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

Disability from inflammatory bowel disease among employees in West Germany

The statistics of the German social security system were used to analyse the epidemiology of inflammatory bowel disease (IBD) in Germany and to assess its impact on disability. Patients granted disability pension for IBD were compared with a control group of patients disabled from other causes. Crohn's disease and ulcerative colitis led to disability in significantly younger patients than other diseases. Disability from Crohn's disease was 2.0-fold more common in women than men (95% confidence interval: 1.8-2.3), while disability from ulcerative colitis was similar in both sexes. White collar employees were affected by both diseases more frequently than blue collar employees, the ratio being 1.3 (1.2-1.5) in Crohn's disease and 1.6 (1.4-1.8) in ulcerative colitis. Although IBD is relatively rare, it has severe socioeconomic implications, because compared with other diseases, predominantly young age groups become disabled.

Inflammatory bowel disease in children

Ulcerative colitis and Crohn's disease are chronic intestinal disorders with diverse presentations that must be familiar to pediatricians. The subtlety of clinical signs and symptoms may be overshadowed by extraintestinal complications. An awareness of diagnostic techniques and the necessity of an integrated approach of medical and surgical management is emphasized. Potential complications may affect prognosis and require their own specific therapy. The management of these disorders entails an individualized assessment of the extent and severity of intestinal involvement, extraintestinal complications, as well as ongoing medical, nutritional, and emotional support.

Nutritional therapy of Crohn's disease in childhood

Crohn's disease is a chronic, incurable inflammatory bowel disease commonly diagnosed in childhood and adolescence. Growth failure represents a common, serious complication unique to the pediatric age group. Although the etiology of growth failure is multifactorial, malnutrition due to inadequate nutrient intake is the primary cause. Recent studies have demonstrated that nutritional supplementation through an enteral or parenteral route restores body composition and reverses linear and ponderal growth failure. The development of elemental diets that can be administered nasogastrically at home has afforded a more practical, less expensive, and less hazardous method of providing Crohn's disease patients with nutritional supplementation and bowel rest. Elemental-diet therapy has also been shown to be a safe, effective method of inducing a remission in acute Crohn's disease. Further studies are required to develop optimal nutritional therapy which may sustain long-term remission in this disease.

Sexual function in women after proctocolectomy

One hundred women who had undergone proctocolectomy with a continence-preserving procedure (50 Kock pouches, 50 ileoanal anastomoses) for ulcerative colitis or polyposis coli were interviewed regarding their preoperative and postoperative sexual function. Frequency of intercourse increased and the incidence of dyspareunia decreased after operation in both groups. Patients who had a Kock pouch had a greater incidence of persistent postoperative dyspareunia than patients who underwent an ileoanal procedure (38% vs. 18%, p less than 0.02). Only one patient in each group reported a postoperative disturbance in ability to achieve orgasm. Most women reported no change in their menstrual cycle, but patients with a Kock pouch had more episodic vaginal discharge than patients with an ileoanal anastomosis (18% vs. 0%, p less than 0.001). Postoperative fertility was minimally impaired. Overall, the majority of women in this study who underwent proctocolectomy for benign diseases experienced enhanced sexual function after operation, which they attributed mainly to improved health.

Latent pulmonary involvement in Crohn's disease: biological, functional, bronchoalveolar lavage and scintigraphic studies

We have investigated the following pulmonary related parameters in 22 patients with Crohn's disease who were free of clinical pulmonary symptoms and had normal chest roentgenograms and in 25 controls: serum angiotensin converting enzyme, pulmonary function tests, bronchoalveolar lavage (lymphocyte count and subpopulations, macrophage viability and superoxide anion release by macrophages) and pulmonary scannings. Serum angiotensin converting enzyme was lower in Crohn's disease (14.1 +/- 5.1) than in controls (25.2 +/- 4.7) (p less than 0.001). Twelve of 22 Crohn's disease (54%) had a bronchoalveolar lavage lymphocytosis (greater than 18% alveolar lymphocytes). Bronchoalveolar lavage lymphocytes subpopulations were quite variable. Twelve of 17 Crohn's disease (71%) had an increase spontaneous and/or stimulated superoxide anion production by alveolar macrophages. Six of 12 Crohn's disease (50%) had an increase physiologic dead space in the upper part of their lung against one of 11 controls (9%). These data suggest that most patients with Crohn's disease have a latent pulmonary involvement.

Clinical and operative experience with non-Caucasian patients with Crohn's disease

Fifteen black patients with Crohn's disease were seen during a ten-year period (1975-1985). They represented 11 percent of our experience with Crohn's disease during that time. These patients had an earlier age of onset of Crohn's symptoms than our white patients, and correct diagnosis was delayed for an average of four years. All 15 patients required abdominal surgery, and seven (47 percent) suffered recurrences necessitating additional abdominal operations. The five-year actuarial estimate of probability of reoperation was 77 percent. Extraintestinal manifestations were present in all patients, and six (40 percent) had multiple manifestations. These disease manifestations are more severe than those noted in series that studied predominantly caucasian Crohn's populations, and suggest that Crohn's disease in the black patient is a distinctly aggressive form.

Inflammation initiates cancer by depleting stem cells

According to the theory presented herewith, neoplasia results solely from stem cell depletion. Besides serving as tissue progenitors, stem cells are postulated to secrete a vital substance 'A' necessary for proper tissue function. Carcinogens interfere with 'A' production mainly by destroying stem cells and since the latter are not replenished, less 'A' is produced. In order to repair the deficiency, the organism grows a special organ, the neoplasm, dedicated to produce a substitute, denominated here as substance 'B'. Since carcinogens continue depleting stem cells, the neoplasm has to grow more and more in order to keep up with the demand, until reaching a stage of decompensation when the harm inflicted by it is greater than its benefit. Any stem cell depleting substance or process e.g. ablation, chemotherapy and inflammation, is regarded here as a carcinogen. Even animal tumor viruses are postulated here to exert their harm mainly by depleting stem cells. Protracted inflammation e.g. ulcerative colitis or cystic mastopathy, hits stem cells and is followed therefore by neoplasia. Age specific incidence rates of such pathologies resemble precursor-successor curves of tracer kinetics. The precursor inflammation hits young adults, while its successive neoplasia is more prevalent in older individuals. Although most age specific curves of adult cancers are unimodal, at least five are bimodal, resembling precursor-successor curves. These are: Hodgkin's disease, seminoma, nasopharyngeal and retroperitoneal tumors and cancer of bone and joints. It is suggested here that these age specific curves are mixtures of two pathologies, an inflammatory, which is prevalent in young persons, followed by neoplasia.

Pregnancy following ileal pouch-anal anastomosis

Of 92 women undergoing proctocolectomy with ileal "J" pouch-anal anastomosis, between January 1981 and May 1983, six have successfully conceived and carried a pregnancy to term. Three patients had transient deterioration of anorectal function during the third trimester of pregnancy which resolved after delivery. Four patients delivered vaginally without perceptible alteration in subsequent continence. Ileal pouch-anal anastomosis is compatible with normal childbearing postoperatively. The route of delivery should be individualized in these patients.

Crohn's disease in the elderly

The natural history of Crohn's disease in 47 patients, 60 years of age or older at the time of diagnosis has been defined, and their clinical management and long term prognosis reviewed. Distal colonic involvement is common in this group while extensive colonic and diffuse small bowel disease is rare. Distal colonic involvement usually carries a good prognosis except for those few patients who present with perforation which accounts for most of the disease related mortality. The pattern of distal ileal disease is similar to that observed in the younger patients except for the acute nature of symptoms at first presentation, and the low recurrence rates after initial surgical resection.

Nonspecific proctocolitis in northeastern Scotland: a community study

An extensive retrospective survey of patients with onset of symptoms of nonspecific protocolitis arising in the decade 1967-1976 was carried out in northeastern Scotland, including the Grampian region, Orkney, and Shetland. Five hundred and thirty-seven cases were identified, and a 97% follow-up was achieved. One hundred and twenty nonhospitalized cases were included. The average annual incidence was 11.3 per 10(5) population, the highest recorded in Europe to date. Moreover, a striking rise in the incidence was noted. A bimodal age distribution and urban predominance was found. The frequency of both nonspecific proctocolitis and Crohn's disease in first-degree relatives was high. The disease was found to be less severe and extensive at onset than suggested by other surveys, 70% having only distal involvement and 68% having a mild first attack. The overall mortality and surgical resection rates in the first attack were both 3%. Severe first attacks carried a striking 23% mortality. The observed long-term mortality differed little from the expected, except in patients with extensive disease or severe first attacks, or both. The risk of relapse correlated with decreasing age at onset but not with the initial extent or severity of disease. The surgical resection rate after 5 yr was 8%. Twelve percent of patients extended their disease by 5 yr. Using the patient-year concept, 68% of patient years were remission years. The youngest age group had the highest percentage of attack years. The percentage of attack years for all patients correlated more closely with extent of disease in each patient year rather than extent of disease at diagnosis.

Observations on 261 consecutive patients with inflammatory bowel disease seen in the Southwest United States

Two hundred and sixty-one consecutive patients with inflammatory bowel disease (IBD) were seen at a private medical and surgical clinic affiliated with Baylor College of Medicine in Houston, Texas, between November 1, 1975, and March 1, 1979. We collected social and demographic data concerning date and place of birth, sex, race, religion, marital status, date and place of disease onset and occupation, in order to determine whether the presentation of IBD in the southwest United States differs from that in other regions. Clinical data concerning presenting symptoms, area of bowel involvement, and number of hospitalizations were tabulated in order to evaluate the mortality and morbidity of disease. Where applicable statistical analysis of the data was accomplished by computer to determine the significance of the findings. Inflammatory bowel disease was noted to be a disease predominantly of whites, with relative sparing of blacks and Latin Americans. Thirteen cases of IBD occurred in a neighboring white, non-Jewish community of Orange, Texas, during the period of study. In the 261 cases morbidity was severe, but the mortality rate was low. There was one death from suicide. No surgical mortalities were noted in 106 patients who underwent one to ten surgical procedures.

Clinical features and natural history of Crohn's disease

Records of 1084 patients entered into the National Cooperative Crohn's Disease Study were analyzed to gather information concerning the natural history and clinical features of Crohn's disease. The age of onset reached a single peak between the second and fourth decade and was evenly distributed in both sexes. There was an average interval of 35 mo from onset of symptoms to diagnosis. Involvement of both colon and terminal ileum was the most frequent pattern and was present in 55% of patients. The disease was confined to the terminal ileum, other areas of the small intestine, or colon-only in 14%, 3%, and 15% of patients, respectively. Sigmoidoscopic abnormalities were seen in 34% of all patients and 51% of patients with Crohn's colitis. Diarrhea, abdominal pain, weight loss, and fever were present in the majority of the patients. Lower GI bleeding, fever, and perianal complications characterized patients with colon-only involvement. The frequency of extra intestinal manifestations was similar in all groups. Among patients who were randomized to placebo, 32% achieved a spontaneous remission by the end of 17 wk, and 53% of these were still in remission at the end of 24 mo. Clinical remission was associated with an improvement in barium x-rays in 18% of the patients. The predicted factors associated with favorable outcome in placebo-treated patients were: previous surgical removal of all observable disease, absence of perianal disease, and Crohn's Disease Activity Index value under 200.

The dilemma of Crohn's disease: long-term follow-up of Crohn's disease of the small intestine

Seventy-four patients having primary Crohn's disease of the small intestine have had follow-up studies for at least 10 years after initial resection, and the results of treatment are presented. The commonest indication for operative treatment was obstruction, followed by fistula formation, intractability, abscess formation, and free perforation. Disease recurred in 69 per cent of patients in this series, and 55 per cent of this group required fruther operative treatment. It is necessary to have a lengthy follow-up period if we are to appreciate fully the serious nature of the recurrence problems of Crohn's disease of the small intestine.