Saudi Journal of Gastroenterology
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Year : 2001  |  Volume : 7  |  Issue : 2  |  Page : 55-58
Ulcerative colitis in Saudi Arabia: A retrospective analysis of 33 cases treated in a regional referral hospital in Gizan


Department of Gastroenterology and Medicine, King Fahad Central Hospital, Gizan, Saudi Arabia

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Date of Submission02-Oct-1999
Date of Acceptance11-Dec-2000
 

   Abstract 

Background: Until recently ulcerative colitis (UC) was considered rare among Arabs. Information on its occurrence among Saudi is scant and limited to a few reports from urban populations. Aim of study: to assess the frequency and clinico-pathologic pattern of this disease in a rural population in Gizan region, Saudi Arabia. Methods: thirty three patients found to have UC over a 4-year period in King Fahad Central Hospital were analyzed retrospectively. Results: there were 24 males and nine females patients with UC (ages ranged from 17-70 years, mean age 43.5 years). The commonest presenting symptoms were abdominal pain and diarrhea in 30 and 26 patients respectively. Extra-intestinal manifestations were rare, occurred in only two patients. Total or pancolitis was found in ten (30%) patients and it was severe in nine of them. The disease extended to the splenic flexure in eight (24.2%) of the patients. A total colectomy was required in one patient with severe pan-colitis and a focus of malignancy was present in the resected specimen. No patient died during the follow-up period that ranged from one to six years. Conclusion: the study confirmed the occurrence of UC among the rural population studied. The male preponderance, the older age at presentation and relatively milder diseases appeared to be differentiating features from the pattern among western populations.

How to cite this article:
Alamin AK, Ayoola EA, El boshra AS, Hamaza MK, Gupta V, Ahmed MA. Ulcerative colitis in Saudi Arabia: A retrospective analysis of 33 cases treated in a regional referral hospital in Gizan. Saudi J Gastroenterol 2001;7:55-8

How to cite this URL:
Alamin AK, Ayoola EA, El boshra AS, Hamaza MK, Gupta V, Ahmed MA. Ulcerative colitis in Saudi Arabia: A retrospective analysis of 33 cases treated in a regional referral hospital in Gizan. Saudi J Gastroenterol [serial online] 2001 [cited 2020 Nov 26];7:55-8. Available from: https://www.saudijgastro.com/text.asp?2001/7/2/55/33402


Ulcerative colitis is a common intestinal disorder in North America and Europe [1],[2] . In contrast, it was considered to be nonexistent among the populations of the Middle East [3],[4]. Recent reports indicated that this disorder might not be as rare as Hitherto believed and that the clinical characteristics and the natural history of the disease among the Arabs may be different from those reported in the Western Countries [5],[6] . Information on the clinopathological description of UC among Saudi patients is limited to few reports from major tertiary hospitals serving urban populations [7],[8],[9],[10] . The geographical and ethnicity-related differences in the incidence and clinical pattern of UC even with the same country, are well-described [1],[11],[12] .

The retrospective analysis reported here was carried out to determine the frequency and clinical pattern of UC among patients evaluated and treated in a regional referral hospital of Gizan province in Saudi Arabia.


   Patients and Methods Top


The study was carried out in KFCH Gizan which is a 500-bedded hospital with modern facilities and a well-equipped endoscopy unit, serving a population of about one million people through referrals from ten general hospitals and their respective catchment primary care centers. The subjects comprised patients who were diagnosed to have ulcerative colitis during a 4-year period (1992-1995). The diagnosis of the ulcerative colitis was based on clinical features (diarrhea, bloody stools); barium, enema, endoscopy findings (mucosal oedema, erythema, granularity, ulcerations, inflammatory polyps or/and contact bleeding) and histologic abnormalities (crypt distortion, cryptitis, mucus deletion and chronic inflammatory cell infiltration. Severity of mucosal inflammation was graded by standard criteria [2] . Patients with specific causes of colitis such as tuberculosis, amebiasis, schistosomiasis were excluded from the analysis. From medical records, information was obtained in regard to the presenting clinical features, presence of extra-intestinal manifestations, results of routine investigations (such as blood count, liver function tests, serum calcium, urea, creatinine and stool examination). Slides of histopathologic specimens, the record findings at colonoscopy where available, reports of barium studies were reviewed. The response to therapy (salazopyrine and/or steroids) and the occurrence of complications during follow­up period were noted.


   Results Top


During the period of four years, 33 of 568 patients who underwent colonoscopic examinations were confirmed to have had UC. There were 24 males and nine females whose ages ranged from 17-70 years (with a mean of 43.5 years). Saudi patients were 24 (16 males and eight females).

The major symptoms on presentation were abdominal pain diarrhoea and hermatochezia (30, 26 and eight patients, respectively). Abdominal clinical findings comprised abdominal tenderness in 19, anemia in six and pyrexia in four patients. Two patients had extraintestinal manifestations of uveitis in one and sacroilitis in the other. By endoscopic assessment, inflammation was limited to the sigmoid colon in 15 (45.5%) patients and to the left side of the colon in eight (24.2%) patients. Subtotal or total colonic involvement occurred in the remaining ten (30.3%) patients. The disease was mild in 15 (45.5%) and moderately severe in nine (27.3%); patients seven of them were males and were females. During the follow-up period, three patients moved away from the region. One male who had the disease for 15 years before presenting to our hospital needed colectomy for severe pancolitis and a focus of early colonic malignancy was detected in the histopathological specimen.


   Discussion Top


Until two decades ago, UC was reported to be rare or nonexistent in Saudi Arabia [3],[4] . In support of the report from a few tertiary hospitals serving urban populations the present analysis confirms its occurrence among a rural population of Saudi Arabia. Similar to the experience in many geographic areas of the world, the prevalence and incidence of UC in the Kingdom is not Known. However, its estimated annual frequency of newly diagnosed UC among patients evaluated by colonoscopy in earlier reports vary from 0.01% in a University Hospital in Riyadh to 6% in a similar center in Dammam [8],[10] . The annual rate of 5.8% in our study is within this range. In the present analysis, eight new cases were diagnosed yearly in our hospital in the period studied and this compares well with the annual frequency. Comparatively, the average numbers were 13 (80 cases in six years) in Al-Madinah, 12 (37 cases in three years) in Riyadh and 7 (76 cases in 11 years) in Dammam [8],[9],[10] . The reported annual frequencies reported from these various studies in the Kingdom are also similar to the observations from Kuwait (15 cases per year) and Iran [5],[6] .

Although new cases are diagnosed at any age, UC is a disease of young adult, with the majority occurring in the third and fourth decades of life [1],[2] . The age of our patients at the time of diagnosis is 43.5 years, which is slightly higher than 29.2 years and 31.8 years reported from Riyadh and Iran patients, respectively [6],[7],[8] . A review of the age distribution among Saudi patients with UC, including those in the present report is similar to the pattern reported from Turkey [13] . This is different from the observations among western populations in whom the onset of disease occurs at a relatively younger age [1],[2] . A contributory factor to this apparent difference might be related to a possible delay in the presentation of patients to health care facilities. For example, study from Riyadh indicated that about half of the patients did not seek medical care until six months after the onset of the symptoms [8] . Furthermore, in the developing countries or among populations where infective causes of diarrhea are common, a diagnosis of UC has to be made only after infective agents have been excluded or after various treatments for common pathogens might have failed especially in situations where laboratory support is inadequate.

Ulcerative colitis is considered to be more common among females, especially among western populations [1],[2],[4] . However, equal sex distribution had been noted in some reports [14] . In contrast to these observations, the male to female ratio was 2.7 in our patients. A possible explanation for the similar male preponderance reported by earlier studies from Saudi Arabia, some authors suggested that in this part of the world fewer females attend hospitals for symptoms like rectal bleeding, due to social and cultural reasons [9] . Although this might be considered to be a reasonable explanation, a similar preponderance found among some patient populations in Europe, makes this less plausible [15] .

The hallmark clinical symptom of UC is bloody diarrhoea often with symptoms of rectal urgency and tenesmus. The clinical features among Saudi patients comprising diarrhea, hematochezia, abdominal pain and occasional abdominal tenderness are consistent with this pattern. However, in contrast to the relatively higher incidences among European and American patients [16],[17] , extraintestinal manifestations such as arthritis and ocular inflammation are relatively rare in Middle Eastern counties [8],[10] .

The majority of patients in our study had the disease limited to segments distal to the splenic flexure. The frequency (30%) of pancolitis in our patients was similar to the rates reported in other surveys in Saudi Arabia and comparable to the frequency of 37% of 1116 American patients [8],[9],[16] . Although it appears that UC may be a mild disease in the majority of Saudi patients, a significant proportion (27%) of our patients presented with severe disease and one patient required colectomy. None of our patients died during the period of follow-up, in contrast to the fatality rate of 2.7% reported among patients reported from Riyadh [8] . Despite the limitations imposed by the relatively small number of cases in our series and in earlier hospital-based surveys in Saudi Arabia, it is evident that UC occurs in Saudi Arabia albeit with a lower frequency and milder severity in comparison with the pattern in the western populations. Extra­intestinal manifestation and complications such as colitis-related cancers are relatively uncommon among Saudi patients. The natural history of UC among Saudi Arabian patients remains to be better defined with long term follow-up of these patients.

 
   References Top

1.Mendeloff AL. The epidemiology of inflammatory bowel disease. Clini Gastroenterol 1980; 9: 259-70.  Back to cited text no. 1    
2.Peppercorn MA. Inflammatory bowel disease. Gastroenterol Clin North Am. 1995; 23: 467-538.  Back to cited text no. 2    
3.Salem SN. Non-specific ulcerative colitis in Bedouin Arabs. Lancet 1967; 473-5.  Back to cited text no. 3    
4.Kirsner J B, Shorter R G. Recent development in non­specific inflammatory bowel disease. N Eng J Med (Second of two parts) 1982; 306: 837-48.  Back to cited text no. 4    
5.Al-Nakib B, Badhakrishman S, Jacob GS, Al-Liddaw H, Al­Guwaih Al. Inflammatory bowel disease in Kuwait. Am J. Gastroenterol 1984;79: 191-4.  Back to cited text no. 5    
6.Melgiessi S H, Furouzandeh B, Gadimi R. Ulcerative colitis in Iran: A review of 112 cases. Am J Gastroenterol 1985; 80: 863-6.  Back to cited text no. 6    
7.Mohammed AE, Al-Karawi M, Hamid M A. Yassawy I. Lower gastrointestinal tract pathology in Saudis: results of endoscopic biopsy findings in 1600 patients. Ann Saudi Med 1987;7:306-11.  Back to cited text no. 7    
8.Hossain J, Al Faleh FZ, Al Mofleh 1, Al Asha A. Laajam M, Al Rashed R. Does ulcerative colitis exist in Saudi Arabia? Analysis of thirty seven cases. Saudi Med J 1989; 10: 360­-82.  Back to cited text no. 8    
9.Khan H A, Mehrous AR, Khawaja F 1. Ulcerative colitis amongst the Saudis; six years experience from Al Madinah region. Saudi J. of Gastroenterol 1996; 2: 69-73.  Back to cited text no. 9    
10.Satti MB, AI-Qurain A, Al-Gindan, A1-Hamdan. Chronic idiopathic ulcerative colitis in Saudi Arabia: A clinicopathological study of 76 cases. Ann Saudi Med 1996;16: 637-40.  Back to cited text no. 10    
11.Niv Y Abukasis G. Prevalence of ulcerative colitis in Israeli kibbutz population. J Clin Gastroenterol 1991; 13:98-101.  Back to cited text no. 11    
12.Radhakrishnan S, Zubaidi G, Daniel M Sachdev GK, Mohan AN. Ulcerative colitis in Oman: A prospective study of the incidence and disease pattern from 1987 to 1994. Digestion 1997,58: 266-70.  Back to cited text no. 12    
13.Kusakcioglu O, Kusakcioglu A, Oz F. Idiopathic ulcerative colitis in Istanbul: Clinical series of 204 cases. Dis Colon Rect 1979; 22: 350-5.  Back to cited text no. 13    
14.Mendeloff Al. Epidemiologic aspects of inflammatory bowel disease: Berk JE, (ED). Bochus Gastroenterology Volume 4, fourth edition, Philadephia: Saunders 1985: 2127-36.  Back to cited text no. 14    
15.Van Gossum A, Adler M, De Reuck M, Dervis G, Fiasse R, Vanheurverzwijn R, Wiloex R, Vanheurverzwijn R, Willox R. Epidemiology of inflammatory bowel disease in Brussels' area (1992-1993), Acta Gastroenterol Belg 1996, 59: 7-9.  Back to cited text no. 15    
16.Farmer RG, Easly K A, Rankin GB, Clinical pattern, natural history and progression of ulcerative colitis: A long term follow-up of 11 16 patients. Dig Dis Sci, 1993; 38: 1137-46.  Back to cited text no. 16    
17.Greenstein AJ, Janourtz HF, Sachar DB. The extra intestinal complications of Crohn's disease and ulcerative colitis: A study of 700 patients. Medicine 1976, 58: 411-2.  Back to cited text no. 17    

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Correspondence Address:
Ephraim Ayoubanji Ayoola
P.O. Box 235 Abu Arish
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19861769

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