Epidemiology and outcome of Crohn's disease in a teaching hospital in Riyadh

AIM: To know the epidemiology and outcome of Crohn's disease at King Khalid University Hospital, Riyadh, Saudi Arabia and to compare the results from other world institutions.METHODS: A retrospective analysis of patients seen for 20 years (between 1983 and 2002). Individual case records were reviewed with regard to history, clinical, findings from colonoscopy, biopsies, small bowel enema, computerized tomography scan, treatment and outcome.RESULTS: Seventy-seven patients with Crohn's disease were revisited, 13% presented the disease in the first 10 years and 87% over the last 10 years. Thirty-three patients (42.9%) were males and 44 (57.1%) were females. Age ranged from 11-70 years (mean of 25.3+11.3 years). Ninety-two (92%) were Saudi. The mean duration of symptoms was 26+34.7 mo. The mean annual incidence of the disease over the first 10 years was 0.32:100 000 and 1.66:100 000 over the last 10 years with a total mean annual incidence of 0.94:100 000 over the last 20 years. The chief clinical features included abdominal pain, diarrhea, weight loss,anorexia, rectal bleeding and palpable mass. Colonoscopic findings were abnormal in 58 patients (76%) showing mostly ulcerations and inflammation of the colon. Eighty nine percent of patients showed nonspecific inflammation with chronic inflammatory cells and half of these patients revealed the presence of granulomas and granulations on bowel biopsies. Similarly, 69 (89%) of small bowel enema results revealed ulcerations (49%), narrowing of the bowel lumen (42%), mucosal thickening (35%) and cobblestone appearance (35%). CT scan showed abnormality in 68 (88%) of patients with features of thickened loops (66%) and lymphadenopathy (37%). Seventy-eight percent of patients had small and large bowel disease, 16% had small bowel involvement and only 6% had colitis alone. Of the total 55 (71%) patients treated with steroids at some point in their disease history, a satisfactory response to therapy was seen in 28 patients (51%) while 27 (49%) showed recurrences of the condition with mild to moderate symptoms of abdominal pain and diarrhea most of which were due to poor compliance to medication. Seven patients (33%) remained with active Crohn's disease. Nine (12%) patients underwent surgery with resections of some parts of bowel, 2 (2.5%) had steroid side effects, 6 (8%) with perianal Crohn's disease and five (6.5%) with fistulae.CONCLUSION: The epidemiological characteristics of Crohn's disease among Saudi patients are comparable to those reported from other parts of the world. However the incidence of Crohn's disease in our hospital increased over the last 10 years. The anatomic distribution of the disease is different from other world institutions with less isolated colonic affection.

Biochemical and radiological predictors of malignant biliary strictures

AIM: Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures.METHODS: We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology,biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS.RESULTS: One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 μmol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically.CONCLUSION: A serum bilirubin level of 84 μmol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.