Management in Health, Vol 16, No 4 (2012)

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EPIDEMIOLOGICAL AND CLINICAL EVOLUTIVE ASPECTS OF THE ULCERATIVE COLITIS

EPIDEMIOLOGICAL AND CLINICAL EVOLUTIVE ASPECTS OF THE ULCERATIVE COLITIS. A 5-YEAR PROSPECTIVE STUDY IN A TERTIARY GASTROENTEROLOGY CENTER

 

Olga BRUSNIC1, MD - specialist, PhD candidate

Professor Daniela DOBRU1- Chief Physician, Head of Doctoral School,

Danusia ONIŞOR1 , MD - specialist, PhD candidate,

Ofelia PASCARENCO1 , MD - specialist, PhD candidate,

Mircea STOIAN2 , MD - specialist, PhD candidate,

 

1 Mureş County Clinical Hospital, Clinical Department of Gastroenterology

2 Mureş County Clinical Hospital, Department of Anesthesia and Intensive Therapy

 

ABSTRACT:

INTRODUCTION: Over the last 3 decades, the improvement of diagnosis criteria in idiopathic inflammatory bowel diseases led to an increased interest on a global level for this pathology. The clinical evolution of the disease, the prognosis and any associated complications are of major importance for the patient and the treating physician.

 

THE AIMS of the study has been to determine the epidemiological and clinical evolutive aspects of the patients with UC in a tertiary Gastroenterology center.

 

MATERIAL AND METHOD. We have performed a prospective observational study on a batch of patients who were being monitored at our clinic in the period January 2007 - December 2011. The lot of study comprised 160 patients with UC. Each patient had a - patient's record - in which we collected the demographic data, family history of inherited and collateral diseases, signs and symptomatology of the disease, the biological markers. There have been evaluated the extraintestinal and bowel complications, the treatment for each patient at the onset of the disease, during the active periods of the disease, and as well in the remission phase of the disease (clinical and endoscopic).

 

RESULTS: The annual incidence of UC patients experienced an ascending trend from 12 newly diagnosed cases in 2007 to 35 new cases in 2010, respectively 30 new cases in 2011. Moreover, the number of monitored UC patients has increased from 58 in 2007 up to 160 in 2011. In the studied lot we had an approximate equal distribution on gender of the patients: 51% women, 49% men. Most of the patients were from of an active urban environment (71%). The minimum onset age of UC was 15, and the maximum age 80. 61% of the patients were non-smokers, and 25% active smokers. According to the extension of lesions, 60% of the patients had left-sided colitis, 22% extensive left-sided colitis, and 17% proctitis. According to the severity of the disease, 54% of the patients had moderate flares of disease, 24% mild flares, 15% severe flares and only 7% have been in clinical and endoscopical remission during the analyzed period.

 

CONCLUSIONS: According to the results obtained UC has an ascending trend of incidence, fact that imposes an appropriate management of the patients with diarrheic syndrome to which there are associated or not pathologic elements (blood, mucus). These data demonstrate the usefulness of endoscopic monitoring in patients with an older dated disease and of those with an extensive form of the disease, including pancolitis, as well as the usefulness of early colectomy in patients with severe dysplasia.

 

Keywords: Ulcerative colitis, Endoscopy, Colorectal cancer, Colectomy.

 

INTRODUCTION: Over the last 3 decades, the improvement of diagnosis criteria in idiopathic inflammatory bowel diseases led to an increased interest on a global level for this pathology. The characteristic phenotype of inflammatory bowel diseases will show us the prognostic of the disease and the treatment as well, for each patient with specific medication for the pursued target.

Ulcerative Colitis (UC) is a continuous or recurrent chronic inflammatory disease, which evolves with flares of activity and clinical remission periods. The clinical features in UC are correlated with the severity and extension of the disease. The clinical activity of the disease is classified into four categories: mild, moderate, severe and phase of remission. In relation to the extension of lesions there are described: proctitis, left-sided colitis and extensive colitis (including pancolitis).

The clinical evolution of the disease, the prognosis and any associated complications are of major importance for the patient and the treating physician.

The aims of the study has been to determine the epidemiological and clinical evolutive aspects of the patients with UC in a tertiary Gastroenterology center.

 

MATERIAL AND METHOD. We have performed a prospective observational study on a batch of patients who were being monitored at our clinic in the period January 2007 - December 2011. The lot of study comprised 160 patients with UC. The diagnosis of the disease has been established based on the clinical, endoscopic and histopathological examination. Each patient had a - patient's record - in which we collected the demographic data (surname/name, age, gender, environment and county of origin, smoker status), family history of inherited and collateral diseases, signs and symptomatology of the disease (stool frequency, presence of rectal bleeds, abdominal pains, body temperature, body weight, asthenia, adynamia). From the biological parameters were taken into consideration the values of the hemoglobin, leukocytes, thrombocytes, of serum transaminases, proteins and of the markers of the inflammation: ESR and CRP. All patients have been examined endoscopically (for evaluation of the extension and severity of the lesions) at the onset and subsequently 1-2 years after the moment of the diagnosis in view of monitoring the evolution of the disease during the said period. There have been evaluated the extraintestinal and bowel complications, and subsequently 1-2 years after the moment of the diagnosis in view of monitoring the evolution of the disease during the said period.

 

There have been evaluated the extra-intestinal and bowel complications, the treatment for each patient at the onset of the disease, during the active periods of the disease, and as well in the remission phase of the disease (clinical and endoscopic).

The coproparasitological examination has been performed to exclude the infectious etiology. Microbiological tests have been performed from stool during refractory or severe relapses and on those with recent history (3 months) of antibiotics therapy, to exclude infection with C. Difficile. The clinical activity of the disease (according to Truelove & Witts' Classification) has been classified into four categories: mild, moderate, severe and remission.

The distribution of lesions, according to the Montreal Classification, has been grouped into: proctitis (lesions limited up to the level of the rectosigmoid junction), left-sided colitis (extensive lesions distal to the splenic flexure) and extensive left-sided colitis including pancolitis (extensive lesions proximal to the splenic flexure). The clinical activity of UC and also the extension of the lesions at onset have been studied, and subsequently at each flare of re-exacerbation of the disease, as well as at the end of the monitored period.

 

Statistical Analysis. The data has been processed with the help of statistical instruments in Excel (Microsoft Excel 2003).

 

RESULTS: The annual incidence of UC patients experienced an ascending trend from 12 newly diagnosed cases in 2007 to 35 new cases in 2010, respectively 30 new cases in 2011. Moreover, the number of monitored UC patients has increased from 58 in 2007 up to 160 in 2011 (figure 1).

 

Figure 1. Temporal tendecies of IBD

 

In the studied lot we had an approximate equal distribution on gender of the patients: 51% women, 49% men. Most of the patients were from of an active urban environment (71%). According to the county of origin, the higher reach refers to the patients from the Mureș county (66,25%) being followed of those from the counties of Sibiu (8,125%), Harghita (6,25%) and Neamț (4,37%).

The minimum onset age of UC was 15, and the maximum age 80. The UC incidence in relation to age experienced a bimodal trend: a first peak of the disease onset was between ages of 31-40, and the second peak has been noticed between ages of 51-70 (figure 2).

 

Figure 2. The evolution of UC incidence in relation to age

 

Concerning the smoker status, 61% of the patients were non-smokers, and 25% active smokers. In the smokers group of patients prevailed the female gender, and in the other two groups (ex-smokers, respectively non-smokers) distribution on genders was approximately equal (figure 3).

 

Figure 3. The effect of smoking on the UC incidence genders.

 

According to the extension of lesions, 60% of the patients had left-sided colitis, 22% extensive left-sided colitis, and 17% proctitis. According to the severity of the disease, 54% of the patients had moderate flares of disease, 24% mild flares, 15% severe flares and only 7% have been in clinical and endoscopical remission during the analyzed period. All patients had been at least once admitted to the hospital, and the maximum number of admissions was 10. The UC evolution in the analyzed period is illustrated in figure 4 and 5.

 

Figure 4. UC extension

 

Figure 5. The severity of UC

 

 

 

Concerning the biological pannel, 63% of the patients presented hypoproteinemia with hypoalbuminemia, 47% of the patients presented anemia. During the active periods of the disease only 13% of the patients had positive values of CRP (figure 6).

 

Figure 6. Serological markers

 

Among the bowel complications, in the studied lot prevailed, lower gastrointestinal bleeding 89%, 8% of the patients presented colonic stenoses, 1% of the patients presented colonic perforation, 2% presented malignization. Among the extraintestinal complications prevailed the arthritis (2%), primary sclerosing cholangitis (PSC) 2% and lingering urinary tract infections (2%).

The presence of low grade dysplasia (LGD) has been identified in 2 patients, high grade dysplasia (HGD) has been identified 1 patient (1%), at whom the evolution of the disease lasted 5 years. Colorectal cancer (CRC) has been identified in 2 patients with a very long evolution of the disease (16 years, respectively 5 years). For these patients the therapeutic indication was surgical intervention. In the situations in which there had been revealed dysplastic changes, the biopsies were performed from areas of stenosis or from areas with inflammatory pseudopolyps. The therapeutic indication for these patients was surgical intervention, respectively total proctocolectomy.

 

DISCUSSIONS: During the period 2007-2011 under the monitoring of the Gastroenterology Clinic there have been 160 patients with ulcerative colitis. A first ascertainment was the increase of the annual incidence of UC: from 12 newly diagnosed cases in 2007 to 35 new cases in 2010, respectively 30 new cases in 2011. The progressive increase of the incidence in the studied period has an unknown cause, but a possible role is occupied by the behavioral factors (nutrition and lifestyle). A recent study which purpose was to evaluate the incidence and prevalence of UC in the south-eastern Europe, reports an ascending trend for countries like Hungary (5.9/105) and Croatia (3.9-5.9/105) in comparison to the countries from the north and west of Europe [1,2]. The data of an epidemiological study performed in 2003 in Romania, reports an incidence of 0.97/100 000 of inhabitants adult population for ulcerative colitis (UC) and 0.50/100 000 of inhabitants for Crohn's disease (CD). The prevalence being of 2.42 to 100 000 of inhabitants adult population for ulcerative colitis UC and, respectively 1.52 for Crohn's disease [3].

In comparison to the literature data, in our study we had an approximate equal distribution on genders, although in 2009 it has been noticed a higher incidence in the female gender. In the populations of north-west European origin it is noticed an incidence of 30% higher in the female gender [4,5,6].

The evolution of the incidence in relation to age is bimodal, with a first peak between ages of 15-25 and a second one, smaller, between ages of 55-65 [6]. From our observations results that the age group 31-40 was predominant.

An important epidemiologic aspect consists in the incidence about twice as higher of UC among non-smokers: persons who abandoned smoking, especially the big smokers, associate a higher risk of developing an inaugural flare or recurrent flares of inflammatory activity of UC [7,8]. In this study we had: 61% non-smokers, 25% active smokers and 14 % ex-smokers, fact that confirms the literature data that the risk of developing UC is lower in smokers in comparison with the other 2 groups.

A recent study has demonstrated that the average period, from the onset of UC and until the occurrence of CRC, is 16 years. The conclusion of the study was that the forms of UC with a long evolution have a high risk to develop CRC [9]. In our study we had only 2 patients with CRC, at one of them the evolution of the disease lasted for 16 years. But we have demonstrated that the forms with a shorter evolution (5 years) also may present an equally high risk for the occurrence of CRC.

 

CONCLUSIONS: According to the results obtained UC has an ascending trend of incidence, fact that imposes an appropriate management of the patients with diarrheic syndrome to which there are associated or not pathologic elements (blood, mucus). These data demonstrate the usefulness of endoscopic monitoring in patients with an older dated disease and of those with an extensive form of the disease, including pancolitis, as well as the usefulness of early colectomy in patients with severe dysplasia.

 

References

1.       Lakatos L, Mester Gerdelyi Z et al: Striking elevation in the incidence and prevalence of inflammatory bowel disease in a province of Western Hungary between 1977 and 2001. World J Gastroenterol 2004, 10:404-9.

2.       Vucelic B, Korac B, Sentic M, et al: Ulcerative colitis in Zagreb Yugoslavia: incidence and prevalence 1980-1989. Int J Epidemiol 1991, 20: 1043-7.

3.       Gheorghe C, Pascu O, Gheorghe L, et al: Epidemiology of inflammatory bowel disease in adult who refer gastroenterology care in Romania: a multicentric study. Eur J Gastroenterol Hepatol, 2004, 16: 1.153-1.161.

4.       Kolosky NA, Bret L, Radford-Smith G. Hygiene hypothesis in inflammatory bowel disease: a critical review of the literature. World J Gastroenterol. 2008; 14:165-173.

5.       Loftus EV Jr. Clinical epidemiology of inflammatory bowel disease: incidence, prevalence, and environmental influences. Gastroenterology. 2004; 126: 1504 - 1517.

6.       Calkins BM, Lilienfeld AM, Garland CF, Mendeloff AI. Trends in the incedence rates of ulcerative colitis and Crohn's disease. Dig Dis Sci 1984; 29:913.

7.       Calkins BM. Smoking factors in ulcerative colitis and Crohn's disease in Baltimore. Am J Epidemiol 1984; 120:498.

8.       Koutrobakis I, Manousonos ON, Meuwissen SGM, Pena AS: Environmental risk factors in inflammatory bowel disease. Hepatogastroenterology 1996; 43: 381 - 393.

9.       C. J. Karvellas, R. N. Fedorak, J. Hanson, and C. K. W. Wong, "Increased risk of colorectal cancer in ulcerative colitis patients diagnosed after 40 years of age," Canadian Journal of Gastroenterology, vol. 21, no. 7, pp. 443-446, 2007.

 

 

 

 

 

 



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