange.

RESULTS

Subjects with Crohn's disease were younger than those with ulcerative colitis or without IBD (odds ratio: 0.85; 95% confidence interval [CI]: 0.83-0.87). Both types of IBD affected female veterans significantly more often than male veterans, the relative female predominance being more pronounced in Crohn's disease than ulcerative colitis (0.70; 0.61-0.81 vs 0.83; 0.71-0.96). Whites were more prone to develop both types of IBD than nonwhites (2.46; 2.27-2.68 vs 2.11; 1.95-2.27). Military duty in Vietnam and a status as prisoner of war both exerted a protective influence against Crohn's disease (0.84; 0.75-0.96 and 0.60; 0.41-0.87, respectively), but not ulcerative colitis.

CONCLUSIONS

The results are consistent with the hypothesis that exposure to poor sanitation decreases the future risk of developing Crohn's disease.

[Initial symptoms, extra-intestinal manifestations and course of pregnancy in chronic inflammatory bowel diseases]

BACKGROUND

In many cases inflammatory bowel disease is accompanied by extraintestinal manifestations. This results in lowering of live quality. The aim of this study was to gather data retrospectively about initial symptoms, extraintestinal manifestations and course of pregnancy in a large unselected population with inflammatory bowel disease in South Germany.

PATIENTS AND METHODS

Data from 1975 to 1989 (392 patients) were analyzed and partially compared with data from 1992 to 1995 (211 patients).

RESULTS

Patients with Crohn's disease in average have been 25 years old at the time point of initial symptoms, whereas the age of ulcerative colitis patients was 30 years (p < 0.0001). The number of Crohn's disease patients with a long interval between initial symptoms and diagnosis (> 1 year) was significantly decreased in the second population (50% vs 38%; p < 0.05). Dominant initial symptoms in Crohn's disease were indisposition, abdominal pain and nonbloody diarrhea in contrast to ulcerative colitis which manifested mostly with bloody diarrhea. Extraintestinal manifestations occurred in 76% of patients with Crohn's disease and 64.6% with ulcerative colitis. Complications during the course of pregnancy have been detected in 40.5% in Crohn's disease and 60% in ulcerative colitis.

CONCLUSION

A better knowledge of initial symptoms and extraintestinal manifestations in inflammatory bowel disease can help to decrease the interval between initial symptoms and the diagnosis. Pregnancy in patients with inflammatory bowel disease needs to be treated with special care.

Inflammatory bowel disease in African-American children living in Georgia

We describe the clinical characteristics of inflammatory bowel disease (IBD) African-American compared with non-African-American children. We identified 172 children with IBD; forty-nine (29%) were African-American. Median symptom duration before IBD diagnosis in African-American children (6 months) was shorter than that of non-African-American children (10 months). The most frequent presenting symptom was hematochezia (ulcerative colitis) and abdominal pain (Crohn's disease) in both racial groups. The estimated incidence of Crohn's disease in African-Americans ranged from 7 per 100,000 to 12 per 100,000, whereas the observed incidence in those with ulcerative colitis was between 5 and 7 per 100,000 during the 10 years of the study. Our pilot study suggests that IBD may be more common in African-American children than previously reported. Prospective population-based studies would be useful to determine whether inheritable factors linked with ethnicity are associated with IBD.

Surgery for Crohn's disease in infants and children

The course of Crohn's disease is quite variable in children. To assess the frequency and indications for surgery with current medical therapy, the authors reviewed the cases of 204 children (ages, 0.2 to 18.8 years at diagnosis, median, 12.8 years) who had Crohn's disease treated at a single institution from December 1968 to January 1994, with a median of 3.8 years of follow-up (range, 0.0 to 22.2 years). Ninety-four children (46%) required surgical resection for the following indications: (1) failure of medical therapy with persistent symptoms or growth retardation (n = 44, 47%), (2) intraabdominal abscess or perforation (n = 15, 16%), (3) fistula formation (n = 13, 14%), (4) obstruction (n = 15, 16%), (5) hemorrhage (n = 4, 4%), and (6) appendectomy at exploration for diagnosis (n = 3, 3%). The probability for surgery 3 years after diagnosis is 28.8% and by 5 years is 47.2%. Resections included ileocolectomy (71 children), colectomy (n = 16), small bowel resection (n = 4), and appendectomy (n = 3). Fourteen fistulas in 13 children required surgical intervention (7 enteroenteral, 3 enterovesical, 2 enterovaginal, and 2 enterocutaneous). The median duration from diagnosis to surgery for the fistulas was 2.6 years (range 0.1 to 9.8 years). Forty patients experienced recurring disease after resection during follow-up with a median of 1.8 years (range 0.4 to 18.1 years). The authors found that the course of the disease was unpredictable, with some children requiring early surgical intervention and others continuing with medical therapy for years.

Epidemiology of inflammatory bowel disease: an update

What have epidemiologic studies on IBD taught so far? Consistent findings are as follows: A high incidence of both CD and UC in industrialized countries and an increase in these areas of the incidence of CD during the years 1960-80 followed by a plateau phase, and a more stable pattern in UC during the same period have been found. A greater number of mild cases have probably been diagnosed recently. This also helps to explain the differences in severity and survival between community and referral centre groups. The male to female ratio is greater than 1 in UC, and this is the opposite in CD. Mortality of IBD has decreased during the past decades. As young people are especially prone to develop IBD, most of those affected will have their disease for many years. In developing IBD, genetic influences are of importance. However, epidemiologic studies strongly point to possible interactions between genetically determined features and environmental or other factors. Of these exogenic factors smoking is the most consistent, being of negative influence in CD and protective in UC. Diet and oral contraceptives may influence disease expression, and perinatal events such as viral infections may alter adult susceptibility. The question remains open whether UC and CD are one diseases entity. Similarities in the epidemiologic features of UC and CD support the idea of IBD being one disease. Other findings suggest dividing UC and CD into further subgroups: in CD it has been suggested that fibrostenotic, penetrating, and inflammatory behaviour should be considered different disease entities; in UC some groups consider ulcerative proctitis a disease entity on its own, separating it from the proximally extending colitis. In therapeutic trials this approach has proved to be of importance, and it is not inconceivable that in subgroups, with regard to aetiopathogenetic mechanisms, different factors have to be looked for.

An HLA study on 149 Japanese patients with Crohn's disease

To search for possible immunogenetic roles in the pathogenesis of Crohn's disease, we examined the HLA-A, -B, -C, -DR and -DQ locus antigens in 149 Japanese patients with Crohn's disease. All patients were living on Kyushu island. We also examined the HLA of 136 healthy controls who resided in Kyushu. The results were compared with both controls throughout Japan and Kyushu controls. In Japanese patients with Crohn's disease, HLA-DR4, especially -DR4.1, and -DQ4 were more frequent than in the controls throughout Japan and in Kyushu. In light of these observations, an immunogenetic factor may have some role in the development of Crohn's disease. The susceptibility to Crohn's disease may relate to HLA-DR4, especially -DR4.1, and -DQ4, in Japanese patients.

Granulomatous tonsillitis. A rare extraintestinal manifestation of Crohn's disease

Oral lesions, varying in nature and location, appear to be one of the common extraintestinal manifestation of Crohn's disease. In particular, oral involvement preceding intestinal disease may lead to the diagnosis of Crohn's disease. The present case report of a 17-year-old male patient describes a very rare nonintestinal manifestation of Crohn's disease with severe granulomatous involvement of the tonsils. A sore throat caused by hyperplastic tonsils with granulomatous inflammation as an oral manifestation of Crohn's disease was the leading symptom in this case.

Inflammatory bowel disease. Part I: Nature and pathogenesis

Once regarded as medical curiosities, ulcerative colitis and Crohn's disease have achieved a remarkable change in status recently and today are among the more compelling of all human illnesses. The cause(s) of inflammatory bowel disease (IBD) are not known. Genetic, environmental, microbial, and immunologic factors are involved, but the precise mechanisms are obscure. The incidence of ulcerative colitis is relatively stable, while Crohn's disease continues to increase in frequency. In 10% to 15% of patients, it is hard to differentiate between ulcerative colitis and Crohn's colitis; however, problems with diagnosis usually resolve with time and repeated examinations. In part I of his two-part monograph on IBD, Dr. Kirsner addresses the nature and pathogenesis of the disease. Increased study of ulcerative colitis and Crohn's disease in recent years has generated new knowledge regarding their etiology. Part I focuses on microbial, immunologic, and genetic mechanisms and the inflammatory processes involved in the disease. In part II, which will be presented in next month's issue of Disease-a-Month, Dr. Kirsner deals with the clinical features, course, and management of IBD, based on the author's 55 years of experience with these problems and supplemented by critical examination of the recent (1988-1990) literature. Particular attention is directed to the symptoms and physical findings of ulcerative colitis and Crohn's disease, the laboratory, radiologic, endoscopic, and pathologic features, and the many systemic complications. The IBDs are mimicked by several enterocolonic infections and other conditions, making differential diagnosis necessary. Inflammatory bowel disease in children and the elderly conforms to conventional clinical patterns modified by the health circumstances of the respective age groups. Because the cause of IBD has not been established, current medical therapy is facilitative and supportive rather than curative. The principles of medical treatment are approximately the same for ulcerative colitis and Crohn's disease. Treatment emphasizes a program rather than a drug and also considers the individuality of the therapeutic response. A clearer understanding of dietary and nutritional needs, including hyperalimentation and electrolyte and fluid balance, aids treatment. Antidiarrheal and antispasmodic preparations and sedatives are prescribed for symptom relief. The bowel inflammation is controlled with sulfasalazine or the newer 5-amino salicylic acid (5-ASA) compounds, antibacterial drugs for complications of Crohn's disease and IBD, adrenocortical steroids, and the immunosuppressive compounds 6-mercaptopurine (6-MP), azathioprine, and cyclosporine, as determined in each patient. The surgical procedures available for treatment of ulcerative colitis include total proctocolectomy and ileostomy or ileoanal anastomosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Epidemiology of inflammatory bowel disease among U.S. military veterans

The Department of Veterans Affairs maintains a computerized patient treatment file that contains all records from veterans treated as inpatients in VA hospitals distributed throughout the United States. Using the patient treatment files from 1986 to 1989, the present study takes advantage of this large national data set to examine demographic and geographic associations of inflammatory bowel disease. Inflammatory bowel disease tended to affect predominantly female, white, and younger veterans, these trends being more marked in cases of Crohn's disease than ulcerative colitis. Hospital discharges secondary to both Crohn's disease and ulcerative colitis appeared to be more frequent in veterans from northern than southern parts of the United States, but did not show a seasonal variation different from the general pattern of all other diagnoses. The results in veterans confirm observations made in other studies and suggest that inflammatory bowel disease among different populations is modulated by similar pathophysiologic mechanisms and environmental risk factors.

Occupational distribution of inflammatory bowel disease among German employees

Previous reports have shown that both Crohn's disease and ulcerative colitis affect people in white collar occupations associated with higher income and higher social class more frequently than other groups in the population. This study sought to carry these analyses one step further and investigate the distribution of inflammatory bowel disease by individual occupations. The German social security statistics for 'rehabilitation' were used to assess the occupational distribution of Crohn's disease and ulcerative colitis. From 1982 to 1988, a total of 12,014 people were granted rehabilitation as a result of inflammatory bowel disease. Low male prevalence of inflammatory bowel disease was found among bricklayers, road construction workers, unskilled workers in brick and stone, unskilled labourers, and security personnel. Low rates were found among women employed in cleaning and maintenance, and in those without occupation. In contrast, a high male prevalence was found among instrument makers, electricians, bakers, and technical assistants. Among female employees, inflammatory bowel disease was significantly associated with sales representatives, office workers, health occupations, and hairdressers. These associations were found in the complete data for 1982-8 as well as in the separate data for the two half periods 1982-5 and 1986-8. Highly significant correlations between the occupational distribution of Crohn's disease and ulcerative colitis were found among both male and female employees. It seems that occupations involving work in the open air and physical exercise are protective, while being exposed to air conditioned artificial working conditions or extended and irregular shift working confer a risk of contracting inflammatory bowel disease.

Predictors of hospitalization early in the course of Crohn's disease. A pilot study

A historical cohort was used to assess the ability of clinical features and laboratory values recorded at the time of initial diagnostic investigations to predict nondiagnostic hospital admissions in the first 3 months following the diagnosis of Crohn's disease. Data were abstracted from the medical records of 225 eligible patients at primary and secondary care level whose disease was diagnosed between 1977 and 1985. The total study group was randomly divided into two groups (group 1, n = 112; group 2, n = 113). Discriminant analysis was performed on data of patients in group 1. The resulting predictive model was then cross-validated on data of patients in group 2. The variables entered into the predictive model were identified using bivariate analysis. Results show that presence of abdominal mass, body temperature, absolute basophil and lymphocyte counts, aspartate aminotransferase and blood urea nitrogen serum levels, and place of residence (urban, rural, or out of province) were the most useful variables for predicting hospitalization in the first 3 months (P for model = 0.0010; accuracy = 88%). Cross-validation on group 2 showed an accuracy of 80%, a positive predictive value of 62%, and a negative predictive value of 84%. This predictive model could be useful for counseling purposes on the primary or secondary care levels.

Pulmonary abnormalities in Crohn's disease

Abnormalities of pulmonary function in Crohn's disease have been described, although the results are conflicting and anecdotal accounts of lung involvement are few. In this study we assessed the prevalence of lung function abnormalities in Crohn's disease, and the relative contributions of age, sex, smoking and past medical history, and Crohn's disease activity to the pulmonary abnormalities found. Twenty-nine patients with Crohn's disease and 29 age-, sex- and smoking-matched volunteer controls underwent detailed respiratory assessment. Airways obstruction due to chronic bronchitis and asthma was present in 13 patients with Crohn's disease, but was not more prevalent than in the control group. FEV1 was similar in both Crohn's disease and control subjects (84.2 +/- 21.2% predicted, mean +/- SD; 93.7 +/- 16.3%, respectively: n.s.). The vital capacity was significantly lower in the Crohn's disease patients than in controls (86.7 +/- 16.6%; 95.9 +/- 12.7%; P less than 0.01), but this may have been influenced by the higher prevalence of past or intercurrent medical illnesses affecting the chest in Crohn's disease patients. No patient had evidence of fibrosing alveolitis or bronchiectasis. The haemoglobin corrected transfer factor was significantly lower in the Crohn's disease patients than in controls (100.4 +/- 17.4%; 113.2 +/- 25.1: P less than 0.05) but the diffusing coefficient was not significantly different. There was a significant correlation (r = 0.44, P less than 0.05) between the residual volume and the Crohn's disease activity index but otherwise no close relationship was observed between Crohn's disease activity, extent or duration and the indices of lung function. These findings suggest that the lungs are relatively unaffected by Crohn's disease.

Geographic origins of Jewish patients with inflammatory bowel disease

Ulcerative colitis and Crohn's disease are more common among Jews than among non-Jews. Despite the existence of studies on the prevalence and incidence of inflammatory bowel disease in relation to the continent of residence or origin, there are no studies on the specific countries of origin of Ashkenazi Jewish patients. We report here the first analysis of 233 U.S. Jewish patients by defined world regions and subregions. Using two different sets of controls (a self-referred Jewish population for Tay-Sachs disease carrier detection and a sample of Jewish persons ascertained through unrelated studies from the same hospital as our patients), we found a significant excess of patients of middle European origin relative to those of Polish or Russian origin. These observations suggest that the inflammatory bowel disease gene(s) are more prevalent in the Jewish population that originated in middle Europe than in those from Poland and Russia. These results further suggest that Jewish patients with inflammatory bowel disease probably represent a nonrandom genetically predisposed subset of the Jewish population. This provides further evidence for the genetic contribution to inflammatory bowel disease in general, and to its higher risk in the Jewish population.

Crohn's disease. A comprehensive approach to management

Crohn's disease is a complicated illness that affects many body systems and processes. Medical and surgical management are the mainstays of treatment. However, the value of a strong physician-patient relationship in providing an optimistic and supportive structure for the patient cannot be overestimated. As advances continue to be made in understanding the pathophysiology of Crohn's disease, better and more specific therapies will likely emerge. For the present, however, treatment must be aimed at acute exacerbations and is essentially symptomatic. As a result, care must be holistic, with the intent of providing not only pharmacologic therapy but social and psychological support as well.

Diffuse panbronchiolitis preceding ulcerative colitis

To expand the clinical spectrum of ulcerative colitis-associated lung disease, we describe a patient with panbronchiolitis associated with ulcerative colitis. In addition to his having a distinctive pulmonary manifestation of this bowel disease, other noteworthy aspects of this patient's course include the onset of pulmonary symptoms several years prior to bowel manifestations and the partial resolution of his pulmonary symptoms following colectomy.