qin ouyang, yufang wang, renwei hu department of medicine ...€¦ · ulcerative colitis 20...

Qin Ouyang, Yufang Wang, Renwei HuDepartment of medicine

West China Hospital, Chengdu,China

Epidemiology of Inflammatory Bowel Disease

In China

IBD cases progressively increased in recent 20 years.

5～6 times hospitalized cases than before in some medical centers.

No large scale study on epidemiology of IBD in this country but more scientific reports published on Chinese literatures.

A literature review on CBM relevant to IBD in China

A Multicentral Clinical Analysis of Hospitalized IBD in China

Some risk factors of IBD reviewed from recent literature

Review and Analysis of Literatures Relevant to IBD

from 1989 to 2003

Materials and Methods

Literatures 1989.1-2003.12 were searched through computer .

1400 kinds of journals, such as series of Chinese medical journals,over 12 million pieces of medical articles.

3384 articles on IBD published

143,511 cases of IBD reported in various Chinese medical journals in recent 15 years.

IBD Articles in Recent 15 Years

2076（1021）

860（474）

255（136）

IBD

32（0）223（136）89-93

122（41）738（433）94-98

274（8）1974（1013）99-03

Year CDUC

Total 2956（1582） 428（49） 3384（1631）

（） Traditional Chinese medicine

General Data of IBD

C DU CContent

2.84.5Average course(year)

37.543.8Average Age

1.37/11.36/1Ratio of male

to female

Clinical Type in UC

Chr oni cr el apsed

58%

Chr oni cper si st ant

23%

Fi r st at t ack18%

Ful mi nant1%

Smal l bowel40. 2%

I l eocol onni c21. 4%

Col oni c36. 2%

ot her s( esophagus, st omach)

2. 2%

Clinical Type in CD

Clinical Severity in UC

Sever e18% Mi l d

36%

Moder at e46%

Surgery and Mortality Rate

1.410.06Mortality

30.70.1Surgery

CD(%)UC(%)Rate

Articles on Extraintestinal manifestations

7.231CD

2.162UC

%NumbersDisease

Skin rashes23. 8%

Arthritis 35. 9%

Others 11. 9%

Oral ulcers28. 4%

Ski nl esi ons31. 3%

Or alul cer s29. 3%

Joi ntl esi ons

20. 7%

Ot her s18. 7%

UC CD

Articles Relevant to Complications

19.282CD

2.678UC

%NumbersDisease

Per f or at i on22%

Megcol on20%

Per i analabcess

10%

Obst r uci on8%

Ot her s7%

Hemor r hage15%

Col on cancer18%

Ot her s5. 4%f i st ul a

5. 7%

Hemor r hage23. 3% Obst r uct i on

27. 2%

Per f or at i on29. 3%

UC CD

Diagnosis of IBD in China

Only 6.9% articles discussed about diagnosis

40.6% papers mentioned about diagnostic criteria

Even lesser commonly used of new revised criteria in 2000.

Misdiagnosed Cases of IBD

Misdiagnosed Rate（％） 60.932.1

C DU C

Others 4. 2%

Infectiouscolitis67. 3%

Hemorroids4. 7%IBS 11. 0%Colonic

cancer 7. 9%

Ischemiccolitis 4.9%

Obstruction 26.7%

Others 14.6%

TB 30.8%Appendicitis 27.9%

UC CD

Articles on IBD Treatment

2084 Total

1994 (95.7%) UC

90 (4.3％) CD

1533 (73.56%) clinical trials

Articles on IBD Clinical Trial

3154

3436

4933TCM

Combined with TCM andWestern medicine

Western Medicine

CD UC Classification

Type and Strength of Evidence in Evidence Base Medicine

Strength of Evidence in these Articles

1

11

516

0

12

38

0 1

6

02

12

1

10

100

1000

1 2 3 4 5 6 Gr ade

Amou

nt o

f ar

ticl

es UCCD

Efficacy of Chinese and Western Medicine

386(87.9%)819(87.4%)93(59.2%)>90

9(2.1%)5(0.5%)15(9.6%)70-79

439(28.7)%937(61.1%)157((10.2%)

39(8.9%)112(12.0%)48(30.6%)80-89

5(1.1%)1(0.1%)1(0.6%)<70

Combined medicineTCMW. Medicine

Articles Efficient

rate

Common Recipes in Chinese Medicine

Common Chinese medical prescriptions：Pulsatilla Decoction（白头翁汤）Powder of Gingseng Poriand Bighead Atractylodes （参苓白术散）Black Pulm Decoction（乌梅汤）,etc.

Common Chinese patent medicine：Powder of natural indigo（青黛散）Powder for treating thoat disease（锡类散）Yunnan white drug（云南白药), etc.

Common component in prescriptions:Bletilla rhizome(白芨), Pulsatilla root（白头翁）Largehead atractylodes rhizome（白术）, White peony root（白芍）Coptis root（黄连）, Amur corktree bark (黄柏)Baikal skullcap root（黄芩）, Membarnous milkvetch rootand（黄芪）etc

Review and Analysis of Review and Analysis of Literatures Relevant to IBDLiteratures Relevant to IBD

from 2003 to 2007from 2003 to 2007

2549 articles on IBD published

132,385 patients with IBD were reported.

There are totally 124,142 UC and 8,243CD

Surgery and Mortality Rate

0.80.05Mortality

37.00.5Surgery

CD(%)UC(%)Rate

Extraintestinal manifestations and Complications

11.1

1.5

Extraintestinalmanifestations(%)

49.8CD

0.6UC

Complications(%)

Disease

Diagnosis of IBD in China

Only 5.6% articles discussed about diagnosis

70.6% papers mentioned about diagnostic criteria

69.3% used of new revised criteria in 2000.

Misdiagnosed Cases of IBD

Misdiagnosed Rate（％） 52.30.8

C DU C

Fi gur e 1. I cr easi ng number of UC pat i ent s r epor t edi n Chi nese ar t i cl es dur i ng a 19- year per i od

05000

10000150002000025000300003500040000

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

Year

Tota

l nu

mber

of

pati

ents

Fi gur e 2. I ncr easi ng number of CD pat i ent sr epor t ed i n Chi nese ar t i cl es dur i ng a 19- year

per i od

0500

1000150020002500300035004000

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

Year

Tota

l nu

mber

of

pati

ents

020000400006000080000

100000120000140000

Tot alnumber

ofpat i ent s

1989-1993

1994-1998

1999-2003

2004-2007

Year

Increasing number of UC Cases every 5 years from 1989-2007

0100020003000400050006000700080009000

Tot alnumber

ofpat i ent s

1989-1993

1994-1998

1999-2003

2004-2007

Year

Increasing number of CD Cases Increasing number of CD Cases every 5 years from 1989every 5 years from 1989--20072007

Conclusion

The incidence and prevalence of IBD are increasing in

recent 19 years.

The differential diagnosis complicated , and the level

of diagnosis needs to be improved.

The therapeutic strategy should be optimized and

clinical trial need to be standardized .

A Clinical Analysis Of

Hospitalized IBD

Patients and Methods

Hospitalized IBD from 23 medical centers in 11 cities

from 1990 to 2003 collected.

Rechecked with Diagnostic criteria

(suggested guideline for the diagnosis and treatment

of IBD in China , 2000. )

Uniform questionnaire

Training courses for Uniformity

Survey time：Jan,2004 to April , 2004

General Data

3100 UC and 515 CD collected and analyzed.

The male to female ratio:

UC: 1.34:1

CD: 1.67:1

050

100150200250300350400450

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003 Year

Numb

er

Number ofhospi t al i zedUC

Number of UCscr eened byendoscopy

Numbers of UC hospitalized and screened

by endoscopy from 1990-2003

0

50

100

150200

250

300

350

1990

1992

1994

1996

1998

2000

2002 year

rati

o(1/

1000

0)

Const i t ut i onal r at i o ofhospi t al i zedUC and GIcases

Const i t ut i onal r at i o ofendoscopi cf i ndi ng

Constitutional ratio of UC hospitalized and endoscopy

0102030405060708090

100

1990

1992

1994

1996

1998

2000

2002 year

Numb

er

Number ofhospi t al i zedCD

Number of CDscr eened byendoscopy

Numbers of CD hospitalized and endoscopy

Constitutional ratio of CD

hospitalized and endoscopy

Age Distribution of UC And CD

0. 5

3. 7

14. 5

22. 624. 6

16. 8

12. 3

4. 5

0. 52

13. 1

20. 9

26. 6

19. 5

8. 57. 4

1 1

0

5

10

15

20

25

30

<10

10- 1920- 2930- 3940- 4950- 5960- 6970- 79>80

AGE

%

UC 44. 0± 15. 1

CD 37. 7± 20. 5

10.3 10.3

10.5 10.5

36.7 36.7

27.0 27.0

15.5 15.5

CD (%)CD (%)

9.89.8〉〉1010yy

11.511.555--1010yy

36.636.611-- 55yy

34.034.011mm--11yy

8.28.2〈〈11mm

UC (%)UC (%)Course

Clinical Course of IBD

Mild

35.4%

Severe

21.7%

Moderate

42.9%

Clinical Severity in IBD

Severe

33.4%

Moderate

50.5%

Mild

16.1%

UC CD

14.0434Total

1.71.75252Ocular lesionsOcular lesions

0.550.551717Anal fistulaAnal fistula

1.91.95959Oral ulcerOral ulcer

1.91.96060RashRash

7.17.1221221ArthralgiaArthralgia

0.390.391212Anal fissureAnal fissure

0.420.421313Anal abscessAnal abscess

%%NumberManifestations

Extraintestinal manifestations of 3100 UC

2.32.31212Ocular lesionsOcular lesions

%%NumberManifestations

22.322.3115115TotalTotal

2.92.91515BiliaryBiliary

3.13.11616RashRash

4.94.92525Oral ulcerOral ulcer

9.19.14747ArthralgiaArthralgia

Extraintestinal manifestations of 515 CD

Lef t col onExt ensi vePancol onRegi onal

Location of 2726 Active UC

66.2%

1.7%

25.8%

6.3%

Location of 515 CD

Smal l bowel28. 0%


Col oni c41. 0%

5Others (1 for each disease)

2Intestinal obstruction

8Acute colitis

26Colonic Amebiasis

76Hemorrhoids

3Pseudomembranous colits

3Hypersensitivity colits

3Hemorrhagic colitis

2Typhoid fever

4Intestinal Tuberculosis

4Irritable Bowel Syndrome

2Appendicitis

189711(22.9%)

Chronic colitis Total

5Polyp of colon

6Crohn disease

373Dysentery

NumberMisdiagnosis

Misdiagnoses of 711 UC

2Eosinophilic gastroenteritis

13Chronic colitis

40Intestinal carcinoma

30Intestinal Tuberculosis

10Peptic ulcer

4Acute pancreatitis

3Allergic purpura

2Behcet’s disease

16Infectious colitis

15lymphoma

292 (56.7%)Total

20Ulcerative colitis

27appendicitis

110Unknown origin

NumberMisdiagnosis

Misdiagnoses of 292 CD

9.6298Total

0.031Cerebral infarction

0.031Intussusception

0.14Toxic megacolon

0.25Infectious shock

0.062Lymphoma

0.411Carcinoma of colon

0.411Intestinal Obstruction

0.826Intestinal perforation

7.6237Severe bleeding

%NumberComplications

Main Complications of 3100 UC

2.111Others

%NumberComplications

0.63Inflamed mass

68.8354Total

4.724Abscess

6.232Perforation

11.358Fistula

17.992Obstruction

26.0134Hemorrhage

Main Complications of 515 CD

32.532.5980980Topical treatmentTopical treatment

9494

6262

115115

16871687

498498

791791

20152015

NumbersNumbers

3.03.0OperationOperation

2.12.1Immunosuppressive Immunosuppressive agentagent

3.73.7Chinese traditional Chinese traditional medicine (oral/topical)medicine (oral/topical)

66.066.0Antibiotics Antibiotics

16.516.5Intravenous SteroidsIntravenous Steroids

26.226.2Oral steroidsOral steroids

66.866.8SASP/5ASASASP/5ASA

%%

Main therapy methods in 3015 UC

33.2 171Operation

13.6 70Immunosuppressive agent

22.7 117Steroids

28.3 146SASP/5ASA

%Number

Main Therapy Methods in 435 CD

UC

80. 9%

11. 6%6. 9%

0. 6%

Outcome of IBD

CD

41. 6%

5. 0%1. 4%

52. 0%

CRPRNRdeat h

Conclusion

A true increase of IBD in China

A slightly male predominance of IBD.

A relatively later onset of illness with no second peak age

occurrence after 50 years.

Most IBD cases run a milder clinical course in China.

Extraintestinal manifestations and complications were

comparatively less.

A fewer fistulae and perianal complications diseases in Chinese

CD.

RISK FACTORS

Familial history of IBD

Articles in China reported that 4.4 - 5.6% patients with UC

had a family history

Which is lower than the 10–20% in developed countries.

Chinese IBD Working Group. Chin J Dig 2008; (in press).

Yuan AL, Xia B, et al. Chin J Dig 2003; 23: 245–6 (in Chinese).

Smoking

Most studies in China suggested that cigarette smoking

was protective factors for UC, while increases the risk

for CD.

Chinese IBD Working Group. Chin J Dig 2008; (in press).Jiang L, Xia B. J Clin Gastroenterol. 2007; 41(3): 280-4.Yuan AL, Xia B, et al. Chin J Dig 2003; 23: 245–6.

No relation between smoking and severity of UC was

detected in a large population of Chinese patients.

Jiang XL.World J Gastroenterol 2002;8:158-161

AAppendectomyppendectomy

As found in western countries, the case-control study of 177 UC cases in Hubei,China also showed that appendectomy had a negative association with development of UC.

Jiang L, Xia B. J Clin Gastroenterol. 2007; 41(3): 280-4

Another study cannot find appendectomy had an association with development of UC in China


Infectious Enterocolitis

A muticenter case-control study of 745 UC cases showed that

infectious enterocolitis was risk factor of UC

In contrast, others have suggested that absence of infections might be a risk factor.


Gent AE, Hellier MD, Grace RH, et al.Lancet.1994 Mar 26;343(8900):766-7

Tea Consumption

Many studies in other countries showed the intake of vitamin C was negatively related to IBD risk

A muticenter case-control study of 745 UC cases showed that tea consumption was protective factor


Breast Feeding

Study in western countries showed that CD patients were three times less likely to have been breastfed.

S. Koletzko, P. Sherman, M. Corey,et al. BMJ. 1989 June 17; 298: 1617–1618

A muticenter case-control study of 745 UC cases in China showed breast feeding was protective factor for UC


Occupation and Education

IBD is generally more common among those of higher socioeconomic status in most.

A retrospective survey of 452 patients with IBD in China showed IBD is associated with young adult professional males and high level of education

Jiang L, Xia B, Li J, et al. Inflamm Bowel Dis. 2006; 12(3):212-7

Mycobacterium avium paratuberculosis

Studies in China showed an animal model of granulomatousenteritis (mimicing CD) has been established by Mycobacterium avium paratuberculosis inoculated intraperitoneally

Miao Ying-lei;Du Yan;On-yang Qin;et al. Clin Dig Dis.1999

There appears to be a strong association between M. aviumparatuberculosis and Crohn's disease

But the causality of this association is unknown.

Gan Huatian;Ouyang Qin;Bu Hong;et al.. J Internal Med.1997 (Chinese).

ITBITB

1. Despite a time lag with the West, above data indicate a true increase of IBD in China with a lot of complicated clinical problems which offers potential opportunities to study the disease prospectively and identify the etiologic factors.

2. An increased IBD seems parallel with Chinese GDP and improvement of quality of life, which help us consider about environmental factors, but not solely genetics, in the pathogenesis of IBD.

3. Now a day, Chinese IBD database has been established and willbe completed throughout to the whole country by COIBD, which will be very helpful for data collecting and analyzing late on.

Summary

Thank You!

Types of IBD Articles

326

128

198

Others

428477641136CD

3384

2956

total

1878212434534Total

1831136393398UC

TherapyDiagnosisBasicReview

Types of IBD Articles

18.4

Others

100

total

51.95.615.98.2(%)

TherapyDiagnosisBasicReview

Chr oni cr el apsed

49%

Chr oni cper si st ant

20%

Fi r st at t ack30%

Ful mi nant1%

Clinical Type in UC

Smal l bowel41. 9%


Col oni c26. 1%

ot her s( esophagus, st omach)

3. 2%

Clinical Type in CD

Clinical Severity in UC

Sever e19% Mi l d

39%

Moder at e42%

2. 4%34. 6%

46. 0%

17. 0% Ful mi nant t ype

Fi r st onset

Chr oni c r el apsi ng

Chr oni c per si st ent

Clinical Types of 3100 UC Cases

Genetic factors

NOD2/CARD15 variants in locus of 16q112(IBD1) have not been found in Chinese CD and UC. (Detected in 74 UC patients, 15 CD patients and 172 healthy individuals. )

Guo QS, Xia B. World Journal of Gastroenterology. 2004; 10: 1069-71.

A higher mutation rate of P268S of NOD2/CARD15 in CD (5/30) but none of UC and control, indicating its possible susceptibility to Chinese CD

Long JH, Zhi FC. Gastroenterol (Chinese). 2007; 12(6): 327-9.

An association with HLA-DQ α1c allele was detected in ANCA+ UC Chinese but not in white patients, (Detected in 18 ANCA-positive UC patients and 104 controls).

Lee YT,Sung JJ. Scand J Gastroenteral 1998;33:623-627.

No difference in CTLA4 gene polymorphism between Chinese and Dutch patients. (Detected in 139 UC , 163 CD, 174 healthy controls of Dutch Caucasian origin as well as 35 patients with UC and 62 healthy controls from the Chinese Han population ).

Genetic factors

Xia B. Scand J Gastroenteral 2002;37:1296-1300

qin ouyang, yufang wang, renwei hu department of medicine ...€¦ · ulcerative colitis 20...

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