Saudi Journal of Gastroenterology
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Year : 2004  |  Volume : 10  |  Issue : 1  |  Page : 22-27
Ulcerative colitis: Al-gassim experience


1 Department of Medicine, King Fahad Specialist Hospital, Buraidah, Al-Gassim, Saudi Arabia
2 Department of Surgery, King Fahad Specialist Hospital, Buraidah, Al-Gassim, Saudi Arabia
3 Department of Laboratory Medicine, King Fahad Specialist Hospital, Buraidah, Al-Gassim, Saudi Arabia

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Date of Submission02-Jun-2003
Date of Acceptance16-Sep-2003
 

   Abstract 

Background: Ulcerative colitis (UC) is being reported more frequently among the Arabs. Information on the clinical severity, endoscopic and histological grading is scanty. Aim: To assess the severity of the disease and its response to therapy in patients referred to a tertiary care referral centre in Gassim region, Kingdom of Saudi Arabia (KSA). Patients and Method: Hospital records of thirty-four patients found to have UC from 1990-2002 were analyzed. The study included clinical severity, endoscopical and histological assessment, response to therapy and frequency of complications. Results: There were 21 males and 13 females with median age 35 (range: 18-76) years. The disease was clinically mild in seven patients (21%), moderate in 11 (32%) and severe in 16 (47%). Endoscopically UC was graded as 2 in three patients (9%), 3 in 21 patients (59%) and 4 in ten patients (29%). Histologically UC was mild to moderate in 11 patients (32%) and severe in 23 (68%). Extent of UC was total in nine patients (26%), up to transverse colon in six (18%), splenic flexure in 14 (41%), rectosigmoid region in four (12%) and only up to the rectum in one (3%). Twenty-nine patients (85%) were treated with salazopyrine and five patients (15%); (two of them were hypersensitive to salazopyrine) received 5­aminosalicylic acid. Proctocolectomy was performed in two with a focus of malignancy. No patient died during the median follow-up period of 48 months (range: 4 months to 12 years). Conclusion: Ulcerative colitis presented with varying severity, more frequently in males in the population studied. Most of the patients responded to salazopyrine and surgery was necessary when malignancy was detected

Keywords: Ulcerative colitis, inflammatory bowel disease, colitis.

How to cite this article:
Contractor QQ, Contractor TQ, Ul Haque I, El Mahdi EE. Ulcerative colitis: Al-gassim experience. Saudi J Gastroenterol 2004;10:22-7

How to cite this URL:
Contractor QQ, Contractor TQ, Ul Haque I, El Mahdi EE. Ulcerative colitis: Al-gassim experience. Saudi J Gastroenterol [serial online] 2004 [cited 2020 Nov 26];10:22-7. Available from: https://www.saudijgastro.com/text.asp?2004/10/1/22/33348


Two decades ago Kirsner and Shorter made an observation that inflammatory bowel disease is rare or non-existent in Saudi Arabia [1] . Few reports were published thereafter stressing that ulcerative colitis did exist in the Arab world [2],[3],[4] . Ulcerative colitis is now being reported from both the urban and rural areas of the KSA [5],[6] . Since environmental factors have been implicated in its etiology, the rapidly changing lifestyle in these countries could be a possible cause for the rising incidence of inflammatory bowel disease in this part of the world [7] . Although the incidence rate of UC in KSA is not known, it is possibly low as it belongs to the low-incidence areas, where the incidence is approximately ten-fold less than in the high-incidence areas. Annual frequency of newly diagnosed cases among patients evaluated by lower gastrointestinal endoscopy has varied from 0.01 % to 6% in earlier reports from KSA [4],[8] . These figures are similar to ones in Kuwait and Iran [2],[9]. It is now well recognized that UC is a worldwide disorder and the diagnosis may be difficult, where infective colitis is common since the endoscopic findings are similar. Improving health care facilities has also resulted in better recognition of this disease in KSA.

Reports from a few regions of KSA have described the disease in these areas and compared it to that in the high-incidence areas [5],[6]. We have analyzed and categorized the clinical presentation, endoscopic and histological staging of the disease and its response to therapy in patients referred to our centre in Gassim region.


   Patients and Methods Top


Over a 12-year period (December 1990­December 2002), 34 patients were diagnosed to have UC on the basis of clinical features, endoscopic findings, histological characteristics and after excluding commonly occurring infections such as amebiasis, shigellosis,  Salmonellosis More Details as well as tuberculosis and schistosomiasis. Clinical severity was classified according to the criteria of Truelove and Witts [10] . Sigmoidoscopic findings were conveniently graded from 0-4 as has been recommended [7] . Histologic assessment of inflammation was graded as: non-significant, mild to moderate and severe [11] .

Complete hemogram, ESR, stool microscopic examination and culture, complete serum chemistry, and C-reactive protein (CRP) were requested at the time of presentation. Colonoscopic examination was recommended for all patients after sigmoidoscopic assessment. Those who did not consent to it had an air double contrast barium enema. Patients with moderate and severe UC received prednisone 30-40mg daily that was reduced over 2-3 weeks as the patient went into symptomatic, endoscopic and histologic remission. If required, the dose of prednisone was increased to induce remission. Salazopyrine was gradually increased to at least 2gms/day to maintain endoscopic and histologic remission. Those who were hypersensitive to salazopyrine were put on 5-amino salicylle acid (enteric coated mesalazine) 800mg daily and the dose was increased to maintain endoscopic and histological remission.

Follow-up endoscopic and histologic assessment was done every six months or if the patient had a symptomatic relapse. Endoscopic documentation of mucosal status is a useful objective indication of the response to treatment [12] . If an endoscopic and histologic remission was maintained. attempt was made to reduce the dose of the medication the patient was receiving. If the patient remained in remission on salazopyrine lgm/day or mesalazine 800mg/day for three years period, then treatment was discontinued and patient was followed up. If symptoms recurred or follow-up endoscopy showed recurrence of the disease, medications were again started. Ten years after the onset of the disease patients underwent surveillance colonoscopy every year. If malignancy or high grade dysplasia were detected, proctocolectomy was advised. If low grade dysplasia was detected, then a repeat colonoscopy would be performed after one­month and if it was confirmed, surgery would be advised [7] .


   Results Top


Clinical characteristics of the patients at the time of presentation are shown in [Table - 1] .Out of the 34 patients 32 were Arabs and two were non-Arab Asians. None of the patients were smokers, no other family member was affected and no patient had an appendectomy in the past. Arthritis of right knee and right hip were diagnosed in two patients. One patient was detected to have right frontal meningioma, which was operated. One is receiving L-thyroxine for hypothyroidism and one had laparoscopic cholecystectomy for cholelithiasis. There were RBCs and pus cells in the stool on microscopic examination in all the patients and stool cultures were negative. Serum albumin was <35 gm/1 in five patients and serum calcium was <2 mmol/1 in two. Sigmoidoscopic and histological grading of UC at presentation is shown in [Table - 2]. Colonoscopy was performed in 27 patients and barium enema in 18 (some had it done prior to their presentation). Nine patients had total colitis, six had involvement up to the transverse colon, 14 up to the splenic flexure, four up to rectosigmoid region and one had only proctitis. Pseudopolyps were detected in seven patients. To induce remission, eight patients received 30mg, 15 received 40mg and one required 50mg prednisone. Ten patients received steroid retention enema.

We prescribed salazopyrine to most of our patients when it was easily available to us. The daily dose to maintain remission in the 29 patients who received it was: 2gm in five patients, 3gm in 15, 4gm in eight and 6gm in one. Maintenance of remission was confirmed on sigmoidoscopy as well as histology. Two patients received mesalazine since they were hypersensitive to salazopyrine. Three patients preferred taking mesalazine, which was prescribed by physicians in the past. The dose of mesalazine ranged from 800 to 1600mg per day. During the follow-up, the daily dose of salazopyrine could be reduced to I gm in five patients and to 1.5gm in three. Three of these patients could remain without medication for a period ranged 6-months two years.

Two patients had proctocolectomy with ileoanal anastomosis performed in two stages. The first patient had high-grade dysplasia in the transverse colon detected on histology only two years after the onset of symptoms. The second patient had an adenocarcinoma in the transverse colon 11 years after the onset of the disease. Median follow-up period was 48 months (range four months to 12 years). There has been no mortality recorded to date in the population studied.


   Discussion Top


Most of the patients were symptomatic for over six months before the diagnosis of UC was made confirming that detection of UC is not easy in countries, where infective colitis is frequently encountered. This can underestimate the incidence of UC in these so-called low-incidence areas. Familial incidence of UC has been recognized and about 10% to 20% have at least one other affected family member [13] . Most of the familial association are in first degree relatives and affected members may have either UC or Crohn's disease. Familial association was not noted in any of our patients. It is generally reported that women are more commonly affected than men but several studies have failed to find this sex difference [14],[15] . Previous reports from KSA have attributed the male predominance to the under reporting of rectal problems by females in this part of the world. Men were more frequently affected in the present study, considering the previous reports this difference is likely to be real.

None of our patients were smokers and this could be due to the fact that smoking is socially and culturally discouraged in this region of KSA. Appendectomy was not performed in any of our patients. Although nonsmoking and low appendectomy rates have been implicated in the etiology of UC, the present number of patients is too small to draw any conclusions [16],[17] . An association between emotional factors and UC and its role as an etiological factor has been noted for a long time [18] . The significance of life events stress in UC was strongly substantiated at all levels in a case control study from the Eastern Province from KSA [19] . None of our patients had a psychiatric assessment but clinically there was no obvious mental state dysfunction.

Extraintestinal manifestations are reported to be uncommon among Saudis [5],[6] . Only two of our patients had arthritis, involving the hip and knee, and this finding is in keeping with previous observations. An acute arthropathy affecting the larger joints in an asymmetric fashion is known to occur in 10% to 15% of the patients [7] . It resolves as the colitis goes into remission. At presentation, about half the patients had clinically severe UC and the majority had severe inflammation on histology and grade 3 or 4 UC on sigmoidoscopy. Twenty-four patients received oral steroids for inducing remission. Ten patients with distal colitis received hydrocortisone retention enema. The classic controlled trial of cortisone acetate by Truelove and Witts has firmly established the beneficial role of glucocorticoids in treating active UC [10] . Comparison between three different doses of prednisone has shown that response is optimum to 40mg as compared to 20mg [7] . Given as a retention enema, betamethasone 17-valerate, beclomethasone and prednisolone metasulfobenzoate are therapeutically effective for distal colitis with minimal effects on the hypothalamic­ pituitary-adrenal axis [20] . Budesonide is also effective both as a retention enema and a colonic-release preparation.

On 2-3gm of salazopyrine daily, most of the patients could be kept in remission. Serial sigmoidoscopie and histological assessment has been recommended in clinical practice to assess the response to therapy [12] . Although the dose of salazopyrine could be reduced to I gm in five patients and 1.5gm in three and three of these could be kept off therapy for six months to two years, all the patients eventually needed medications. None of the patients following up with us needed immunosuppressants. It seems from our experience that UC responds well to therapy in this part of the world and remission can be maintained in some patients on much lesser medication than that required in high-incidence areas [21] .

Sulphasalazine is usually well tolerated but 30% are believed to report adverse reactions [22] . In the present study only two patients could not tolerate this agent due to hypersensitivity and had to be put on mesalazine. The dose-dependent adverse effects were overcome by starting the dose at 0.5gm daily and gradually increasing it over a week. Five patients were eventually treated with enterically coated mesalazine. Adverse effects with these drugs occur in less than 5% of patients. There are several mesalazine preparations as well as two prodrugs, olsalazine and balasalazide. It is not very clear, which of these compounds should be preferred. Topical treatment with these drugs is also effective in treating active distal colitis [23] . The most widely used immunosuppressants are azathioprine and 6-mercaptopurine. Intravenous cyclosporine is being increasingly used in severe UC. Anecdotal evidence suggests that weekly administration of methotrexate is effective for patients with refractory disease [7] . Extent of involvement in the present study is similar to that reported in the past from KSA. Surgical intervention for high grade dysplasia and adenocarcinoma in the transverse colon was necessary for two of our patients. Hence the risk of cancer should not be underestimated in this part of the world [6] .

In conclusion, UC in Gassim Region presents with varying severity but response to therapy is good. Remission can be maintained in some patients with a small dose of salazopyrine and few can go off the medications for six months to two years. There is a definite risk of malignancy and cancer surveillance after ten years of the illness is mandatory.

 
   References Top

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2.Al-Nakib B, Radhakrishan S, Jacob GS, et al. Inflammatory Bowel Disease in Kuwait. Am J Gastroenterol 1984; 79: 191-4.  Back to cited text no. 2    
3.Mohammed AE, Al-Karawi M, Hamid MA, Yassawy 1. 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. 3    
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7.Jewell DP. Ulcerative Colitis. In: Feldman M, Friedman LS, Sleisenger MH. (Eds). Sleisenger Fordtran's Gastrointestinal and Liver Disease. Pathophysiology/Diagnosis/Management. Seventh edition. Philadelphia: Saunders, 2002: 2039-67.  Back to cited text no. 7    
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14.Mendeloff Al. Epidemiologic aspects of inflammatory bowel disease: Berk JE, (Ed). Bockus Gastroenterology Volume 4, fourth edition. Philadelphia: Saunders 1985: 2127-36.  Back to cited text no. 14    
15.Van Gossum A, Adler M, De Reuck M, et al. Epidemiology of inflammatory bowel disease in Brussels' area (1992-1993). Acta Gastroenetrol Belg 1996; 59: 7-9.  Back to cited text no. 15    
16.Lindberg E, Tysk C, Anderson K, Jarnerot G. Smoking, and inflammatory bowel disease. A case control study. Gut 1988; 29: 352-8.  Back to cited text no. 16    
17.Rutgeerts P. Dhaens G, Hiele M, et al. Appendectomy protects against ulcerative colitis. Gastroenterology 1994; 106: 1251-3.  Back to cited text no. 17    
18.Murray CD. Psychological Factors in Etiology of Ulcerative Colitis and Bloody Diarrhea. Am J Med Sci 1930; 180: 39-48.  Back to cited text no. 18    
19.Abumadini MS. Hafeiz HB. Al-Qurain A, Yassawy M1, Abdulkarim MM. Life events stress in ulcerative colitis: A case control study. Saudi J Gastroenterol 2002; 8: 53-8.  Back to cited text no. 19    
20.Jewell DP. Corticosteroids for the management of ulcerative colitis and Crohn disease. Gastroenterol Clin North Am 1989; 18: 21-34.  Back to cited text no. 20  [PUBMED]  
21.Azad Khan AK, Howes DT. Piris J, Truelove SC. Optimum dose of sulphasalazine for maintenance treatment in lcerative colitis. Gut 1980;21: 232-40.  Back to cited text no. 21    
22.Taffet SL, Das KM. Sulfasalazine: Adverse effects and desensitization. Dig Dis Sci 1983; 28: 833-42.  Back to cited text no. 22  [PUBMED]  
23.Campieri M, Gionchetti P, Belluzzi A. Optimum dosage of 5-aminosalicylie acid as rectal enema in patients with ulcerative colitis. Gut 1991; 32: 929-31.  Back to cited text no. 23    

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Correspondence Address:
Qais Qutub Contractor
King Fahad Specialist Hospital, P 0 Box 2290, Buraidah, Al-Gassim
Saudi Arabia
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PMID: 19861824

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