Survey of Inflammatory Bowel Diseases in India
Govind K Makharia1, Balakrishnan S Ramakrishna2, Philip Abraham3, Gourdas Choudhuri4, Sri Prakash Misra5, Vineet Ahuja1, Shobna Bhatia6, Deepak K Bhasin7, Sunil Dadhich8, G K Dhali9, Devendra C Desai3, Uday C Ghoshal4, B D Goswami10, S K Issar11, A K Jain12, V Jayanthi13, G Loganathan14, C Ganesh Pai15, A S Puri16, S S Rana7, Gautam Ray17, S P Singh18, Ajit Sood19, for the Indian Society of Gastroenterology Task Force on Inflammatory Bowel Disease
1
All India Institute of Medical Sciences, New Delhi; 2Christian Medical College, Vellore; 3P D
Hinduja National Hospital, Mumbai; 4Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow; 5M L N. Medical College, Allahabad; 6Seth G S Medical College and K E M Hospital, Mumbai; 7Post Graduate Institute of Medical Education & Research, Chandigarh; 8
Jodhpur Medical College, Jodhpur; 9Institute of Post Graduate Medical Education & Research, 10
Guwahati Medical College, Guwahati;
Kolkata; 12
Choithram Hospital, Indore;
Salem;
15
13
18
Bhilai Steel Plant Hospital, Bhilai;
Government Stanley Hospital, Chennai;
Kasturba Medical College, Manipal;
Hospital, Kolkata;
11
16
14
Vidya Hospital,
G B Pant Hospital, New Delhi;
S C B Medical College, Bhubaneswar;
19
17
B R Singh
Dayanand Medical College,
Ludhiana.
Conflict of interest: None of the authors has any conflict of interest to report. Funding: The data collection and analysis activities of the Task Force were funded through an unrestricted education grant from Sun Pharma Pvt. Ltd.
1
Correspondence address: Prof B S Ramakrishna Department of Gastroenterology Christian Medical College Vellore, Tamilnadu, India Email:
[email protected]
2
Abstract Introduction: Inflammatory bowel disease (IBD), both ulcerative colitis (UC) and Crohn’s disease (CD), once thought to be uncommon, is now seen commonly in India. The Indian Society of Gastroenterology (ISG) Task Force on IBD decided to collate data on the clinical spectrum of IBD currently prevailing in India. Methods: An open call to members of ISG was given through publication of a proforma questionnaire in the Indian Journal of Gastroenterology and the web portal of ISG. The proforma contained questions related with demographic features, family history, risk factors, clinical manifestations and characteristics, course of disease, and pattern of treatment of IBD. Results: Of 1255 filled questionnaires received, 96 were rejected and 1159 (92.3%) were analyzed. Of these 745 (64.3%) had UC, 409 (35.3%) CD, and 5 had indeterminate colitis. The mean duration from onset of symptoms to arriving at a diagnosis was shorter in UC than in CD (p=0.019). More than one half of patients (UC 51.6%, CD 56.9%) had one or more extraintestinal symptoms. A definite family history of IBD was present in 2.9% (UC 2.3% and CD 4.6%; p=0.12). The extent of disease was pancolitis 42.8%, left-sided colitis 38.8%, and proctitis 18.3% in UC, and both small and large intestine 39.6%, isolated colonic 31.4% and isolated small intestinal 28.9% in CD. 18.8% and 4.4% of patients with CD had stricturing and fistulizing disease, respectively. Chronic continuous and intermittent disease course was present in 35.5% and 47.2% in UC and 23.1% and 68.8% in CD. While only 4% of patients with UC had undergone colectomy, 15.2% of patients with CD underwent surgical intervention. Conclusions: The present survey provides a reasonable picture of the demographic features and clinical manifestations of Indian patients with IBD, their risk factors, course of disease, and the treatment given to them. 3
Introduction Ulcerative colitis (UC) was first reported from India in the late 1930s, but large case series were reported only from the 1960s onwards [1-10]. Two studies, both from northern India, reported a population prevalence of ulcerative colitis (UC) of approximately 42 per 100,000 persons with a crude incidence rate of 6 per 105 population [11,12]. The first report of Crohn’s disease (CD) from India appeared in the literature in 1972, approximately 30 years after the first recorded UC reports, and dealt with the surgical pathology of operated cases [13]. Subsequent Indian publications on CD focused on diagnostic differentiation of CD from tuberculosis, but included several small and two larger case series [14-24]. There is no information on the population-based incidence and prevalence of Crohn’s disease in India. The Indian Society of Gastroenterology (ISG) established a Task Force on Inflammatory Bowel Disease (IBD) in 2003. Its aim was to obtain a representative picture of the current demographic and clinical profile of patients with IBD in the country and develop guidelines for management of IBD. Methods The core committee of the ISG-IBD Task Force drafted a prospective data collection questionnaire for IBD, which was published in the Indian Journal of Gastroenterology (2006;25:110-8) and posted on the ISG website (www.isg.org.in/admin/myuploads/Inflammatory_Bowel_Disease.pdf). An open call was given to all members of the ISG to participate in the data collection. Hard copies of the questionnaire were distributed to those who requested it. Participating physicians were requested to complete the questionnaire for consecutive patients with UC and CD seen by them, diagnosed on the basis of a standard combination of clinical, endoscopic and histological features [25,26]. The Ethics 4
Committees of the All India Institute of Medical Sciences, Delhi and the Christian Medical College, Vellore approved the study plan. The data in this manuscript were generated from those who responded to the invitation; all the respondents were qualified gastroenterologists. All completed questionnaires were dispatched to the coordinator (GKM) who screened them for completeness of data. Questionnaires that had inadequate information were rejected. Identifying data of patients were removed from the completed questionnaires after coding in order to maintain confidentiality. The data were entered in a datasheet by a data-entry operator; each entry was double checked by the first author. Data on diet were available in less than a half of questionnaires and were not considered for analysis. All the study variables were compared between the two categories of IBD, namely, UC and CD. Quantitative characteristics were compared using Student’s t test or Wilcoxon rank sum test as appropriate. Categorical information was compared between the two groups using the chisquare test. Results Completed questionnaires were received from the north (Chandigarh, Delhi, Ludhiana), central (Bhilai, Indore, Jodhpur, Lucknow), west (Mumbai), east (Guwahati, Kolkata, Cuttack) and south zones (Chennai, Manipal, Vellore) of the country. (Table 1) Of the 1255 completed questionnaires received, 96 were rejected because of grossly incomplete data. The 1159 (92.3%) questionnaires analyzed included 708 with complete data and 451 with incomplete data but containing vital information. The 1159 patients with IBD included 745 (64.3%) with UC, 409 (35.3%) with CD, and five (0.4%) with indeterminate colitis; the last group was excluded from final analysis. 5
Demographic characteristics The mean age of patients with UC and CD was 38.5 (13.5) and 35.9 (13.9) years, respectively (p=0.002). The male-to-female ratio was 1.4 in UC and 1.3 in CD (p=0.32). Duration of illness Median (range) duration of illness in patients with CD (48 [1-516] months) was higher than in those with UC (24 [1-612] months) (p=0.002). There was no difference in the median (range) time interval from onset of symptoms to the first diagnosis in patients with UC (96 [1-456] months) and CD (12 [1-288] months) (p=0.08). Clinical manifestations Chronic diarrhea, blood in stool, anorectal pain and pedal edema were significantly more common in patients with UC in comparison to CD (Table 2). On the other hand, abdominal pain, perianal fistula, fever and presence of abdominal mass were significantly more common in CD compared to UC. Data on extra-intestinal manifestations were available in 738 questionnaires. More than a half of the patients surveyed had one or more complaints referable outside the gastrointestinal tract; in about 40% of those with extra-intestinal symptoms, more than one manifestation was noted (Table 3). Joints pain with or without arthritis was present in 33.2% and 26.3% of patients with UC and CD, respectively (Table 3). Personal history and relevant past history and prior surgery There was no difference in the number of patients with UC and CD who reported smoking (21.3% vs 24.2%; p=0.28) or consumption of alcohol (13.3% vs 11.7%; p=0.44) or oral contraceptive pills (9.7% vs 7.8%; p=0.63). A greater percentage of patients with CD had undergone appendicectomy compared to those with UC (8.2% vs 2.1%; p
