Smoking does influence disease behaviour and impacts the need for therapy in Crohn's disease in the biologic era.

BACKGROUND: Recently, the notion that smoking may adversely affect Crohn's disease (CD) outcomes has been challenged by the suggestion that the widespread use of immunosuppressants and anti-TNF drugs might offset the adverse effects of tobacco. AIM: To reassess the influence of tobacco smoking on disease phenotype and complications on a time-dependent analysis, taking into account the different therapeutic interventions. METHODS: We designed a retrospective cohort study of 3224 patients with Crohn's disease. The data were collected from the Spanish national inflammatory bowel disease registry (ENEIDA), including information regarding demographics, clinical characteristics, disease complications, therapeutic interventions and smoking status. Patients were classified as nonsmokers, smokers and former smokers, according to their present and past smoking habits. RESULTS: In the univariate analysis, smokers had more strictures (22.6% vs. 19.3%, P < 0.05) and less colonic involvement (7.2% vs. 10.9%, P < 0.05), and were more frequently under treatment with steroids (91.6% vs. 85.8%, P < 0.05), immunosuppressants (73.5% vs. 63.6% P < 0.05) or anti-TNF drugs (31.4% vs. 25.1%, P < 0.05) than nonsmokers. In the time-dependent multivariate analysis, smokers were found to have a significantly decreased survival free of stricturing disease (HR: 1.5, CI 95% 1.18-1.90) or perianal complications (HR: 1.50, CI 95% 1.01-1.46), and had a higher risk for requiring thiopurine therapy (HR: 1.20, CI 95% 1.05-1.30). CONCLUSION: These results suggest that, despite the widespread use of immunosuppressants and anti-TNF drugs, smokers with Crohn's disease still have a more severe disease course, with increased therapeutic requirements when compared with nonsmokers.

[Epidemiology in inflammatory bowel disease in five areas of Asturias. Spain]. / Epidemiología de la enfermedad inflamaroria intestinal crónica en cinco áreas de Asturias. España.

AIMS: The epidemiologic analysis inflammatory bowel disease (IBD) is a powerful research tool to assess the contribution of environmental factors to its etiology. IBD has been reported to have varying frequencies in different parts of the world, and there seem to be significant differences in the disease pattern and clinical course. The aim of the present study was to assess the disease pattern of IBD in Asturias (Spain). PATIENTS AND METHODS: A descriptive epidemiological population based study, retrospective (1954-1993) and prospective (1994-97), was performed to study 1018 patients found, bigger than 14 years, to have IBD, in five areas of Asturias (Spain) (461.965 inhabitants). RESULTS: During the period of time studied, we diagnosed 1018 IBD [565 ulcerative colitis (55.5%), 415 (40.8%) Crohn's disease and 38(3.7%) indeterminate colitis], with 482 females (47.2%), 536 males (52.8%), and male/female: 1.11. Age at diagnosis were 39.49 +/- 1.08 (95% CI : 38.41 +/- 40.57); (UC: 43.95 +/- 1.47; CD: 33.53 +/- 1.51; IC: 38.26 +/- 5.14. p = 0.000. Age at onset previously at diagnosis for UC: 42.84 +/- 1.34; CD: 30.68 +/- 1.40; IC: 36.74 +/- 4.86 (p = 0.000). Diagnosis criteria: UC: syntomatic 97.34% (p = ns), endoscopy 96.63% (p = 0.000 pathology 90.26% (p = 0.000). CD: radiology 83.61% (p =0.000). Study level in CD: 57.57 (p = 0.0005). Family history: 8.4%. The most frequent involvement at diagnosis of UC was proctitis only, in 13.6%, 269% rectum and sigmoid 26% let colitis, 20% pancolitis, and in CD colon only, in 16.7%, 30.3% terminal ileum, 41.3% ileo-colon of the patients. This also helps to explain the differences in severity, need for surgery, and survival noted between community based studies. CONCLUSIONS: We highlight the uniformity of distribution of the inflammatory bowel disease in relation to types and sex. The high frequency of familial Crohn's disease suggests a genetic predisposition. Highlighting a bigger morbilidad for the Crohn's Disease reflected in the surgical requirements, but however with smaller mortality that in ulcerative colitis.

Epidemiología de la enfermedad inflamatoria intestinal crónica en cinco áreas de Asturias. España / Epidemiology in inflammatory bowel disease in five areas of asturias. Spain

Objetivo: La epidemiología de la enfermedad inflamatoria intestinal crónica (EIIC) es una poderosa herramienta de investigación que contribuye a la evaluación de los factores medioambientales que influyen en su etiología. El objetivo de este estudio es conocer distintos aspectos epidemiológicos de la EIIC en nuestro medio. Pacientes y métodos: Estudio epidemiológico descriptivo, poblacional, multicentrico, retrospectivo entre 1954 y 1993 y prospectivo entre 1994 y 1997. Se incluyen 1018 enfermos mayores de 14 años, diagnosticados de EIIC en 5 áreas del Principado de Asturias (España), con un censo de 461.965 habitantes. Resultados: Del total de 1018 identificados [565 CU (55,5 por ciento) (incluyendo proctitis), 415 EC (40,8 por ciento) y 38 CI (3,7 por ciento)], 482 son mujeres (47,2 por ciento) y 536 varones (52,8 por ciento), con una relación V/M de 1,11. La edad media al diagnóstico es de 39,49 ± 1,08 (IC; 95 por ciento: 38,41 - 40,57), [CU: 43,95 ± 1,47; EC: 33,53 ± 1,51; CI: 38,26 ± 5,14]. p = 0,000. La edad media de inicio de síntomas previo al diagnóstico es 37,66 ± 0,97 (CU: 42,84 ± 1,34; EC: 30,68 ± 1,40; CI: 36,74 ± 4,86 (p = 0,000). El diagnóstico de CU ha sido posible con criterios clínicos en el 97,34 por ciento (p = ns), criterios endoscópicos en el 96,63 por ciento (p = 0,000) y criterios histológicos en el 90,26 por ciento (p = 0,000). En la EC: criterios radiológicos 83,61 por ciento (p = 0,000). El nivel cultural es superior en la EC: 57,57 (p = 0,0005). Asociación familiar del 8,4 por ciento. Extensión: en la CU: proctitis 13,6 por ciento, 26,9 por ciento colitis distal, 26 por ciento colitis izquierda, 6 por ciento colitis extensa y el 20 por ciento pancolitis; En la EC el 30,3 por ciento tienen afectación de íleon terminal, el 16,7 por ciento colon, el 41,3 por ciento colon e intestino, el 11,7 por ciento son intestinales extensas y el 3,7 por ciento tienen afectación gastro-duodenal; En la CI destaca un 39,5 por ciento de afectación discontinua. La media de cirugías necesarias para el control de la enfermedad es de 0,44 ± 6,11, (26,62 por ciento de los enfermos). CU: 0,12 ± 3,33 (9,91 por ciento); EC: 0,91 ± 12,9 (50,36 por ciento), p = 0,000. Tasa de Mortalidad de 47,15 /1000 habitantes (CU: T = 61,94; EC: T = 26,50; CI: T= 0,004) p = 0,046. RMS: 0,467 (CU: 6,14; EC: 2,63; CI: 100). Conclusiones: Este estudio que abarca una importante población de enfermos, pretende aportar nuestros resultados epidemiológicos a la Enfermedad Inflamatoria Intestinal Crónica. Nuestros resultados no difieren substancialmente de los de otras publicaciones. La colitis ulcerosa y la enfermedad de Crohn así como el sexo, se distribuyen uniformemente. La elevada asociación familiar entre estas enfermedades sugiere un origen genético de la EIIC. La enfermedad de Crohn se expresa con mayor morbilidad reflejada en los requerimientos quirúrgicos, pero sin embargo con menor mortalidad que en la colitis ulcerosa (AU)

[Incidence and prevalence of inflammatory bowel disease. Asturian study in 5 areas (EIICEA). Spain]. / Incidencia y prevalencia en enfermedad inflamatoria intestinal crónica. Estudio asturiano en cinco áreas (EIICEA). España.

AIMS: To know and to compare Inflammatory Bowel Disease (IBD) Incidence and Prevalence rates in in five areas of Asturias (Spain). We conducted a prospective epidemiologic study of IBD in the Province of Liege (1 million inhabitants). PATIENT AND METHODS: We conducted a descriptive, populational, collaborative epidemiologic study, retrospective between 1954 and 1993 and prospective between 1994 and 1997. All patients diagnosed according to a standard protocol for case ascertainment and definition of IBD, aged 14 years or more are included, in five areas of Asturias (Spain) (461,965 inhabitants). RESULTS: For the period 1954 to 1997, 1018 IBD have been diagnosed [565 ulcerative colitis (UC) (55.5%), 415 Crohn's disease (CD) (40.8%) and 38 undefined IBD (IC) (3.7%)]; [482 women (47.2%), 536 males (52.8%)]. In the 4 year-prospective period, 306 cases were collected: 176 UC (57.51%), 110 CD (35.94) and 20 IC (6.53%); UC/CD: 1.6. Without appreciable and significant differences between Frequency of illness groups and sexes. IBD incidence rate (per 100,000 per year) (1954-97) is 5.12 (95% CI = 3.05-7.18) (UC: 2.84; CD: 2.08; IC: 0.19; UC/CD 1.36). In the 4 years- prospective study, IBD incidence rate is 16.55 (95% CI = 12.84-20.25), (UC: 9.52; CD: 5.95; IC: 1.08; UC/CD: 1.6). IBD prevalence rate in 1997 is 205.21 (95% CI = 182.14-227.29), (UC: 109.96; CD: 87.45; IC: 7.79). Comparisons have settled down among the studied areas, without finding differences statistically significant. CONCLUSIONS: Inflammatory Bowel Disease incidence and prevalence rates of in our region are homogeneous between the cities investigated and superior than those historically reported in Spanish studies. These results were similar to those observed in European studies.

Dolor torácico y colitis ulcerosa / Toracic pain and ulcerous colitis

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Estudio multicéntrico. EIICEA. Asturias. Incidencia y prevalencia en enfermedad inflamatoria intestinal crónica. Estudio asturiano en cinco áreas (EIICEA). España / Incidence and prevalence of inflammatory bowel disease in Asturias (Spain)

Objetivo: Conocer y comparar la incidencia y prevalencia de la enfermedad inflamatoria intestinal crónica (EIIC) en 5 áreas del Principado de Asturias (España).Pacientes y métodos: Estudio epidemiológico descriptivo, poblacional, multicéntrico, retrospectivo entre 1954 y 1993 y prospectivo entre 1994 y 1997. Se incluyen todos los enfermos mayores de 14 años, diagnosticados de EIIC según un protocolo estándar para el diagnóstico y definición, en 5 áreas del Principado de Asturias, con un censo de 461.965 habitantes. Resultados: En el periodo de tiempo estudiado, han sido diagnosticados 1018 enfermos con EIIC [565 CU (55,5%), 415 EC (40,8%) y 38 CI (3,7%)]; [482 mujeres (47,2%), 536 varones (52,8%)]. En el periodo de 4 años de estudio prospectivo, se identifican 306 EIIC: 176 CU (57,51%), 110 EC (35,94) y 20 CI (6,53%); CU/EC: 1,6. La frecuencia de aparición de los distintos grupos de enfermedad no presenta diferencias significativas, así como tampoco existen diferencias entre ambos sexos. La tasa de incidencia media anual (1954-97) en EIIC es 5,12 (IC 95% = 3,05 - 7,18) (CU: 2,84; EC: 2,08; CI: 0,19; CU/EC 1,36). En el periodo de tiempo de estudio prospectivo, la tasa de incidencia media anual de la EIIC es 16,55 (IC 95% =12,84 - 20,25), (CU: 9,52; EC: 5,95; CI: 1,08; CU/EC: 1,6). La prevalencia, referida a 1997 para la EIIC es de 205,21 (IC 95% = 182,14227,29), (CU: 109,96; EC: 87,45; CI: 7,79). Se han establecido comparaciones entre las áreas estudiadas, sin encontrar diferencias estadísticamente significativas. Conclusiones: Las tasas brutas de incidencia y de prevalencia de la enfermedad inflamatoria intestinal crónica en nuestro medio son superiores a las históricamente descritas en otras áreas de nuestro país y similares a las publicadas en poblaciones de alta incidencia. No hemos encontrado diferencias significativas entre las cinco áreas que componen el estudio (AU)

[Epidemiology of chronic inflammatory bowel disease in Gijón, Asturias]. / Epidemiología de la enfermedad inflamatoria intestinal crónica en Gijón. Asturias.

AIMS: To determine several aspects of the epidemiology of chronic inflammatory bowel disease (IBD), including distribution of the various forms of IBD, sex, age at diagnosis considering lag-time to diagnosis, criteria used in the diagnosis, the relationship between educational level and activity, familial aggregation, phenotype (site and clinical type), number of admissions and mean hospital stay/year, surgical requirements and mortality. PATIENTS AND METHODS: We carried out a retrospective (1954-1993) and prospective (1994-97) descriptive epidemiologic population study, in the fifth health district of Gijón in Asturias (Spain), with 225,798 inhabitants. A total of 595 patients diagnosed with chronic IBD according to the diagnostic criteria described by Lennard-Jones and Truelove for Crohn's disease (CD) and ulcerative colitis (UC) and according to Ashley B. Price's criteria for indeterminate colitis (IC) were studied. In all patients a complete clinical follow-up was performed. RESULTS: During the study period, we diagnosed 595 patients with IBD [305 patients with UC (51.3%), 272 (45.7%) patients with CD and 18 (3%) with IC]. Sex distribution was 287 females (48.2%) and 308 males (51.8%), with a male/female ratio of 1.07. Mean age at presentation was 38.79 +/- 17.44 years (UC: 43.37 +/- 17.55; CD: 33.98 +/- 16.16; IC: 33.73 +/- 13.48), p = 0.000. Age at onset prior to diagnosis was as follows: UC: 42.03; CD: 30.47; IC: 30.99 (p = 0.000). Diagnostic criteria used in UC was symptomatic in 99.01% (p = ns), endoscopic in 95.04% (p = 0.000), and pathologic in 87.21% (p = 0.000); in CD diagnostic criteria used was radiologic in 85.29% (p = 0.000). A total of 29.1% of patients with UC and 66.7% of those with CD had higher education (p = 0.0005). Family history was found in 9.8%. Anatomical site was as follows: in UC: rectum 21%, 28.2% rectum and sigmoid, 22.3% left colitis, 4.2% distal to hepatic flexure and 24% pancolitis; in CD: 32.72% terminal ileum, 19.11% colon, 37.13% ileo-colon, 11.02% extensive intestinal and 3.67% gastro-duodenal. A total of 8.37% of patients with UC and 14.51% of those with CD had been hospitalized during the previous 4 years; mean hospital stay was 1.63 days in UC and 2.27 days in CD. The mean surgical requirements were 0.54 +/- 1.08 (31.59%); UC: 0.11 +/- 0.36 (10.2%); CD: 1.04 +/- 1.38 (56.25%), p = 0.000. The mortality rate was 48.73 deaths/1,000 inhabitants (UC: T = 65.57; CD: T = 33.08; IC:T= 0) p = ns. The standardized mortality ratio was 4.83 (UC: 6.51; CD: 3.28). CONCLUSIONS: We highlight the uniformity of the distribution of IBD in relation to types of disease and sex. Patients with CD had a higher level of education. Genetic components play an important role in these diseases and familial aggregation was high, especially in CD. Complicated situations are infrequent in this group of patients. Morbidity was higher in patients with CD as reflected by surgical requirements and hospital stay. Mortality was lower in CD than in UC.

[Incidence and prevalence of inflammatory bowel disease in Gijon, Asturias, Spain]. / Incidencia y prevalencia de la enfermedad inflamatoria intestinal en Gijón (Asturias).

AIM: To determine the incidence and prevalence of inflammatory bowel disease in our area and to compare our results with those of other series from Spain and other parts of the world. PATIENTS AND METHODS: Descriptive epidemiologic population study, retrospective (1954-1993) and prospective (1994-1997) in health district V of Gijón in Asturias (Spain) with 225,798 inhabitants. Diagnostic criteria used were those described by Lennard-Jones and Truelove for Crohn's disease and ulcerative colitis and those described by Ashley B. Price for indeterminate colitis. Annual incidence was expressed per 100,000 inhabitants. Prevalence was calculated excluding cured patients: proctocolectomized in ulcerative colitis (10 cases) and deaths (29 cases). RESULTS: During the period studied, 595 patients were diagnosed with bowel disease (305 patients with ulcerative colitis, 272 with Crohn's disease and 18 with indeterminate colitis). Mean annual incidence (1954-1997) was 6.128 (95% CI: 2.90-9.36). In the 4-year prospective study the incidence was 15.49 (95% CI: 11.19-21.79), 9.36 for ulcerative colitis, 6.08 for Crohn's disease and 0.77 for indeterminate colitis (UC/CD: 1.58). Prevalence was 246.23 (95% CI: 225.6-226.70, 212.79 for ulcerative colitis, 116.47 for Crohn's disease and 7.97 for indeterminate colitis. CONCLUSIONS: Incidence and prevalence obtained in our environment were higher than those described in other areas of Spain and were similar to those found in areas of Europe and other parts of the world with a higher incidence. Incidence and prevalence have increased since 1980, probably due to the widespread use of endoscopy as a diagnostic technique. Rates were higher in the prospective study than in the retrospective one.

Enfermedad de Crohn: un amplio espectro clínico

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Mortality and causes of death in patients with chronic inflammatory bowel disease in Gijón, Asturias (Spain).

OBJECTIVE: to review mortality, survival, influence of age at diagnosis and at death, cause of death, and relation with the extent of chronic inflammatory bowel disease, in a city in northern Spain. METHOD: descriptive retrospective epidemiological study of 516 patients diagnosed in Gijón (Asturias) between 1954 and 1997. RESULTS: of the 26 patients who died (5.03%), 18 had ulcerative colitis, 8 had Crohn's disease, and none had indeterminate colitis. Mortality was higher than in the general population, with a standard mortality ratio (SMR) of 5 (95% confidence interval 1.6-11.6). We found no differences in sex ratio (p = 0.63). Mean duration of the disease was 10 +/- 8 years in surviving patients, and 6 +/- 6 years in patients who died (p = 0.02). Duration was longer in Crohn's disease than in ulcerative colitis (p = 0.014). Mean age at diagnosis for chronic inflammatory bowel disease was 37.5 +/- 17 years in patients who survived, and 58 +/- 18 years in patients who died (p = 0.0005). Mean age at death was 64 +/- 20 years. In Crohn's disease, the most frequent cause of death was the primary disease (50%), followed by tumors of different origin (37.5%). In ulcerative colitis the primary disease was also the most frequent cause of death (38.%), followed by thromboembolic disease (22.2%) and tumors (22.2%). CONCLUSIONS: mortality among patients with chronic inflammatory bowel disease is higher than in the general population in our setting, decreases as duration of the disease increases, and is higher in patients diagnosed at older ages. Fewer than half the deaths were due to the primary disease; many patients with Crohn's disease died from tumors or thromboembolic disease.