Paediatric inflammatory bowel disease in a multiracial Asian country

Global Epidemiology and Geographic Variations of Pediatric-Onset Inflammatory Bowel Disease: A Comprehensive Analysis of the Global Burden of Disease Study 1990 to 2019

BACKGROUND

An increasing incidence of pediatric-onset inflammatory bowel disease (PIBD) has been reported in many countries. However, the global burden and distribution of this disease remain less understood. We aimed to examine the global epidemiology and trends of PIBD from 1990 to 2019.

METHODS

Data from the 2019 Global Burden of Disease Study, covering 204 countries, were analyzed. We assessed key measures like incidence, prevalence, mortality, and disability-adjusted life years (DALYs) using linear regression to calculate annual percentage changes and assess trends.

RESULTS

Between 1990 and 2019, the PIBD incidence rate increased and the DALY rate and mortality rate declined. The incidence rate was notably elevated in the high Socio-demographic Index (SDI) quintile, reaching 6.3 per 100 000 person-years, corresponding to 13 914 new cases in 2019. Incidence and prevalence of PIBD positively correlated with the SDI, while higher death and DALY burdens were observed in lower-SDI countries. In 2019, the top 5 countries with the highest PIBD incidence rates were Canada (19.9 per 100 000 population), Denmark (12.4 per 100 000 population), Hungary (8.5 per 100 000 population), Austria (8.1 per 100 000 population), and the United States (7.4 per 100 000 population). Several countries experienced significant increases in incidence rates from 1990 to 2019, led by Taiwan (annual percent change 4.2%), followed by China (2.8%), Japan (2.1%), Australia (1.8%), and Hungary (1.6%).

DISCUSSION

PIBD incidence has significantly increased since 1990. High-SDI countries face higher incidence, while lower-SDI countries experience higher mortality and DALY burdens. The study underscores the need for ongoing monitoring and research to address this emerging public health issue.

Landscape of inflammatory bowel disease in Singapore

Inflammatory bowel disease (IBD), primarily Crohn’s disease and ulcerative colitis, had been widely recognized to affect the Western population. However, the notable rise in prevalence of IBD in Asia, including Singapore, had garnered much attention to the causal role of the shift in trend, and more importantly, effective and safe management of the conditions of these groups of patients in terms of therapy, healthcare economics as well as patient well-being. This review presents a summary of the current landscape of IBD in Singapore, and discuss on areas that can be explored to improve and better understand the local condition, as prevalence continues to grow.

Incidence trends of pediatric onset inflammatory bowel disease in the years 2000-2009 in Saxony, Germany-first results of the Saxon Pediatric IBD Registry

Aims

In developed countries, the incidence of inflammatory bowel disease (IBD) such as Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Therefore, we aimed to investigate the incidence rates and trends over time in the population of children and adolescents in one of the federal states of Germany, in Saxony.

Methods

Over the 10-year period 2000–2009 all 31 children’s hospitals and pediatric gastroenterologists, respectively in Saxony reported all IBD patients up to 15 years of age to the Saxon Pediatric IBD Registry. The completeness of the registry was estimated as 96.7% by independent surveys in the years 2005–2009. Incidence rates were presented as age-standardized incidence rates (ASR) regarding New European Standard Population 1990 per 100,000 person-years (PY) with 95% confidence intervals [CI]. Joinpoint and linear regression was used for trend analyses.

Results

344 patients with confirmed IBD between 2000–2009 were included in the epidemiological evaluation: 212 (61.6%) patients with CD, 122 (35.6%) with UC and 10 (2.9%) with unclassified IBD (IBD-U). The ASR per 100,000 PY over the whole observation period was 7.2 [6.4–7.9] for IBD, 4.4 [3.8–5.0] for CD, 2.6 [2.1–3.0] for UC and 0.2 [0.1–0.3] for IBD-U. For IBD, the ASR per 100,000 PY increased from 4.6 [2.8–6.3] in 2000 to 10.5 [7.5–13.6] in 2009. The incidence trend analysis of ASRs using the joinpoint regression confirmed a significant increase of IBD as well as UC. The mean age at first diagnosis decreased significantly during the observation period from 11.5 (11.0–13.4) in 2000 to 9.6 (5.1–13.5) years in 2009. The median of the diagnostic latency among IBD patients was 3 months.

Conclusion

The incidence of IBD in children and adolescents in Saxony was slightly higher than the average of other countries in the same time period and followed the trend towards a general increase of IBD. The age at diagnosis was subject to a very unfavorable downward trend.

Hepatobiliary manifestations in children with inflammatory bowel disease: A single-center experience in a low/middle income country

BACKGROUND

There has been a worldwide increase in the reported incidence of inflammatory bowel disease (IBD) in children over the past 2-3 decades. The hepatobiliary (HB) manifestations of IBD have been well-studied in children in industrialized and developed countries but are infrequently reported in low- and middle-income countries (LMIC) such as Egypt.

AIM

To determine the prevalence of the HB manifestations in a cohort of Egyptian children with IBD.

METHODS

This cross-sectional observational study was carried out over a period of 6 mo (between June 2013 to December 2013) at the Paediatric Hepatology and Gastroenterology Units of Cairo University Children's Hospital, which is the largest paediatric tertiary care centre in the country.

RESULTS

The study included 48 patients with confirmed IBD based upon clinical, laboratory, endoscopic and histopathological features, 29 (60.4%) were male. Twenty-four patients (50%) had ulcerative colitis (UC), 11 (22.9%) had Crohn's disease (CD) and 13 (27.1%) had unclassified-IBD (IBD-U), which was formerly known as indeterminate colitis. The mean age of the patients at the time of presentation was 8.14 (± SD 4.02) years and the mean age at the time of study enrolment was 10.16 (± SD 4.19) years. All patients were screened for HB manifestations by physical examination, liver function tests, imaging and liver biopsy when indicated. HB disorders were confirmed in 13 patients (27.1%). Transaminases were elevated in 3 patients (6.3%). Two patients (4.2%) had elevated biliary enzymes (one was diagnosed as primary sclerosing cholangitis (PSC) and the other was diagnosed with PSC/autoimmune hepatitis overlap syndrome and the third patient had hepatitis C virus infection. Ten patients (20.8%) had bright echogenic liver on ultrasound suggesting fatty infiltration as a sequel of malnutrition or medication toxicity.

CONCLUSION

The commonest HB disorders in Egyptian children with IBD were abnormal liver function tests, fatty infiltration and PSC. These HB manifestations in paediatric patients in LMIC may be relatively more common than in industrialized countries. Therefore, IBD patients in LMIC should be meticulously screened for liver disease to allow prompt diagnosis and management.

Pediatric inflammatory bowel disease: Is it really uncommon in Asian children?

Background/Aim

Inflammatory bowel disease (IBD) is said to be rare in Asian children, and there is scarce information from India. We therefore analyzed our experience of pediatric IBD.

Methods

Prospectively maintained data of 105 consecutive children [median age 12 (IQR:7–14) years, 71 males] with IBD from July 2001 through June 2016 were retrospectively analyzed. Their detailed clinical features, endoscopic appearance, histopathology, and treatment outcomes were recorded. For Crohn's disease (CD), disease phenotype and disease location were assessed as per Paris classification.

Results

Disease spectrum includes ulcerative colitis (UC), 55 (52%); CD, 43 (41%); and IBD‐unclassified, 7 (7%). There was a significant increase in the number of cases in the last 5 years compared to the previous 10 years (63 vs. 42, r² = 0.96). Most UC cases (75%) had extensive/pancolitis, 74% of CD had colonic/ileocolonic disease, and 65% had inflammatory phenotype. Fever, growth failure, pain in abdomen, and need for surgery were significantly more frequent in CD than in UC (P < 0.0001). Over a median follow up of 19 (IQR: 7–48) months, remission was achieved in 48 of 51 (94%) UC patients and in 24 of 34 (70.6%) CD patients; an immunomodulator was required to maintain remission in 67% of UC cases. In CD, there was a significant reduction in the use of empirical antitubercular therapy (76%, P = 0.008) with time, and disease progressed in three.

Conclusions

IBD is not uncommon, and the incidence seems to be increasing among Indian children. UC is more common than CD and is more often an extensive disease. CD is mainly an inflammatory phenotype. The majority of children with IBD required an immunomodulator to maintain remission.

Pediatric Chronic Inflammatory Bowel Disease in a German Statutory Health INSURANCE-Incidence Rates From 2009 to 2012

OBJECTIVE

The incidence of pediatric inflammatory bowel disease (PIBD) varies over time and geographic region. We attempted to generate incidence rates form German health insurance data.

METHODS

We used health care data for 2009-2015 provided by BARMER, a major statutory health insurance company in Germany, insuring approximately 8% of the pediatric population. We applied a Canadian case definition for PIBD based on International Classification of Diseases coding, documentation of (ileo)colonoscopy and the number of PIBD related visits, without external validation for Germany. An internal validation of the specificity of the diagnosis by checking whether the identified incident cases had also prescriptions of PIPD specific drugs was performed.

RESULTS

In 2012, 187 pediatric patients were newly diagnosed, accounting for an overall PIBD incidence of 17.41 (95% CI 15.08-20.10) per 100,000 insured children and adolescents from 0 to 17.9 years per year compared with 13.65/100,000 (95% CI 11.63-16.01) in 2009. The age-specific incidence showed a steep increase as of the age of 7 years. The PIBD prevalence in 2012 was 66.29/100,000.

CONCLUSIONS

In conclusion, the incidence of PIBD in 0 to 17.9-year-olds in Germany with health BARMER health insurance in 2012 is among the highest reported in the literature.

Current global trends in the incidence of pediatric-onset inflammatory bowel disease

AIM

To perform a comprehensive review and provide an up-to-date synopsis of the incidence and trends of inflammatory bowel disease (IBD).

METHODS

We systematically searched the MEDLINE (source PubMed), EMBASE and Cochrane Library databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (period: 1985-2018) to identify studies reporting population-based data on the incidence of pediatric-onset (< 19 years at diagnosis) IBD in full manuscripts. Two authors carried out screening and data extraction. Choropleth interactive maps and temporal trends were used to illustrate the international differences and incidences of and changes in IBD and subtypes.

RESULTS

In total, one hundred forty studies reporting data from 38 countries were considered in this review. The highest annual pediatric incidences of IBD were 23/100000 person-years in Europe, 15.2/100000 in North America, and 11.4/100000 in Asia/the Middle East and Oceania. The highest annual incidences of Crohn's disease (CD) were 13.9/100000 in North America and 12.3/100000 in Europe. The highest annual incidences of ulcerative colitis (UC) were 15.0/100000 in Europe and 10.6/100000 in North America. The highest annual incidences of IBD-unclassified (IBD-U) were 3.6/100000 in Europe and 2.1/100000 in North America. In the time-trend analyses, 67% of CD, 46% of UC and 11% of IBD-U studies reported an increasing incidence (P < 0.05). The risk of IBD is increasing among first-generation of migrant populations.

CONCLUSION

Globally, the incidence of IBD varies greatly by geographical areas. The steadily increasing incidence of pediatric IBD over time indicates its emergence as a global disease, suggesting that studies should investigate the environmental risk factors among pediatric cohorts.

Asians have more perianal Crohn disease and ocular manifestations compared with white Americans

Background

Inflammatory bowel disease (IBD) is increasing in Asians. We sought tobetter understand differences in IBD between Asians and whites in the United States (U.S.).

Methods

We used data from the Sinai-Helmsley Alliance for Research Excellence cohort to assess disease characteristics for U.S.-born Asians, Asian immigrants and whites. We used bivariate analyses to describe clinical characteristics by race. We used logistic regression to determine baseline odds of immunosuppression and binomial regression to estimate risk ratios for worsening disease at follow-up.

Results

We included 5,223 whites, 35 U.S.-born Asians and 81 Asian immigrants. Crohn's disease (CD) was present in 64% of whites, 40% of U.S.-born Asians and 51% of Asian immigrants. At baseline, 58% of whites, 62% of U.S.-born Asians and 67% of Asian immigrants were in remission by disease activity index score (p=0.238). There were no significant differences in CD location and behavior or ulcerative colitis (UC) extent. Asians had significantly more perianal disease than whites (33% versus 18%, p=0.007). Asians were more likely to have ocular manifestations compared with whites (3.4% versus 0.7%, p=0.022). Asians were also significantly less likely to be depressed than whites (25% versus 35%, p=0.022). Adjusting for confounders, Asians had half the odds of being treated with biologics compared with whites (OR: 0.45, 95% CI: 0.30-0.67). Adjusting for disease behavior and remission status, there were no differences in IBD-related surgery or hospitalization, new biologic or steroid prescription or relapse rates between Asians and whitesat follow-up.

Conclusion

Asians are more likely to have perianal disease and ocular extra-intestinal manifestations. After controlling for confounders, Asians were less likely to be treated with biologic agents. Despite this, there were no significant differences in outcome sover time between Asians and whites. Differences in disease phenotypes in Asians may reflect differences in genetics.

Diagnosis and management of inflammatory bowel disease in children

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are lifelong conditions that often begin in childhood. The implications of IBD are of particular importance in children because of the potential negative effects on growth, development, psychosocial function, and overall wellbeing. The key management strategy is to achieve sustained control of intestinal inflammation and monitor for potential complications of the disease and side effects of therapies. Overall, the evidence on the management of IBD in children is less extensive than in adults, but good quality multicenter studies and various guidelines and society consensus statements are available. This review summarizes the evidence on the pathophysiology, diagnosis, and approaches to management of children and adolescents with IBD.

Crohn's disease should be considered in children with inflammatory oral lesions

This systematic review presents the oral manifestations of paediatric Crohn's disease. Our review of 28 papers published from 2000 to 2015 showed that the prevalence of oral manifestations was 10-80%. Specific symptoms included mucosal tags, swelling of the lips, cheeks and gingiva, and cobblestoning mucosa. Nonspecific symptoms included aphthous-like ulcers, angular cheilitis, lip fissuring and gingivitis.

CONCLUSION

The oral manifestations of Crohn's disease might precede intestinal inflammation or coincide with it. Crohn's disease should be considered in children with multiple oral manifestations and paediatric dentists, and gastroenterologists should be involved in their coordinated evaluation and follow-up.

A questionnaire survey of pediatric inflammatory bowel disease in India

BACKGROUND

Inflammatory bowel disease (IBD) is not uncommon in children and is an important cause of morbidity. Since information on IBD in Indian children is sparse, the study aimed at highlighting the salient features in them.

MATERIALS AND METHODS

A questionnaire survey was done among 221 children and adolescents with IBD [ulcerative colitis (UC) 93 (42.1 %); Crohn's disease (CD) 122 (55.2 %); unclassified (IBD-U) 6 (2.7 %)] across seven centers in India. The cut-off age was 18 years and below.

RESULTS

The mean age of presentation for UC and CD was 10.2 ± 4.4 and 11.0 ± 4.5 years, respectively, with no gender difference. Diarrhea (69.9 %, p = 0.001) and blood in the stools (90.3 %, p = 0.0001) were common in UC, whereas abdominal pain (73.8 %, p = 0.01), fever (39.3 %, p = 0.0001), anemia (64.7 %, p = 0.001), and growth failure (76.2 %, p = 0.0001) were common in CD. Extraintestinal manifestations (EIM) were a feature in 23.6 % and 36.1 % of UC and CD, respectively. Pancolitis (E3) was predominant in UC (70.9 %) and 88 % required steroids. Ileocolonic CD (L3) was common in 72.9 %; 76.2 % required azathioprine for maintenance. Of the children with UC, 11.8 % had complications like massive hemorrhage and toxic megacolon, while 27 % of CD had fistulae, perianal abscess, stricture, and perforation. Biologicals were used in 0.8 % of severe UC and in 12.2 % of CD. In UC, 4.3 % required surgical intervention.

CONCLUSION

Pediatric inflammatory bowel disease (P-IBD) in India shares similarities with adult-onset IBD. Distinctive features were growth failure and more severe forms of the disease necessitating immunomodulators.

Epidemiology of inflammatory bowel disease: focus on Asia

The epidemiology of inflammatory bowel disease (IBD) is changing globally. Incidence and prevalence may have stabilized in high-incidence areas such as North America and Europe but they continue to rise in previously low-incidence areas such as Eastern Europe, Asia, and much of the developing world. This epidemiological shift likely relates to westernization of lifestyle, changes in diet, and improved hygiene as part of socioeconomic development in developing countries. In Asia, UC is more prevalent than CD, although the UC:CD ratio is narrowing in certain areas. Clinical manifestations of IBD in Asia resemble the Western population, but with some differences, including higher prevalence of males and ileo-colonic CD, less familial clustering, lower surgical rates and extra-intestinal manifestations. These differences may relate to time, genetics and environmental factors. Studying the epidemiology of IBD in an area of rapidly increasing incidence may lead to discovery of important etiologic factors associated with disease development.

Enteral nutrition in Crohn's disease: an underused therapy

This paper reviews the literature on the history, efficacy, and putative mechanism of action of enteral nutrition for inflammatory bowel disease in both paediatric and adult patients. It also analyses the reasoning behind the low popularity of exclusive enteral nutrition in clinical practice despite the benefits and safety profile.