Profile of Ulcerative Colitis in a North Indian Hospital

Transcription

1 ORIGINAL ARTICLE Profile of Ulcerative Colitis in a North Indian Hospital Ajit Sood*, Vandana Midha*, Neena Sood**, Sandeep Puri*, Vikas Kaushal* Abstract Background : The increasing prevalence of ulcerative colitis has been reported from Western countries. Even in India the disease is now being diagnosed more commonly. However, there is need to study the disease course and its associated complications from our country. Aim : To study the natural history, clinical profile and course of ulcerative colitis in India. Methodology : A hospital based study registering previously diagnosed and newly diagnosed cases of ulcerative colitis, was carried out from Ist January, 1993 to 31st December, The course and severity of the disease and response to treatment was monitored in all patients prospectively. The response to treatment was assessed as complete remission, partial remission, and relapse. Patients with irregular follow up were not included. Results : Out of a total of 148 registered patients, 120 patients on regular follow up were analysed. The average duration of symptoms prior to the entry was 2.7 years. Eighty eight (73.34%) had severe disease, 16 (13.34%) had moderate and 16 (13.34%) had mild disease at presentation. One hundred nine (90.84%) patients had episodic disease; none presented with acute fulminant colitis. Twenty one patients (17.5%) developed various complications. Conclusions : Ulcerative colitis was responsible for a hosital admission rate of 12/10,000. Most of the patients presented with severe disease as contrary to the previously reported literature from our country. Complications do occur but sinister complications like fulminant colitis and carcinoma are uncommon. Key Words : Ulcerative Colitis, Clinical Profile. Many studies have been published describing various aspects of the disease from Europe and the United States over the past 50 years. However, more data is required from India to study the disease course in our country. The earlier studies reported from India suggested low incidence of the disease and a milder disease pattern. However, subsequent reports in the late nineties have reported a more aggressive course of the disease. Also, an increased incidence has been reported probably reflecting increased awareness, availability of better facilities for diagnosis or truly increased incidence. The present report assesses the magnitude of the disease in a tertiary medical centre in North India and studies its natural history, course, and clinical profile. Materials and Methods A hospital based registration of previously * Unit of Gastroenterology, Departments of Medicine and Pathology**, Dayanand Medical College and Hospital, Ludhiana , Punjab established as well as newly diagnosed cases of ulcerative colitis was carried out from Ist January, 1993 to 31st December, Ulcerative colitis was diagnosed on the basis of clinical picture, failure to isolate known bacterial and protozoal pathogens on stool examination, sigmoidoscopy and histological findings supporting the diagnosis. The treatment principles were generally homogenous, maintenance therapy with sulfasalazine (4-6 gm) or 5-aminosalicylic acid (5-ASA) and glucocorticoids for flare-up episodes, administered orally for periods of weeks. Patients who had severe disease and required hospitalization were treated with parenteral steroids initially alongwith antimicrobials - ciprofloxacin and metronidazole. In cases of failure of medical therapy, the patients were evaluated for surgery. Patients were followed-up for their disease course as relapse, partial remission or complete remission. Relapse was defined as worsening of symptoms recognised by the patient (rectal bleeding, loose stools and bowel frequency) with sigmoidoscopic appearance of active colitis

2 (granularity, friability and/or spontaneous bleeding). Complete remission was defined as clinical improvement with absence of symptoms of active disease (rectal bleeding, stool frequency) with a sigmoidoscopic appearance of grade 0 or 1 (Baron et al : 0-normal mucosa, 1-granular oedematous mucosa with loss of vascular pattern, 2-bleeding to light touch, 3-spontaneous bleeding). Partial remission was defined as clinical improvement with stool frequency still more but less than 50% of previous, and sigmoidoscopy showing downgrading of severity (grade 1-2). Complications were evaluated as local and systemic. Results During the five year study period a total of 148 patients were registered, out of which 120 who were on regular follow-up were analysed. Mean follow up for the patients was 3.4 ± 1.6 year within a minimum follow up of 2 years for each patient. The maximum number of patients were in the age group of years (65%). The mean age at onset of disease was years in men and 32.9 years in women. Males were affected slightly more than females, the ratio being 1.04:1. The average duration of symptoms prior to the hospital entry was 2.7 years. Fifty eight patients (48.34%) had a disease duration of less than 2 years, 30 (25%) had 2-5 years, 22 (18.34%) had 5-10 years and 10 (8.34%) had disease of more than 10 years. On the basis of criteria of Truelove and Witt, 78 (65%) had severe disease, 24 (20%) had moderate and 18 (15%) had mild disease at presentation. Clinical Presentation Majority of the patients presented with intestinal symptoms like chronic diarrhoea (n=95) and/or rectal bleeding (n=80). The presentation with predominant extraintestinal manifestations, like joint pains(1), pyrexia of unknown origin(4), sclerosing cholangitis(2), was uncommon. These patients admitted to history of diarrhoea off and on but never of the magnitude requiring medical aid. The patients of pyrexia of unknown origin did not have any evidence of intraabdominal or perianal abscesses suggesting that disease activity was the cause of fever. Arthritis in our patients was polyarticular involving small and medium sized joints. The striking feature was the episodic presentation of arthritis with prolonged periods of spontaneous relief. Two patients who presented with sclerosing cholangitis were specifically investigated and found to have inflammatory bowel disease. One patient presented with two months history of diarrhoea with bleeding per rectum and was found to have colitis and carcinoma of sigmoid colon simultaneously. There was no past history of diarrhoea. Course One hundred and nine (90.81%) cases had episodic disease with remissions and relapses. Eleven (9.18%) had chronic continuous course and none presented with acute fulminant colitis requiring surgery at the presentation itself. The cumulative relapse rate between the time of registration and minimum follow-up of 2 years was 123. Hence the number of relapses per patient was 1.2/year. During the follow up, 51 patients (42.86%) had more than 2 relapses and 11 (9.18%) had a chronic relapsing course (more than 5 relapses) per year. Fourteen patients (12.25%) remained in remission for more than two years. Various factors incriminated by patients as precipitating cause for relapse were emotional disturbances like family feuds, death of family member (n=8), academic examination (n=6), dietary factors (n=12), pregnancy (n=2), seasonal variations (n=4), infections (n=4) and use of drugs (n=6). Ten patients underwent proctocolectomy due to refractoriness to medical therapy (n=6), carcinoma (n=3) and life threatening haemorrhage (n=1). One patient who refused surgery died due to refractoriness to medical therapy. Endoscopic Findings At presentation all the patients had grade II-III Journal of Indian Academy of Clinical Medicine Vol. 5 No

3 disease. The extent of the disease was proctosigmoiditis in 30 (25%), left sided in 57 (47.5%) and pancolitis in 33 (27.5%). Pseudopolypi were seen in 20 patients (16.67%). Complications Toxic megacolon and severe haemorrhage were seen in 2 patients each. One patient had pneumatosis cystoides intestinalis. He was diagnosed as ulcerative colitis 3 months back and again presented with fever and mild diarrhoea. His X-ray chest showed large amount of air under both domes of diaphragm. Barium studies showed changes of ulcerative colitis but no evidence of perforation. He did well on oral steroids and the peritoneal air disappeared. Carcinoma was detected in 4 cases. One patient had presented with colitis and carcinoma synchronously. The other two patients had a mean duration of disease of 10 years. One patient had a chronic disease of 15 years with total colectomy and ileorectal anastomosis done 8 years back. He had persistence of symptoms and on sigmoidoscopy rectum showed active proctitis with mass lesion. Systemic complications included arthralgias in 7 patients and arthritis in 3. Two patients had sclerosing cholangitis. No patient had pyoderma gangrenosum, erythema nodosum or eye involvement. Discussion Ulcerative colitis is a common disease in most of the industrialized countries in the world. The highest incidence is reported from Scandinavian countries and Scotland followed by England and North America 1-6. It was thought to be uncommon in the developing countries 7-9 but field studies to know the true prevalence are not available. In India, the diagnosis of ulcerative colitis is made with some diffidence on account of high incidence of dysenteric disorders. Almost 60 years ago Chopra and Ray (1939) had reported 120 cases of nonspecific ulcerative colitis which surprisingly went unnoticed in subsequent literature, leaving one to believe that ulcerative colitis is rare in this country 10. However, subsequently Tandon et al in published a series of ulcerative colitis dispelling the exisiting myth. An epidemiologic survey conducted in the general population in Northern India 12 also revealed a profile almost similar to that of the west but still large field studies are required from our country to find out the true incidence and point prevalence of the disease. In a study reported 30 years ago from a North Indian hospital, the hospital admission rate was shown as 9.4 per 10,000 admissions 13. The present study shows a higher hospital admission rate (12 per 10,000). This is similar to reported admission rate of 10 cases per 10,000 hospital admissions in the United Kingdom. Comparable figures from USA are , Switzerland 6 and Norway 5 per 10,000 hospital admissions 14. The clinical picture as observed in the present series is almost similar to the one widely described in the literature from the western countries. The disease was severe (by Truelove and Witts criteria) in majority of patients (65%), a pattern which is contrary to the belief that ulcerative colitis in India runs a mild course 13,15,16. This may reflect a changing pattern of the disease here. This pattern is quite similar to the one reported from west. However, the disease course reported in Indian immigrants to England and Durban is mildmoderate on clinical presentation 17,18. In the West there was a variance in the severity reported in epidemiological studies and hospital based studies. None of the patients presented with acute fulminant colitis in our study, though on subsequent course, two patients required surgery due to this complication. Its incidence in the western series is reported to be from 5-8%. Half of the patients in this study had left sided colitis (47.5%) with proctosigmoiditis in 25% and pancolitis in 27.5%. In one of the latest reviews from the West, 46% had proctosigmoiditis, 17% left sided colitis and 37% had pancolitis 19. The course of the disease was characterized by relapses and remission in majority (90%) with only 10% pursuing a chronic continuous course. The 126 Journal of Indian Academy of Clinical Medicine Vol. 5 No. 2

4 cumulative relapse rate was 1.2 per patient per year. The clinical response to glucocorticoids was generally very dramatic at the first use of the drug while patients, who had chronic active disease showed less prompt response. If steroids were tapered off very quickly the relapse rate was higher and hence, once started steriods should be tapered gradually over weeks. In our country, drug compliance cannot be ensured as patients have a tendency to omit or reduce drugs on their own once the symptomatic recovery occurs. Proper awareness of the disease is required to ensure compliance. Nearly 45% of the patients suffered from relapse within one year of disease diagnosis. The relapse may be set off by many factors and attention needs to be focussed on the identification of the cause to optimise the management of the individual. Kochhar et al in 1993 reported infectious agents especially Clostridium difficile, to be the cause of acute exacerbations. This is in contrast with the findings in developed countries 20. Hence in a tropical country like ours infectious agents should be specifically looked for and treated. The complication rate was less (17.5%) as compared to the reports of 31-40% 14 from western countries. Four cases of colitis carcinoma were detected during the study period. Variable reports are available from our country regarding colitis cancer. Some consider it distinctly rare 21 whereas others recommend cancer surveillance as it is not a rare entity 22. A very high incidence is reported from Mount Sinai Hospital, New York, St. Mark's Hospital, London and Birmingham, UK 21. Complications like erythema nodosum and pyoderma gangrenosum were absent. No patient had eye symptoms though we did not do slit lamp examination. Seven percent patients had arthralgias and approximately 3% had arthritis. Patients in our study have far less systemic complications as compared to what is recognised in the west and some Indian studies 23,24. In conclusion, the present study gives an overview of the present disease status of ulcerative colitis in our country. The patients generally reach hospital after prolonged symptomatology and have severe disease. Nearly two third of the patients have left sided disease or pancolitis. Though local complications are seen frequently but sinister complications like perforation, haemorrhage, toxic megacolon are not common. Carcinoma does remain a dreaded complication and regular follow up is mandatory in patients with long history of disease even when they are symptom free. References 1. Whelan G. Epidemiology and inflammatory bowel disease. Med Clin North Am 1990; 74: Kildebo S, Nordgaard K, Aronsen O et al. The incidence of ulcerative colitis in Northern Norway from 1983 to Scand J Gastroenterol 1990; 25: Langholz E, Munkholm P, Nielsen OH et al. Incidence and prevalence of ulcerative colitis in Copenhagen country from 1962 to Scand J Gastroenterol 1991; 26: Stonnington CM, Phillips SF, Melton LJ et al. Chronic ulcerative colitis : Incidence and prevalence in a community. Gut 1987; 28: Stowe SP, Redmond SR, Stormont JM et al. An epidemiologic study of inflammatory bowel disease in Rochester, New York. Hospital incidence. Gastroenterology 1990; 98: Ekbom A, Helmick C, Zack M et al. The epidemiology of inflammatory bowel disease : A large, population based study in Sweden. Gastroenterology 1991; 100: Mayberry JF. Crohn's disease in developing countries. Ital J Gastroenterol 1980; 12: Mayberry JF, Mann R. Inflammatory bowel disease in rural sub-saharan Africa : Rarity of diagnosis in patients attending mission hospitals. Digestion 1989; 44: Mendeloff AI, Calbins BM. The epidemiology of idiopathic inflammatory bowel disease. In : Kurner JB, Shorter NG, eds. Inflammatory bowel disease. Philadelphia : Lea and Febiger 1988; 3: Chopra RN, Ray PN. Indian Med Gas 1939; 74: Tandon BN, Mathur AK, Mohapatra LN et al. A study of the prevalence and clinical pattern of non-specific ulcerative colitis in northern India. Gut 1965; 6 (5): Khosla SN, Girdhar NK. Epidemiology of ulcerative colitis in the hospital and general population of Northern India. Ind J Gastroenterol 1989; 8 (4): (Suppl). 13. Chuttani HK, Nigam SP, Sama SK et al. Ulcerative colitis in the tropics. British Medical Journal 1967; 4: Journal of Indian Academy of Clinical Medicine Vol. 5 No

5 14. Bebchuk IO, Rogers AC, Downey JL. Chronic ulcerative colitis in a North American Indian. Gastroentology 1961; 40: Maroo MK, Nag NG, Sortartur SV et al. Ulcerative colitis in Southern Maharashtra. J Indian Med Assoc 1974; 63: Chuttani PN. Symposium on ulcerative colitis. J Asoc Physician India 1968; 16: Probert CS, Jayanthi V, Pinder D et al. Epidemiological study of ulcerative proctocolitis in Indian migrants and the indigenous population of Leicestershire. Gut 1992; 33 (5): Rajput HI, Seebaran AR, Desai Y. Ulcerative colitis in the Indian population of Durban. South African Medical Journal 1992; 81 (5): Farmer RG, Easley KA, Rankin GB. Clinical pattern, natural history and progression of ulcerative colitis : A long term follow up of 116 patients. Dig Dis Sci 1993; 38: Kochhar R, Ayyagari A, Goenka MK et al. Role of infectious agents in exacerbations of ulcerative colitis in India. A study of Clostridium difficile. Journal of Clinical Gastroenterology 1993; 16 (1): Antia FP. Ulcerative colitis and cancer colon. Indian J Gastroenterol 1986; 5 (4): Kochhar R, Goenka MK, Kaushik SP et al. Colorectal carcinoma in Indian patients with idiopathic ulcerative colitis. European Journal of Cancer Prevention 1992; 1 (4): Kochhar R, Mehta SK, Nagi B et al. Extraintestinal manifestations of idiopathic ulcerative colitis. Indian J Gastroenterol 1991; 10 (3): Habeeb MA, Rajalingam R, Dhar A et al. HLA association and occurrence of autoantibodies in Asian Indian patients with ulcerative colitis. American J Gastroenterol 1997; 92 (5): Journal of Indian Academy of Clinical Medicine Vol. 5 No. 2