| Abstract|| |
To determine the pattern of lower gastrointestinal disease in the Eastern region of Saudi Arabia we analysed 1907 colorectal biopsies obtained from 1590 consecutive patients (1256 males & 334 females), evaluated during a 13 year period (1983-1996) in a tertiary care teaching hospital. The age range was 6-81 years with a mean of 37 + 15. During the same period 6874 new patients were seen in the Gastroenterology Clinics. Saudi Arabs constituted 970 (61 %) of all patients. The remaining 620 (39%) were non-Saudi, mostly of Arab origin from neighbouring countries. The most common presenting symptom for referral was abdominal pain (1193 patients, 75%) followed by diarrhea (636 patients, 40%). The most frequent histologic diagnosis was a normal mucosa followed by non specific proctocolitis accounting respectively for 37.9% and 37.4% of all cases. These were followed by schistosomiasis, 113 (7.1%), adenocarcinoma, 91 (5.7%) and ulcerative colitis, 91 cases with a relative frequency of 5.7% and a calculated prevalence of 1.3%. Of significance was the encounter of 14 cases of Crohn's disease amounting to 0.9% of all cases with a calculated prevalence of 0.2%. A minority of 83 patients (5.2%) were cases of either a benign polyp, diverticular disease, tuberculosis, ischaemia, lymphoma, pseudomembranous colitis (PMC), eosinophilic gastroenteritis or malacoplakia. These data show that although a "normal mucosa" and "nonspecific proctocolitis" were the dominant diagnoses, significantly, ulcerative colitis and Crohn's disease exist and should be considered in the differential diagnosis of lower GI disease.
Keywords: Lower Gastrointestinal Diseases, Ulcerative Colitis, Crohn′s Disease, Saudi Arabia.
|How to cite this article:|
Al Quorain AA, Satti MB, Al Gindan YM, Al-Hamdan A. The pattern of lower gastrointestinal disease in the eastern region of Saudi Arabia: A retrospective analysis of 1590 consecutive patients. Saudi J Gastroenterol 2000;6:27-32
|How to cite this URL:|
Al Quorain AA, Satti MB, Al Gindan YM, Al-Hamdan A. The pattern of lower gastrointestinal disease in the eastern region of Saudi Arabia: A retrospective analysis of 1590 consecutive patients. Saudi J Gastroenterol [serial online] 2000 [cited 2022 Jan 27];6:27-32. Available from: https://www.saudijgastro.com/text.asp?2000/6/1/27/33501
Of previous studies from Saudi Arabia, most of the published reports dealt with the pattern of disease related to upper gastrointestinal tract and only a few reports investigated the pattern of disease involving the lower gastrointestinal tract,,. Furthermore there are only few reports on chronic inflammatory bowel disease that emerged from developing countries including middle eastern areas,,. However during the last 13 years more cases have been encountered particularly from the Middle East,,,,,. The objective of this study is to describe the pattern of disease affecting the lower gastrointestinal tract and to determine in particular the relative frequency of chronic inflammatory bowel disease (CIBD) in the Eastern region of Saudi Arabia. The final goal is to compare these findings with those from the area and from western hemisphere countries.
| Patients and methods|| |
A retrospective evaluation was performed on all lower gastrointestinal (L.G.I) endoscopies done during the 13-year period (1983-1996) at King Fahd Hospital of the University, Al Khobar. Of all such cases only those who had a biopsy were included. The medical records were reviewed for age, sex, nationality, symptoms and duration, endoscopic findings, results of stool analysis and follow-up information. All pertinent histologic sections and paraffin blocks were retrieved for review and evaluation. Using standard histologic criteria and in the light of clinical and endoscopic findings, patients were categorized into various diagnostic entities: Patients presenting with recurrent abdominal pain, chronic diarrhea with or without rectal bleeding who had endoscopic features of hyperemia, contact bleeding, friability of mucosa with or without ulceration were suspected as having CIBD. Confirmatory histologic features of chronic proctocolitis [Figure - 1] included some or all of the features of: crypt distortion, cryptitis, mucin depletion, Paneth cell metaplasia and chronic inflammatory infiltrate, preferably at the base of the crypts. Patients having such features were considered to have CIBD, consistent with ulcerative colitis. Presence of granuloma in mucosal biopsies raised the possibility of Crohn's disease [Figure - 2]. However its absence did not preclude the diagnosis. Presence of bilharzial ova in biopsies is confirmatory of schistosomiasis. Cases where there is only an increase in mononuclear and acute inflammatory cells but with normal architecture and no other histological evidence of CIBD, bilharzial ova or fetures to indicate ischaemia, neoplasia or other diagnostic entity, were labeled as nonspecific proctocolitis, or acute self-limited colitis. In cases otherwise, where no abnormality was noted a diagnosis of normal colonic mucosa was made.
| Results|| |
During the 13-year period (1983-96), 6874 new patients attended the gastroenterology clinics. Of these a total of 1590 patients underwent lower gastrointestinal endoscopy and biopsy. A total of 1907 biopsies obtained from these patients were reviewed. Of all endoscoped patients 1256 (79%) were males and 334 (21%) were females, with an age range of 6-81 years and a mean of 37 + 15. Saudi Arabs constituted 970 (61%) of all patients and the remaining 620 (39%) were non Saudis, mostly of Arab origin from neighbouring countries. The main presenting symptom for referral was abdominal pain (1193 patients, 75%) followed by diarrhea (636 patients, 40%). The diagnostic entities distributed among males and females are shown in [Table - 1].
Normal colonic mucosa and non-specific protocolitis
The diagnoses of "normal colorectal mucosa" and "non specific proctocolitis" were predominant, seen in 603 and 595 patients amounting to 37.9% and 37.4% of all cases respectively [Table - 1]. The majority of these patients were males who presented with minimal symptoms and had undergone a single endoscopy in 93% and 89% of cases respectively [Table - 2]. Those who had a repeat endoscopy were those in whom the histologic diagnosis or the endoscopic findings were inconclusive to exclude CIBD. Most of these patients had no more follow up in the clinics and were considered free of GI disease, while a few were treated as irritable bowel syndrome.
Schistosomiasis was the commonest of infective proctocolitides, involving 113 (7.11%) patients, mostly males [Table - 1] with an age range of 15-49 years and a mean of 29. Ova were identified histologically in colorectal biopsies on first endoscopy in 96 (85%) patients and on second biopsy in 17 (15%) patients [Table - 2].
Of all patients, 52 (46%) were Saudis and 61 (54%) were non Saudi Arabs. Of all 113 patients stool examination revealed schistosomal ova in only 34 (30%) patients.
Twenty-four patients (1.5%%), of whom 19 (79%) were Saudis, had radiologic and endoscopic evidence of diverticular disease of the colon with normal colorectal mucosal biopsies. Males were 18 (75%) while females were 6 (25%). Recurrent abdominal pain was the dominant symptom.
Adenomatous polyps were seen in 35 (2.2%) patients mostly males [Table - 1]. Twentry-seven (77%) were Saudis and 8 (23%) were non Saudis. Most polyps (80%) were on the left colon.
Chronic idiopathic ulcerative colitis
Ninety-one (5.72%) patients satisfied the diagnostic clinicopathological criteria of ulcerative colitis, accounting for a prevalence of 1.3% relative to all new patients attending the gastroenterology clinics. Their demographic data are shown in [Table - 3]. Most patients were Saudis or non Saudi Arabs; only six patients were Asians with an age range of 20-49 years [Table - 3]. Diarrhea and abdominal pain were the commonest presenting symptoms, followed by hematochesia. Endoscopically 64 patients (70%) had either a low or moderate grade severity and in the majority of patients (90%) the disease was restricted to the distal segments of the bowel (Stage I or II). Only one patient, Asian, developed colonic epithelial dysplasia which was surgically mananged.
Forteen patients (0.9%) had a final diagnosis of Crolm's disease amounting to a calculated prevalence of 0.2% [Table - 1]. Males equaled females with an age range of 16-39 years and a median of 23 years. All patients were Saudi Arabs. Recurrent colicky abdominal pain was the main presenting symptom in all patients, associated with weight loss in 12 patients, diarrhea in 7, fever in 5, arthralgia in 5, recurrent perianal abscess or fistula in 3 and bleeding per rectum in one patient. Histological examination demonstrated granulomatous inflammation in 9 patients (64%) involving variably the colon, stomach [Figure - 3], appendix (presented as acute appendicitis), terminal ileum or mesenteric lymph nodes. The disease involved both small and large bowel in 9 patients, the small bowel with or without the appendix or stomach in 3 patients, while apparent involvement of the colon in isolation was noted in two patients. Because of the presence of colonic or gastric granulomas, four patients with small bowel involvement were initially kept on antituberculous therapy without a therapeutic response. However prompt response followed steroid therapy for Crohn's disease. Overall twelve patients were managed with steroids and aminosalicylic acid while two were surgically treated.
| Discussion|| |
This study is one of few that investigates the pattern of lower gastrointestinal disease based on histologic diagnosis of mucosal endoscopic biopsies. Our results showed that the most prevalent diagnosis on endoscopy was a "normal mucosa" accounting for 37.9% of all cases. Some of these patients probably had irritable bowel syndrome (IBS) or noncolonic abdominal disorders.
This is evidenced by the fact that only 7% of them had a repeat endoscopic biopsy for either persistent symptoms or for excluding CIBD [Table - 2]. Such a "normal colonic biopsy" diagnosis was also the commonest in the Riyadh study. The second major group in our study is the histological diagnosis of "nonspecific proctocolitis" amounting for 37.4% of all patients. This may relate to unrecognized resolving bacterial infections or other irritants. Their symptoms were usually transient and a repeat biopsy was required in only 11 % to exclude CIBD [Table - 2]. Only 149 (8.4%) patients had such a diagnosis in the Riyadh study. This may relate to variations in the interpretation of the extent and quality of the mucosal inflammatory infiltrate and the overlap with what would be considered "normal". In such cases to avoid the designation of "chronic" the terminology of "acute self limited colitis" is most consistent in acute cases and "normal mucosa" for cases in resolution. The fact remains that some of these cases must be followed up to exclude, on histological evidence, CIBD Of infectious proctocolitis, the commonest was schistosomiasis accounting for 7.1 % compared to a figure of 9.2% in the Riyadh study. Stool examination proved less sensitive than the rectal biopsy in identification of ova. These were identified on first biopsy in 85% of cases [Table - 2], whereas stool examination revealed ova in only 30% of patients.
Chronic idiopathic ulcerative colitis and Crohn's disease are rarely encountered in developing nations. Only scattered reports appeared in the literature on both diseases from Middle Eastern countries,,,,,,,, including few reports from Saudi Arabia,,, The disease is known to be more common in Europe and North America,, Previous hospital-based studies confirm the existence of both diseaes with a relative frequency of 6% for ulcerative colitis and 0.9% for Crohn's disease resulting in an approximate ratio of 7:1,. This report add 15 more cases of IUC and two more cases of Crohn's disease managed during the 5-year period since 1991. These data provide more evidence that both diseases are increasingly recognized. Ulcerative colitis involved more commonly males (65%). This pattern is similar to the previous study from Riyadh but unlike wester experience and that from Iran. The age range is 688 with a mean of 38 years. The disease most commonly involved the age group 20-49 (72.5%), similar to that reported from Iran and from Turkey  where only 11.3% were under 20 years and 19.1% above the age of 50. Only 35% of our patients (32 out of 91) were under 30 years of age compared to a figure of 54% (20 out of 37 patients) reported from Riyadh. Diarrhea, abdominal pain and hematochesia were the commonest symptoms among patients with ulcerative colitis. These were also the leading presenting symptoms of patients from the area,. Ulcerative colitis as seen here is generally of low grade. In a previous study on IUC 72% had either grade I or II, but still lower than a figure of 91% reported by both studies from Kuwait and Iran and a 92% figure from Riyadh. In our patients the disease was less extensive, with a low stage (Stage I and II) occurring in 91% of cases, comparable to 89.7% from Turkey, 86% from Kuwait and 73% from Riyadh. This shows that ulcerative colitis in middle eastern population is a generally less extensive disease and of mild to moderate severity as was reported from other developing countries,. This is further supported by the fact that only one of our patients (1.3%) developed colonic dysplasia to justify surgical intervention. Crohn's disease exists with much lower frequency in comparison to IUC in a ratio of 1:7. This contrasts to a ratio of 5.3:1 from Kuwait. The disease affects a younger age group with a median age of 23 years compared to 38 years in IUC. Abdominal pain, colicky in nature associated with weight loss, commonly without diarrhea, constituted a significant feature of the disease occurring in all patients. Abdominal pain was noted in 93% of patients from Kuwait, and in all 7 patients of the Riyadh study. Weight loss, a notable feature of our cases, similarly was a feature in all 7 patients of the latter study. The disease involved both small and large bowel in most patients and perianal disease was relatively frequent, occurring in 3 patients (21%), compared to a figure of 7.7% from KuwaiO but lower than a figure of 36% from Western experience. Identification of granuloma occurred in 9 patients (64%), nearly similar to reported frequency from the west and relatively more than that reported from Kuwait (4 out of 14; 29%). In the presence of granuloma, differentiation of Crohn's disease from GI tuberculosis was a major problem. The belief that Crohn's disease is rare in this area has led to initiation of antituberculous therapy in four of our patients without a therapeutic response. However all four patients therafter responded dramatically to steroids and one of them had right hemicolectomy as a definitive treatment. Similarly two of the 14 patients from Kuwait were initially treated as tuberculosis and later proved to have Crohn's disease. Nevertheless still today, where mucosal granuloma is a feature, considering the clinical data, tuberculosis has to be excluded and a therapeutic trial may be justified. Adenomas are seen in only 35 (2.2%) patients. The value of biopsy in confirming the diagnosis, excluding nonneoplastic polyps cannot be overstressed. Adenocarcinoma was encountered in 91 (5.7%) patients, mostly Saudi male. The majority of tumors (78%) were on the left colon and rectum. In conclusion, although "normal mucosa" and "nonspecific proctocolitis" are the most common diagnoses, CIBD exists in Saudi Arabia and physicians should be aware of this fact to guard against delay in diagnosis and development of complications. However as most endoscoped patients turned to have insignificant pathology, the cost-effectiveness of lower GI endoscopy should carefully be evaluated. It appears that the now more frequent encounter of CIBD in developing countries parallels the exponential growth in development and industrialization, tendency to a more Western type of dietary habits and exposure to more psychological stress in addition to increased awareness of the disease and improvement in diagnostic modalities. The value of histological examination of mucosal biopsy in establishing the features of chronicity makes it a cornerstone in the diagnosis of C1131). Its role in the segregation of adenomatous polyps and confirmation of cancer cannot be overemphasised.
| References|| |
|1.||Mohamed AE, Al Karawi MA, Hanid MA, Yawawy I. Lower gastrointestinal tract pathology in Saudis: Results of endoscopic biopsy findings in 1,600 patients. Ann Saudi Med 1987;7:306-11. |
|2.||Satti MB, Al Quorain A, Al Gindan Y, Al Hamdan A. Chronic idiopathic ulcerative colitis in Saudi Arabia: a clinicopathologic study of 76 cases. Ann Saudi Med 1996;16:637-40. |
|3.||Al Gindan Y, Satti MB, Al Quorain A, Al Hamdan A. Crohn's disease in Saudi Arabia: a clinicopathologic study of 12 cases. Saudi J Gastroenterol 1996;2:150-5. |
|4.||Salem SN. Non-specific ulcerative colitis in Bedouin Arabs. The Lancet 1967;1:473-5. |
|5.||Gilat T, Lilos P, Zemishlany Z, Ribak J, Benaroya Y. Ulcerative colitis in the Jewish population of Tel-Aviv Yafo III: Clinical course. Gastroenterology 1976;70:14-19. [PUBMED] |
|6.||Kusakcioglu 0, Kusakcioglu A, Oz F. Idiopathic ulcerative colitis in Istanbul. Clinical review of 204 cases. Dis Col & Rect 1979;22:350-5. |
|7.||Mir Madjlessi SH, Forouzandeh B, Ghadimi R. Ulcerative colitis in Iran: a review of 112 cases. Am J Gastroenterol 1985;11:862-6. |
|8.||Hossain J, Al Faleh FZ, Al Mofleh IA, Al Aska A, Laajam MA, Al Rashed RS. Does ulcerative colitis exist in Saudi Arabia? Analysis of thirty-seven cases. Saudi Med J 1989;10:360-2. |
|9.||Al Nakib B, Rdhakrishnan S, Jacob GS, Al Liddawi H, Al Ruwaih A. Inflammatory bowel disease in Kuwait. Am J Gastroenterol 1984;79:191-4. |
|10.||Hossain J, Al Mofleh IA, Laajam MA, Al Rashed RS, Al Faleh FZ. Crohn's disease in Arabs. Ann Saudi Med 1991;11:40-46. |
|11.||Whitehead R. Gastrointestinal and oesophageal pathology, 2nd Ed Edinburgh, 1995, Churchill Livingstone. |
|12.||Dundas SAS, Dutton J, Skipworth P. Reliability of rectal biopsy in distinguishing between chronic inflammatory bowel disease and acute self limited colitis. Histopathology 1997;31:60-66. |
|13.||Garland CF, Lilienfeld AM, Mendeloff Al, Markowitz JA, Terrell KB, Garland FC. Incidence rates of ulcerative colitis and Crohn's disease in fifteen areas of the United States. Gastroenterology 1981;81:1115-24. |
|14.||Sinclair TS, Brunt PW, Mowat NAG. Non-specific proctocolitis in north eastern Scotland: a community study. Gastroenterology 1983;85:1-11. |
|15.||Evans JG, Acheson ED. An epidemiological study of ulcerative colitis and regional enteritis in the Oxford area. Gut 1975;6:311-24. |
|16.||Chuttani HK, Nigam SP, Sama SK, Dhanda PC, Gupta PS. Ulcerative colitis in the tropics. Br Med J 1967;4:204-7. [PUBMED] [FULLTEXT]|
|17.||Aktan H, Paykoc Z, Ertan A. Ulcerative colitis in Turkey: clinical review of sixty cases. Dis Colon Rectum 1970;13:62-5. |
|18.||George B, Rankin H, Watts D. National co-operative Crohn's disease study. Extra-intestinal manifestations and perianal complications. Gastroenterology 1979;77:914-20. |
Mohamed B Satti
Professor of Pathology, P.O. Box 40029, Al Khobar 31952
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2], [Table - 3]