Familial aggregation of inflammatory bowel disease in India: prevalence, risks and impact on disease behavior

Spectrum and trend of pediatric inflammatory bowel disease: A two-decade experience from northern India

BACKGROUND

Pediatric inflammatory bowel disease (IBD) has been known to be a disease predominant in the west. There is scarcity of data on pediatric IBD (P-IBD) from northern India. The objective of our study was to analyze the clinical spectrum of P-IBD in northern India.

METHODS

A retrospective analysis of 126 children (<18-year old) diagnosed with IBD from January 1999 to December 2019 was done on a pre-designed proforma. It was systematically entered in a MS Excel spreadsheet and analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0. The descriptive phenotypes of Ulcerative colitis (UC) and Crohn's disease (CD) were revised according to the Paris classification.

RESULTS

Of 126 children, UC was diagnosed in 76 (60.3%), CD in 44 (34.9%) and IBD-unclassified (IBD-U) in six (4.76%) patients. The mean age at diagnosis was 11.3 years; 38.8% were < 10 years with the male: female ratio of 1.6:1. Sixteen children (12.7%) had very early onset IBD (VEOBD). Overall, the median time to diagnosis in IBD was 12 months (interquartile range [IQR]: 3.25-24), which was as high as 52.5 months (IQR: 11-98) in CD. Pancolitis with bleeding per rectum and ileocolonic involvement with pain in abdomen were the commonest presentations in UC and CD, respectively. Stricturing disease was seen in 27% of CD cases. Relapses were seen in 46% (35/76) of U.C and 23% (10/44) of CD kids. Step-up treatment protocol was employed in them with the use of biologicals in 12% of cases. There was a 2.75-fold rise in the IBD cases in the last 10 years (2010-20). There was reduction in time to diagnosis (21 months vs. 90 months; p - 0.012) and empirical anti-tubercular therapy use (90% vs. 5.8%) in CD over two decades.

CONCLUSION

From our experience in a tertiary care centre in northern India, P-IBD is on the rise. UC is more common than CD. Pancolitis and ileocolonic disease are the commonest disease sites in UC and CD, respectively There is a significant delay in the time to diagnosis in CD. Stricturing disease was seen in a quarter of children with CD.

Inflammatory bowel disease in families with four or more affected first-degree relatives

BACKGROUND

Family history increases the risk for inflammatory bowel diseases (IBDs). However, data on differences in phenotypic characteristics among patients with a strong family history of IBD are scarce and controversial. The aim of the study was to compare the phenotypic features of IBD patients with four or more affected first-degree relatives with sporadic cases of IBD.

METHODS

Patients with familial and sporadic IBD were identified from the institutional IBD database. IBD patients from families with at least four first-degree affected relatives were selected for analysis and were compared to non-matched sporadic cases with IBD chosen randomly. Comparison for type of IBD (Crohn's disease (CD) vs. ulcerative colitis (UC)), age at onset as well as for disease extent, behavior, extraintestinal manifestations and indicators of severe disease were analyzed.

RESULTS

Thirty-five patients with familial IBD (28 CD, seven UC) were compared to 88 sporadic IBD patients (61 CD, 24 UC and three IBDU). Disease duration was 10.3 ± 8.2 in the familial and 8.0 ± 7.2 years in the sporadic cases, p=.13. The familial cases were younger at diagnosis (19.3 ± 8.6 vs. 25.7 ± 11.8, p=.004). Patients with familial compared to sporadic IBD were significantly more likely to require steroid treatment (80% vs. 54.5%, p=.009), biological treatment (94.3%, vs. 63.6%, p<.001) or surgery (25.7%, vs. 11.4%, p=.048).

CONCLUSIONS

IBD with a very strong positive family history is associated with younger age at onset and a more adverse IBD phenotype compared to sporadic IBD.

Following the Indian Immigrant: adoption of westernization results in a western gut microbiome and an increased risk of inflammatory bowel diseases

Indians who migrate to westernized countries such as Canada, the USA, and the UK are at an increased risk of developing inflammatory bowel disease (IBD). While the underlying aetiology of IBD remains unclear, a gut microbiome, i.e. no longer symbiotic with its host, is a major player. Increasing IBD incidence in Indian immigrants may be due to the adoption of western practices that result in loss of tolerance of a symbiotic community in the gut and its underlying immune responses. However, little is known about the microbial changes in the Indian gut, including shifts in the microbiome when they migrate to westernized countries. In this Current Opinion, we discuss what is known about the Indian gut microbiome and how living in a westernized environment may be impeding what was once a symbiotic relationship with their gut microbiome and intestinal mucosae, which may be the driving factor in their increased risk of IBD.

Phenotypic Pattern of Early Versus Later-Onset Pediatric Inflammatory Bowel Disease in a Eurasian Country

OBJECTIVES

It is not clear whether the characteristics of pediatric inflammatory bowel disease (IBD) differ between Eastern and Western countries. The aim of this study was to analyze the characteristics of PIBD in Turkey, according to the age at diagnosis.

METHODS

The data of 176 children with IBD who were followed in our center were analyzed. Patients were divided into early (EO-IBD, onset at 2 to &lt;10 years) and later-onset (LO-IBD, 10 to ≤17 years) IBD according to the age at diagnosis. Patients' data with ulcerative colitis (UC) and Crohn's disease (CD) were compared.

RESULTS

Of 176 patients, 47 (26.7%) were diagnosed with EO-IBD. Patients with early-onset ulcerative colitis (EO-UC) had the highest rate of family history of IBD (17.6%). Pancolitis was the most common form of UC regardless of the age at onset. The rate of moderate-severe disease activity in later-onset UC (62.5%) was higher than in EO-UC (37.5%). A higher rate of extraintestinal manifestations was observed in EO-IBD patients, particularly in EO-UC (38.2%) than in LO-IBD patients. Patients with early-onset CD (EO-CD) had predominantly colonic involvement and nonstricturing, nonpenetrating disease behavior. The rate of perianal disease in patients with later-onset CD (LO-CD) (64.5%) was noticeably higher than those with EO-CD (23%).

CONCLUSIONS

Our results suggest that patients with EO-UC represented a distinct phenotype with a mild disease activity, high rate of extraintestinal symptoms, and a high proportion of family history. The analysis of our IBD cohort also demonstrated remarkably high rate of perianal disease, particularly in patients with LO-CD.

Clinical Phenotype and Disease Course of Inflammatory Bowel Disease: A Comparison Between Sporadic and Familial Cases

BACKGROUND

The role of genetic and environmental factors in inflammatory bowel disease's (IBD) clinical course is not fully clear. We aimed to assess the clinical phenotype, disease course, and prognosis of familial IBD in comparison with sporadic cases.

METHODS

We conducted a prospective national matched case-control study of registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) recruited from 2017 until 2020. Sporadic and familial IBD patients were matched based on age, sex, and disease duration. Data on demographics, past medical disease, family history of IBD, disease type, clinical phenotype, extraintestinal manifestations, IBD medications, IBD activity using the IBD-control-8 questionnaire and the Manitoba IBD index, emergency visits in the past 12 months, admissions in the past 3 months, history of colon cancer, IBD-related surgeries, and aggressive phenotype were gathered. Variable distributions were compared between sporadic and familial cases.

RESULTS

Overall, 5231 patients with ulcerative colitis (UC, 18.3% familial) and 1438 patients with Crohn's disease (CD, 16.7% familial) were registered in the IRCC. Age at diagnosis was similar between familial and sporadic cases. After matching, 3523 UC patients and 908 CD patients were enrolled in the study. Extraintestinal manifestations, UC extent, CD location and behavior, anti-TNF use, disease activity, colon cancer, IBD-related surgeries and the aggressive phenotype were similar between these sporadic and familial cases.

CONCLUSIONS

The prevalence of familial UC and CD cases in Iran was more similar to western countries, and family history did not show a predictive value for disease phenotype, course, and outcomes in our study.

Emerging inflammatory bowel disease demographics, phenotype, and treatment in South Asia, South-East Asia, and Middle East: Preliminary findings from the Inflammatory Bowel Disease-Emerging Nations' Consortium

BACKGROUND AND AIM

Inflammatory bowel disease (IBD) is emerging in the newly industrialized countries of South Asia, South-East Asia, and the Middle East, yet epidemiological data are scarce.

METHODS

We performed a cross-sectional study of IBD demographics, disease phenotype, and treatment across 38 centers in 15 countries of South Asia, South-East Asia, and Middle East. Intergroup comparisons included gross national income (GNI) per capita.

RESULTS

Among 10 400 patients, ulcerative colitis (UC) was twice as common as Crohn's disease (CD), with a male predominance (UC 6678, CD 3495, IBD unclassified 227, and 58% male). Peak age of onset was in the third decade, with a low proportion of elderly-onset IBD (5% age > 60). Familial IBD was rare (5%). The extent of UC was predominantly distal (proctitis/left sided 67%), with most being treated with mesalamine (94%), steroids (54%), or immunomodulators (31%). Ileocolic CD (43%) was the commonest, with low rates of perianal disease (8%) and only 6% smokers. Diagnostic delay for CD was common (median 12 months; interquartile range 5-30). Treatment of CD included mesalamine, steroids, and immunomodulators (61%, 51%, and 56%, respectively), but a fifth received empirical antitubercular therapy. Treatment with biologics was uncommon (4% UC and 13% CD), which increased in countries with higher GNI per capita. Surgery rates were 0.1 (UC) and 2 (CD) per 100 patients per year.

CONCLUSIONS

The IBD-ENC cohort provides insight into IBD in South-East Asia and the Middle East, but is not yet population based. UC is twice as common as CD, familial disease is uncommon, and rates of surgery are low. Biologic use correlates with per capita GNI.

What Are the Different Phenotypes of Inflammatory Bowel Disease in Asia?

The burden of inflammatory bowel disease (IBD) in Asia has been increasing over the past decades. Although patients with IBD show heterogenous phenotypes depending on the individual characteristics, no significant differences have been established in the IBD phenotypes of Western and Asian populations. However, despite the much lower incidence of IBD in Asia than in Western countries, the incidence has been rapidly increasing in Asia while remaining stable in Western countries. The incidence of ulcerative colitis (UC) showed an earlier and a more marked increase than the incidence of Crohn disease (CD), but the UC-to-CD ratio has recently decreased because of a relative increase in the incidence of CD in Asia. While CD shows a significant male predominance, UC only shows a slight male predominance. A recent study reported that the incidence of IBD in Asia showed a bimodal age distribution with increasing IBD prevalence, similar to the findings of Western studies. CD in Asian patients, especially those in East Asia, is characterized by ileocolonic involvement and perianal fistula. The frequency of extraintestinal manifestations, including primary sclerosing cholangitis, appears to be lower in Asia, but this finding should be interpreted with caution due to the transient and nonspecific nature of these manifestations. Although familial aggregation is lower in East Asia, it may also be explained by the low prevalence of IBD in Asia. Thus, more studies should focus on the differences in phenotypes in Asian IBD patients versus Western patients.

Impact of Demographic, Clinical and Psychosocial Variables on Drug Adherence and Outcomes in Indian Patients With Inflammatory Bowel Disease: Cost is not the Only Factor!

BACKGROUND AND AIMS

Barriers to drug adherence in the developing world are multifactorial and under evaluated. We aimed to evaluate predictive factors of medication adherence in Indian patients with inflammatory bowel disease (IBD) and association of adherence with quality of life (QOL) and relapse free remission.

MATERIALS AND METHODS

Adherence was assessed in consecutive IBD patients using a self-administered survey questionnaire including Morisky Medication Adherence Scale together with interview and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) to assess QOL. Logistic regression analysis was used to identify variables correlating with adherence, Cox proportional hazards method used for variables associated with relapse and Kaplan-Meier survival curve used for comparing relapse free remission in adherent and nonadherent.

RESULTS

A total of 467 consecutive outpatients (279 ulcerative colitis, 188 Crohn's disease, mean age 38.6 y) were mostly on mesalazine 439 (94%) or thiopurines 213 (46%). Self-reported nonadherence was noted in 236/467 (51%). Disease remission was associated with medication adherence [P=0.003, odds ratio (OR): 1.75, 95% confidence interval (CI): 1.21-2.52]. Medication-related factors like high dosing frequency (>3/d) (OR: 0.39, P=0.005) and concomitant non-IBD medications (OR: 0.44, P=0.007) were associated with nonadherence. Psychosocial factors associated with nonadherence were lack of drug information (OR: 0.30, P<0.001), feeling depressed (OR: 0.43, P<0.001), comorbidities (OR: 0.47, P=0.005), doubts about efficacy (OR: 0.49, P=0.001) and perceived poor QOL (OR: 0.61, P=0.01). High-cost perception was associated with nonadherence in univariate analysis (OR: 0.47, P<0.001) but lost significance on multivariate analysis (OR: 0.68, P=0.07). Physician imparting disease information (OR: 2.5, P=0.14) and physician reinforcement (OR: 1.8, P=0.049) were associated with adherence.Adherence was associated with improved QOL (SIBDQ, R=0.724). Nonadherence was associated with >3-fold risk of recurrence within 2 years (hazard ratio: 3.89, 95% CI: 2.74-5.52, P<0.001).

CONCLUSIONS

Nonadherence is common in Indian IBD patients but adherence is associated with improved QoL and lower probability of relapse. Psychosocial and medication-related factors are important determinants of adherence compared with demographic or clinical variables and should be addressed.

Inflammatory bowel diseases in Tamil Nadu: A survey of demographics, clinical profile, and practices

BACKGROUND

Inflammatory bowel disease (IBD) is increasingly diagnosed in South Asia. This survey by the Tamil Nadu Chapter of the Indian Society of Gastroenterology (TNISG) documents the demography, clinical profile, and therapeutic practices related to IBD in Tamil Nadu.

METHODS

TNISG members from 32 institutions completed an online cross-sectional questionnaire on IBD patients from March 2020 to January 2021.

RESULTS

Of 1295 adult IBD patients, 654 had Crohn's disease (CD), 499 ulcerative colitis (UC), and 42 IBD-unclassified (IBD-U). CD and UC showed a unimodal age distribution. A total of 55% were graduates or postgraduates. A positive family history was noted in 30, other risk factors were uncommon. In CD, the pattern of involvement was ileocolonic (42.8%), ileal (34.7%), colonic (18.9%), and upper gastrointestinal (3.5%); while in UC, disease was characterized as extensive (44.9%), left-sided (41.7%), or proctitis (13.4%). Perineal disease, perianal fistulae, and bowel obstruction were noted in 4.3, 14.0, and 23.5%, respectively, of CD. The most widely used drugs were mesalamine, azathioprine, and corticosteroids. Surgery was undertaken in 141 patients with CD and 23 patients with UC. Of the 138 patients with pediatric IBD (≤16 years), 23 were characterized as very early onset IBD (VEO-IBD), 27 as early-onset, and 88 as adolescent IBD. VEO-IBD were more likely to have a positive family history of IBD and were more likely to have perineal disease and to have the IBD-U phenotype. Among pediatric IBD patients, corticosteroids, mesalamine, and azathioprine were the most commonly used medications, while 25 pediatric patients received biologics.

CONCLUSION

This study provides important information on demography, clinical profile, and treatment practices of IBD in India.

Very early onset inflammatory bowel disease in a South Asian country where inflammatory bowel disease is emerging: a distinct clinical phenotype from later onset disease

BACKGROUND/AIMS

Information on pediatric inflammatory bowel disease (PIBD) and very early onset IBD (VEOIBD) are sparse in India, where IBD is emerging. We aimed to evaluate characteristics of VEOIBD and later onset PIBD (LO-PIBD) in India.

METHODS

We performed retrospective analysis of a large, prospectively maintained IBD registry. PIBD was divided in to VEOIBD ( < 6 years) and LO-PIBD (6-17 years). Demographic data, disease characteristics and treatment were compared between the PIBD groups and with other Asian/Western studies as well as the adult patients of the registry.

RESULTS

Of 3,752 IBD patients, 292 (7.8%) had PIBD (0-17 years) (175 Crohn's disease [CD], 113 ulcerative colitis [UC], 4 IBD-undifferentiated; 22 VEOIBD [7.5%], and 270 LO-PIBD [92.5%]). VEOIBD patients had more severe disease compared to LO-PIBD in both UC (P= 0.003) and CD (P< 0.001). Familial IBD was more common in VEOIBD (13.6%) compared to LO-PIBD (9.2%). Ileal disease (L1) was an independent risk factor for diagnostic delay in pediatric CD. Diagnostic delay ( > 6 months) was significantly lower in VEOIBD (40.9%) than in LO-PIBD (78.8%) (P< 0.001). Compared to other Asian and Western studies, extensive UC (72.5%) and complicated CD (stricturing/penetrating: 42.7%) were relatively more common. Perianal CD was relatively less frequent (7.4%). PIBD had a significantly higher number of complicated and ileal CD and extensive UC comparison to adult cohort of the registry.

CONCLUSIONS

VEOIBD has more aggressive phenotype than LO-PIBD. Disease appears distinct from other Asian and Western studies and adult onset disease, with more complicated CD and extensive UC.

Epidemiology and diagnosis of inflammatory bowel diseases

Background: Over the past three decades, inflammatory bowel diseases (IBD) have been rapidly increasing in the African, South American, and Asian countries, including Korea. However, in Korea, the public awareness of IBD remains low, and diagnostic delay is not uncommon due to the physicians' lack of clinical experience. It is essential to understand the trends and regional differences in the epidemiology of IBD for proper diagnosis and treatment.Current Concepts: Although lower than those of the West, the prevalence and incidence of IBD in Korea rank among the highest in Asia and are steadily increasing. In the past 10 years, the prevalence of IBD has almost doubled, while its incidence has decreased gradually. As compared to Western IBD patients, Korean patients have higher proportion of proctitis in ulcerative colitis, male predominance, more ileocolonic involvement, and higher incidence of perianal fistula in Crohn disease. There is no single gold standard for the diagnosis of IBD. Thus, diagnosis can be made by clinical evaluation, including a detailed history taking, physical examination, and a combination of endoscopic, radiologic, laboratory, and histologic findings.Discussion and Conclusion: Population-based studies have revealed the current trends and characteristics of the epidemiology of IBD in Korea. Continued education and development of diagnostic tools will help clinicians to diagnose IBD accurately and differentiate it from other diseases such as intestinal tuberculosis.

Paediatric inflammatory bowel disease in India: a prospective multicentre study

BACKGROUND

Paediatric inflammatory bowel disease (PIBD) is increasing across the world. However, information from India is sparse. This multicentre study evaluated the demographics, clinical phenotype and outcome of PIBD from India.

METHODS

Data of children (≤18 years) with PIBD were collected using a proforma containing details of demographics, clinical profile, extraintestinal manifestations (EIM), investigations, disease extent and treatment.

RESULTS

Three hundred twenty-five children [Crohn's disease: 65.2%, ulcerative colitis: 28.0%, IBD unclassified (IBDU): 6.7%, median age at diagnosis: 11 (interquartile range 6.3) years] were enrolled. 6.9% children had family history of IBD. Pancolitis (E4) was predominant in ulcerative colitis (57.8%) and ileocolonic (L3, 55.7%) in Crohn's disease. Perianal disease was present in 10.9% and growth failure in 20.9% of Crohn's disease cases. Steroids were the initial therapy in 84.2%, 5-amino salicylic acid in 67.3% and exclusive enteral nutrition (EEN) in 1.3% cases. Overall, immunomodulators and biologics were given to 84.3 and 17.9% cases, respectively, and 2.9% cases underwent surgery. Very early onset IBD (VEOIBD) was seen in 60 (19.2%) children. IBDU was commoner in the VEOIBD than the older-PIBD (18/60 vs 4/253; P < 0.001). VEOIBD-Crohn's disease patients more often had isolated colonic disease than the older Crohn's disease (45.4% vs 11.8%; P < 0.001). Prevalence of perianal disease, EIM, therapeutic requirements and outcome were not different between VEOIBD and older-PIBD.

CONCLUSION

Disease location and phenotype of PIBD in Indian children is similar to the children from the west. However, the therapeutic options of EEN, biologics and surgery are underutilized. VEOIBD accounted for 19.2% of PIBD.

Inflammatory bowel disease in India: challenges and opportunities

Evidence is emerging that inflammatory bowel diseases (IBDs) are becoming increasingly prevalent in developing countries, altering the previously held view that these were diseases of the West. Within this is a substantial increase in the burden of this disease in India, a matter of great importance to the country itself as well as in furthering our understanding of the disease. There is comparatively less data on this, both from the epidemiological standpoint as well as on disease pathogenesis in this particular cohort and is very much a subject matter of evolving understanding and research. This article aims to look at the changing global distribution of the disease and its implications. The Indian disease phenotype, and the aetiology of disease development will also be addressed with particular focus on differing pathogenetic processes in the Indian subpopulation, with consideration of what clues may be offered by the increasing incidence of the disease in this developing nation. Available evidence will be evaluated with the objective of providing a comprehensive overview of the development of IBD in India.