A critical review of epidemiological studies in inflammatory bowel disease

The globalization of inflammatory bowel disease: the incidence and prevalence of inflammatory bowel disease in Brazil

PURPOSE OF REVIEW

Epidemiological studies of inflammatory bowel disease (IBD) in newly industrialized countries are limited, due to a lack of medical surveillance systems and reliable and unified registries and databases. In Brazil, reliable data on the incidence and prevalence of Crohn's disease and ulcerative colitis is scarce. The objective of the present review is to describe in detail the available data on the incidence and prevalence of Crohn's disease and ulcerative colitis in Brazil.

RECENT FINDINGS

The authors identified the single four population-based studies which refer to incidence and prevalence of IBD in the country (two from São Paulo, one from Espírito Santo and one from the state of Piauí). These studies demonstrate a remarkable growth in the incidence and estimated prevalence of IBD in Brazil, with higher number of cases in more developed regions.

SUMMARY

The increase in incidence over time and the higher current prevalence are indicative of a historical progression in relation to the number of IBD patients in our country, similar to what was observed in countries from Asia and approximating those of the northern hemisphere. Epidemiological studies with more accurate methodology are needed in Brazil.

Increasing rate of inflammatory bowel disease: a 12-year retrospective study in NingXia, China

Background

In China, the incidence of Inflammatory bowel disease (IBD) has shown a significant growth trend. Analysis of the epidemiology, clinical manifestations, diagnostic means, and treatment of IBD will further improve the clinician's understanding of IBD, improve knowledge and further enable early diagnosis and standardized therapeutic management. The purpose of this study was to analyze the clinical characteristics of IBD inpatients in General Hospital of NingXia Medical University over a 12-year period to identify trends in clinical and epidemiological features, clinical manifestations, and treatment programs.

Methods

By excluding188 patients with incomplete information or incompatible with the 2012 Guidlines cases, we retrospectively analyzed the case records of 567 inpatients with a diagnosis of IBD admitted to the General Hospital of NingXia Medical University between January 2002 and December 2014. The clinical epidemiological features, clinical manifestations, diagnostic methods, and therapeutic status were analyzed.

Results

Over the study period, IBD hospitalization rates in 2002 and 2014 groups was 1.96 % and 4.05 %, increased 2.07 times. Of 567 cases of IBD, 483 (85.19 %) cases were categorized as ulcerative colitis (UC) and 84 as Crohn’s disease (CD) (14.81 %). Total male cases were 321 (56.61 %). Mean age of cases was 49.06 ± 14.92 years for UC and 44.84 ± 14.67 years for CD. The majority of UC was located in the colon, with a moderate level of disease activity. A combination of clinical manifestations and colonoscopy was mostly used to make a diagnosis; relatively the rate of pathological diagnosis was low, with a small proportion of patient’s diagnosed based on radiology. Treatment with SASP/5ASA and steroids was applied to the majority of inpatients and 47.83 % were treated with antibiotics; in contrast, only 1.86 % cases were treated with immunosuppressive therapy.

Conclusions

An increasing trend of admissions for IBD can be observed in our study; there are some differences in clinical features and treatment compared with Western countries, and further research into this is required.

Trichuris suis ova therapy in relapsing multiple sclerosis is safe but without signals of beneficial effect

Background:

An observational study has suggested that relapsing–remitting multiple sclerosis patients with helminth infections have lower disease activity and progression than uninfected multiple sclerosis patients.

Objective:

To evaluate the safety and efficacy on MRI activity of treatment with TSO in relapsing MS.

Methods:

The study was an open-label, magnetic resonance imaging assessor-blinded, baseline-to-treatment study including ten patients with relapsing forms of multiple sclerosis. Median (range) age was 41 (24–55) years, disease duration 9 (4–34) years, Expanded Disability Status Scale score 2.5 (1–5.0), and number of relapses within the last two years 3 (2–5). Four patients received no disease modifying therapy, while six patients received IFN-β. After an observational period of 8 weeks, patients received 2500 ova from the helminth Trichuris suis orally every second week for 12 weeks. Patients were followed with serial magnetic resonance imaging, neurological examinations, laboratory safety tests and expression of immunological biomarker genes.

Results:

Treatment with Trichuris suis orally was well-tolerated apart from some gastrointestinal symptoms. Magnetic resonance imaging revealed 6 new or enlarged T2 lesions in the run-in period, 7 lesions in the early period and 21 lesions in the late treatment period. Two patients suffered a relapse before treatment and two during treatment. Eight patients developed eosinophilia. The expression of cytokines and transcription factors did not change.

Conclusions:

In a small group of relapsing multiple sclerosis patients, Trichuris suis oral therapy was well tolerated but without beneficial effect.

Highlights in IBD Epidemiology and Its Natural History in the Paediatric Age

Background. The number of patients of all age brackets diagnosed with Inflammatory Bowel Disease (IBD) has risen dramatically worldwide over the past 50 years. IBD's changing epidemiology suggests that environmental factors play a major role in modifying disease expression. Aim. To review studies carried out worldwide analyzing IBD epidemiology. Methods. A Medline search indicating as keywords “Inflammatory Bowel Disease,” “epidemiology,” “natural history,” “Crohn's Disease,” “Ulcerative Colitis,” and “IBD Unclassified” was performed. A selection of clinical cohort and systematic review studies that were carried out between 2002 and 2013 was reviewed. Studies referring to an earlier date were also considered whenever the data were relevant to our review. Results. The current mean prevalence of IBD in the total population of Western countries is estimated at 1/1,000. The highest prevalence and incidence rates of IBD worldwide are reported from Canada. Just as urbanization and socioeconomic development, the incidence of IBD is rising in China. Conclusions. Multicenter national registers and international networks can provide information on IBD epidemiology and lead to hypotheses about its causes and possible management strategies. The rising trend in the disease's incidence in developing nations suggests that its epidemiological evolution is linked to industrialization and modern Westernized lifestyles.

Aspectos epidemiológicos das doenças intestinais inflamatórias na macrorregião de saúde leste do Estado de Minas Gerais

A doença de Crohn e a colite ulcerativa são entidades clínicas distintas, porém relacionadas, que se incluem no grupo das doenças intestinais inflamatórias. Esse artigo trata-se de um estudo epidemiológico a fim de descrever a produção do conhecimento em doenças inflamatórias intestinais, levando em consideração os casos de internações registrados, decorrentes do agravamento da doença, nas unidades de saúde da macrorregião de saúde leste do Estado de Minas Gerais. As doenças inflamatórias intestinais são consideradas um dos grandes problemas da população moderna, uma vez que geram repercussões importantes na qualidade de vida de seus portadores, acarretando alterações no âmbito social, psicológico e profissional. Durante o período de 1998 a 2005, foram registradas 363 internações hospitalares, em função das doenças intestinais inflamatórias, distribuídas em 184 e 179 casos nos gêneros masculino e feminino, respectivamente. Em função da escassez de estudos e do número de internações na macrorregião leste do Estado de Minas Gerais, pesquisas devem ser conduzidas a fim de delinear o perfil dos pacientes portadores de doenças inflamatórias intestinais, bem como detectar as possíveis alterações biopsicossociais a fim de promover uma assistência multiprofissional, humanizada e baseada em evidências.

Appendicectomy as a therapy for ulcerative proctitis

OBJECTIVES

Available data regarding whether appendicectomy performed after the onset of ulcerative colitis can modulate its clinical course are currently limited. This study aimed at addressing this issue.

METHODS

In this study, we report a prospective case series of 30 adult patients (median age 35 years, range 17-70 years; male/female: 11/19) with ulcerative proctitis (median duration of symptoms 5 years, range 8 months to 30 years; median Simple Clinical Colitis Activity Index score 9, range 7-12), who underwent appendicectomy in the absence of any history suggestive of previous appendicitis. Patients were subsequently followed up clinically with the assessment of the Simple Clinical Colitis Activity Index for a median of 14 months (range 9-32 months).

RESULTS

After appendicectomy, the clinical activity index improved significantly to a median score of 2 (range 0-12) (P<0.0005). The improvement in the clinical activity index occurred in 27 of 30 (90%) patients, whereas the index remained unchanged in the remaining 3 of 30 (10%) patients. Furthermore, 12 of 30 (40%) patients experienced a complete resolution of symptoms (clinical activity index score of 0) by 12 months, such that all pharmacological treatments could be withdrawn, and have remained in remission off all previous treatments for a median 9 months (range 6-25 months). The time required for a complete resolution of symptoms post appendicectomy ranged from 1 to 12 months (median 3 months) (Kaplan-Meier analysis). None of the clinical or histological factors analyzed were significantly associated with post-appendicectomy outcome.

CONCLUSIONS

This case series, the largest reported so far, provides rationale for controlled trials to properly evaluate the possible role of appendicectomy in the treatment of ulcerative proctitis.

[Socioeconomic and nutritional profile of patients with inflammatory bowel disease at a university hospital]

BACKGROUND

Inflammatory bowel diseases include chronic and relapsing inflammatory disorders, represented by ulcerative proctocolitis and Crohns disease, commonly associated with malnutrition.

AIM

Characterize the nutritional and socioeconomic profile of patients hospitalized at the Pernambuco "Hospital das Clínicas", Recife, PE, Brazil.

METHODS

Cross-sectional study carried out at the gastroenterology clinic, which was previously approved by the Ethics Commission for studies involving human beings. The methods included clinical history data, socioeconomic conditions and nutritional assessment. Data were subject to statistical analysis (Students t test for equal and unequal variables).

RESULTS

The sample consisted of 24 male and female patients, with a mean age of 43.83 +/- 16.13 years, mostly married, coming from Recife, with low income, who lived in their own house with relatives. We found a higher prevalence of ulcerative proctocolitis (62.5%), with diagnosis time of more than 5 years, symptoms of abdominal pain, bloody-mucous diarrhea with 6-9 evacuations/day, with the distal colon being the most affected part. Osteoporosis was present in 26.7% of cases. Nutritional status was assessed through the body mass index. The weight loss percentage corresponded to 41.7% and 70.8%, respectively, classified as malnourished, associated or not with high prevalence levels of anemia, hypoalbuminemia and hypocalcemia. Gender correlation evidenced higher triceps fold and arm circumference values in men.

CONCLUSIONS

Despite the study limitations, data suggest relevant information about the occurrence of these diseases in the northeast of Brazil, as well as about its frequent association with important nutritional deficiencies.

Incidence of inflammatory bowel disease in Primorsko-goranska County, Croatia, 2000-2004: A prospective population-based study

OBJECTIVE

It has been suggested that the incidence of inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn's disease (CD), is higher in northern than in southern Europe. Recent epidemiological studies showed the loss of the previously described geographical north-south gradient. The aim of this study was to investigate the incidence of UC and CD in Primorsko-goranska County, Croatia.

MATERIAL AND METHODS

In the period 1 January 2000 to 31 December 2004 (5 years) all new patients diagnosed with IBD were prospectively identified according to a standard protocol for case ascertainment and definition. A total of 178 residents (81 F, 97 M) were newly diagnosed as having IBD during the study period. Of these, 70 had UC and 100 CD. Eight patients had indeterminate IBD. The data on patients were collected using a data form completed by gastroenterologists.

RESULTS

Annual age-standardized incidence rates were 4.3/10(5) (95% CI 2.6-6.0) for UC and 7.0/10(5) (95% CI 3.4-10.6) for CD. The highest incidence rate was observed in the age group 35-44 years for UC and the 25-34 years age group for CD. The incidence of IBD was higher in the urban than in the rural population, with the exception of on the islands.

CONCLUSIONS

The incidence of IBD was higher than previously observed in Croatia. Our results suggest that CD incidence rates in the northern coastal part of Croatia are currently comparable with those reported in northern Europe.

Anxiety, functional health status, and coping ability in patients with ulcerative colitis who are undergoing colonoscopic surveillance

BACKGROUND

Patients with long-standing extensive ulcerative colitis (UC) have an increased risk of developing colorectal cancer (CRC). High-risk UC patients are nowadays enrolled in surveillance programs to decrease CRC incidence and mortality, although little is known about patients' concerns and anxiety when subjected to colonoscopic surveillance. The aims of this study were to evaluate functional health status, general state of health, anxiety, and coping ability in patients with UC taking part in such a program in a university hospital setting.

METHODS

Forty-one patients with long-standing, extensive/total UC in remission (median disease duration, 21.0 years) undergoing surveillance comprised the study group. Twenty patients with extensive disease but with shorter disease duration (median, 8.0 years) and 19 patients with only distal involvement UC acted as controls. Four different self-administered questionnaires (SAQs) were used. The SAQ assessments were made twice in the study group and once in the controls.

RESULTS

No statistically significant differences were found in any of the SAQ assessments. The median scores obtained were well within the ranges seen in normal healthy subjects.

CONCLUSIONS

Colonoscopic surveillance in long-standing UC does not seem to generate increased anxiety or impairment of functional or general health status among participating patients. Rather, UC patients in clinical remission seem to cope just as well as healthy individuals irrespective of the CRC risk or surveillance procedures.

A stress management programme for Crohn's disease

The present study was designed to assess the effectiveness of techniques of behavioural assessment and treatment of Crohn's disease (CD). On the assumption that stress events have a pronounced influence on the life of Crohn's patients, we proposed stress management treatment. This is intended to control stress and improve patients' personal and social competence. Forty-five patients with Crohn's disease were randomly assigned to one of three treatment groups, two experimental groups: stress management and self-directed stress management, and a control group: conventional medical treatment. The subjects underwent eight individual sessions which were specific to each condition. All subjects completed symptom monitoring diaries. The subjects who received training in stress management experienced a significant post-treatment reduction of tiredness (P < 0.1), constipation (P < 0.1), abdominal pain (P < 0.5) and distended abdomen (P < 0.5). The subjects who received training in self-directed stress management experienced a significant reduction in tiredness (P < 0.1) and abdominal pain (P < 0.5). No significant changes were observed in symptomatology in the conventional medical treatment group. Similar results were obtained in the 12 month follow-up.

Systematic review of fibroadenoma as a risk factor for breast cancer

Fibroadenoma (FA) is a common breast lesion occurring in 25% of asymptomatic women. Several studies considered FA as a risk factor for breast cancer, prompting a systematic review of the literature. We selected cohort and case-control studies. Seven studies satisfied the selection criteria. Dupont et al. (1994) and McDivitt et al. (1992) were considered to provide the strongest evidence, showing the relative risk for excised FA without hyperplasia in the range 1.48-1.7, with hyperplasia 3.47-3.7, and with hyperplasia and atypia 6.9-7.29, persisting for more than 20 years. Five studies by Levi et al. (1994), Ciatto et al. (1997), Moskowitz et al. (1980), Carter et al. (1988), and Levshin et al. (1998), were considered to provide weaker evidence, although they showed similar results. None of the results could be used to quantify the risks of excised, non-excised, and asymptomatic FA. More care should be taken in managing patients with complex FAs and FAs with hyperplasia with or without atypia. Core biopsy may be a better option in diagnosis of FAs. Regular screening may be advisable in patients with FAs and a family history of breast cancer in a first-degree relative. More rigorous research is needed in this area.

Role of appendicitis and appendectomy in the pathogenesis of ulcerative colitis: a critical review

Besides a genetic predisposition, a causal role of various environmental factors has been considered in the etiology of ulcerative colitis (UC). The association between appendectomy and UC has recently been the subject of intense scrutiny in the hope that it may lead to the identification of important pathogenetic mechanisms. Published data from animal models of colitis demonstrated reduction in experimental colitis after appendectomy, especially if performed at an early age. Several epidemiological case control and cohort studies have shown a strong and consistent relationship. The metaanalysis of 17 case-controlled studies showed an overall odds ratio 0.312 (95% confidence intervals = 0.261-0.373) in favor of appendectomy (p < 0.0001). One of the two recent large cohort studies is in agreement with these results, but the other failed to confirm them. All these studies have suggested that alterations in mucosal immune responses leading to appendicitis or resulting from appendectomy may negatively affect the pathogenetic mechanisms of UC. Further investigation of the role of appendectomy in UC is expected to open new fields for basic scientific research and may lead to the improvement of our understanding for the disease pathogenesis.

[Trends in the occurrence (1980-1999) and clinical features of Crohn's disease and ulcerative colitis in a university hospital in southeastern Brazil]

BACKGROUND

Crohn's disease and ulcerative colitis are regarded as uncommon in developing countries, but studies on their occurrence in Brazil are scarce. Aims - To determine the occurrence of Crohn's disease and ulcerative colitis in a Brazilian university hospital throughout a 20-year period, and analyze the demographical, clinical and evolutive features of these cases.

METHODS

The frequencies of new cases of Crohn's disease and ulcerative colitis admitted from January 1980 up to December 1999 were calculated and a descriptive analysis of the features of all cases seen from January 1990 up to December 1999 was performed.

RESULTS

A total of 257 new cases (126 with Crohn's disease and 131 with ulcerative colitis) was recorded. The frequencies of admissions for both Crohn's disease and ulcerative colitis have increased progressively from 40 up to 61 cases/10.000 new admissions and Crohn's disease gradually became more common than ulcerative colitis. For both diseases, there was predominance of women, age at admission in the range of 30-40 years, Caucasian origin, married state and non-smokers. Digestive symptoms presented were similar to those already described for both diseases and there were no differences between Crohn's disease and ulcerative colitis regarding the frequencies of general complaints and extra-intestinal manifestations (29.5% vs 23.3%), including thromboembolism (5.9% vs 5.4%). Obstruction and/or perforation were seen in up to 59.2% of Crohn's disease cases, whereas 53.7% of all ulcerative colitis cases presented as severe forms. In Crohn's disease cases with obstruction, smoking was significantly more common than in non-complicated cases. In ulcerative colitis cases of increased severity, general complaints, extra-intestinal manifestations and pancolitis were significantly more frequent than in less severe forms.

CONCLUSIONS

For the last 20 years, there have been an increased frequency of admission of inflammatory bowel diseases, and Crohn's disease have become more prevalent than ulcerative colitis. Demographical, clinical and evolutive features of these diseases seems to be similar to those already described, but there seems to be a predominance of more severe forms of both diseases.

Review of harmful gastrointestinal effects of carrageenan in animal experiments

In this article I review the association between exposure to carrageenan and the occurrence of colonic ulcerations and gastrointestinal neoplasms in animal models. Although the International Agency for Research on Cancer in 1982 identified sufficient evidence for the carcinogenicity of degraded carrageenan in animals to regard it as posing a carcinogenic risk to humans, carrageenan is still used widely as a thickener, stabilizer, and texturizer in a variety of processed foods prevalent in the Western diet. I reviewed experimental data pertaining to carrageenan's effects with particular attention to the occurrence of ulcerations and neoplasms in association with exposure to carrageenan. In addition, I reviewed from established sources mechanisms for production of degraded carrageenan from undegraded or native carrageenan and data with regard to carrageenan intake. Review of these data demonstrated that exposure to undegraded as well as to degraded carrageenan was associated with the occurrence of intestinal ulcerations and neoplasms. This association may be attributed to contamination of undegraded carrageenan by components of low molecular weight, spontaneous metabolism of undegraded carrageenan by acid hydrolysis under conditions of normal digestion, or the interactions with intestinal bacteria. Although in 1972, the U.S. Food and Drug Administration considered restricting dietary carrageenan to an average molecular weight > 100,000, this resolution did not prevail, and no subsequent regulation has restricted use. Because of the acknowledged carcinogenic properties of degraded carrageenan in animal models and the cancer-promoting effects of undegraded carrageenan in experimental models, the widespread use of carrageenan in the Western diet should be reconsidered.