Ulcerative colitis in northern Portugal and Galicia in Spain

Incidence Trends of Inflammatory Bowel Disease in a Southern European Country: A Mirror of the Western World?

INTRODUCTION

Inflammatory bowel disease (IBD) affects people from all age categories worldwide. Although the incidence of the disease is stabilizing or decreasing in most Western world countries, its prevalence is still increasing because of the rise in life expectancy and better disease management. This work intends to identify the trends related to IBD incidence nationwide, analyzing regional, sex, and age distributions.

METHODS

Data were provided by the Portuguese Shared Services of the Ministry of Health. This study consisted of a retrospective analysis of all first consultations coded for "Chronic enteritis/ulcerative colitis" (D94) in a primary healthcare setting, between 2017 and 2020, in Portugal. The primary outcome measure was the IBD incidence rate per 100,000 inhabitants. We also calculated the incidence rate per person-year and forecasted incidence until 2024.

RESULTS

Between 2017 and 2019, the incidence rate of IBD in Portugal decreased from 54.9 to 48.6 per 100,000 inhabitants. The average incidence was 20 new cases of IBD per 1,000 person-year. It was predicted that, in December 2023, IBD incidence would reach 305.4 new cases (95% Prediction Interval 156.6-454.3), a similar result to the values forecasted for December 2021 (305.4, 95% Prediction Interval 197.3-413.6).

DISCUSSION

The incidence of IBD slightly declined from 2017 to 2019, and it is posed to stabilize in the future. The presented data are of the utmost importance for the characterization of IBD in Southern European countries and the establishment of future health policies in the setting of compounding prevalence in the Western world.

Radon exposure and inflammatory bowel disease in a radon prone area

INTRODUCTION

Inflammatory Bowel Disease (IBD) is a multifactorial pathology with an increasing incidence. There is no study having assessed a possible relationship with residential radon exposure, very high in the study area. The aim of the study was to analyze if residential radon concentration is associated with a higher incidence of IBD.

MATERIAL AND METHODS

An ecological study has been performed. All incident cases of Inflammatory Bowel Disease in the area of Santiago de Compostela were included between January and December 2017. Radon levels at a municipal level were correlated with demographic factors and type of IBD.

RESULTS

96 patients were included, 63 (65.6%) with ulcerative colitis, 29 (30.25) with Crohn's disease and 4 (4.2%) with indeterminate colitis. The incidence rate per 100,000 inhabitants-year was 21.6 cases. There were no statistically significant differences on the type of disease developed regarding radon levels (p>0.05). No correlation between radon levels and cumulative incidence of Inflammatory Bowel Disease at municipal level was observed (Spearman's rho = 0.13, p-value 0.5).

CONCLUSION

In the area of Santiago de Compostela there is a higher incidence of IBD in comparison with previous studies taking western countries as reference, but in this study we have not found any correlation with municipal average radon concentration and incidence of IBD or any of its types.

Clinical and Demographic Profile of Inflammatory Bowel Disease Patients in a Reference Center of São Paulo, Brazil

Background

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract with an increasing incidence in developing countries.

Purpose

To report clinical and demographic data of CD and UC at a referral center for inflammatory bowel disease (IBD) in São Paulo.

Patients and Methods

We conducted a retrospective cross-sectional study on adult patients with established IBD. Demographic and clinical data were obtained by medical records analysis from the IBD Outpatient Clinic of EPM-UNIFESP, from October 1997 to October 2017.

Results

Of 658 patients included, 355 had UC (54%) and 303 had CD (46%). UC was more prevalent in women than CD (219 [61.7%] vs 152 [50.2%], p=0.003). The median time between the onset of symptoms and diagnosis was 13 (5-38) months, with a longer duration for CD patients. CD mostly affected the ileocolonic location (47.9%). CD patients with stricture, fistula and/or perianal disease (213/303, 70.3%) were younger at diagnosis, had a longer disease duration, higher rates of corticosteroid, immunomodulatory, and biological therapy, hospitalization, and referral to surgery, compared to patients without complication. Extensive colitis was the most common extension of UC (50.6%), which was more frequently associated with younger age at diagnosis, hepatobiliary disease, increased need for hospitalization, higher use of immunomodulatory, and biologic therapy, compared to patients with less extensive disease. In the last 5 years, CD patients were more frequently on biologic and/or immunomodulatory (70.9%) therapy, and UC patients often received salicylates (78.1%) and immunomodulatory (28.1%) treatments. There was a consistent reduction in salicylate usage for CD in the last 5 years compared to the total period of follow-up.

Conclusion

Despite the increasing incidence, we highlight the diagnostic delay and a more complicated CD and extensive UC in this cohort, reflecting a high need for immunomodulatory and biological treatment, hospitalization, and surgery.

Age at Diagnosis Is Determinant for the Outcome of Inflammatory Bowel Disease: Is It a Myth?

INTRODUCTION

Patients with elderly-onset inflammatory bowel disease were previously associated with a less aggressive course of the disease. However, there are conflicting data that need further validation. We aimed to determine the association between age at diagnosis and the development of progressive disease in patients with Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

This cohort study included patients with CD and UC followed in 6 secondary and tertiary care centers in mainland Portugal. Patients were divided into a derivation (80%) cohort and a validation (20%) cohort. The primary outcome was progressive disease. Logistic regression analysis, receiver operating characteristic curves, and the areas under the curve (AUC) were performed. Odds ratios with 95% confidence intervals (CIs) were estimated.

RESULTS

The derivation cohorts included 1245 patients with CD (68% with progressive disease) and 1210 patients with UC (37% with progressive disease), whereas the validation cohorts included 302 patients with CD and 271 patients with UC, respectively, with similar outcome proportions. In our final model, age at diagnosis older than 60 years was significantly associated with a lower risk of developing progressive disease (odds ratio 0.390, 95% CI 0.164-0.923, P = 0.032), with a high discriminative power (AUC 0.724, 95% CI 0.693-754) in patients with CD. However, according to this model, no significant associations were found between age at diagnosis and the risk of developing progressive disease in patients with UC. No differences were observed in the AUC values between the validation and the derivation cohorts.

DISCUSSION

Patients with elderly-onset CD, but not patients with UC, were associated with a less progressive course of the disease.

Diagnosis and natural history of preclinical and early inflammatory bowel disease

Inflammatory bowel disease is a chronic and progressive disorder of the gastrointestinal tract. A relevant proportion of patients develop complicated lesions, defined as strictures, fistulas and/or abscesses already at diagnosis, and this proportion increases over time. The preclinical phase defines the period of time from the appearance of the first immune disturbances until the development of overt disease, and it may be present months to years before the diagnosis. Multiple biomarkers (e.g., C-reactive protein, interleukin-6, fecal calprotectin) and cellular mechanisms (e.g., complement cascade, lysosomes, innate immunity, and glycosaminoglycan metabolism) are already altered during this period. Research in this area allows the description of the initial immune disturbances that may identify potential targets and lead to the development of new drug therapies. During this period, different interventions in high-risk individuals, including drugs or environmental factors, will open the possibility of innovative strategies focused on the reduction of complications, or even prevention trials for inflammatory bowel disease. Here, we review the most relevant findings regarding the characteristics, prevalence and biomarkers associated with preclinical disease, along with their possible use in our future clinical practice.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on topical therapy in ulcerative colitis

Although most patients with ulcerative colitis should be given topical treatment, different studies have shown that they are underused in clinical practice. The purpose of this article is to answer 10 specific questions about which drugs are available for topical use in the treatment of ulcerative colitis, and their characteristics in terms of formulation, dosage, presentation, application and proximal distribution of rectal-administered drugs. The efficacy of available topical drugs and the benefits of combining different formulations and routes of administration, and their usefulness during disease remission are evaluated. Finally, a series of recommendations addressed to patients are given on the correct application of topical treatment.

Hospitalization trends of the Inflammatory Bowel Disease landscape: A nationwide overview of 16 years

INTRODUCTION

In this study, we aimed to determine the hospitalization rates of Inflammatory Bowel Disease (IBD) in a southern-european country and its associated charges over a period of 16 years.

METHODS

We identified all discharges with a primary diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) between 2000 and 2015 in data provided by the Central Administration of Health Services (ACSS). National estimates of hospitalization rates were assessed and adjusted to gender, age, population, and hospitalizations. Hospitalization charges were also assessed.

RESULTS

There were an estimated 31 358 and 16 669 discharges for CD and UC, respectively. From 2000 to 2015, hospitalization rates per 100000 habitants increased for CD (8.4-11.2) and remained stable for UC (4.4-4.9). The hospitalization rate for IBD increased slightly over time (12.8 per 100 000 habitants in 2000 and 16.1 in 2015). Annual total hospitalization charges amounted to 4.0M€ in 2000 and 5.7M€ in 2015. This increase was mainly due to a rise in the total expenses of CD-related hospitalizations.

CONCLUSION

CD hospitalization rates per 100000 inhabitants increased over time while remaining constant for UC. Hospitalization charges for IBD increased approximately 2.0M€ during the study period, representing an important burden in the national healthcare system.

Endoscopic progression of ulcerative proctitis to proximal disease. Can we identify predictors of progression?

INTRODUCTION

Ulcerative proctitis is a type of ulcerative colitis circumscribed to the rectum. Proximal progression rates of the disease have been reported as between 27% and 54%. Several predictive factors have been identified for its progression; however, none has been established as definitive.

MATERIAL AND METHODS

Retrospective study of patients diagnosed with ulcerative proctitis with at least 12 months of follow-up. Patients diagnosed between January 1992 and March 2017. Variables were collected at the time of diagnosis and during the first year of follow-up. The extent of the progression was evaluated endoscopically during follow-up. The endoscopic progression rate was determined and possible risk factors related to this progression were evaluated.

RESULTS

The analysis involved 137 patients. In 77 of the patients, we performed a second colonoscopy during follow-up to evaluate endoscopic progression. The average time before the second colonoscopy performed was 5 years (SD 3.9). Of the 77 patients, 32 (41.6%) presented proximal progression to the rectosigmoid junction. Logistic regression analysis showed a statistically significant association for progression in patients who had suffered one or more flares in the first year following diagnosis. Significant progression was also observed in those with the longest time of progression at the final colonoscopy.

CONCLUSIONS

Ulcerative proctitis is not a stable disease over time. In addition, during the first year of the disease progression, it is possible to predict in which patients the disease will progress to more extensive forms.

Systematic review with meta-analysis: proximal disease extension in limited ulcerative colitis

BACKGROUND

Disease extent in ulcerative colitis is one of the major factors determining prognosis over the long-term. Disease extent is dynamic and a proportion of patients presenting with limited disease progress to more extensive forms of disease over time.

AIM

To perform a systematic review and meta-analysis of epidemiological studies reporting on extension of ulcerative colitis to determine frequency of disease extension in patients with limited ulcerative colitis at diagnosis.

METHODS

We performed a systematic literature search to identify studies on disease extension of ulcerative colitis (UC) and predictors of disease progression.

RESULTS

Overall, 41 studies were eligible for systematic review but only 30 for meta-analysis. The overall pooled frequency of UC extension was 22.8% with colonic extension being 17.8% at 5 years and 31% at 10 years. Extension was 17.8% (95% CI 11.2-27.3) from E1 to E3, 27.5% (95% CI 7.6-45.6) from E2 to E3 and 20.8% (95% CI 11.4-26.8) from E1 to E2. Rate of extension was significantly higher in patients younger than 18 years (29.2% (CI 6.4-71.3) compared to older patients (20.2% (CI 13.0-30.1) (P<.0001). Risk of extension was significantly higher in patients from North America (37.8%) than from Europe (19.6%) (P<.0001).

CONCLUSIONS

In this meta-analysis, approximately one quarter of patients with limited UC extend over time with most extension occurring during the first 10 years. Rate of extension depends on age at diagnosis and geographic origin. Predicting those at high risk of disease extension from diagnosis could lead to personalised therapeutic strategies.

How is inflammatory bowel disease managed in Spanish gastroenterology departments? The results of the GESTIONA-EII survey

INTRODUCTION

Not all national health centers include specialized units or clinicians devoted to inflammatory bowel disease. The goal of the survey was to gain an insight into the management of this disease within Spanish gastroenterology departments via a survey among their members.

MATERIAL AND METHODS

An online survey was conducted in February and March 2015, among SEPD members (2017 clinician members), who were split into three categories: heads of department, general gastroenterologists, and experts in this disease. The results of the last two surveys are reported, including demography-related questions and specific questions on the strategies and resources available for the care of these patients.

RESULTS

A total of 166 responses were received (response rate 8.19%), excluding those from heads of department (previously published). Sixty gastroenterologists considered themselves experts in inflammatory bowel disease, and 106 non-experts in it, the latter being either general gastroenterologists or specialists in other areas, mainly endoscopy. Twenty-eight percent of non-expert gastroenterologists said their hospitals had specific units, with a monographic clinic in 46%. However, 26% reported that they were treating affected patients themselves. Experts in inflammatory bowel disease reported that their institute had resources to support their work, but there was a lack of surgeons with expertise in this condition, particularly in county hospitals.

CONCLUSIONS

At least, within SEPD members, 2 out of 3 experts in inflammatory bowel disease seem to have the resources available for their work (nurses, day unit, telephone line, database, referrals, joint sessions). Although there is room for improvement (email to contact patients, devoted surgeon, absence of referral protocols), and 2 out of 3 are concerned about pharmacy costs. Since a substantial number of patients remain treated by general practitioners, rapid referral programs might be helpful in this setting.

Ulcerative Colitis: Update on Medical Management. Curr Gastroenterol Rep. 2015;17:44. [PMID: 26386686 DOI: 10.1007/s11894-015-0466-9]

Ulcerative colitis (UC) is a chronic inflammatory bowel disease whose pathogenesis is multifactorial and includes influences from genes, the environment, and the gut microbiome. Recent advances in diagnosis and treatment have led to significant improvement in managing the disease. Disease monitoring with the use of therapeutic drug monitoring, stool markers, and assessment of mucosal healing have garnered much attention. The recent approval of vedolizumab for treatment of moderate to severe UC has been a welcome addition. Newer biologics, including those targeting the Janus tyrosine kinase (JAK) pathway, are on the horizon to add to the current armamentarium of anti-TNF alpha and anti-integrin therapies. The recent publication of the SCENIC consensus statement on surveillance and management of dysplasia in UC patients supports the use of chromoendoscopy over random biopsies in detecting dysplasia. This review highlights these recent advances along with others that have been made with ulcerative colitis.

The Demographic and Clinical Characteristics of Ulcerative Colitis in a Northeast Brazilian Population. Biomed Res Int. 2015;2015:359130. [PMID: 26509150 PMCID: PMC4609765 DOI: 10.1155/2015/359130]

INTRODUCTION

The purpose of this study was to describe the clinical and demographic characteristics of UC in Bahia, a Brazilian state, and to identify the variables associated with extensive colitis, steroid therapy, immunosuppression, and colectomy.

METHODS

In this cross-sectional study UC patients were interviewed, and additional information was collected from the medical records. Descriptive statistics and multivariate Poisson regression analysis were used.

RESULTS

This study included 267 individuals, the mean age of whom was 39.4 years at diagnosis. There was a predominance of females and left-side colitis. Extensive colitis was positively associated with male gender, diarrhea, weight loss, and a younger age at diagnosis. In contrast, active smoking and a family history of IBD were negatively associated with extensive colitis. Positive associations were observed between steroid therapy and diarrhea, weight loss, urban patients, extraintestinal manifestations (EIMs), and hospitalization. Younger age and weight loss at diagnosis, a family history of IBD, extensive colitis, EIMs, hospitalization, and steroid therapy were all positively associated with immunosuppression. In contrast, Caucasian individuals, smokers, patients with rectal bleeding, and rural patients areas were all observed to have a decreased likelihood of immunosuppression.

CONCLUSIONS

Our results corroborate the association between higher prevalence of extensive colitis and younger age at diagnosis. An association between steroid therapy and clinical presentation at diagnosis was observed. The observation that white individuals and rural patients use less immunosuppressive drugs highlights the need to study the influence of environmental and genetic factors on the behavior of UC in this population.

Surgical and medical treatment in patients with acute severe ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory disease of the mucosa of the colorectum. The treatment of UC depends on the severity of symptoms and the extent of the disease. Acute severe colitis (ASC) occurs in 12-25% of patients with UC. Patients with ASC must be managed by a multidisciplinary team. Medically or surgically aggressive treatment is carried out with the final aim of reducing mortality. Intravenous administration of corticosteroids is the mainstay of the therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids for 3 days. If there has been no response to medical rescue therapy after 4-7 days, the patient must undergo colectomy in emergency surgery. Prolonged observation is counterproductive, as over time it increases the risk of toxic megacolon and perforation, with a very high mortality rate. The best potential treatment is subtotal colectomy with ileostomy and preservation of the rectum. Emergency surgery in UC should not be seen as a last chance, but can be considered as a life-saving procedure. Colectomies in emergency setting are characterized by high morbidity rates but the mortality is low.

Influence of urban/rural and coastal/inland environment on the prevalence, phenotype, and clinical course of inflammatory bowel disease patients from northwest of Spain: a cross-sectional study

BACKGROUND

Data on the influence of rural/urban and coastal/inland environment on inflammatory bowel disease (IBD) are either conflicting or lacking. Our aim was to analyze whether the environment has any influence on the prevalence, phenotype, and course of IBD.

MATERIALS AND METHODS

We carried out a multicenter retrospective study in 1194 IBD patients from Galicia, Spain. Urban areas were defined as those with over 25,000 inhabitants. Sex, age, family history, smoking, Montreal classification, extraintestinal manifestations, steroid dependence/refractoriness, and treatment were assessed. We used the Student's t-test/Mann-Whitney U tests to compare continuous variables and χ to compare categorical variables. Logistic regression was also used.

RESULTS

Living in urban municipalities was a risk factor for Crohn's disease [relative risk (RR) 1.47; 95% confidence interval (CI) 1.25-1.73; P<0.001]; living in coastal municipalities was a protective factor for ulcerative colitis (RR 0.71; 95% CI 0.60-0.85; P<0.001). Crohn's disease patients living on the coast had more frequent ileocolonic disease and needed immunosuppressives more frequently than inland patients (RR for inland 0.65; 95% CI 0.47-0.90; P=0.008). Urban Crohn's disease patients needed immunosuppressives more frequently than rural patients (RR 1.41; 95% CI 1.04-1.92; P=0.027). Urban ulcerative colitis patients had left-sided colitis less frequently. Coastal ulcerative colitis patients more frequently had extensive colitis.

CONCLUSION

Crohn's disease was found more frequently in urban and coastal areas and ulcerative colitis in inland municipalities. Place of residence may also influence phenotype and clinical course as patients living on the coast have more frequent ileocolonic Crohn's disease phenotype, extensive ulcerative colitis, and greater need for immunosuppressive therapy.

Epidemiology, demographic characteristics and prognostic predictors of ulcerative colitis

Ulcerative colitis (UC) is a chronic disease characterized by diffuse inflammation of the mucosa of the colon and rectum. The hallmark clinical symptom of UC is bloody diarrhea. The clinical course is marked by exacerbations and remissions, which may occur spontaneously or in response to treatment changes or intercurrent illnesses. UC is most commonly diagnosed in late adolescence or early adulthood, but it can occur at any age. The incidence of UC has increased worldwide over recent decades, especially in developing nations. In contrast, during this period, therapeutic advances have improved the life expectancy of patients, and there has been a decrease in the mortality rate over time. It is important to emphasize that there is considerable variability in the phenotypic presentation of UC. Within this context, certain clinical and demographic characteristics are useful in identifying patients who tend to have more severe evolution of the disease and a poor prognosis. In this group of patients, better clinical surveillance and more intensive therapy may change the natural course of the disease. The aim of this article was to review the epidemiology and demographic characteristics of UC and the factors that may be associated with its clinical prognosis.