| Abstract|| |
Ulcerative Colitis is now being recognized amongst the Arabs. After consideration of the clinical, endoscopic and histopathological data, 80 Saudi patients out of 1,182, were diagnosed as ulcerative colitis. There were 47 males and 33 females. The age ranged between two and 90 years (mean 36.5 years). Endoscopically, the disease was limited to the rectum in 22.5%, rectum and sigmoid in 30%, extended up to the splenic flexure in 27.5% and beyond the splenic flexure in 20% of the patients.
Our data supports the recent observation that ulcerative colitis is not uncommon in this part of the world. There are differences in the extent of disease and the presence of local complications, between our patients and those in the high incidence areas.
|How to cite this article:|
Khan HA, Mahrous ARS, Fachartz, Khawaja FI. Ulcerative colitis amongst the Saudis: Six-year experience from Al-Madinah region. Saudi J Gastroenterol 1996;2:69-73
|How to cite this URL:|
Khan HA, Mahrous ARS, Fachartz, Khawaja FI. Ulcerative colitis amongst the Saudis: Six-year experience from Al-Madinah region. Saudi J Gastroenterol [serial online] 1996 [cited 2020 Nov 25];2:69-73. Available from: https://www.saudijgastro.com/text.asp?1996/2/2/69/34029
Ulcerative colitis is an inflammatory disorder of unknown cause, affecting the rectum, and extending proximally to involve a variable extent of the colonic mucosa. In western countries like the United States, United Kingdom, other European countries and Australia, the incidence ranges from three to 15 cases, per year, per 100,000 people  . With increase in the awareness about the disease and improved diagnostic facilities, ulcerative colitis is being detected more frequently in other parts of the world as well  . Some recent studies from Kuwait and the Kingdom of Saudi Arabia have reported ulcerative colitis amongst the Arabs ,, . We performed this retrospective analysis, to assess the frequency of the disease amongst the people of Al-Madinah region of Saudi Arabia, and to compare the characteristics of our patients and the nature of the disease, with those in the high incidence areas. The study was conducted at the Gastroenterology Department of King Fahad Hospital, Al-Madinah, Al-Munawarah. The hospital is the referral center for the entire Al-Madinah region, serving a population of about 500,000.
| Methods|| |
The records of all the lower gastrointestinal endoscopies performed at King Fahad Hospital, Al-Madinah, between 1410-1415 Hijrah were retrospectively reviewed. Patients were referred to the Gastroenterology Department of the hospital from various peripheral hospitals spread throughout the region, as well as from other general hopsitals in Al-Madinah, Al-Munawara. In total, 1,182 patients underwent lower gastrointestinal endoscopic procedures during the six-year study period. Five hundred and sixty patients had colonoscopy performed and six hundred and twenty two patients underwent flexible sigmoidoscopic examination. Olympus colonofiberoscopes (ITI0, 20HL, P1OL) and flexible sigmoidoscope (plOS) were used. Colonoscopies were performed under conscious sedation with diazepam and pethidine, while the flexible sigmoidoscopies required no sedation. The patients had standard bowel preparation prior to the endoscopic examinations, except where inflammatory bowel disease was clinically suspected. Colonic biopsies were taken, where indicated, and examined by experienced histopathologists.
The diagnosis of ulcerative colitis was made after consideration of the clinical history, endoscopic findings and histopathological examination. Patients who had proctitis and/or colitis secondary to infective causes (bacterial, protozoal and parasitic) were excluded. Crohn's disease, antibioticassociated colitis, ischemic and radiation colitis were also excluded.
| Results|| |
Out of the total of 1,182 patients, 111 were diagnosed as having ulcerative colitis. They comprised 80 Saudi nationals, 16 Non-Arabs and 15 Non-Saudi Arabs [Figure - 1]. Amongst the Non-Arabs there were 10 Pakistanis, 3 Bangladeshis, 2 Indians and 1 Afghani. The Non-Saudi Arabs included 4 Egyptians, 3 Yemenis, 2 Mauritanians and 1 patient each from Kuwait, Tunisia, Sudan, Palestine, Syria and Morocco. The data of the 80 Saudi patients were then further analyzed.
Year-wise distribution of the Saudi patients is shown in [Figure - 2]. The average frequency of patients in our study was about 13 per year.
Age and Sex characteristics
There were 47 males (58.7%), and 33 females (41.3%). The age ranged between two and 90. The average age was 39.5 and 33 years, for male and female patients, respectively. The age distribution of the patients is shown in [Figure - 3]. Half of the patients were aged between 20-39 years.
Extent of Disease
The disease was limited to the rectum only (proctitis) in 18 patients (22.5%). Proctosigmoiditis with extension limited to the sigmoid colon was present in 24 patients (30%). Left-sided colitis (i.e. disease extending proximally beyond the sigmoid colon, up to the splenic flexure) was documented in 22 patients (27.5%). Only 16 patients (20%) had involvement proximal to the splenic flexure [Table - 1].
The endoscopic picture of the patients varied depending upon the severity and activity of the disease [Figure - 4]. Loss of vascular pattern, mucosal edema and erythema was found in mild cases, while severe disease was associated with contact bleeding and ulceration. Pseudopolyps were detected in 16 patients (20%). The psedopolyps mostly affected the left colon, proximal to the rectum. No other complications of colitis, like stricture and carcinoma etc. were detected in our study.
| Discussion|| |
Diagnosis of ulcerative colitis is difficult in areas where infective colitis is common. With the improvement in diagnostic facilities it is being recognized in most countries  . The endoscopic pattern of infectious and inflammatory colitis may be indistinguishable. Stool cultures are negative in more than 50% of cases, but the histologic appearances may be helpful. Presence of chronic inflammatory infiltrate, crypt architectural abnormalities and basal lymphoid aggregates, may help in differentiating between the two, with a probability of 80% , .
Since the observation by Kirsner et al  , that inflammatory bowel disease is rare or non-existent in Saudi Arabia, there have been a few reports about the presence of ulcerative colitis , , and Crohn's disease  , in the kingdom. In our analysis, an average 13 Saudi patients having ulcerative colitis are presenting to our unit every year. This compares well with the yearly frequency of 12 reported by Hossain et at  . In the analysis by Mohammed et al, 28 Saudi patients of ulcerative colitis were detected over a period of seven years  . However in that study 111 Saudi patients were labeled as having nonspecific colitis.
The etiology of ulcerative colitis remains unknown. Various factors, including genetic, environmental, immunologic and psychosomatic have been implicated. Familial clustering of the disease has been recognized for many years. Between 10-20 % of the patients will have at least one other family member affected  . Among the environmental factors, infective agents, allergy to food constituents like milk, and oral contraceptive use have all been proposed as contributing factors  . Many studies have constantly found that ulcerative colitis is more common in nonsmokers than in smokers , .
There is geographical variation of the disease. High incidence areas include United Kingdom, United States, Northern Europe and Australia  . Dietary factors, by influencing both the frequency of stools and the bacterial population may contribute to this variation  . Racial differences have also been noted. In the United States, Jews are more prone to ulcerative colitis than non-Jews, whereas Blacks and American Indians have a lower incidence than the White population  .
Generally, ulcerative colitis is considered to be more common amongst women, especially in populations with a predominant English origin. However, Mendellof et al noted an equal sex distribution  . The male to female ratio in our patients was 1.4:1. The explanation for the slight male predominance might be, that in this part of the world, due to social and cultural reasons, fewer female patients attend hospital for symptoms like rectal bleeding etc.
Ulcerative colitis primarily affects young adults (ages 20-40 years), although new cases are identified at all ages  . The bulk of our patients also presented in the third and fourth decades [Figure - 3]. A number of series have shown a secondary peak of incidence for new cases, beginning about age 50 , . This was not seen amongst our patients.
The main presenting symptoms of our patients were rectal bleeding, diarrhea and abdominal pain. Constipation was occasionally present in patients having proctitis. Extraintestinal manifestations of inflammatory bowel disease were not seen.
Majority of our patients had the disease distal to the splenic flexure. Proctitis and proctosigmoiditis were found in the same proportion as western patients. Only 20% had colitis extending proximal to the splenic flexure. Pancolitis was rarely seen. This is in contrast to western studies. In a large series of the Cleveland clinic, 37% of ulcerative colitis patients initially presented with pancolitis  . By the conclusion of follow-up, half the patients with limited disease extended to pancolitis. In ulcerative colitis, there is the important prognostic and therapeutic distinction between pancolitis patients and patients with left-sided disease or proctosigmoiditis. It has been demonstrated that the extent of disease determines the cancer risk, predicted response to medical treatment and probability of complications  .
Endoscopy may underestimate the extent of disease, though it is still superior to radiology. In a comparative study, double contrast barium enema, endoscopy and histological examination found pancolitis in respectively 18%, 38% and 62% of patients with ulcerative colitis  . Endoscopically, a wide spectrum of mucosal abnormalities were seen in our patients. These ranged from early findings like loss of vascular pattern and erythema, to more florid lesions like ulcerations and pseudopolyps. The frequency of pseudopolyps in our patients was 20%. It compares well with the frequency rates in different series. Edwards and Truelove encountered pseudopolyps in 14.9%  , de Dombal et al in 20.5%  , and Jalen et al in 19%  . Pseudopolyps tend to be found more in patients with extensive disease. For unknown reasons they are rarely seen in the rectum  . They are not premalignant and may regress. Pseudopolyposis per se is not an indication for surgery.
The cumulative cancer rates in ulcerative colitis are 5-10% in-patients who have had ulcerative colitis for more than 20 years and 12-20% in those who have had the disease for 30 years  . In our analysis, apart from pseudopolyps local colonic complications, like carcinoma and stricture, were not seen. As far as we are aware, no colitis-related cancer has been reported in Saudi Arabia.
The smaller proportion of patients having extensive disease in our analysis, plus the absence of complications like carcinoma and stricture, suggest that our patients did not have long-standing disease. Therefore, we might be seeing patients with relative early disease. This would support the suggestion that the increase in the number of colitis patients in the Kingdom, is due to a true recent increase in the incidence of the disease. Follow-up is needed to see the natural course of the disease. It is possible that with the passage of time, the colitis in our patients may extend. This may in turn make the pattern of disease similar to that in the West. The incidence of ulcerative colitis in Saudi Arabia is not known. Epidemiological studies need to be done to calculate its true incidence. However, our data supports the observation, that it is not uncommon amongst the Saudis.
| References|| |
|1.||Jewell DP. Ulcerative Colitis. In: Sleisenger MH, Fordtran JS, (Eds). Gastrointestinal Disease. Pathophysiology/ Diagnosis/Management. Fifth edition. Philadelphia: Saunders, 1993:1305-30. |
|2.||Mendeloff Al. The epidemiology of inflammatory bowel disease. Clin Gastroenterol 1980;9:259-70. |
|3.||Al-Nakib B, Radhadkrishan S, Jacob GS, et al. Inflammatory Bowel Disease in Kuwait. Am J Gastroenterol 1984;79:191-4. |
|4.||Mohammed AE, Al-Karawi M, Hamid MA, Yassawy I. Lower Gastrointestinal tract pathology in Saudis: results of endoscopic biopsy findings in 1,600 patients. Ann Saudi Med 1987;7:306-11. |
|5.||Hossain J, Al-Faleh FZ, Al-Mofleh I, Al Aska AK, Laajam M, Al Rashid R. Does ulcerative colitis exist in Saudi Arabia? Analysis of thirty-seven cases. Saudi Med J 1989;10:360-2. |
|6.||Allison MC, Hamilton-Dutoit SJ, Dhillon AP, et al. The value of rectal biopsy in distinguising self-limited colitis from early inflammatory bowel disease. Q J Med 1987;248:985-95. |
|7.||Surawicz CM, Belie L. Rectal biopsy helps to distinguish acute self-limited colitis from idiopathic inflammatory bowel disease. Gastroenterology 1984;86:10413. |
|8.||Kirsner JB, Shorter RG. Recent development in inflammatory bowel disease. N Eng J Med 1982;306:837-48. |
|9.||Hossain J, Al-Mofleh IA, Laajam MA, Al-Rashid RS, Al-Faleh FZ. Crohn's disease in Arabs. Ann Saudi Med 1991;11:40-6. |
|10.||Lindberg E, Tysk C, Anderson K, Jamerot G. Smoking and inflammatory bowel disease. A case control study. Gut 1988;29:352-8. |
|11.||Srivasteva ED, Russell MAH, Feyerabend C, Rhodes J. Effect of ulcerative colitis and smoking on rectal blood flow. Gut 1990;31:1021-8. |
|12.||Mendeloff Al. Epidemiologic aspects of Inflammatory Bowel Disease. In: Berk JE, (Ed). Bockus Gastroenterology Volume 4. Fourth edition. Philadelphia: Saunders, 1985:2127-36. |
|13.||Garland C, Lilienfield A, Mendeloff AI, et al. Incidence rates of ulcerative colitis and Crohn's disease in fifteen areas of the Unites States. Gastroenterology 1981;81:1115-24. |
|14.||Langman MJS. Epidemiology of Chronic Digestive Disease. Chicago; Year Book Medical Publishers; 1979:80-102. |
|15.||Farmer RG, Easley KA, Rankin GB. Clinical pattern, natural history and progression of ulcerative colitis; A long-term follow-up of 1116 patients. Dig Dis Sci. 1993;38:1137-46. |
|16.||Pera A, Bellando P, Caldera V, et al. Colonoscopy in inflammatory bowel disease; diagnosis, accuracy and proposal of an endoscopy score. Gastroenterology 1987;92:181-5. |
|17.||Edwards FC, Truelove SC. The course and prognosis of ulcerative colitis. Part 3. Complications. Gut 1964;5:1-15. |
|18.||Dedombal FT, Watts JMcK, Watkinson G, et al. Local complications of ulcerative colitis. Stricture, pseudopolyposis and carcinoma of colon and rectum. Br Med J 1966;1:1442-7. |
|19.||Jalan KN, Walker RJ, Sircus W, et al. Pseudopolyposis in ulcerative colitis. Lancet 1969;2:555-9. [PUBMED] |
|20.||Lennard-Jones JE, Melville DM, Morson BC, et al. Pre-cancer and cancer in extensive ulcerative colitis. Findings among 401 patients over 22 years. Gut 1990;31:800-6. |
Hamid A Khan
Department of Gastroenterology, King Fahad Hospital Madinah Al-Munawarah
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1]