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Revista colombiana de Gastroenterología

Print version ISSN 0120-9957On-line version ISSN 2500-7440

Rev Col Gastroenterol vol.25 no.2 Bogotá Apr./June 2010

 

Prevalence and demographic characteristics of inflammatory bowel disease in Cartagena, Colombia

Ismael de Jesús Yepes Barreto, MD. (1), Rafael Carmona, MD. (2), Fela Díaz, MD. (3), Ignacio Marín-Jiménez, MD. (1)

(1) Department of Gastroenterology, Hospital Gregorio Maranon, Madrid, Spain.

(2) Department of Gastroenterology, Madre Bernarda Clinic, Cartagena de Indias, Colombia.

(3) Department of Gastroenterology, Comfamiliar Clinic, Cartagena de Indias, Colombia.

Received: 28-01-10 Accepted: 26-05-10

Abstract

Background: Globally, prevalence of inflammatory bowel disease (IBD) is around 396 cases per 105 inhabitants. However, it has been considered to have low incidence and prevalence in Hispanic populations. To date there is little published epidemiological information on IBD in South America.

Objectives: Estimate the prevalence of IBD in an adult population affiliated to an EPS in the city of Cartagena, Colombia.

Methods: All patients with confirmed IBD who received medical care in COOMEVA EPS up until June 01, 2006 were identified through reviewing their medical records. Prevalence was estimated in relation to the over age 15 patient population enrolled in the EPS at the time of data collection.

Results: 26 patients with IBD were the basis for calculating prevalence in our population. Six individuals had CD and 20 were diagnosed with UC. The estimated overall prevalence of IBD was 29 x 105 (95% CI: 17-40).

Conclusion: IBD still seems to be a rare disease in South America. Its incidence may be increasing according to recent data from other Hispanic communities. Our results are consistent with studies in other populations where IBD is an emerging disease.

Key words

Inflammatory bowel disease, South America, Crohn's disease, ulcerative colitis.

BACKGROUND

Crohn's Disease (CD) and Ulcerative Colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract which primarily affect the small intestine and colon. They are part of a spectrum of diseases known today as Inflammatory Bowel Disease (IBD).

Traditionally, IBD has been regarded as a common pathology in industrialized countries, with the highest incidences found in Europe and North America (1). This indicates that environmental, dietary and genetic factors are involved in the pathogenesis of the disease. Globally, prevalence of IBD seems to be around 396 per 105 people (2). However, this picture appears to change dramatically depending upon the geographic area in which it is calculated. In recent reviews a north-south gradient of prevalence has been reported (1, 3).

Nevertheless it is likely that prevalences are rising in areas traditionally considered to have low prevalence rates such as Eastern Europe (4-6) and Asia (7). It seems increasingly clear that the incidence of IBD is a dynamic process in which incidence and prevalence in different geographic areas change over time (1).

Although epidemiological data on IBD in Hispanic populations are scarce, recent studies from Puerto Rico (8, 9) and Brazil (10) have now shed some light on this subject. Nevertheless, we are still far from knowing the real prevalence of this disease in Central and South America. The precariousness of the information systems of the various national health services, the high prevalence of infectious intestinal diseases, the insidious nature of IBD's symptoms, the lack of diagnostic tools such as endoscopy in some geographical areas and physicians' lack of familiarity with this disease all combine to make epidemiological study of IBD in developing countries a difficult task.

In 1993, the Colombian government implemented major reforms, forming entities called "Health Promotion Companies" (Empresas Promotoras de Salud - EPS) to manage the provision of health care. Every Colombian worker must be affiliated to one, and only one, EPS. Independent of their sex, social status or income, each affiliated worker contributes 4% of his or her monthly salary. This has facilitated an improvement in access to medical care and diagnostic tests, making it easier to identify diseases considered less prevalent in this environment. This new insight combined with better information systems have provides us with a great opportunity to initiate epidemiological studies in this population.

METHODS

The initial diagnoses of IBD were obtained from the computerized database of HPC. 90,932 individuals over 15 years of age who had received medical care as of June 1, 2006 were included in the medical record review. Medical records of patients diagnosed with CD or UC were reviewed, and then this data was confirmed with the gastroenterologists involved in the management of these patients.

The Lennard-Jones criteria were used for diagnosis of IBD cases. Cases which were impossible to diagnose were rejected. Then prevalence by age group, diagnosis and gender were calculated. The presence or absence of risk factors such as alcohol consumption, smoking, immunizations and oral contraceptive use could not be determined due to insufficient data in medical records.

STATISTICAL ANALYSIS

Results are expressed as frequencies and percentages with their corresponding confidence intervals. Pearson's Chi-square test was used to compare prevalences between different groups. Statistical calculations were done with EPIDAT 3.1. A p value of <0.05 was considered statistically significant.

RESULTS

Among the 90,932 individuals whose records were reviewed, 60 IBD diagnoses were identified. 34 cases were dismissed after a review of clinical records, most of them because of a wrong initial diagnosis. Finally, 26 patients with IBD became the basis for calculation of prevalence in our population. Six individuals had CD, and 20 were diagnosed with UC (figure 1). The mean age of our subjects was 40 + or - 12.7 years (range 17-79). Estimated overall prevalence of IBD was 29 per 105 (95% CI 17-40). Most of this was due diagnoses of CU which had an estimated prevalence of 22 per 105 (95% CI 12-22). CD diagnoses were less frequent. Estimated CD prevalence was 7 per 10 5 (95% CI 1-12) (Table 1). UC prevalence among women was 30.4 per 105 (95% CI 14-47), considerably higher than the prevalence among men which was 12 per 105 (95% CI 4-28). No gender differences were found for prevalences of CD (6.1 per 105 for women vs. 7.2 per 105 for men). In general, the prevalence of IBD was higher in females, 37 per 105 (95% CI 19-54), than in men, 19 per 105 (95% CI 5-34) (Table 2). The highest prevalence, 67 per 105 (95% CI 22-155) was in the 45-49 year old group which had 6 cases of IBD. The next highest prevalence rate was among the group of patients aged 50-54 years. With 3 cases of IBD this group had a prevalence rate of 54 per 105 (95% CI 11-158) (Table 3).

Figure 1. Identification of cases.

Table 1. Prevalence and diagnoses.

Table 2. Prevalence and gender.

Table 3. Prevalencia y edad.

DISCUSSION

The first published epidemiological data about IBD in South America come from studies performed in hospital populations. Their primary aim was to describe clinical and demographic characteristics of patients with IBD (11-14).

A study conducted by Linares et al in Argentina and Panama (15) reported incidences of 2.2 per 105 and 1.2 per 105. For their calculations they based prevalence rates on the number of new cases which occurred in each of two hospitals over a period of seven years. They divided these cases by the population living in the area of influence of each institution. Based upon this, they concluded that incidences of IBD were even lower than those estimated for Hispanic communities living outside of Latin America. Nevertheless, the facts that only one case of CD has been identified in Argentina, and none have been identified in Panama suggest that actual cases of IBD were underestimated. As has already been seen, CD is rare, but not non-existent in other Hispanic-American populations.

More recently, the results of the Appleyard group (9) in Puerto Rico and Victoria (10) in Brazil, have contradicted the findings of the Linares study. These newer studies observed not only higher rates of incidence but also clear upward trends (Table 4).

Table 4. Incidence

Torres et al reported overall IBD prevalence of 106.1 per 105 inhabitants (62 per 105 for UC and 41.4 per 105 for CD) in a population receiving medical services from a private insurer in Puerto Rico. However, because of the privacy policy of the insurance company they were unable to review patients' clinical histories to verify diagnoses. This could have resulted in an overestimation of the number of cases if alternative diagnoses had been arrived at late, as occurred in our study in which 56.6% of cases initially diagnosed with IBD were rejected for this reason.

Recently, Appleyard estimated the incidence and prevalence of IBD from 1996 to 2000 in a population of 814,256 (2000 census) in southern Puerto Rico. They found a prevalence of 5.89 per 105 for CD and 12.53 per 105 for UC. Total IBD prevalence of 24.81 per 105 also included cases of indeterminate colitis. These authors acknowledge that they may have underestimated the true incidence of IBD due to the loss of some cases that were not addressed in the study area. However if 93 cases diagnosed before 1996 had been included, their values would have been slightly higher (16).

Finally, a study conducted in the state of Sao Paulo, Brazil (10) found overall prevalence of IBD of 22.6 x 105 (CU: 14.81 x 105, CD: 5.65 x 105).

Our results are closer to those estimated by the last two authors (Table 5). Cartagena is located on the Caribbean coast of Colombia. Its population is composed mainly of descendants of Africans and southern Europeans as are the populations of Puerto Rico and Brazil. Nevertheless, large socioeconomic differences among these three countries make comparisons more difficult to assess. The fact that in our population, women were more likely to have IBD was not confirmed in the study of Appleyard (9) but appears to coincide with the data from Brazil (10).

Table 5. IBD prevalence in Latin America

In accordance with the findings of other Latin American authors, we also found a higher prevalence of UC than of CD (p <0.01) (9, 10, 14).

Our results are comparable to those of studies in Croatia (17, 18) and Japan (19) in which the findings suggest that the incidence of UC is higher than that of the CD in populations where IBD is an emerging disease. Usually, increased incidence of UC precedes an increase in the incidence of CD by 15 to 20 years.

The small number of cases in our study may have affected the accuracy of our results. Like our colleagues, we may have underestimated the number of patients affected since our sample was small compared with the study population of Cartagena which has a population of 985,400 people (20).

However, the high cost of medicine in Colombia coupled with the fact that these individuals can be affiliated to one, and only one, EPS, make it unlikely that they would have sought medical care in other medical centers or cities. This, together with the fact that our figures are consistent with those reported in other Latin American populations and in countries where IBD seems to be an emerging public health problem, gives strength to our results.

CONCLUSIONS

Our results suggest that IBD is not a frequent occurring pathology in Cartagena, a finding that is in agreement with recent data from studies in other Latin American communities. Nevertheless, these observations should be confirmed with prospective studies designed specifically to study the incidence and prevalence of IBD in this population. The epidemiology of gastrointestinal diseases should become the object of continuous research in this country. Knowledge of the real epidemiological profile of these pathologies, including those that occur infrequently, will aid us in the development of efficacious health care strategies and keep us alert to opportune diagnostic possibilities.

Conflicts of interest

None.

References

1. Loftus EV Jr, Sandborn WJ. Epidemiology of inflammatory bowel disease. Gastroenterol Clin North Am 2002; 31(1): 1-20.

2. Lakatos PL. Recent trends in the epidemiology of inflammatory bowel diseases: up or down? World J Gastroenterol 2006; 12(38): 6102-8.

3. Shivananda S, Lennard-Jones J, Logan R, et al. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut 2007; 56(11): 1638-9

4. Lakatos L, Lakatos PL. Is the incidence and prevalence of inflammatory bowel diseases increasing in Eastern Europe? Postgrad Med J 2006; 82(967): 332-7.

5. Lakatos L, Mester G, Erdelyi Z, et al. Striking elevation in incidence and prevalence of inflammatory bowel disease in a province of western Hungary between 1977-2001. World J Gastroenterol 2004; 10(3): 404-9.

6. Sincić BM, Vucelić B, Persić M, et al. Incidence of inflammatory bowel disease in Primorsko-goranska County, Croatia, 2000-2004: A prospective population-based study. Scand J Gastroenterol 2006; 41(4): 437-44.

7. Sood A, Midha V, Sood N, et al. Incidence and prevalence of ulcerative colitis in Punjab, North India. Gut 2003; 52(11): 1587-90.

8. Torres EA, De Jesús R, Pérez CM, et al. Prevalence of inflammatory bowel disease in an insured population in Puerto Rico during 1996. P R Health Sci J 2003; 22(3): 253-8.

9. Appleyard CB, Hernández G, Rios-Bedoya CF. Basic epidemiology of inflammatory bowel disease in Puerto Rico. Inflamm Bowel Dis 2004; 10(2): 106-11.

10. Victoria CR, Sassak LY, Nunes HR. Incidence and prevalence rates of inflammatory bowel diseases, in midwestern of São Paulo State, Brazil. Arq Gastroenterol 2009; 46(1): 20-5.

11. Dolcini H, Arabehety JT, Stapler NM. Ulcerative colitis. Follow-up of 100 patients, with some comments on the general features of this disease in Argentina. Am J Proctol 1967; 18(2): 132-5.

12. Gutiérrez Blanco H. Characteristics of chronic ulcerative colitis in Uruguay (187 CASES). Prensa Med Argent 1963; 50: 2755-62.

13. Calderón AV, Velarde OF, Yoshidaira MY, et al. Clinical and epidemiological profile of ulcerative colitis in a hospital in Lima. Rev gastroenterol Peru 2004; 24: 135-142.

14. Figueroa CC, Quera PR, Valenzuela EJ, et al. Inflammatory bowel disease: experience of two Chilean centers. Rev Med Chil 2005; 133(11): 1295-304.

15. Linares de la Cal JA, Cantón C, Hermida C, et al. Estimated incidence of inflammatory bowel disease in Argentina and Panama (1987-1993). Rev Esp Enferm Dig 1999; 91(4): 277-86.

16. Frangos CC. Correction on the prevalence data of inflammatory bowel disease in Puerto Rico. Inflamm Bowel Dis 2007; 13(10): 1314-5.

17. Vucelic B, Korac B, Sentic M, et al. Epidemiology of Crohn's disease in Zagreb, Yugoslavia: A ten-year prospective study. Int J Epidemiol 1991; 20: 216-20.

18. 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.

19. Morita N, Toki S, Hirohashi T, et al. Incidence and prevalence of inflammatory bowel disease in Japan: Nationwide epidemiological survey during the year 1991. J Gastroenterol 1995; 30: 1-4.

20. Departamento administrativo nacional de estadística (DANE). www.dane.gov.co. Colombia. Censo 2005.

1. Loftus EV Jr, Sandborn WJ. Epidemiology of inflammatory bowel disease. Gastroenterol Clin North Am 2002; 31(1): 1-20.         [ Links ]

2. Lakatos PL. Recent trends in the epidemiology of inflammatory bowel diseases: up or down? World J Gastroenterol 2006; 12(38): 6102-8.        [ Links ]

3. Shivananda S, Lennard-Jones J, Logan R, et al. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut 2007; 56(11): 1638-9.        [ Links ]

4. Lakatos L, Lakatos PL. Is the incidence and prevalence of inflammatory bowel diseases increasing in Eastern Europe? Postgrad Med J 2006; 82(967): 332-7.        [ Links ]

5. Lakatos L, Mester G, Erdelyi Z, et al. Striking elevation in incidence and prevalence of inflammatory bowel disease in a province of western Hungary between 1977-2001. World J Gastroenterol 2004; 10(3): 404-9.        [ Links ]

6. Sincic BM, Vucelic B, Persic M, et al. Incidence of inflammatory bowel disease in Primorsko-goranska County, Croatia, 2000-2004: A prospective population-based study. Scand J Gastroenterol 2006; 41(4): 437-44.        [ Links ]

7. Sood A, Midha V, Sood N, et al. Incidence and prevalence of ulcerative colitis in Punjab, North India. Gut 2003; 52(11): 1587-90.        [ Links ]

8. Torres EA, De Jesús R, Pérez CM, et al. Prevalence of inflammatory bowel disease in an insured population in Puerto Rico during 1996. P R Health Sci J 2003; 22(3): 253-8.        [ Links ]

9. Appleyard CB, Hernández G, Rios-Bedoya CF. Basic epidemiology of inflammatory bowel disease in Puerto Rico. Inflamm Bowel Dis 2004; 10(2): 106-11.        [ Links ]

10. Victoria CR, Sassak LY, Nunes HR. Incidence and prevalence rates of inflammatory bowel diseases, in midwestern of São Paulo State, Brazil. Arq Gastroenterol 2009; 46(1): 20-5.        [ Links ]

11. Dolcini H, Arabehety JT, Stapler NM. Ulcerative colitis. Follow-up of 100 patients, with some comments on the general features of this disease in Argentina. Am J Proctol 1967; 18(2): 132-5.        [ Links ]

12. Gutiérrez Blanco H. Characteristics of chronic ulcerative colitis in Uruguay (187 CASES). Prensa Med Argent 1963; 50: 2755-62.        [ Links ]

13. Calderón AV, Velarde OF, Yoshidaira MY, et al. Clinical and epidemiological profile of ulcerative colitis in a hospital in Lima. Rev gastroenterol Peru 2004; 24: 135-142.         [ Links ]

14. Figueroa CC, Quera PR, Valenzuela EJ, et al. Inflammatory bowel disease: experience of two Chilean centers. Rev Med Chil 2005; 133(11): 1295-304.         [ Links ]

15. Linares de la Cal JA, Cantón C, Hermida C, et al. Estimated incidence of inflammatory bowel disease in Argentina and Panama (1987-1993). Rev Esp Enferm Dig 1999; 91(4): 277-86.        [ Links ]

16. Frangos CC. Correction on the prevalence data of inflammatory bowel disease in Puerto Rico. Inflamm Bowel Dis 2007; 13(10): 1314-5.        [ Links ]

17. Vucelic B, Korac B, Sentic M, et al. Epidemiology of Crohn's disease in Zagreb, Yugoslavia: A ten-year prospective study. Int J Epidemiol 1991; 20: 216-20.        [ Links ]

18. 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.        [ Links ]

19. Morita N, Toki S, Hirohashi T, et al. Incidence and prevalence of inflammatory bowel disease in Japan: Nationwide epidemiological survey during the year 1991. J Gastroenterol 1995; 30: 1-4.        [ Links ]

20. Departamento administrativo nacional de estadística (DANE). www.dane.gov.co. Colombia. Censo 2005.        [ Links ]

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