A descriptive study of inflammatory bowel disease in eastern regions of Libya: A based survey of Benghazi's hospitals

Asma Elsanussi Mohamed Abdelsalam; Salem Ishtewi Abdalla

doi:10.4103/LJMS.LJMS_73_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 2 | Page : 72-75

A descriptive study of inflammatory bowel disease in eastern regions of Libya: A based survey of Benghazi's hospitals

Asma Elsanussi Mohamed Abdelsalam¹, Salem Ishtewi Abdalla²
¹ Department of Internal Medicine, Faculty of Medicine, University of Benghazi, Aljumhouria Hospital, Benghazi, Libya
² Department of Medicine, Faculty of Medicine, University of Benghazi, Benghazi Medical Center (Gastroenterology Unit), Benghazi, Libya

Date of Submission	29-Dec-2019
Date of Acceptance	26-Mar-2020
Date of Web Publication	22-May-2020

Correspondence Address:
Dr. Asma Elsanussi Mohamed Abdelsalam
Department of Internal Medicine, Aljumhouria Hospital, P. O. Box 17501, Benghazi
Libya

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_73_19

Abstract

Aim: The aim of this study was to determine the prevalence and the clinical characteristics of inflammatory bowel disease (IBD) in the eastern region of Libya. Patients and Methods: This cross-sectional and retrospective study was conducted in the gastroenterology clinic of the Internal Medicine Department of Aljumhouria Hospital and Benghazi Medical Center, which serves patients from Benghazi city as well as patients from most eastern regions of Libya. Data were obtained by searching in medical records of patients in whom the diagnosis of ulcerative colitis (UC) or Crohn's disease (CD) was confirmed by clinical, laboratory, endoscopic, histological, and radiological criteria over the period from 2000 to 2011. This descriptive epidemiologic study included the demographic and clinical characteristics of IBD patients. Results: A total of 243 patients were included in this study: 143 (59%) patients were diagnosed with UC and the other 100 (41%) patients had CD. The estimated prevalence of IBD in the Benghazi area, depending on these data, would at least be 24.3/100,000 population, which is much higher than the previously estimated prevalence (1.2–3.6/100,000 population). The mean age was 37.32 years, and the median was 37 years. Young adults were the most common, and the female-to-male ratio was 1.6:1 in CD and slightly lower in UC. The majority of patients had a mild form of the disease, whereas one-third had a moderate-to-severe illness. Abdominal pain and diarrhea were the most common presenting symptoms. Extraintestinal manifestation (most commonly arthralgia and backache) was seen in 135 patients (55.7%). Conclusion: The results of this study were similar to previous studies regarding demographic characteristics and disease patterns. Nevertheless, the prevalence of IBD has increased compared to previous national figures.

Keywords: Benghazi hospitals, Crohn's disease, epidemiology of inflammatory bowel disease in eastern Libya's hospitals, inflammatory bowel disease, ulcerative colitis

How to cite this article:
Mohamed Abdelsalam AE, Abdalla SI. A descriptive study of inflammatory bowel disease in eastern regions of Libya: A based survey of Benghazi's hospitals. Libyan J Med Sci 2020;4:72-5

How to cite this URL:
Mohamed Abdelsalam AE, Abdalla SI. A descriptive study of inflammatory bowel disease in eastern regions of Libya: A based survey of Benghazi's hospitals. Libyan J Med Sci [serial online] 2020 [cited 2023 Mar 30];4:72-5. Available from: https://www.ljmsonline.com/text.asp?2020/4/2/72/284694

Introduction

Ulcerative colitis (UC) and Crohn's disease (CD) are incurable chronic diseases of the intestinal tract. The two diseases are often grouped as inflammatory bowel disease (IBD) because of their similar symptoms, and they are characterized by remitting and relapsing course.^[1],[2] UC is a chronic, recurrent disease characterized by diffuse mucosal inflammation that exclusively affects the colon. The CD, on the other hand, is a chronic, recurrent disease characterized by segmental transmural inflammation, which may affect any part of the gastrointestinal tract from the mouth to the anus.^[3] There is an overlap between these two conditions in their clinical features, histological and radiological abnormalities. IBD affects people of all age groups but usually begins before the age of 30 years, with a peak incidence from the age of 14 to 24 years. The disease may have a second smaller peak between the age of 50 years and 70 years. The incidence is slightly higher in females than in males.^[4] The exact etiology of IBD is mostly unknown, but in general, IBD occurs as a result of the interaction between different factors, including environmental, genetic, and immunologic factors.^[5]

The prevalence and incidence of IBD have historically been higher in developed countries. There are hundreds of articles describing the incidence of CD and UC in many regions of the world.^[6],[7] The incidence rates started to increment in the late 1930s in the United States and the 1950s in North and Western Europe.^[8],[9],[10] Recently evaluated data from 167 studies in Europe in the period between 1930 and 2008 show that the highest reported prevalence values for IBD were in Western Europe.^[11] IBD affects as many as 4 million people worldwide. However, both the incidence and prevalence rates of IBD are still low in South America, Asia, and Africa compared with Europe and North America; they are rapidly increasing.^{[8],[12],[13]} Yet, studies from other countries in the Middle East show conflicting results.^{[14],[15],[16],[17],[18],[19]} Limited data are available from Libya. Unfortunately, just a few epidemiological studies were found, one of which was a hospital-based descriptive retrospective study conducted in 2006 about IBD in children in eastern Libya. This study showed that the prevalence of IBD was 3.6/100,000 population, and the incidence rate was 0.9/100,000 population during the period (1997–2006).^[20] Another retrospective study was conducted in the western regions of Libya during the period (1991 to 2010) found 319 patients have IBD.^[21] Moreover, there is a lack of data on IBD prevalence in southern parts of Libya; this is attributed mainly to the lack of a national registry system as well as an epidemiological survey system for IBD cases.

The present study aimed to determine the prevalence and the clinical characteristics of IBD (UC and CD) in the eastern region of Libya.

Patients and Methods

This hospital-based cross-sectional and retrospective study was carried out on patients with IBD who were attending gastroenterology clinics at Benghazi Medical Center and Aljamhouria Hospital in the period from the year (2000 to 2011). According to the ethical responsibility, the office of the research management in the Libyan board of medical specialties reviewed and approved the present study. The gastroenterologist consultants thoroughly examined all medical records of patients with IBD. Patients came from different eastern Libyan cities, but the vast majority of patients were from Benghazi city. All new and previously diagnosed IBD patients attending gastroenterology clinics were included. Inclusion criteria included symptoms suggestive of IBD plus one of the following: endoscopic and histological diagnosis of IBD, radiological diagnosis of IBD, and operative findings and histology suggestive of IBD during laparotomy or laparoscopy. Patients younger than 16 years; patients presenting with infective colitis, diverticulitis, and ischemic colitis; and those with controversial endoscopic or histological findings such as nonspecific colitis were excluded from the study.

The diagnosis of IBD was based on clinical, radiological, and endoscopic criteria with histological confirmation. All registered IBD patients had documented complete medical notes and regular follow-up with regular complete blood picture, erythrocyte sedimentation rate, C-reactive protein, and stool routine examination. Patients were subjected to upper gastrointestinal endoscopy, assessment, and surveillance colonoscopy. The Barium studies and computed tomography scan were also performed as needed. Clinical information was collected regarding demographic characteristics, age at presentation, gender, nationality, clinical presentation, history of admission, family history of IBD, history of smoking, disease characteristics, and extraintestinal manifestations. The information on location and extension of IBD was established according to the corresponding criteria. For cases of UC, information about disease location and extension were assessed according to colonoscope findings, histological and radiological studies. The Truelove and Witts Severity Index was used to evaluate the severity of the of UC. In addition to the Montreal classification, which was used to assess the extent of UC ;the classification as proctitis (limited to rectum), distal colitis (limited to the rectum and sigmoid colon), left sided colitis (colitis extending distal to splenic flexure), and extensive colitis or pancolitis (extending proximal to the splenic flexure).^[22] The extent of CD, was determined by endoscopic and radiological methods and was classified as upper gastrointestinal, small bowel, and both large and small bowel disease.^[22] The disease severity of CD cases was assessed using the Crohn's Disease Activity Index. Extraintestinal manifestations considered in this study were included arthralgia, backache, red eyes, and oral ulcers.

Statistical analysis

The present epidemiologic study was conducted as an observational study of a cohort of IBD patients. Collected data were presented using proportion and percentage and mean ± standard deviation when possible. The relative prevalence rates of UC and CD were calculated using the total number of residents in the two hospitals' catchment areas. The prevalence rates for different studied characteristics of UC and CD were calculated, and the rates were expressed as the number of patients per 243 patients.

Results

Epidemiology and clinical features

There were 243 confirmed cases of IBD: 143 UC patients and 100 CD patients; 104 IBD patients (43%) were male and 139 (57%) were female. Age at diagnosis varies from 11 to 60 years. The mean age was 37.32 years, and the median was 37 years. The most common age group involved is 31–40 years (82 patients, 33.7%), and the lowest age group affected was 11–20 years (10 patients, 4.1%).

A total of 119 (49%) patients were admitted to the hospital at least once during their course of illness; 124 (50.1%) patients did not have the history of admission. Abdominal pain was a significant symptom seen in 181 patients (74.6%), while bloody diarrhea was observed in 132 patients (54.4%), and nonbloody diarrhea was found in 74 (30.5%) patients. Rectal bleeding and weight loss were observed in 36 (14.8%) patients and 45 (18.5%) patients, respectively. Less common presenting symptoms were anemia in 16 patients (6.6%) and perianal fistula in 21 patients (8.65%).

Endoscopic and histological findings

Two hundred and twelve patients (87.3%) were diagnosed by colonoscopy and histopathology, 29 patients (11.95%) were diagnosed during surgery as incidental diagnosis, and only 2 patients (0.82%) were diagnosed by barium study. A total of 143 patients (59%) had histological features of UC, namely neutrophil infiltration, crypt abscesses, and goblet cell depletion. Fifty-seven of them were male and 86 were female. Three patients (2.1%) with UC had features of dysplasia; all three of these patients were females. One hundred patients (41%) showed histological features of the CD; these include chronic inflammatory cell infiltrates and lymphoid hyperplasia. Some CD patients had noncaseating epithelioid cell granuloma.

Location (site) of involvement

In UC, the rectum and rectosigmoid area were considered the most common involved sites in 93.7% of patients (134 patients). The descending colon was involved in 69 patients (48.25%), while the transverse colon in 32 patients (22.38%). The ascending colon was involved in 17 patients (11.89%).

In CD, the small intestine was involved in 57 (57%) patients with CD and the large intestine alone was affected by 6 CD patients (6%). Both small and large bowels were involved in 37 patients (37%).

Extension of colitis

Seventy-two UC patients (50.35%) had proctitis/proctosigmoiditis at the time of diagnosis. Another 39 patients (27.3%) had left-sided colitis, and 32 patients (22.35%) had extensive colitis involving colonic mucosa proximal to the splenic flexure (pancolitis).

Severity of disease

One hundred and twenty-nine IBD patients (53.1%) had mild disease, 64 patients (26.4%) had moderate disease, and 50 patients (20.5%) had severe disease. The majority of UC patients had mild colitis (90 patients), whereas only 36 CD patients had mild disease. On the other hand, more patients with severe disease were found in CD (30 patients), and only 20 UC patients had severe disease, while the number of moderate patients of UC and CD was very close with a slight increase of CD patients (34 patients).

Extraintestinal manifestations of IBD were seen in 135 patients (55.6%). Sixty-five patients (26.78%) had arthralgia, 44 patients (18.1%) had a backache, 14 patients (5.8%) had oral ulcers, and 12 patients (4.9%) had red eye.

Discussion

IBD was thought to be infrequent in Libya. However, there have been unofficial reports over 3 years (1998–2000) about the presence of 75 cases with IBD in Benghazi hospitals, which showed that a significant number of cases have diagnosed with IBD (unpublished data). In addition to the study which had conducted at Tripoli hospital (1991–2010)^[21]; therefore, it is evident that IBD not as uncommon as previously thought in Libya. However, it is considered low as compared to Western developed countries.

Over the study period, 243 cases of IBD (143 patients had UC and 100 patients had CD) were diagnosed. Most of the patients were from Benghazi city and neighboring areas. Since these data were collected from the two largest hospitals in the target area during the study period given that the catchment area of more than one million population, the estimated prevalence of IBD is going to be at least 24.3/100,000 population. If we considered that many patients attend another smaller hospital and some private clinics, the prevalence of IBD would be higher than this. This figure is much higher than the previously quoted figures in the previous reports and also the study conducted in 2006 in a Benghazi hospital.^[20] The increased prevalence could be explained either by the actual increase in disease prevalence, possibly due to Westernized lifestyle, or by increased awareness of the disease by health professionals and increased use of advanced diagnostic tools such as video-assisted endoscopy and capsule endoscopy. Estimating true prevalence is vital for future health planning and medication supplement in the community. IBD mostly involves active young people in their productive age and hence can lead to significant effects on a country's economy and affect the quality of life in these patients.^[23] In the present study, 20% of patients had a severe disease that needs more attention and possible admission. Therefore, these patients consume the most diagnostic resources and the more expensive medications.^[24],[25]

The results of this study were in resemble previous studies from most Western countries and other Arab countries.^{[6],[10],[12],[13],[14],[15],[16],[17],[18],[19]} The clinical characteristics of IBD were similar compared to the last survey performed in Tripoli hospitals from 1991 to 2010,^[21] the prevalence of UC was more than CD, and there were more female IBD patients in this cohort. The clinical picture observed in the present series is almost like the one widely described in the literature from Western countries and the MENA region. Most of the patients were diagnosed by endoscopy, and most of the patients had a mild form of the disease. Furthermore, dysplasia was only found in UC patients, all of which were similar to the last studies in Asia, the MENA region, and Western countries.^{[6],[10],[12],[13],[14],[15],[16],[17],[18],[19]} The prevalence of small bowel disease for CD patients was high in the present study, similar to studies that had conducted in Iran, Kuwait, and Lebanon.^{[15],[17],[19]}

Conclusion

The results of this study were similar to previous reviews regarding the demographic characteristics and disease pattern. Nonetheless, the prevalence of IBD has increased compared to previous national figures. This increase could be due to the introduction of more advanced diagnostic tools. More epidemiological population-based studies are needed to determine the prevalence of IBD in the Libyan population accurately.

Acknowledgments

We wish to thank Dr. Adel Elmestieri and Dr. Sahar Abdelmoatei for their contributions to data collection. We also acknowledge the involvement of all the staff of gastroenterology units at Aljamhouria Hospital and Benghazi Medical Center, Benghazi, Libya.

Financial support and sponsorship

This work was self-funded by the authors, and external funding was not received.

Conflicts of interest

There are no conflicts of interest.

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