Trends in incidence rates of ulcerative colitis and Crohn's disease

The role of gut microbiota and probiotics in preventing, treating, and boosting the immune system in colorectal cancer

The gut microbiome plays a significant role in developing colorectal cancer (CRC). The gut microbiome usually acts as a protective barrier against harmful pathogens and infections in the intestine, while also regulating inflammation by affecting the human immune system. The gut microbiota and probiotics play a role not only in intestinal inflammation associated with tumor formation but also in regulating anti-cancer immune response. As a result, they associated with tumor progression and the effectiveness of anti-cancer therapies. Research indicates that gut microbiota and probiotics can be used as biomarkers to predict the impact of immunotherapy and enhance its efficacy in treating CRC by regulating it. This review examines the importance of gut microbiota and probiotics in the development and progression of CRC, as well as their synergistic impact on anti-cancer treatments.

Correlation of Socioeconomic and Environmental Factors With Incidence of Crohn Disease in Children and Adolescents: Systematic Review and Meta-Regression

BACKGROUND

The worldwide incidence of Crohn disease (CD) in childhood and adolescence has an increasing trend, with significant differences between different geographic regions and individual countries. This includes an increase in the incidence of CD in countries and geographic regions where CD was not previously prevalent. In response to the increasing incidence, the pediatric care landscape is facing growing challenges.

OBJECTIVE

This systematic review and meta-analysis were undertaken to comprehensively delineate the incidence rates of CD in pediatric populations across different countries and to explore potential influencing factors.

METHODS

We performed a systematic review of PubMed and Embase (via Ovid) for studies from January 1, 1970, to December 31, 2019. In addition, a manual search was performed in relevant and previously published reviews. The results were evaluated quantitatively. For this purpose, random effects meta-analyses and meta-regressions were performed to investigate the overall incidence rate and possible factors influencing the incidence.

RESULTS

A qualitative synthesis of 74 studies was performed, with 72 studies included in the meta-analyses and 52 in the meta-regressions. The results of our meta-analysis showed significant heterogeneity between the individual studies, which cannot be explained by a sample effect alone. Our findings showed geographical differences in incidence rates, which increased with increasing distance from the equator, although no global temporal trend was apparent. The meta-regression analysis also identified geographic location, UV index, and Human Development Index as significant moderators associated with CD incidence.

CONCLUSIONS

Our results suggest that pediatric CD incidence has increased in many countries since 1970 but varies widely with geographic location, which may pose challenges to the respective health care systems. We identified geographic, environmental, and socioeconomic factors that contribute to the observed heterogeneity in incidence rates. These results can serve as a basis for future research. To this end, implementations of internationally standardized and interoperable registries combined with the dissemination of health data through federated networks based on a common data model, such as the Observational Medical Outcomes Partnership, would be beneficial. This would deepen the understanding of CD and promote evidence-based approaches to preventive and interventional strategies as well as inform public health policies aimed at addressing the increasing burden of CD in children and adolescents.

TRIAL REGISTRATION

PROSPERO International prospective register of systematic reviews CRD42020168644; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168644.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-037669.

Should the Mediterranean diet be recommended for inflammatory bowel diseases patients? A narrative review

Inflammatory bowel diseases (IBD) are chronic, progressive and relapsing inflammatory disorders of unknown etiology that may cause disability over time. Data from epidemiologic studies indicate that diet may play a role in the risk of developing and the course of IBD. It is known that the group of beneficial bacteria was reduced in the IBD and that the Mediterranean diet (MD)-which is defined as eating habits characterized by high consumption of plant foods, mainly cereals, vegetables, fruit as well as olive oil, and small portions of dairy products, sweets, sugar and meat products-affects gut microbiota, enriching beneficial bacteria, which support gut barrier function and reduce inflammation. Although several studies support different favorable effects of MD on IBD, adherence to MD by IBD patients is generally low, including patients from the Mediterranean Basin. Patients avoid many products which are elements of MD because there cause gastrointestinal symptoms. Patients should be encouraged to have a healthy and well-balanced diet according to individual tolerance of products. A good option seems to be good modified MD, changing hard-to-digest products to easy digest.

Nonlinear Association between Serum 25-Hydroxyvitamin D and All-Cause Mortality in Adults with Inflammatory Bowel Disease in a Prospective Cohort Study

BACKGROUND

Nonlinear association between serum 25-hydroxyvitamin D [25(OH)D] concentration and all-cause mortality has been widely reported for the general population, but this association has not been quantified for individuals with inflammatory bowel disease (IBD).

OBJECTIVES

The aim was to explore the association between serum 25(OH)D and all-cause mortality in individuals with IBD.

METHODS

We identified 2690 females and 2532 males aged 40-69 y with diagnosed IBD at baseline in the UK Biobank. Serum 25(OH)D concentration was measured by direct competitive chemiluminescent immunoassay. The outcome was all-cause mortality, ascertained via the death registry. Cox proportional hazard regression was used to evaluate associations between serum 25(OH)D in quintiles and all-cause mortality among individuals with IBD [Crohn disease (CD; n = 1760) and ulcerative colitis (UC; n = 3462)]. Restricted cubic splines were used to investigate potential nonlinearity.

RESULTS

During the mean follow-up period of 11.9 y, 529 deaths (198 in CD and 331 in UC) were documented among 5222 individuals with IBD. Compared with the lowest quintile of serum 25(OH)D, HRs for the second to the highest quintiles were 0.82 (95% CI: 0.63, 1.06), 0.63 (95% CI: 0.47, 0.83), 0.64 (95% CI: 0.48, 0.85), and 0.74 (95% CI: 0.55, 0.99), respectively. Nonlinearity was detected in the dose-response association between serum 25(OH)D concentration and all-cause mortality (P-nonlinearity < 0.001), and 25(OH)D concentrations of 44-78 nmol/L were associated with a 50% lower risk of all-cause mortality (than 10 nmol/L). Subgroup analyses showed that the nonlinear association mostly applied to females (P-nonlinearity < 0.001 compared with 0.080 in males).

CONCLUSIONS

We observed a nonlinear association, mostly applicable to females, between serum 25(OH)D concentrations and all-cause mortality among individuals with IBD. A 25(OH)D concentration range of 44-78 nmol/L can serve as a starting point for future research to confirm recommended 25(OH)D concentrations for individuals with IBD.

Cutaneous Manifestations of Inflammatory Bowel Disease: A Basic Overview

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal (GI) tract that is subdivided into Crohn's disease (CD) and ulcerative colitis (UC). CD is characterized by involvement of the entire GI tract, while UC mainly affects the distal GI tract. Moreover, both CD and UC can present with extraintestinal manifestations (EIMs) of the disease affecting multiple organ systems including the hepatobiliary tract, kidney, bones, eyes, joints, and skin. These complications can cause significant morbidity and negatively impact the quality of life for IBD patients. Although the pathogenesis of EIMs is not clearly elucidated, it is postulated that the diseased GI mucosa similarly stimulates excess immune responses at the extraintestinal sites. Cutaneous EIMs occur in up to 15% of patients with IBD, often predating their IBD diagnosis. They are categorized into (1) specific, (2) reactive, (3) associated, and (4) treatment-induced. Here, we review the epidemiological, clinical, diagnostic, and histologic features of the most commonly described cutaneous EIMs of IBD along with their respective treatment options.

Biologic monotherapy versus combination therapy with immunomodulators in the induction and maintenance of remission of Crohn's disease and ulcerative colitis

Despite current guidelines, the optimal treatment of patients with inflammatory bowel disease (IBD) remains challenging. The available medications are not without risk and there is not a single correct treatment regimen for every patient. Personalizing treatment and selecting the most appropriate therapy is crucial for optimal response, remission, quality of life, and healthcare utilization. Biologics, especially anti-tumor necrosis factor-α medications, are widely used in the induction and maintenance of disease remission in patients with IBD. Similarly, immunomodulators, including thiopurines and methotrexate, are traditionally popular for the maintenance of remission. In this manuscript, we review the use of biologic monotherapy vs. combination therapy with immunomodulators for the treatment of ulcerative colitis and Crohn’s disease. We examine overall remission, immunogenicity and adverse effects, mainly serious infections and malignancy, in an effort to help guide treatment decisions and weigh the risks and benefits of biologic monotherapy vs. combination therapy.

Rates of inflammatory bowel disease in Hispanics comparable to non-Hispanic Whites: results of a cohort study

PURPOSE

Previous studies have suggested that inflammatory bowel disease (IBD) occurs at higher rates among non-Hispanic Whites (NHWs) compared to other ethnicities; however, Hispanics as the largest minority in the United States remain underrepresented in IBD research and we hypothesize that they have similar rates of IBD. We examined the epidemiology, demographics, clinical presentation, and treatment of IBD in a predominantly Hispanic cohort in Los Angeles (LA) County.

METHODS

This was a retrospective cohort study based at Olive View-UCLA Medical Center, one of the three major safety-net hospitals in LA County. Electronic medical records from 2015 to 2018 were queried, and biopsy-proven cases of IBD (n = 170) were identified. Outcomes included the incidence and prevalence of IBD, disease distribution, treatment, and IBD-related surgery.

RESULTS

The incidence of IBD among Hispanics was 175 (95% confidence interval [CI] 127-240) and 113 (95% CI 62-200) for NHWs per 100,000 person-years. Prevalence of IBD per 100,000 people was 418 (95% CI 341-512) for Hispanics and 557 (95% CI 431-739) for NHWs. Notably, the proportion of Hispanic IBD patients with a history of smoking was 21.5% vs 50.8% in NHWs (p = 0.011). There were no significant differences between the two groups with regard to Montreal classification, pharmacotherapy, or IBD-related surgery.

CONCLUSIONS

In one of the largest US studies of Hispanics with IBD, and the only one to have both clinical and histopathologic confirmation as inclusion criteria, we found the incidence and prevalence of IBD among Hispanics to be higher than previously recognized and comparable to NHWs. Additionally, Hispanic IBD patients had lower rates of smoking compared to NHWs.

Systematic review and meta-analysis of the incidence and prevalence and 30-year trend of inflammatory bowel diseases in Asia: a study protocol

INTRODUCTION

Inflammatory bowel diseases, including ulcerative colitis (UC), Crohn's disease (CD) and inflammatory bowel disease type unclassified (IBDU), are debilitating conditions that are rapidly growing in developing countries. Given the absence of a comprehensive systematic review and meta-analysis containing a rigorous pooled estimate of incidence and prevalence of UC, CD and IBDU, this study was conducted to determine the incidence and prevalence of these conditions in Asia and their 30-year trend.

METHODS AND ANALYSIS

Based on predefined criteria, electronic databases, including PubMed/MEDLINE, Scopus, WoS (Clarivate Analytics), Embase and Google Scholar, and some databases pertaining to Asian countries will be searched for population-based cross-sectional studies and the baseline data and final reports of population-based cohort studies involving paediatric and adult patients, with no language restrictions, from 1 January 1988 to 30 December 2018. Any disagreement in the stages of screening, selecting, quality assessment and data extraction between the two independent reviewers will be resolved by consensus, and if the disagreement is not resolved, a third expert opinion will be sought. The combination method will be used based on methodological similarities in the included studies by the Fixed Effect Model or the Random Effect Model. Forest plots will be plotted for all the studies to show the separated and pooled incidence and prevalence and their corresponding 95% CIs. The Q-statistic test and I² statistic will be used to assess statistical heterogeneity. Funnel plots will be used to assess potential reporting bias and nonsignificant study effect. Begg's and Egger's tests will also be performed, and significant results (p>0.1) shall suggest a publication bias, in which case the 'trim and fill' method will be used. The time trends for UC, CD and IBDU will be calculated using a cumulative meta-analysis.

ETHICS AND DISSEMINATION

Since this review will use previously published studies, it will not require the consent of an Ethics Committee. The results will be prepared and disseminated through a peer-reviewed journal and will be presented in relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42019131477.

Gut Barrier Dysfunction-A Primary Defect in Twins with Crohn's Disease Predominantly Caused by Genetic Predisposition

BACKGROUND AND AIMS

The aetiology of Crohn's disease is poorly understood. By investigating twin pairs discordant for Crohn's disease, we aimed to assess whether the dysregulated barrier represents a cause or a consequence of inflammation and to evaluate the impact of genetic predisposition on barrier function.

METHODS

Ileal biopsies from 15 twin pairs discordant for Crohn's disease [monozygotic n = 9, dizygotic n = 6] and 10 external controls were mounted in Ussing chambers to assess paracellular permeability to 51Chromium [Cr]-EDTA and trancellular passage to non-pathogenic E. coli K-12. Experiments were performed with and without provocation with acetylsalicylic acid. Immunofluorescence and ELISA were used to quantify the expression level of tight junction proteins.

RESULTS

Healthy co-twins and affected twins displayed increased 51Cr-EDTA permeability at 120 min, both with acetylsalicylic acid [p < 0.001] and without [p < 0.001] when compared with controls. A significant increase in 51Cr-EDTA flux was already seen at 20 min in healthy monozygotic co-twins compared with controls [p≤0.05] when stratified by zygosity, but not in healthy dizygotic co-twins. No difference in E. coli passage was observed between groups. Immunofluorescence of the tight junction proteins claudin-5 and tricellulin showed lower levels in healthy co-twins [p < 0.05] and affected twins [p < 0.05] compared with external controls, while ELISA only showed lower tricellulin in Crohn's disease twins [p < 0.05].

CONCLUSION

Our results suggest that barrier dysfunction is a primary defect in Crohn's disease, since changes were predominantly seen in healthy monozygotic co-twins. Passage of E. coli seems to be a consequence of inflammation, rather than representing a primary defect.

Very early onset inflammatory bowel disease

Very early onset inflammatory bowel disease (VEO-IBD) represents a unique and growing subset of patients with inflammatory bowel disease (IBD). Some VEO-IBD patients present with immunodeficiency and possess loss of function genetic mutations involving immune pathways that cause their IBD. A search for Mendelian causes of IBD is likely most beneficial when the presentation involves extra-intestinal autoimmunity or involves intestinal histopathology that is atypical for IBD. While a subset of these young patients will have highly aggressive courses (and likely present with immunodeficiency), the majority of patients with VEO-IBD appear to have disease courses similar to that of their older counterparts. Most notably, many of these young children will require long courses of immunosuppression simply as a result of the profoundly early presentation-thus increasing their long-term risks of cancer and opportunistic infections.

Assessment of corticosteroid-related quality of care measures for ulcerative colitis and Crohn's disease in the United States: a claims data analysis

OBJECTIVE

To evaluate corticosteroid (CS)-related quality of care indicators in patients with ulcerative colitis (UC) and Crohn's disease (CD) in the US.

METHODS

Adults diagnosed with UC or CD and prescription fills for an oral CS were identified from a large commercial US claims database (2005-2013). Quality indicators included prolonged CS use (≥60 days), use of CS-sparing therapy, and bone loss assessment. State-level variations in quality of care indicators were estimated using logistic regression models adjusting for age, gender, insurance plan type, and CD severity.

RESULTS

Of the 25,063 UC and 22,155 CD patients receiving CS, 16.1% and 12.6%, respectively, were prolonged CS users. Among prolonged CS users, 52.5% of UC and 68.2% of CD patients used CS-sparing therapy. Bone loss assessment was observed in 11.0% of UC patients with prolonged CS use and 7.7% of newly diagnosed CD patients. Prolonged CS use was the lowest in Kentucky (odds ratio [OR] = 0.59) and the highest in Wisconsin (OR = 1.41) for UC patients; the lowest in North Carolina and New York (both OR = 0.71) and the highest in Utah (OR = 2.42) for CD patients. CS-sparing therapy use was the lowest in Delaware (OR = 0.42) and the highest in Michigan (OR = 0.83) for UC patients; it was significantly different only in South Carolina (OR = 0.57) for CD patients. Bone loss assessment rates were the highest in Arizona (OR = 1.83) for UC patients and were the lowest in Mississippi (OR = 0.52) and the highest in Texas (OR = 1.51) for CD patients.

LIMITATIONS

Information on disease severity was not available in the database.

CONCLUSIONS

Significant regional variations in all three quality indicators were observed across the US.

HLA-C*01 is a Risk Factor for Crohn's Disease

BACKGROUND

A dysregulated mucosal immune response to the intestinal environment in a genetically susceptible host is hypothesized to be critical to the pathogenesis of Crohn's disease (CD). Therefore, we examined CD-susceptibility genes involved in the immune response through a genome-wide association study and consecutive genotyping of human leukocyte antigens (HLAs) and killer cell immunoglobulin-like receptors.

METHODS

An initial genome-wide association study was performed with 275 CD patients and 2369 controls from a Korean population. To validate the loci identified in the genome-wide association study, replication genotyping was performed in a different cohort of 242 CD patients and 1066 controls. Finally, high-resolution genotyping of HLA and killer cell immunoglobulin-like receptor was performed.

RESULTS

Four susceptibility loci, a promoter region in tumor necrosis factor (ligand) superfamily member (TNFSF15) and 3 independent regions in HLAs, showed significant associations with CD. Among them, rs114985235 in the intergenic region between HLA-B and HLA-C showed the strongest association, with an increased risk of CD (P = 8.71 × 10; odds ratio, 2.25). HLA typing in this region showed HLA-C*01 to be responsible for the association of CD among 43 HLA-B and HLA-C genotypes identified in the Korean population. However, the interaction of HLA-C with killer cell immunoglobulin-like receptor had little effect on the development of CD.

CONCLUSIONS

We newly identified HLA-C*01 as a prominent CD-susceptibility HLA allotype in the Korean population. In addition, these results confirm that genetic variations in immune response genes, such as HLAs and TNFSF15, are important host factors for the pathogenesis of CD.

Impact of metabolic syndrome on the hospitalization rate of Crohn's disease patients seen at a tertiary care center: a retrospective cohort study

BACKGROUND/AIMS

Recent studies suggest that markers of mesenteric inflammation, such as increased adipose tissue, may be associated with poor outcomes in Crohn's disease (CD). This study's hypothesis is that CD patients with metabolic syndrome (MetS) have more CD-related hospitalizations than CD patients without MetS.

METHODS

We conducted a retrospective cohort study of CD patients seen from 2000 to 2012 at our tertiary care center. We analyzed crude and age-, sex- and duration of CD-adjusted incidence rate ratio (IRR) of CD-related hospitalization of those with MetS versus those without MetS. We also investigated possible associations between individual component conditions of MetS and rate of CD-related hospitalization.

RESULTS

A total of 868 CD patients were included. There were 37 (4%) patients with MetS at initial observation. After multi-variable adjustment, patients with MetS had a CD-related hospitalization rate twice that of those who did not have MetS. High triglycerides (TG), low high density lipoprotein (HDL) cholesterol and diabetes mellitus (DM) were associated with increased risk of CD-related hospitalization.

CONCLUSIONS

CD patients with MetS have a higher rate of CD-related hospitalization compared to those without MetS. Hypertriglyceridemia, low HDL cholesterol and DM may be good markers of local and systemic inflammation as seen in CD.

The association between race and Crohn's disease phenotype in the Western Cape population of South Africa, defined by the Montreal Classification System

Background

Inter-racial differences in disease characteristics and in the management of Crohn's disease (CD) have been described in African American and Asian subjects, however for the racial groups in South Africa, no such recent literature exists.

Methods

A cross sectional study of all consecutive CD patients seen at 2 large inflammatory bowel disease (IBD) referral centers in the Western Cape, South Africa between September 2011 and January 2013 was performed. Numerous demographic and clinical variables at diagnosis and date of study enrolment were identified using an investigator administered questionnaire as well as clinical examination and patient case notes. Using predefined definitions, disease behavior was stratified as ‘complicated’ or ‘uncomplicated’.

Results

One hundred and ninety four CD subjects were identified; 35 (18%) were white, 152 (78%) were Cape Coloured and 7(4%) were black. On multiple logistic regression analysis Cape Coloureds were significantly more likely to develop ‘complicated’ CD (60% vs. 9%, p = 0.023) during the disease course when compared to white subjects. In addition, significantly more white subjects had successfully discontinued cigarette smoking at study enrolment (31% vs. 7% reduction, p = 0.02). No additional inter-racial differences were found. A low proportion of IBD family history was observed among the non-white subjects.

Conclusions

Cape Coloured patients were significantly more likely to develop ‘complicated’ CD over time when compared to whites.

CT and MR enterography in children and adolescents with inflammatory bowel disease

The term inflammatory bowel disease (IBD) is used to describe multiple idiopathic disorders of the gastrointestinal tract. As many as one-quarter of patients with IBD initially present in childhood or adolescence. Multiple methods can be used to diagnose IBD in this age group, including computed tomographic (CT) enterography, magnetic resonance (MR) enterography, small bowel follow-through examination, ileocolonoscopy, and capsule endoscopy. However, CT enterography and MR enterography have become the imaging modalities of choice due to their exquisite image quality, rapid acquisition time, lack of need for bowel preparation, and ability to help diagnose the extraintestinal complications of IBD. In addition to being radiation free, MR enterography can help evaluate peristalsis, has high contrast resolution, and allows the use of diffusion-weighted imaging. The authors discuss the use of CT enterography and MR enterography in the context of pediatric IBD in terms of advantages and disadvantages, protocol, and imaging findings.

National estimates of the burden of inflammatory bowel disease among racial and ethnic groups in the United States

BACKGROUND

The epidemiology of inflammatory bowel disease (IBD) is poorly characterized in minorities in the U.S. We sought to enumerate the burden of IBD among racial and ethnic groups using national-level data.

METHODS

Data from the National Health Interview Survey was used to calculate prevalence and incidence of IBD among adults (≥ 18 years) in 1999. The Nationwide Inpatient Sample was queried to ascertain rates of IBD-related hospitalizations and the Underlying Cause of Death Database was accessed to quantify IBD-related mortality.

RESULTS

An estimated 1,810,773 adult Americans were affected by IBD yielding a prevalence of 908/100,000, which was higher in Non-Hispanic Whites (1099/100,000) compared with Non-Hispanic Blacks (324/100,000), Hispanics (383/100,000), and non-Hispanic Other (314/100,000). Relative to Non-Hispanic Whites, the odds ratios for having a diagnosis of IBD associated with being Non-Hispanic Black, Hispanic, and Other Non-Hispanic race after adjusting for age, sex, and geographic region were 0.33 (95% CI: 0.19 - 0.57), 0.45 (95% CI: 0.26 - 0.77), and 0.34 (95% CI: 0.12 - 0.93), respectively. IBD incidence was similarly lower in Non-Hispanic Blacks (24.9/100,000) and Hispanics (9.9/100,000) compared to Non-Hispanic Whites (70.2/100,000). The ratio of IBD hospitalizations to prevalence was disproportionately higher among Non-Hispanic Blacks (7.3%) compared with Non-Hispanic Whites (3.0%) and Hispanics (2.7%). Similarly, the ratio of IBD-related mortality was greater in Non-Hispanic Blacks (0.061%) compared to Non-Hispanic Whites (0.036%) and Hispanics (0.026%).

CONCLUSIONS

IBD disease burden is lower in ethnic minorities compared to Non-Hispanic Whites. However, IBD-related hospitalizations and deaths seem disproportionately high in Non-Hispanic Blacks.

Challenges in designing a national surveillance program for inflammatory bowel disease in the United States

This review describes the history of U.S. government funding for surveillance programs in inflammatory bowel diseases (IBD), provides current estimates of the incidence and prevalence of IBD in the United States, and enumerates a number of challenges faced by current and future IBD surveillance programs. A rationale for expanding the focus of IBD surveillance beyond counts of incidence and prevalence, to provide a greater understanding of the burden of IBD, disease etiology, and pathogenesis, is provided. Lessons learned from other countries are summarized, in addition to potential resources that may be used to optimize a new form of IBD surveillance in the United States. A consensus recommendation on the goals and available resources for a new model for disease surveillance are provided. This new model should focus on "surveillance of the burden of disease," including (1) natural history of disease and (2) outcomes and complications of the disease and/or treatments.

Inflammatory bowel disease in Chinese children: a multicenter analysis over a decade from Shanghai

BACKGROUND

The purpose was to estimate the incidence and characteristics of childhood inflammatory bowel disease (IBD) during 2000-2010 in Shanghai, China.

METHODS

IBD patients between the ages of 0 and 18 years old were identified by survey of computerized medical information. Relevant data were extracted from their corresponding medical records.

RESULTS

A total of 153 IBD cases were included in the study. Among them, 107 were males and 46 were females (male/female ratio, 2.3:1.0). Eighty-two had Crohn's disease (CD) and 71 had ulcerative colitis (UC). The peak prevalence of IBD was observed in the 10-14-year-old age group. The annual incidence of IBD in the 0 to 14 years age group of Shanghai residents steadily increased from 2000 to 2010. The most common symptoms of IBD were diarrhea (68.6%), bloody stool (68.6%), and abdominal pain (61.4%). More CD than UC patients had anemia and raised erythrocyte sedimentation rate and C-reactive protein levels. Ileocolonic type disease was more common in CD patients, and left-side colon involvement was more common in UC. Of all CD patients, 33 had mild active disease and 49 had moderate/severe disease. In UC patients, 34 were mild and 37 were moderate/severe disease.

CONCLUSIONS

This retrospective, multicenter hospital-based study over a decade shows a steadily increasing trend of childhood IBD in China. This suggests a need for population-based epidemiological studies to explore the risk factors.

Contribution of higher risk genes and European admixture to Crohn's disease in African Americans

BACKGROUND

African Americans (AAs) are an admixed population of West African (WA) and European ancestry (EA). Crohn's disease (CD) susceptibility genes have not been established. We therefore evaluated the contribution of European admixture and major established risk genes to AA CD.

METHODS

Ninety-seven admixture informative markers were genotyped for ancestry estimates using STRUCTURE. Overall, 354 AA CD cases and 354 ethnicity-matched controls were genotyped for total 21 single nucleotide polymorphisms (SNPs) in ATG16L1, NOD2, IBD5, IL23R and IRGM by TaqMan or direct sequencing. Association was evaluated by logistic regression, adjusted for ancestry.

RESULTS

Mean EA was similar among the CD cases and controls (20.9% and 20.4%, respectively, P = 0.58). No significant admixture differences were observed among 211 to 227 cases stratified by phenotypic subclassifications including onset, surgery, site, and behavior. CD was associated with NOD2 carrier (6.93% CD, 2.15% Controls, P = 0.007), ATG16L1 Thr300Ala (36.1% CD, 29.3% Controls, P = 0.003), SLC22A4 and SLC22A5 (IBD5 locus) functional SNPs (Leu503Phe [10.5% CD, 7.6% Controls, P = 0.05] and g-207c [41.3% CD, 35.7% Controls, P = 0.03], respectively), and IL23R rs2201841 (18.2% CD, 13.8% Controls, P = 0.03), but not IRGM variants, nor three African ancestral NOD2 nonsynonymous variants. IBD5 risk was recessive. An all-minor allele IBD5 haplotype from EA was associated (P = 0.05), whereas a more common haplotype isolating g-207c was not.

CONCLUSIONS

Specific functional gene variations contribute significantly to AA CD risk. Established NOD2, SLC22A4-A5, and ATG16L1 variants show increased CD risk, with IBD5 recessive. Although CD is more common in whites, European admixture is similar among AA cases and controls.

Direct health care insurer and out-of-pocket expenditures of inflammatory bowel disease: evidence from a US national survey

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC) are chronic, debilitating conditions that can have important economic and clinical implications.

AIM

To quantify individual and national estimates of the health care and patient out-of-pocket (OOP) costs of CD and UC.

METHODS

In a retrospective study using 1996 to 2009 data from the Medical Expenditure Panel Survey, individuals' self-reported health conditions were mapped to International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Individuals with a code of 555.x (CD) or 556.x (UC) were identified. Health care services and costs included prescriptions and inpatient, outpatient, emergency room, office, and home health services. OOP costs were the portion of individuals' total payments for health care services.

RESULTS

There were 358 individuals with CD (mean age 49.0 years; 55 % female), 198 individuals with UC (mean age 47.1 years; 64 % female), and 206,993 individuals without inflammatory bowel disease (IBD) (mean age 48.2 years; 58 % female). Annual per capita health insurer and OOP costs for individuals with CD were greater than those without IBD ($9,526 versus $3,781, p < 0.001 and $1,603 versus $866, p < 0.001, respectively). Health insurer and OOP costs were greater for UC compared with those without IBD ($6,443 versus $3,781, p < 0.001 and $1,263 versus $866, p < 0.001, respectively). US national aggregate annual estimates of health insurer, OOP, and total direct costs secondary to CD are $2.04 billion, $0.26 billion, and $2.29 billion, respectively. Aggregate health insurer, OOP, and total direct costs attributable to UC are $0.53 billion, $0.07 billion, and $0.61 billion, respectively.

CONCLUSIONS

The direct costs associated with CD and UC are substantial. The extent to which appropriate diagnosis and treatment reduces the total health care costs for individuals with CD or UC should be examined.

Economic burden of inflammatory bowel disease: a UK perspective

Inflammatory bowel diseases (IBDs) are chronic, relapsing conditions that have no permanent drug cure, may occur for the first time in early life and have the potential to produce long-term morbidity. In the era of emerging biological drug therapies, the costs associated with IBD have attracted increased attention. This review considers the available information on the macroeconomics of ulcerative colitis and Crohn's disease. In relation to direct medical costs, the consistent findings are: hospital (in-patient) costs are incurred by a minority of sufferers but account for approximately half the total cost; and drug costs contribute less than a quarter of the total healthcare costs. Data for levels of costs associated with lost productivity are more variable, but some studies have estimated that 'indirect' costs falling on society exceed medical expenditures. Lifetime costs for IBD are comparable to a number of major diseases, including heart disease and cancer. Over the next 5-10 years, the contribution of drug costs to the overall profile of cost-of-illness will change significantly as biological therapies play an increasing role. A key economic question is whether the health gains realized from exciting new drugs will also lead to reduced expenditures on hospitalization and surgery.

Colorectal cancer in inflammatory bowel disease: What is the real magnitude of the risk?

The association between inflammatory bowel disease (IBD) and colorectal cancer (CRC) has been recognised since 1925 and still accounts for 10%-15% of deaths in IBD. IBD-associated CRC (IBD-CRC) affects patients at a younger age than sporadic CRC. The prognosis for sporadic CRC and IBD-CRC is similar, with a 5-year survival of approximately 50%. Identifying at risk patients and implementing appropriate surveillance for these patients is central to managing the CRC risk in IBD. The increased risk of colorectal cancer in association with IBD is thought to be due to genetic and acquired factors. The link between inflammation and cancer is well recognised but the molecular biology, immune pathobiology and genetics of IBD-CRC are areas of much ongoing research. This review examines the literature relating to IBD-CRC, focusing on the incidence of IBD-CRC and examining potential risk factors including age at diagnosis, gender, duration and extent of colitis, severity of inflammation, family history of sporadic CRC and co-existent primary sclerosing cholangitis (PSC). Confirmed risk factors for IBD-CRC are duration, severity and extent of colitis, the presence of co-existent PSC and a family history of CRC. There is insufficient evidence currently to support an increased frequency of surveillance for patients diagnosed with IBD at a younger age. Evidence-based guidelines advise surveillance colonoscopy for patients with colitis 8 to 10 years after diagnosis, with the interval for further surveillance guided by risk factors (extent of disease, family history of CRC, post-inflammatory polyps, concomitant PSC, personal history of colonic dysplasia, colonic strictures). There is a move away from using random colonic biopsies towards targeted biopsies aimed at abnormal areas identified by newer colonoscopic techniques (narrow band imaging, chromoendoscopy, confocal microendoscopy).

National burden of pediatric hospitalizations for inflammatory bowel disease: results from the 2006 Kids' Inpatient Database

OBJECTIVES

: The objective of the present study was to quantify the national pediatric inpatient inflammatory bowel disease (IBD) burden in terms of the number of IBD-related hospitalizations, the number of days spent in the hospital, and hospitalization costs.

METHODS

: Hospitalizations for children and adolescents 20 years and younger with a primary diagnosis of either Crohn disease (CD) or ulcerative colitis (UC) were selected from the 2006 Kids' Inpatient Database (KID). Length of the hospital stay in days (LOS) and charges for the hospitalization were found directly in the Kids' Inpatient Database, and cost was calculated using the hospital's cost-to-charge ratio. Predictor variables included patient characteristics, such as age and severity of illness, and hospital characteristics. Ordinary-least-squares regressions were developed and estimated to explain hospitalization costs.

RESULTS

: In 2006, there were 10,777 IBD-related hospitalizations. The total and mean costs for CD were $66.3 million and $10,176 (95% confidence interval [CI] $9647-$10,705), and for UC were $48.6 million and $11,836 (95% CI $10,760-$12,912). For CD, 0- to 5-year-old patients had the highest mean LOS (8.10, 95% CI 5.53-10.67, days) and mean cost ($13,894, 95% CI $9053-$18,735), whereas, for UC, 11- to 15-year-old patients had the highest mean LOS (7.49, 95% CI 6.88-8.10, 95% CI 5.53-10.67, days) and mean cost ($13,407, 95% CI $11,704-$15,110).

CONCLUSIONS

: For a pediatric disease with a rather low prevalence rate, the estimated annual inpatient pediatric burden of IBD is a sizeable $152.4 million (2010 US$) and 64,985 days spent in the hospital. As medications and outpatient treatments improve for the treatment of IBD, there is an opportunity for significant reduction in inpatient burden.

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.

Current management of inflammatory bowel disease and colorectal cancer

INFLAMMATORY BOWEL DISEASES (IBDS) CAN BE DIVIDED INTO TWO MAJOR DISORDERS: ulcerative colitis and Crohn's disease. Although IBD-associated colorectal cancer (IBD-CRC) accounts for only 1-2% of all cases of colorectal cancer, IBD with colon involvement is among the top three high-risk conditions for colorectal cancer. Today, colorectal cancer accounts for approximately 10-15% of all deaths among IBD patients. Indeed, patients with IBD colitis are six times more likely to develop colorectal cancer than the general population and have a higher frequency of multiple synchronous colorectal cancers. Since IBD-CRC was first described in 1925, the colon remains the primary site of neoplasms in IBD patients today. Ulcerative colitis-associated colorectal cancer is most common in the rectum and sigmoid colon, whereas Crohn's disease-associated colorectal cancer is evenly distributed between the different colon segments. Chemoprevention of colorectal cancer remains an important goal, and colonoscopy surveillance programs are critical to early detection in these patients. Newer methods, such as chromoendoscopy, are currently being investigated as complementary techniques to enhance early detection of dysplasia and cancer in this high-risk population. We present a comprehensive review of the relationship between inflammatory bowel disease and colorectal cancer. Major themes covered include risk factors for IBD-CRC and the molecular pathobiology of progression from dysplasia to cancer, endoscopic surveillance and new methods for early detection of dysplasia, approaches to prevention of IBD-CRC, and current recommendations and controversies regarding the treatment of dysplasia. In particular, disagreement has arisen over optimal management of low-grade dysplasia, with some IBD experts now advocating close colonoscopic surveillance of patients with low-grade dysplasia rather then total colectomy.

Crohn's disease and small bowel adenocarcinoma: a population-based case-control study

BACKGROUND

Although Crohn's disease (CD) is thought to predispose to adenocarcinomas of the small bowel, the association has not been well studied in an older population.

AIMS

The objective of our study was to evaluate the association of CD with small bowel cancer in a population-based case-control study.

METHODS

All cases of small bowel cancer in persons 67 and older in the Surveillance, Epidemiology and End Results catchment area and in the Medicare claims data base were compared with cancer-free controls residing in the same geographic area. We used multivariable logistic regression models adjusted for demographic and other factors.

RESULTS

We identified 923 cases of small bowel cancer and 142,273 controls. Although we found a strong association between CD and small bowel cancer (OR = 12.07; 95% CI: 6.07-20.80; P < 0.001), the prevalence of CD in patients with small bowel cancer was low (1.6%).

CONCLUSIONS

Although CD is a significant risk factor for small bowel cancers among individuals older than 67, the absolute risk is small.

IMPACT

Older individuals with CD can be reassured that although there is an association between CD and small bowel cancer, the absolute risk remains small.

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.

African-American inflammatory bowel disease in a Southern U.S. health center

Background

Inflammatory Bowel Diseases (IBD) remain significant health problems in the US and worldwide. IBD is most often associated with eastern European ancestry, and is less frequently reported in other populations of African origin e.g. African Americans ('AAs'). Whether AAs represent an important population with IBD in the US remains unclear since few studies have investigated IBD in communities with a majority representation of AA patients. The Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S) is a tertiary care medical center, with a patient base composed of 58% AA and 39% Caucasian (W), ideal for evaluating racial (AA vs. W) as well and gender (M vs. F) influences on IBD.

Methods

In this retrospective study, we evaluated 951 visits to LSUHSC-S for IBD (between 2000 to 2008) using non-identified patient information based on ICD-9 medical record coding (Crohn's disease 'CD'-555.0- 555.9 and ulcerative colitis 'UC'-556.0-556.9).

Results

Overall, there were more cases of CD seen than UC. UC and CD affected similar ratios of AA and Caucasian males (M) and females (F) with a rank order of WF > WM > AAF > AAM. Interestingly, in CD, we found that annual visits per person was the highest in AA M (10.7 ± 1.7); significantly higher (* -p < 0.05) than in WM (6.3 ± 1.0). Further, in CD, the female to male (F: M) ratio in AA was significantly higher (*- p < 0.05) (1.9 ± 0.2) than in Caucasians (F:M = 1.3 ± 0.1) suggesting a female dominance in AACD; no differences were seen in UC F: M ratios.

Conclusion

Although Caucasians still represent the greatest fraction of IBD (~64%), AAs with IBD made up >1/3 (36.4%) of annual IBD cases from 2000-2008 at LSUHSC-S. Further studies on genetic and environments risks for IBD risk in AAs are needed to understand differences in presentation and progression in AAs and other 'non-traditional' populations.

Inflammatory bowel disease in children: epidemiological analysis of the nationwide IBD registry in Japan

OBJECTIVE

We analyzed the database of the Japanese nationwide inflammatory bowel disease (IBD) registry, which was started in 1975, to characterize basic epidemiological and clinical features of childhood IBD, comparing them to those in adults.

STUDY DESIGN

We analyzed the age of disease onset, disease severity and anatomical distribution in patients that were newly registered between 2003 and 2006 (n = 2,940 for CD and 14,857 for UC). We also analyzed the current age, gender and family history of IBD of all patients filed in 2005, which included patients who were newly registered in 2005 and those who had been registered before 2005 and for whom an annual report had been received in 2005 (total number of subjects: 10,934 for CD and 37,846 for UC).

RESULTS

At the time of registration, 10.6% of CD and 5.9% of UC patients were ≤ 16 years old. In CD, the male to female ratio was 2.6 in adult- and 1.7 in childhood-onset patients (P < 0.001). In UC, the male to female ratio was close to 1 in both age groups. In comparison with adults, pediatric patients more commonly had a positive family history for CD and UC (P < 0.001), tended to have more severe disease at the time of registry (P < 0.001 for CD, P < 0.05 for UC) and more often had extensive colitis in UC (P < 0.001).

CONCLUSION

The nationwide registry in Japan showed IBD in children has clinical features that are distinct from those in adults.

Inflammatory bowel disease in Korea: epidemiological, genomic, clinical, and therapeutic characteristics

Inflammatory bowel disease (IBD) describes chronic inflammatory disease of the intestines and has a variable course; Crohn's disease and ulcerative colitis comprise the two main forms of the condition. Although IBD occurs worldwide, its epidemiologic and clinical characteristics vary depending upon the geographic location and the ethnicity of the population. Identifying the characteristic features of IBD in populations living in different geographical locations and with different ethnicities may provide significant clues about its etiology and pathophysiology, which in turn may be helpful in the development of more appropriate treatment strategies for IBD for these different populations. Therefore, it is important for each country and region to evaluate critically the epidemiology, genomics, and clinical characteristics of IBD among its own population. We have performed a critical review of the recent data in Korea, and describe herein the current epidemiologic and genotypic status, as well as the clinical manifestations and therapeutic responses of IBD that are unique to Korean patients.

Hospitalizations are increasing among minority patients with Crohn's disease and ulcerative colitis

BACKGROUND

Rates of inflammatory bowel disease (IBD) appear to be increasing among nonwhite populations outside the United States, but national data describing the incidence and prevalence of IBD are not available for minority patients. The aim of this study was to examine time trends of hospital discharge among minority patients with IBD.

METHODS

Nationally representative data describing hospital discharges were obtained from the National Hospital Discharge Survey for the years 1994 to 2006. Race-specific annual proportions of hospitalizations including a discharge diagnosis of ulcerative colitis and Crohn's disease were calculated. Trends in proportions were assessed for statistical significance using the extended Mantel-Haenszel chi-square test for trend.

RESULTS

The proportion of hospitalizations including a discharge diagnosis of IBD increased significantly from 1994 to 2006 among the total population and among Asian, black, and white patients separately. Increases were statistically significant when analysis was performed for Crohn's disease and ulcerative colitis combined and separately. Marked increases were seen among Asians.

CONCLUSIONS

The proportion of hospitalizations including a discharge diagnosis of IBD increased significantly among minority and nonminority patients from 1994 through 2006. The causes underlying these changes are not certain and should be further investigated.

Significance of bowel wall thickening on computed tomography scan: higher risk of pathology among African Americans compared to Hispanics

PURPOSE

The aims of our study were to examine the role of colonoscopy as further workup for bowel wall thickening reported on computed tomography (CT) scans and to investigate whether there were significant differences in pathology found among the racial groups in our study population.

METHODS

This is a retrospective study from March 2005 and January 2007 of all patients who have undergone colonoscopy for bowel wall thickening found on CT scans of the abdomen.

RESULTS

Of 94 patients with bowel wall thickening on CT scans, 7 (8%) had adenocarcinoma, 5 (5%) had large adenomas, 3 (3%) had infectious colitis, 2 (2%) ischemic colitis, 1 (1%) had inflammatory bowel disease, and 1 (1%) had a benign stricture. Bowel wall thickening on CT scan predicted clinical pathology in 34% of African Americans, as compared to 14% of Hispanics. Patients with significant pathology were more likely to have anemia and lower albumin levels.

CONCLUSION

Patients with bowel wall thickening found on CT scans should be referred for colonoscopy, given that significant pathology is found in 20% of the cases. African Americans were 2.5 times more likely to have clinically significant pathology as compared to Hispanics.

Hospitalizations for inflammatory bowel disease among US military veterans 1975-2006

BACKGROUND

The Department of Veterans Affairs (VA) is the largest healthcare system in the United States. The VA database was used to analyze patterns of hospitalization for inflammatory bowel disease (IBD) among US military veterans.

METHODS

The study used the VA Patient Treatment File (PTF) between 1975 and 2006. Each hospital record extracted from the PTF included diagnosis, patient age, and ethnicity. Patient age was analyzed in three age groups: 0-44, 45-64, and 65+. Patient ethnicity was analyzed by two broad categories as white and nonwhite.

RESULTS

Among veterans, Crohn's disease was more common than ulcerative colitis and both diseases were more common in whites than in nonwhites. During the past 30 years, the age distributions of both diseases have shifted towards older patients who have come to represent an increasingly larger fraction of patients with Crohn's disease, as well as ulcerative colitis. Hospitalization rates for inflammatory bowel disease among whites recently declined, while most rates among nonwhites continued to rise throughout the observation period.

CONCLUSION

The present study revealed a time-dependent shift towards older ages in the age distribution of IBD among hospitalized veterans. These changes, which have been observed similarly in other US statistics, may reflect a birth-cohort phenomenon underlying the long-term time trends of IBD.

Health care expenditures in ulcerative colitis: the perspective of a self-insured employer

OBJECTIVE

This study was designed to investigate the incidence, prevalence, treatment patterns, disease severity, and direct costs associated with ulcerative colitis (UC) for claimants in health plans offered by a large self-insured employer in the United States.

METHODS

Retrospective analysis of medical claims with and without UC identified from a population of approximately 500,000 employees, retirees, and dependents.

RESULTS

Costs for UC claimants were more than twice those for the comparator group ($14,486 vs $6158; P < 0.005). Total health care costs for the severe disease cohort were double those of the mild or moderate cohorts ($26,875 vs $12,154 and $12,731), as were inpatient costs ($13,516 vs $3235 and $2244). The annual incremental cost of treating severe disease was $6812 (P < 0.005) compared with mild UC.

CONCLUSION

UC is a significant predictor of increased medical costs with severe disease, driven mainly by inpatient costs.

Breastfeeding and genetic factors in the etiology of inflammatory bowel disease in children

Inflammatory bowel disease is a chronic, debilitating disorder of the gastrointestinal tract. The etiology of inflammatory bowel disease has not been elucidated, but is thought to be multifactorial with both environ-mental and genetic influences. A large body of research has been conducted to elucidate the etiology of inflammatory bowel disease. This article reviews this literature, emphasizing the studies of breastfeeding and the studies of genetic factors, particularly NOD2 polymorphisms.

Crohn's disease in an African-American population

OBJECTIVE

African-Americans have been underrepresented in most large Crohn's disease (CD) trials. This study was undertaken to assess the course and character of CD in African-Americans in comparison with whites.

METHODS

We retrospectively compared the course and character of CD in African-American and white patients at 3 Atlanta hospitals. Ninety-nine patients (55 African-American, 44 whites) were enrolled. Telephone interviews and chart reviews were used to identify disease location, presence of fistulae and perirectal disease, surgical history, and medication use. Patients with ulcerative colitis or indeterminant colitis, and all non-African-Americans or whites, were excluded.

RESULTS

The numbers of male and female patients were similar (50 and 49). Overall, men comprised 54% of white patients and 47% of African-American patients. There were no significant differences in the setting in which CD were diagnosed, number of flares per year, or duration of symptoms before diagnosis. White patients were more likely to seek care for their CD in a clinic setting, both their primary care physicians (1.31 versus 0.21 visits/yr, P < 0.001) and their gastroenterologists (3.2 versus 2.3 visits/yr, P = 0.03). Small bowel (SB) disease was present more frequently in white patients, 84% versus 65% (P = 0.03), and SB resection was more common in this group, 59% versus 16% (P < 0.01). Colonic disease was more common in African-American patients, 89% versus 63% (P = 0.002). Perirectal fistulae were more frequent in African-American patients, 58% versus 22% (P < 0.001) white patients were more likely to report complete compliance with medical therapy, 77% versus 49% (P = 0.004). African-American patients more frequently discontinued medical therapy because they "felt better" (27% versus 9%, P = 0.02). Medication usage, including immunosuppressants, was similar in both groups, except that white patients were more likely to receive multiple doses of infliximab (34% versus 11%, P = 0.005). Both groups felt equally informed about CD, but white patients felt that their disease was under good control a greater percentage of the time, 71% versus 58% (P = 0.04).

CONCLUSIONS

These data lend credence to the suggestion that the nature of CD may be different in African-Americans compared with whites. However, despite this apparent difference in disease manifestation, the contribution of socioeconomic factors, access to health care, and understanding of the disease likely play a role as well.

Crohn's disease, autoimmune thyroiditis, and beta-thalassemia trait in an adolescent: an unusual combination of diseases

An adolescent with complaints of fatigue, tachycardia, abdominal discomfort, and blood-stained diarrhea is presented. Clinical and laboratory evaluation revealed a microcytemic anemia with iron deficiency, beta thalassemia, and thyrotoxicosis with thyroid antibodies. Crohn's disease was confirmed on endoscopy. A rapid normalization of clinical and laboratory parameters was observed following the initiation of therapy and further exacerbation of her illness was prevented. Although the simultaneous occurrence of Crohn's disease, autoimmune thyroiditis, and a beta-thalassemia trait is likely to be coincidental, the combination of an autoimmune thyroid disease and Crohn's disease is rare in pediatrics. Several issues of importance in the treatment of these conditions are discussed. Rectal blood loss associated with Crohn's disease may lead to severe iron deficiency, especially in patients with preexistent beta-thalassemia trait, and those with thyroiditis are prone to developing hypothyroidism following treatment, requiring that they be monitored closely.

Inflammatory bowel disease: incidence, prevalence, and disease characteristics in Barbados, West Indies

BACKGROUND

The incidence of inflammatory bowel disease (IBD) may be lower among people of African descent than Caucasians. However, incidence studies among the former are uncommon and are often limited by incomplete case ascertainment or uncertainty about the size of the "at-risk" population.

METHODS

We report the incidence and prevalence of IBD among people of African ancestry in Barbados from island-wide disease surveillance over a 25-year period beginning January 1980.

RESULTS

The annual incidence of IBD age standardized to the world population was 1.85 per 100,000 person-years (95% confidence interval [CI] 1.53-2.22) for ulcerative colitis (UC) and 0.70 per 100,000 person-years (0.51-0.95) for Crohn's disease (CD). These incidence rates increased to 2.09 and 0.76 when standardized to the US population. The UC incidence rate increased from 1.3 in 1980-1984 to 2.3 in 1995-1999, and decreased to 1.6 in 2000-2004. The CD incidence rate followed a similar trend, rising from 0.3 in 1980-1984 to 1.3 in 1990-1994 before decreasing to 0.6. IBD prevalence in December 2004 was 44.3 per 100,000 person-years (36.7-53.0) for UC and 16.7 per 100,000 person-years (12.2-22.4) for CD. In the island-nation of Barbados, with a population in 2000 of 270,000, we expect between 4.3 and 6.1 new cases of UC and between 1.5 and 2.6 new cases of CD each year.

CONCLUSIONS

The reported rates are generally lower than reported for European and North American Caucasians, and are similar to The French West Indies--the only other IBD disease register in the Caribbean.

Racial differences in disease extent and severity in patients with ulcerative colitis: a retrospective cohort study

INTRODUCTION

Ulcerative colitis (UC) is increasing in African-Americans (AA). The objectives of this study were to assess disease extent and severity in UC by race.

METHODS

Disease extent and severity was assessed in UC outpatients evaluated at the University of Maryland and Baltimore VA from 1997 to 2005.

RESULTS

About 197 patients were identified; 47 were AA (23%). Of AA, 23% had proctitis, 23% had left-sided colitis, and 53% had extensive colitis compared to 10%, 31%, and 59% of Caucasians, respectively (P = 0.056). African-Americans were less likely to ever receive steroids (45% versus 62%; P = 0.065), be treated with > or = 2 courses of steroids (54% versus 68%; P = 0.242) or be steroid dependant (33% versus 46%; P = 0.304). After adjustment, only female gender (OR 0.32, [0.16-0.66]) and age at diagnosis (OR 2.50, [1.28-4.90]) were associated with extensive colitis. Being seen at UMMS (OR 5.10, [2.60-10.10]) was associated with steroid use.

CONCLUSION

Race was not associated with extent of colitis or disease severity in UC.

The prevalence of gastrointestinal diseases in Israeli adolescents and its association with body mass index, gender, and Jewish ethnicity

OBJECTIVE

The objectives of this study were to describe gastrointestinal (GI) disease prevalence in Israeli adolescents, and possible associations between prevalence and body mass index (BMI), sex and Jewish ethnicity.

DESIGN

A retrospective analysis of screening for GI disease performed by the Israeli Defense Forces recruiting office between 1998 and 2003.

SETTING

Screening was performed at the recruiting office, and included detailed history and physical examination performed by a general practitioner. Further testing was performed as needed and the final diagnosis was established by a gastroenterologist at the recruiting office.

PATIENTS

Seventeen-year-old Israeli nationals.

RESULTS

During the study period, 466,855 (58.5% male) adolescents were screened for GI disease. Peptic ulcer disease, irritable bowel syndrome, and nonulcer dyspepsia were the most prevalent disorders affecting 466/10, 460/10, and 296/10, respectively. There was an increase in the prevalence of lactose intolerance during the study period and also an increase in the prevalence of peptic ulcer disease in females. The prevalence of inflammatory bowel disease has also increased from 100/10 to 149/10, although this trend failed to reach statistical significance (P=0.097). Higher BMI was associated with statistically significant higher prevalence rates of gastroesophageal reflux disease (P<0.05). A stronger association in females was found in gallbladder disease (P<0.001). Lower BMI was associated with higher prevalence rates of irritable bowel syndrome (P<0.001), and higher rates of inflammatory bowel disease and lactose intolerance in males (P<0.01 and <0.001, respectively).

CONCLUSIONS

GI diseases are not uncommon among adolescents, and for some disorders prevalence is rising. The association between BMI and prevalence has been further clarified.

Passive smoking and inflammatory bowel disease: a meta-analysis

OBJECTIVES

Active smoking has a well-documented role in the etiology of inflammatory bowel disease (IBD), but the role of passive smoking has been unclear. This meta-analysis examined the relationship between prenatal smoke exposure and childhood passive smoke exposure and the development of IBD.

METHODS

We searched the MEDLINE and EMBASE databases to identify observational studies regarding the relationship between prenatal and/or childhood passive smoke exposure and the development of Crohn's disease (CD) and/or ulcerative colitis (UC). Pooled odds ratios (OR) were calculated for each relationship.

RESULTS

A total of 534 and 699 potential studies were identified from the MEDLINE and EMBASE databases, respectively, of which 13 met all of our inclusion criteria. Overall, we did not observe a positive relationship between childhood passive smoke exposure and CD (OR 1.10, 95% confidence interval [CI] 0.92-1.30) or UC (OR 1.01, 95% CI 0.85-1.20). Likewise, we did not observe an association between prenatal smoke exposure and CD (OR 1.10, 95% CI 0.67-1.80), or prenatal smoke exposure and UC (OR 1.11, 95% CI 0.63-1.97).

CONCLUSIONS

Our meta-analysis suggests that there is not a strong association between childhood passive smoke exposure and the development of CD. We found no evidence that childhood passive smoke exposure exerts a protective effect against UC, as is the case in active smoke exposure. The heterogeneity among the small number of studies limited the ability to draw conclusions about prenatal smoke exposure.