The incidence of inflammatory bowel disease in a rural region of Southern Germany: a prospective population-based study

Incidence, Paris classification, and follow-up in a nationwide incident cohort of pediatric patients with inflammatory bowel disease

OBJECTIVES

The aim of the study was to evaluate the incidence, baseline disease characteristics, and disease location based on the Paris classification in pediatric inflammatory bowel disease (IBD) in the Hungarian nationwide inception cohort. In addition, 1-year follow-up with therapy was analyzed.

METHODS

From January 1, 2007 to December 31, 2009, newly diagnosed pediatric patients with IBD were prospectively registered. Twenty-seven pediatric gastroenterology centers participated in the data collection ensuring the data from the whole country. Newly diagnosed patients with IBD younger than 18 years were reported. Disease location was classified according to the Paris classification.

RESULTS

A total of 420 patients were identified. The incidence rate of pediatric IBD was 7.48/10⁵ (95% confidence interval [CI] 6.34/10⁵-8.83/10⁵). The incidence for Crohn disease (CD) was 4.72/10⁵ (95% CI 3.82-5.79), for ulcerative colitis (UC) 2.32/10⁵ (95% CI 1.71-3.09), and for IBD-unclassified 0.45/10⁵ (95% CI 0.22-0.84). Most common location in CD was L3 (58.7%); typical upper gastrointestinal abnormalities (ulcer, erosion and aphthous lesion) were observed in 29.9%. Extensive colitis in patients with UC (E4, proximal to hepatic flexure) was the most common disease phenotype (57%), whereas only 5% of children had proctitis. A total of 18.6% of patients had ever severe disease (S1). Frequency of azathioprine administration at diagnosis was 29.5% in patients with CD, and this rate increased to 54.6% (130/238) at 1-year follow-up. In UC, only 3.3% received azathioprine initially, and this rate elevated to 22.5% (25/111). Use of corticosteroid decreased from 50% to 15.3% in patients with UC. Rate of bowel resection in patients with CD during the first year of follow-up was 5%.

CONCLUSIONS

The incidence of pediatric IBD in Hungary was among the higher range reported. This is the first large, nationwide incident cohort analyzed according to the Paris classification, which is a useful tool to determine the characteristic pediatric CD phenotype.

Incidence and natural history of ulcerative colitis in the Uppsala Region of Sweden 2005-2009 - results from the IBD cohort of the Uppsala Region (ICURE)

BACKGROUND AND AIMS

The incidence of ulcerative colitis (UC) increased during the 20th century in Western Europe and the North America, but there are conflicting reports whether the incidence has declined, stabilized or continued to increase. The aim of this study was to evaluate the incidence of UC in the Uppsala Region, Sweden.

METHODS

All new UC patients in Uppsala County (305,381 inhabitants) were prospectively registered during 2005-2006 and the same for all new UC patients in the Uppsala Region (642,117 inhabitants) during 2007-2009. The extent and severity of disease according to the Montreal classification, relapse rates and surgery were assessed.

RESULTS

526 UC patients were included. The mean overall incidence for the time period was 20.0 (95% CI: 16.1-23.9) cases per 100,000 inhabitants. The incidence among children <17 years of age was 8.9 per 100,000. The extent at diagnosis was evenly distributed (E1: n=167, 32%, E2: n=161, 31%, E3: n=163, 31%). Half of the cases had moderate to severe symptoms (S1: n=269, 51%, S2: n=209, 40%, S3: n=45, 8.6%). 228 (43%) relapsed and 13 (2.5%) required colectomy during the first year. Children had a higher proportion of extensive disease vs adults (27/42 vs 136/484), but no increased risk for severe symptoms or colectomy.

CONCLUSION

In this prospective population-based study we found one of the highest incidences of UC in the world. The proportion of severe cases is comparable with historical data. The conclusion is that the nature of UC has not changed, only the incidence.

Phenotype of inflammatory bowel disease at diagnosis in the Netherlands: a population-based inception cohort study (the Delta Cohort)

BACKGROUND

To describe the clinical characteristics of inflammatory bowel disease (IBD) at diagnosis in The Netherlands at the population level in the era of biologics.

METHODS

All patients with newly diagnosed IBD (diagnosis made between January 1, 2006 and January 1, 2007) followed in 9 general hospitals in the southwest of the Netherlands were included in this population-based inception cohort study.

RESULTS

A total of 413 patients were enrolled, of which 201 Crohn's disease (CD) (48.7%), 188 ulcerative colitis (UC) (45.5%), and 24 IBD unclassified (5.8%), with a median age of 38 years (range, 14-95). Seventy-eight patients with CD (38.8%) had ileocolonic disease and 73 patients (36.3%) had pure colonic disease. In 8 patients (4.0%), the upper gastrointestinal tract was involved. Nineteen patients with CD (9.5%) had perianal disease. Thirty-nine patients with CD (19.4%) had stricturing phenotype. Of the patients with UC and IBDU, 39 (18.4%) suffered from pancolitis and 61 (29%) from proctitis. Severe endoscopic lesions at diagnosis were seen in 119 patients (28.8%, 68 CD, 49 UC, and 2 IBDU), whereas 98 patients (23.7%) had severe histological disease activity. Thirteen patients (3.1%, 10 CD and 3 UC) had extraintestinal manifestations at diagnosis. Twenty-three patients (5.6%, 20 CD and 3 UC) had fistula at diagnosis.

CONCLUSIONS

In this cohort, 31% of the patients with CD had complicated disease at diagnosis, 39% had ileocolonic disease, 9.5% had perianal disease, and in 4% the upper gastrointestinal tract was involved. Most patients with UC suffered from left-sided colitis (51%). Severe endoscopic lesions were reported in 34% of the patients with CD and 26% of the patients with UC. Three percent of the patients with IBD had extraintestinal manifestations.

Management of the elderly patients with inflammatory bowel disease: practical considerations

The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.

The impact of JNK inhibitor D-JNKI-1 in a murine model of chronic colitis induced by dextran sulfate sodium

Purpose:

The c-Jun N-terminal kinases (JNK) are involved in the activation of T cells and the synthesis of proinflammatory cytokines. Several studies have established the relevance of the JNK pathway in inflammatory bowel diseases. The present study analyzed the therapeutic effect of D-JNKI-1, a specific JNK-inhibiting peptide, in a low-dose dextran sulfate sodium (DSS) model of chronic colitis.

Methods:

DSS colitis was induced in female C57/BL6 mice by cyclic administration using different concentrations of DSS (1.0% and 1.5%). Mice in the intervention groups received subcutaneous administration of 1 μg/kg D-JNKI-1 on days 2, 12, and 22. They were monitored daily to assess the severity of colitis, body weight, stool consistency, and the occurrence of occult blood or gross rectal bleeding using evaluation of the disease activity index. The animals were sacrificed after 30 days, and the inflamed intestine was histologically evaluated using a crypt damage score. Immunohistochemical quantification of CD4⁺ and CD8⁺ cells was also carried out.

Results:

Administration of 1 μg/kg D-JNKI-1 resulted in a significant decrease in the disease activity index (P = 0.013 for 1.0% DSS; P = 0.007 for 1.5% DSS). As a mild form of colitis was induced, histological examination did not show any distinct damage to the mucosa and crypts. However, expression of CD4⁺ and CD8⁺ cells was reduced in mice treated with D-JNKI-1 (not significant).

Conclusion:

Administration of D-JNKI-1 resulted in a clinical attenuation of chronic DSS colitis, and a therapeutic effect of D-JNKI-1 must therefore be assumed. The decrease in CD4⁺ and CD8⁺ cells may reflect the influence of D-JNKI-1 on T-cell activation, differentiation, and migration.

The burden of inflammatory bowel disease in Europe

Inflammatory bowel diseases (IBD) are chronic disabling gastrointestinal disorders impacting every aspect of the affected individual's life and account for substantial costs to the health care system and society. New epidemiological data suggest that the incidence and prevalence of the diseases are increasing and medical therapy and disease management have changed significantly in the last decade. An estimated 2.5-3 million people in Europe are affected by IBD, with a direct healthcare cost of 4.6-5.6 bn Euros/year. Therefore, the aim of this review is to describe the burden of IBD in Europe by discussing the latest epidemiological data, the disease course and risk for surgery and hospitalization, mortality and cancer risks, as well as the economic aspects, patients' disability and work impairment.

Incidence of inflammatory bowel disease in the province of Styria, Austria, from 1997 to 2007: a population-based study

BACKGROUND

The incidence of inflammatory bowel disease (IBD) varies widely between different countries. This large variation is also observed for the incidence of its main two forms, ulcerative colitis (UC) and Crohn's disease (CD). Controversy exists whether IBD incidence is increasing, especially in western countries. Currently no data are available for Austria. This study therefore aimed to evaluate for the first time the incidence of IBD over an eleven-year period in Styria, a province of Austria with a population of 1.2 million.

METHODS

All patients with an initial diagnosis of IBD between 1997 and 2007, who were Styrian residents, were eligible for this retrospective study. Data were acquired from electronically stored hospital discharge reports and individual reports by patients and physicians. According to population density Styria was divided into two rural and one urban area.

RESULTS

Throughout the study period 1527 patients with an initial diagnosis of IBD were identified. The average annual incidence was 6.7 (95% CI 6.2-7.1) per 100,000 persons per year for CD and 4.8 (95% CI 4.5-5.2) for UC. The average annual incidence increased significantly (p<0.01) for both diseases during the 11 year study period. Median age at initial diagnosis was 29 years (range 3-87) for CD and 39 years (range 3-94) for UC. At diagnosis, 8.5% of all IBD patients were <18 years of age. The incidence of both CD and UC was significantly higher in the urban area than in rural areas (CD: 8.8, 95% CI 7.8-9.8 versus 5.5, 95% CI 4.7-6.4 and 5.9, 95% CI 5.3-6.7; [p<0.001]; UC: 5.8, 95% CI 5.1-6.6 versus 4.0, 95% CI 3.4-4.7 and 4.7, 95% CI 4.1-5.4; [p=0.04]).

CONCLUSION

We observed an overall increase in the incidence of ulcerative colitis and Crohn's disease in a part of Austria during an eleven year period. IBD was more predominant in the largest urban area than in rural areas.

Rapidly increasing incidence of eosinophilic esophagitis in a large cohort

BACKGROUND

Recent literature has shown increasing incidence and prevalence rates of eosinophilic esophagitis (EoE). However, data are mainly based on small studies and come from centers dedicated to EoE. Aim of this study was to estimate the incidence rates of EoE by using a large database.

METHODS

We performed a cross-sectional study of the pathology reports describing esophageal eosinophilia from 1996 through 2010, using the nationwide network and registry of histo- and cytopathology in The Netherlands (PALGA). All histopathology reports nationwide enter this database. We classified cases according to the diagnosis made by the pathologist. Annual incidence rates of EoE were estimated.

KEY RESULTS

Our search criteria yielded 8838 positive pathology reports. Eosinophilic esophagitis was diagnosed in 674 patients, of which 74% were men. In another 174 patients, no distinction was made between eosinophilia caused by gastro-esophageal reflux disease or EoE. The incidence of EoE increased considerably over the years, being 0.01 in 1996, 0.01 in 2000, 0.14 in 2005, and 1.31 per 100,000 persons in 2010. Eosinophilic esophagitis was diagnosed in all age groups, but in 2010 the highest incidence was seen in 20-29 years old males, in whom it was estimated to be 3.23 per 100,000 persons. The incidence in children was 0.73 per 100,000 in 2010. No seasonal variation in diagnosis of EoE was observed.

CONCLUSIONS & INFERENCES

In this large study, we found robust data on increasing incidence rates of pediatric and adult EoE in the past 15 years. This rapidly increasing incidence has not reached a plateau yet.

High prevalence but insufficient treatment of iron-deficiency anemia in patients with inflammatory bowel disease: results of a population-based cohort

Background. Iron-deficiency anemia is described to be a common problem in patients with inflammatory bowel disease (IBD), which is frequently associated with a reduced quality of life. Therefore, the aim of this study is to assess the prevalence of iron deficiency anemia in a population-based cohort at time of first diagnosis and during the early course of the disease. Methods. As far as available, lab values of patients registered in the population-based “Oberpfalz cohort” were screened. In anemic patients, we further investigated all laboratory results to differentiate between iron deficiency and other reasons for anemia. All patients with any kind of anemia were interviewed separately according to symptoms of iron-deficiency anemia and administration of iron. Results. In total, we evaluated hemoglobin values of 279 patients (183 Crohn's disease, 90 ulcerative colitis, and 6 indeterminate colitis). Lab data which allowed further differentiation of the type of anemia were available in 70% of anemic patients, in 34.4% values of iron, ferritin and transferrin saturation had been measured. At time of first diagnosis, an iron-deficiency anemia was diagnosed in 26 of 68 patients with anemia (38.2%, 20 CD, 4 UC, and 2 IC patients), but only 9 patients (34.6%) received subsequent iron therapy. After one year, 27 patients were identified to have an iron-deficiency anemia (19 CD, 8 UC), 20 of them were treated with iron (71.4%). Of 9 patients with proven iron-deficiency anemia at time of first diagnosis and subsequent administration of iron, 5 (55.5%) had iron-deficiency anemia despite permanent treatment after one year. In total, 38 patients (54.3%) did not receive any iron substitution at all despite of proven iron-deficiency anemia, and only 13 patients of 74 patients were treated with intravenous iron (17.6%). Conclusion. We found a high prevalence of iron-deficiency anemia at different points during the early course of disease in this population-based cohort of IBD patients. Surprisingly, only in one-third of patients with proven anemia, further diagnostic approach was undertaken. Even patients with diagnosed iron-deficiency anemia were infrequently and inconsequently treated with iron preparations, despite the high impact on quality of life.

Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review

BACKGROUND & AIMS

We conducted a systematic review to determine changes in the worldwide incidence and prevalence of ulcerative colitis (UC) and Crohn's disease (CD) in different regions and with time.

METHODS

We performed a systematic literature search of MEDLINE (1950-2010; 8103 citations) and EMBASE (1980-2010; 4975 citations) to identify studies that were population based, included data that could be used to calculate incidence and prevalence, and reported separate data on UC and/or CD in full manuscripts (n = 260). We evaluated data from 167 studies from Europe (1930-2008), 52 studies from Asia and the Middle East (1950-2008), and 27 studies from North America (1920-2004). Maps were used to present worldwide differences in the incidence and prevalence of inflammatory bowel diseases (IBDs); time trends were determined using joinpoint regression.

RESULTS

The highest annual incidence of UC was 24.3 per 100,000 person-years in Europe, 6.3 per 100,000 person-years in Asia and the Middle East, and 19.2 per 100,000 person-years in North America. The highest annual incidence of CD was 12.7 per 100,000 person-years in Europe, 5.0 person-years in Asia and the Middle East, and 20.2 per 100,000 person-years in North America. The highest reported prevalence values for IBD were in Europe (UC, 505 per 100,000 persons; CD, 322 per 100,000 persons) and North America (UC, 249 per 100,000 persons; CD, 319 per 100,000 persons). In time-trend analyses, 75% of CD studies and 60% of UC studies had an increasing incidence of statistical significance (P < .05).

CONCLUSIONS

Although there are few epidemiologic data from developing countries, the incidence and prevalence of IBD are increasing with time and in different regions around the world, indicating its emergence as a global disease.

[Pregnancy under immunosuppression]

The desire to have children and pregnancy itself are important topics in the treatment of patients under immunosuppression. In this review the risks of frequently prescribed immunosuppressants are discussed regarding the safety of mother and child during and after pregnancy. Knowledge of the specific risks of immunosuppressants in pregnancy is important to balance the therapy between the patients' desire to be treated most effectively and to deliver a healthy child after an uncomplicated pregnancy. Generally, an interdisciplinary approach is advisable in treating and counseling immunosuppressed patients with a desire to have children and during pregnancy.

Female patients suffering from inflammatory bowel diseases are treated less frequently with immunosuppressive medication and have a higher disease activity: a subgroup analysis of a large multi-centre, prospective, internet-based study

BACKGROUND

The introduction of immunosuppressants and biologic agents has led to active debate and research about optimal therapeutic strategies considering risk factors and predictors of clinical outcome in inflammatory bowel disease (IBD). Data about gender-specific treatment differences and risk factors is lacking for IBD. The aim of the present study was to evaluate gender-related differences in the treatment of a distinct IBD patient population treated in the Rhein-Main region, Germany.

METHODS

Data about past medical history, disease status and medical treatment of 986 outpatients treated in ten gastroenterological practices and three hospitals were collected from November 1st 2005-July 31st 2007 and analyzed with regard to gender-related differences in therapy and disease management.

RESULTS

With the exception of an extended disease duration in women, no significant gender-related differences in demographic and clinical characteristics were observed. Men showed a significantly higher remission rate than women (p=0.025), while women received significantly less immunosuppressive medication compared to men (p=0.011). In addition, treatment with immunosuppressants was not different in women with child-bearing potential compared to menopausal women.

CONCLUSION

Our investigation demonstrates for the first time gender-specific differences in the therapeutic management in a large cohort of IBD patients.

Medical and surgical therapy of inflammatory bowel disease in the elderly - prospects and complications

Population ageing is a global phenomenon. People aged 65 years and older comprise approximately 16% of the population of Europe. The medical management of elderly patients with inflammatory bowel disease (IBD) is challenging with respect to diagnosis, pharmaceutical and surgical treatment, and complications. IBD has a late onset in 10%-15% of patients, with the first flare occurring at 60 to 70 years of age; others suffer from the disease for several decades. Even though the natural course of the disease in geriatric populations and the diagnostic options may not differ much from those in younger patients, distinct problems exist in the choice of medical therapy. Recommended clinical practise has been rapidly evolving towards an intensified initial treatment in IBD. However, in patients older than 65 years, a gentler approach should be used, and a combination of immunosuppressive agents should be avoided because of increased risk of infectious and neoplastic complications. Furthermore, elderly patients with severe IBD show prolonged, complicated post-operative clinical courses with worse hospital outcomes, so early surgical intervention for elderly patients is recommended. This article provides an overview of elderly IBD patient care, including medical and surgical therapeutic considerations and emphasises the necessity of close collaborations between gastroenterologists and surgeons.

Epidemiology and natural history of inflammatory bowel diseases

In the West, the incidence and prevalence of inflammatory bowel diseases has increased in the past 50 years, up to 8-14/100,000 and 120-200/100,000 persons, respectively, for ulcerative colitis (UC) and 6-15/100,000 and 50-200/100,000 persons, respectively, for Crohn's disease (CD). Studies of migrant populations and populations of developing countries demonstrated a recent, slow increase in the incidence of UC, whereas that of CD remained low, but CD incidence eventually increased to the level of UC. CD and UC are incurable; they begin in young adulthood and continue throughout life. The anatomic evolution of CD has been determined from studies of postoperative recurrence; CD begins with aphthous ulcers that develop into strictures or fistulas. Lesions usually arise in a single digestive segment; this site tends to be stable over time. Strictures and fistulas are more frequent in patients with ileal disease, whereas Crohn's colitis remains uncomplicated for many years. Among patients with CD, intestinal surgery is required for as many as 80% and a permanent stoma required in more than 10%. In patients with UC, the lesions usually remain superficial and extend proximally; colectomy is required for 10%-30% of patients. Prognosis is difficult to determine. The mortality of patients with UC is not greater than that of the population, but patients with CD have greater mortality than the population. It has been proposed that only aggressive therapeutic approaches, based on treatment of early recurrent lesions in asymptomatic individuals, have a significant impact on progression of these chronic diseases.

5-aminosalicylates prevent relapse of Crohn's disease after surgically induced remission: systematic review and meta-analysis

OBJECTIVES

Evidence from randomized controlled trials (RCTs) for the use of 5-aminosalicylic acid (5-ASA) drugs in Crohn's disease (CD) in remission after a surgical resection is conflicting. We conducted a systematic review and meta-analysis of RCTs to examine this issue.

METHODS

MEDLINE, EMBASE, and the Cochrane central register of controlled trials were searched (through April 2010). Eligible trials recruited adults with luminal CD in remission after a surgical resection and compared 5-ASAs with placebo, or no treatment. Dichotomous data were pooled to obtain relative risk (RR) of relapse of disease activity, with a 95% confidence interval (CI). The number needed to treat (NNT) was calculated from the reciprocal of the risk difference.

RESULTS

The search strategy identified 3,061 citations. Eleven RCTs were eligible for inclusion containing 1,282 patients. The RR of relapse of CD in remission after surgery with 5-ASA vs. placebo or no therapy was 0.86 (95% CI=0.74-0.99) (NNT=13). Sulfasalazine was of no benefit in preventing relapse in 448 patients (RR=0.97; 95% CI=0.72-1.31), but mesalamine was more effective than placebo or no therapy (RR=0.80; 95% CI=0.70-0.92) in 834 patients, with an NNT of 10.

CONCLUSIONS

Mesalamine is of modest benefit in preventing relapse of CD in remission after surgery. Its use should be considered in those in whom immunosuppressive therapy is either not warranted or contraindicated.

Epidemiology of pediatric inflammatory bowel disease: a systematic review of international trends

BACKGROUND

Temporal trends in the incidence of pediatric-onset inflammatory bowel disease (IBD) are controversial and a wide range of estimates have been reported worldwide. We conducted a systematic review of research describing the epidemiology of childhood-onset IBD to assess changes in incidence rates over time and to evaluate international differences.

METHODS

The following electronic databases were searched for articles published 1950-2009: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane IBD/Functional Bowel Disorders Group Specialised Trial Register. All included studies reported incidence or prevalence of IBD, Crohn's disease (CD) or ulcerative colitis (UC). Two authors independently completed the data extraction form for each eligible study. Choropleth maps demonstrated the international incidence of IBD, CD, and UC. Incidence of CD and UC was graphed using data from studies reporting rates in multiple time periods.

RESULTS

The search yielded 2209 references and review resulted in 139 included studies from 32 countries. A wide range of incidence was reported internationally; however, rates of IBD were not described in most countries. Twenty-eight studies (20.1%) used statistical analysis to assess trends over time, and 77.8% reported statistically significantly increased incidence of pediatric IBD. Of studies calculating statistical trends in CD incidence, 60% reported significantly increased incidence. Of similar UC studies, 20% reported significantly increased incidence.

CONCLUSIONS

Globally rising rates of pediatric IBD (due primarily to the rising incidence of CD) was demonstrated in both developed and developing nations; however, most countries lack accurate estimates. Analyzing incidence trends may help identify specific environmental and genetic risk factors for pediatric IBD.

Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease--review of the literature

BACKGROUND

Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence.

METHODS

We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP.

RESULTS

The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months.

CONCLUSION

Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.

Circulating levels of chemerin and adiponectin are higher in ulcerative colitis and chemerin is elevated in Crohn's disease

BACKGROUND

Chemerin is an adipokine that stimulates chemotaxis of cells of the innate immune system. Inflammatory bowel disease (IBD) is linked to an impaired immune response and, therefore, we hypothesized that systemic chemerin may be altered in IBD patients.

METHODS

Serum was collected from patients with Crohn's disease (CD, 230 patients), ulcerative colitis (UC, 80 patients), and healthy controls (HC, 80 probands). Chemerin and adiponectin, which has already been measured in the serum of similar cohorts by others, were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Chemerin was elevated in IBD compared to HC and was higher in male CD than UC patients. Female and male CD patients had lower adiponectin levels compared to UC, and adiponectin was lower in female CD patients compared to female HC. Adiponectin tended to be higher in female and male UC patients compared to HC and this difference became significant in the whole study group. Correlations with disease activity were only found in males. Here, chemerin was higher in CD patients on remission but was reduced in UC with nonactive disease. Adiponectin was higher in UC with inactive disease. Treatment with corticosteroids was linked to elevated adiponectin in male CD patients and higher chemerin in female UC patients. Unlike adiponectin, which was elevated in female serum in all cohorts, chemerin was only higher in female UC patients.

CONCLUSIONS

These findings further indicate potential regulatory functions of adipokines in intestinal inflammation that are partly gender-dependent and that may even be associated with the distinct immunopathogenesis of UC and CD.

Ulcerative colitis in the Tuzla region of Bosnia and Herzegovina between 1995 and 2006: epidemiological and clinical characteristics

BACKGROUND

Bosnia and Herzegovina (B&H) is one of the Eastern European countries that lacks data on the epidemiology of ulcerative colitis (UC).

AIMS

We aimed to assess the epidemiological and clinical characteristics of UC in Tuzla Canton of B&H during a 12-year period (1995-2006).

PATIENTS AND METHODS

We retrospectively evaluated hospital records of both UC inpatients and outpatients residing in Tuzla Canton of B&H (total of 496 280 inhabitants) between 1995 and 2006. Patients that firmly satisfied the diagnostic criteria for UC were included in the study. Incidence rates were calculated with age standardization using European population standards. Trends in incidence were evaluated as moving 3-year averages.

RESULTS

During the observed period, 214 patients met the diagnostic criteria for UC. The average age-standardized incidence was found to be 3.43/10 inhabitants [95% confidence interval (CI) = 2.97-3.89], ranging from 0.22 to 7.44 per 10. The mean annual crude incidence in the last 5 years of study (2002-2006) was 5.55/10 (95% CI = 4.63-6.48). The prevalence of UC during the observed period was found to be 43.1/10 (95% CI = 37.3-48.8). The incidence of UC increased dramatically from the average of 1.01/10 in the period between 1995 and 1997 to 6.04/10 between 2004 and 2006, as did the number of colonoscopies performed, from 29 in 1995 to 850 in 2006. The average yearly incidence of confirmed UC cases detected on colonoscopy was 5.56 per 100 colonoscopies per year (95% CI = 4.81-6.30) and only 3.92 per 100 colonoscopies (95% CI = 3.26-4.57) in the last 5 years of the observed period.

CONCLUSION

Tuzla Canton of B&H is a region with an increasing incidence of UC, which is most likely a direct consequence of a wider use of colonoscopy. We believe that in the next few years, the incidence of UC in this region will probably reach the annual incidence rate of 6 per 10 inhabitants.

Natural history and complications of IBD

Inflammatory bowel diseases (IBD), mainly ulcerative colitis and Crohn's disease, are chronic, heterogenic, lifelong illnesses with young age of onset and a great potential for disability. The natural history of these diseases is influenced by multiple factors of environmental and genetic origin. Multidisciplinary research has increased our knowledge of the mechanisms involved during the development and outcome of the diseases, including disease complications. Immunomodulatory treatment has demonstrated greatly improved efficacy in moderate to severe disease activity. The long-term effect on the natural course of disease and sustained reduced burden on society over many years require study. This article summarizes recent knowledge on factors influencing the natural history of IBD, including the impact of treatment. Increased understanding of disease mechanisms is needed as a basis for new treatment strategies in the future.

Inflammatory bowel disease in the elderly

This article reviews the epidemiology, clinical manifestations, diagnosis, prognosis, and treatment of inflammatory bowel disease (IBD), which will grow in prevalence as the population ages. Prognosis of late-onset ulcerative colitis (UC) is generally similar to that of early-onset UC, whereas in Crohn disease it is probably better because of a tendency for colonic involvement. Disease complications are related more to the duration of the inflammatory bowel disease than the subject's current age. The diagnosis in elderly patients can be challenging due to the large number of conditions that mimic IBD on radiologic, endoscopic, and histologic testing. Distinguishing these conditions from IBD will significantly alter prognosis and treatment. Complications related to IBD and its treatment are common and must be recognized early to limit their impact in a vulnerable elderly population.

Inflammatory Bowel Disease in South Limburg (the Netherlands) 1991-2002: Incidence, diagnostic delay, and seasonal variations in onset of symptoms

BACKGROUND AND AIMS

Increasing incidence in Inflammatory Bowel Disease (IBD) has been suggested. Recent data on population based incidence rates within Europe are however scarce. Primary aim was to investigate prospectively the incidence of IBD within a well-defined geographical and administrative area of the Netherlands, the South Limburg IBD registry. Secondary aims were to study the duration of symptoms before diagnosis (lag time) and seasonal influences on the incidence of IBD.

METHODS

The incidence was examined using standardized registration of all newly diagnosed IBD patients, between 1-1-1991 and 1-1-2003. Medical records were reviewed to verify the diagnosis. At inclusion, diagnostic lag time was registered in months.

RESULTS

Age standardized incidence rates per 100,000 person-years (p-y) were: Crohn's Disease, male 4.84, female 7.58; Ulcerative Colitis, male 8.51, female 6.92; and Indeterminate Colitis, male 1.05, female 0.93. Incidence rates did not significantly changes over time in either Crohn's Disease, Ulcerative Colitis or Indeterminate Colitis. Lag time was 5 (0-360) months in Crohn's Disease, 3.0 (0-480) months in Ulcerative Colitis and 3.0 (0-180) months in Indeterminate Colitis. Lag time was not significantly different between the periods 1991-1993 and 2000-2002, and no statistical differences in the onset of symptoms per calendar month or season were found.

CONCLUSIONS

Our results, from the South Limburg region (the Netherlands), show no significant change in incidence rates of IBD. The incidence found is relatively high compared to other European countries. Lag time did not change during the study period, and seasonal influence of incidence rates could not be confirmed.