Saudi Journal of Gastroenterology
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Year : 1996  |  Volume : 2  |  Issue : 3  |  Page : 150-155
Crohn's disease in Saudi Arabia: A clinicopathological study of 12 cases


1 Department of Internal Medicine, College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia
2 Department of Pathology, College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia

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Date of Submission09-Apr-1996
Date of Acceptance15-Jun-1996
 

   Abstract 

In this report we present our experience with 12 cases of Crohn's disease out of 1279 consecutive colorectal biopsies (0.9%), seen during an l 1 years period (1983-1994) in a tertiary care teaching hospital. During the period 76 cases (6%) of Ulcerative Colitis (UC) were seen. Of the 12 patients with Crohn's disease, seven were males and five were females, all Saudi nationals aged 16-39 with a median of 23 years, relatively younger than those with UC seen during the same period. Recurrent colicky abdominal pain was the striking presenting symptoms in all patients, commonly associated with weight loss. The disease involved both small and large bowel in eight patients (67%) and the colon alone in one patient. Granulomas were seen in seven patients (58%). Surgery was offered for two patients and most of the remaining patients were symptomatic on follow up.

How to cite this article:
Al-Gindan YM, Satti MB, Al-Quorain AA, Al-Hamdan A. Crohn's disease in Saudi Arabia: A clinicopathological study of 12 cases. Saudi J Gastroenterol 1996;2:150-5

How to cite this URL:
Al-Gindan YM, Satti MB, Al-Quorain AA, Al-Hamdan A. Crohn's disease in Saudi Arabia: A clinicopathological study of 12 cases. Saudi J Gastroenterol [serial online] 1996 [cited 2019 Nov 13];2:150-5. Available from: http://www.saudijgastro.com/text.asp?1996/2/3/150/34021


Until recently it was generally believed that chronic idiopathic ulcerative colitis (UC) and Crohn's disease are rarely seen in nonindustrialized areas including the Middle-Eastern, Asian and African countries. There are only few reports that emerged from such areas [1],[2],[3] . However during the last 12 years more cases have been encountered particularly from the Middle East [3],[4],[5],[6],[7] . It appears that the now more frequent encounter of chronic inflammatory bowel disease in such countries parallels the exponential growth in development and industrialization, tendency to a more western type of dietary habits and exposure to more psychological stress associated with such a life. Furthermore, increased awareness of the disease and improvement in diagnostic modalities play a significant role. This study from Saudi Arabia further documents that Crohn's disease exists in the Arabian Peninsula, though with much lower frequency than in western hemisphere countries.


   Patients and Methods Top


A retrospective evaluation of all lower gastrointestinal (L.G.I.) endoscopies during 1983-1994 at King Fahd Hospital of the University, Al-Khobar was performed. Of all such cases only those who had a biopsy were included. The medical records were reviewed for age, sex, nationality, symptoms and duration, endoscopic findings and follow up information.

All pertinent histological sections and paraffin blocks were retrieved for review and evaluation. Using standard histological criteria and in the light of clinical and endoscopic findings, patients were categorized into various diagnostic entities. Colonic infections were excluded by repeat stool examination and culture. Follow up information for disease progression and outcome were retrieved from patients' charts.

The diagnosis of Crohn's disease was considered a possibility in patients with recurrent symptoms whenever there is radiological evidence of isolated or associated small bowel disease, endoscopic evidence of linear ulcerations, aphthoid ulcers or cobblestoning with skip lesions or presence of granulomas anywhere in the GIT with the exclusion of tuberculosis as a possibility. Histologically mucosal chronic inflammation and mucin depletion in endoscopic biopsies, or transmural chronic inflammation with fibrosis in resection specimens were indicative diagnostic features. The presence of granulomatous inflammation [Figure - 1], was supportive of the diagnosis of Crohn's disease, but its absence did not preclude such a diagnosis.


   Results Top


Of a total of 1279 patients who underwent lower gastrointestinal endoscopy and biopsy during the 11-year period, 12 patients were considered to have Crohn's disease (0.9%). Comparatively, during the same period, 76 patients satisfied diagnostic criteria for idiopathic chronic ulcerative colitis (UC), a relative frequency approaching 6.0%. The final tissue diagnoses of all endoscoped patients are shown in [Table - 1]. A diagnosis of normal colorectal mucosa or nonspecific proctocolitis constituted the predominant diagnoses amounting to 42.4% and 32% of all cases respectively.

Out of 1279 patients, 972 (76%) were males and 307 (24%) were females, with a mean age of 37.5+ 15 years. Saudi nationals constituted 742(58%). The remaining 537 (42%) were non-Saudis, mostly of Arab origin from neighboring countries. The most common presenting symptom for referral was abdominal pain (977 patients, 76.2%) followed by diarrhea (495 patients, 38.7%). Preendoscopic evaluation revealed a 5.4% (69 patients) positive rate of hepatitis B surface antigen and a negative rate of 68.1% (871 patients). Screening was not done for the remaining patients.

The final diagnosis of Crohn's disease was based on clinical, radiologic, tissue examination and follow-up information. The data is shown in [Table - 2],[Table - 3]. Seven were males and five were females with an age range at presentation of 16-39 years and a median of 23 years. All patients were Saudi nationals. Recurrent colicky abdominal pain was the main presenting symptom in all patients. This was associated with weight loss in 10 patients, diarrhea in seven, fever in five, arthralgia in three, recurrent perianal abscess or fistula in three and bleeding per rectum in one patient. One patient had finger clubbing. All 12 patients were anemic.

Histopathological examination demonstrated granulomatous inflammation in seven patients (58%). The diagnostic granulomatous inflammation involved the colon in two patients, colon and stomach in one patient and the appendix (presented as acute appendicitis), stomach [Figure - 2], and terminal ileum and mesenteric lymph nodes in one patient each. Based on both radiology and tissue examination, the disease involved the small intestine alone in only three patients (Cases 1,4 & 5), where isolated or multiple strictures with ulcerations were seen [Figure - 3]. It involved both small and large bowel in eight patients [Figure - 4], while apparent involvement of the colon in isolation was noted in one patient (Case 11).

Ten patients showed symptomatic improvement and gained weight on standard medical therapy for Crohn's disease (steroids with aminosalysilic acid) while two patients were treated surgically: one with ilea] resection and the other with right hemicolectomy. Four patients were initially kept on antituberculous therapy without a therapeutic response. The follow-up period ranged between one and 11 years with a mean of 4 years. The two patients who were surgically treated were well and showed much improvement. Of the 10 medically treated patients two were asymptomatic, six were with mild symptoms while one showed no improvement and thus was started on a trial dose of imuran therapy. One patient was lost on follow up [Table - 3].


   Discussion Top


Chronic idiopathic ulcerative colitis and Crohn's disease are rarely encountered in developing nations. Only few scattered reports appeared in the literature on both diseases from middle eastern countries [1],[2],[3],[4],[5],[7] , including two reports from Saudi Arabia [5],[7] . The disease is known to be common in Europe and North America [8],[9],[10] . Our hospital-based study confirms the existence of both diseases with a relative frequency of 6% for ulcerative colitis and 0.9% for Crohn's disease resulting in an approximate ratio of 7:1 [Table - 1].

Crohn's disease exists with much lower frequency in comparison to UC in a ratio of 1:7. This compares to a ratio of 5.3:1 from Kuwait [6] . The disease affects a younger age group with a median age of 23 years compared to 36 years in UC. Abdominal pain, colicky in nature and associated with weight loss, constituted a significant marker of the disease occurring in all 12 patients. This may or may not be associated with diarrhea which occurred in only seven (58%) of our patients. This is unlike the presentation of UC where diarrhea was the commonest symptom followed by hematochesia. The latter occurred in only one patient (9%) of those with Crohn's disease. Abdominal pain was a feature noted in 93% of patients from Kuwait [6] , and in all the seven patients of the Riyadh study [7] . Weight loss, a notable feature of our cases, was similarly noted in all the seven patients of the latter study [7] . The disease radiologically involved both small and large bowel in eight patients (67%). Perianal disease was relatively frequent occurring in three (27%), commoner than a figure of 7.7% from Kuwait [6] and comparable to a figure of 36% from Western experience [12] . Histopathologic confirmation with identification of granulomatous inflammation occurred in seven patients (58%). This is nearly similar to reported frequency from the West and relatively more than that reported from Kuwait (four out of 14; 29%) [6] .

Differentiation of Crohn's disease from G.I. tuberculosis was a major problem in the presence of granulomas. The belief that Crohn's disease is rare in this area has led to initiation of antituberculous therapy in four of our patients without a therapeutic response. All four patients thereafter responded dramatically to steroids and one of them had right hemicolectomy. In Case 4, the presence of skip lesions with midileal stricture [Figure - 4] and gastric granuloma was more indicative of Crohn's disease that was proved by the therapeutic response. Similarly two of the 14 patients from Kuwait were initially treated for tuberculosis and later proved to have Crohn's disease (6). The problem of distinguishing Crohn's disease from G.I. tuberculosis was previously addressed by Tandon and Prakash [13] .

In summary, our results confirm that Crohn's disease exists in the Arabian Peninsula [7],[14] though with a much lesser frequency than UC. It affects a younger age group and commonly presents with colicky abdominal pain and weight loss. Diarrhea may occur but hematochesia is a rare manifestation. Where granulomas are a feature, tuberculosis has to be excluded and a therapeutic trial may be justified. However, Crohn's disease has to be considered and treated to avoid delay in diagnosis and to guard against complications. A recommendation that should be taken into consideration by gastroenterologists in the Kingdom, under the umbrella of the Saudi Gastroenterology Association, is to initiate a national registry of chronic inflammatory bowel disease with present diagnostic criteria in an attempt to unravel its prevalence in a large national study.

 
   References Top

1.Salem SN. Non-specific ulcerative colitis in Bedouin Arabs. The Lancet 1967; 1:473-5.  Back to cited text no. 1    
2.Gilat T, Lilos P, Zemishlany Z, Ribak J, Benaroya Y. Ulcerative colitis in the Jewish population of Tel-Aviv Yafo III. Clinical course. Gastroenterology 1976;70:14-9.  Back to cited text no. 2    
3.Kusakcioglu O, Kusakcioglu A, Oz F. Idiopathic ulcerative colitis in Istanbul. Clinical review of 204 cases. Dis Col & Rect 1979;22:350-5.  Back to cited text no. 3    
4.Mir-Madjlessi SH, Forouzandeh B, Ghadimi R. Ulcerative colitis in Iran: a review of 112 cases. Am J Gastroenterology 1985;11:862-6.  Back to cited text no. 4    
5.Hossain J, Al-Faleh FZ, Al-Mofleh I, Al-Aska A, Laajam MA, Al-Rashed R. Does ulcerative colitis exist in Saudi Arabia? Analysis of 37 cases. Saudi Med Journal 1989;10:360-2.  Back to cited text no. 5    
6.Al-Nakib B, Radhadkrishnan S, Jacob GS, Al-Liddawi H, Al-Ruwaih A. Inflammatory bowel disease in Kuwait. Am J Gastroenterol 1984;79:191-4.  Back to cited text no. 6    
7.Hossain J, Al-Mofleh IA, Laajam MA, Al-Rasheed RS, Al-Faleh FZ. Crohn's disease in Arabs. Annals of Saudi Med 1991;11:40-6.  Back to cited text no. 7    
8.Garland CF, Lilienfeld AM, Mendeloff Al, et al. Incidence rates of ulcerative colitis and Crohn's disease in 15 areas of the United States. Gastroenterology 1981;81:115-24.  Back to cited text no. 8    
9.Sinclair TS, Brunt PW, Mowat NAG. Non-specific proctocolitis in north eastern Scothland: a community study. Gastroenterology 1983;85:1-11.  Back to cited text no. 9    
10.Evans JG, Acheson ED. An epidemiological study of ulcerative colitis and regional enteritis in the Oxford area. Gut 1975;6:311-24.  Back to cited text no. 10    
11.Greenstein AJ, Janowitz HD, Sachar DB. The extraintestinal complications of Crohn's disease and ulcerative colitis: a study of 700 patients. Medicine 1976;55:411-2.  Back to cited text no. 11    
12.George B, Rankin H, Watts D. National cooperative Crohn's disease study. Extra-intestinal manifestations and perianal complications. Gastroenterology 1979;77:91420.  Back to cited text no. 12    
13.Tandon HD, Prakash A. Pathology of intestinal tuberculosis and its distinction from Crohn's disease. Gut 1972;13:260-9.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Mokhtar A, Khan MA. Crohn's disease in Saudi Arabia. Saudi Med J 1982;3:207-8.  Back to cited text no. 14    

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Correspondence Address:
Mohamed B Satti
Professor of Pathology, P.O. Box 40029, Al-Khobar 31952
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864824

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]

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