Epidemiology and Natural History of Inflammatory Bowel Diseases

In the West, the incidence and prevalence of inflammatory bowel diseases has increased in the past 50 years, up to 8–14/100,000 and 120–200/100,000 persons, respectively, for ulcerative colitis (UC) and 6–15/100,000 and 50–200/100,000 persons, respectively, for Crohn's disease (CD). Studies of migrant populations and populations of developing countries demonstrated a recent, slow increase in the incidence of UC, whereas that of CD remained low, but CD incidence eventually increased to the level of UC. CD and UC are incurable; they begin in young adulthood and continue throughout life. The anatomic evolution of CD has been determined from studies of postoperative recurrence; CD begins with aphtous ulcers that develop into strictures or fistulas. Lesions usually arise in a single digestive segment; this site tends to be stable over time. Strictures and fistulas are more frequent in patients with ileal disease, whereas Crohn's colitis remains uncomplicated for many years. Among patients with CD, intestinal surgery is required for as many as 80% and a permanent stoma required in more than 10%. In patients with UC, the lesions usually remain superficial and extend proximally; colectomy is required for 10%–30% of patients. Prognosis is difficult to determine. The mortality of patients with UC is not greater than that of the population, but patients with CD have greater mortality than the population. It has been proposed that only aggressive therapeutic approaches, based on treatment of early recurrent lesions in asymptomatic individuals, have a significant impact on progression of these chronic diseases. In the West, the incidence and prevalence of inflammatory bowel diseases has increased in the past 50 years, up to 8–14/100,000 and 120–200/100,000 persons, respectively, for ulcerative colitis (UC) and 6–15/100,000 and 50–200/100,000 persons, respectively, for Crohn's disease (CD). Studies of migrant populations and populations of developing countries demonstrated a recent, slow increase in the incidence of UC, whereas that of CD remained low, but CD incidence eventually increased to the level of UC. CD and UC are incurable; they begin in young adulthood and continue throughout life. The anatomic evolution of CD has been determined from studies of postoperative recurrence; CD begins with aphtous ulcers that develop into strictures or fistulas. Lesions usually arise in a single digestive segment; this site tends to be stable over time. Strictures and fistulas are more frequent in patients with ileal disease, whereas Crohn's colitis remains uncomplicated for many years. Among patients with CD, intestinal surgery is required for as many as 80% and a permanent stoma required in more than 10%. In patients with UC, the lesions usually remain superficial and extend proximally; colectomy is required for 10%–30% of patients. Prognosis is difficult to determine. The mortality of patients with UC is not greater than that of the population, but patients with CD have greater mortality than the population. It has been proposed that only aggressive therapeutic approaches, based on treatment of early recurrent lesions in asymptomatic individuals, have a significant impact on progression of these chronic diseases. View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Inflammatory bowel disease (IBD) includes Crohn's disease (CD) and ulcerative colitis (UC), chronic diseases that generally begin in young adulthood and last throughout life. Although progress has been made in understanding these diseases, their etiology is unknown. Their incidence is increasing worldwide, and the diseases remain incurable. IBD places a heavy burden on populations because it reduces quality of life and capacity for work and increases disability. The prevalence of IBD is more than 200 cases per 100,000 inhabitants in the West, and IBD has a major impact on health care resources. Most data on epidemiology and the natural history of IBD have been taken from population-based studies performed in Scandinavia and in Olmsted County, Minnesota, during the years 1950–1970; data have been collected and maintained using remarkable systems. Disease progression and prognosis greatly changed radically with the discoveries of steroid therapies in the 1950s, immunosuppressants in the 1970s, and more recently, biologics. Although these treatments do not have severe complications and improve quality of life, it is not clear whether they are able to modify the long-term course of the diseases. The highest incidences of CD and UC have been reported in northern Europe,1Vind I. Riis L. Jess T. et al.Increasing incidences of inflammatory bowel disease and decreasing surgery rates in Copenhagen City and County, 2003-2005: a population-based study from the Danish Crohn colitis database.Am J Gastroenterol. 2006; 101: 1274-1282Crossref PubMed Scopus (197) Google Scholar the United Kingdom,2Yapp T.R. Stenson R. Thomas G.A. et al.Crohn's disease incidence in Cardiff from 1930: an update for 1991-1995.Eur J Gastroenterol Hepatol. 2000; 12: 907-911Crossref PubMed Google Scholar, 3Rubin G.P. Hungin A.P. Kelly P.J. et al.Inflammatory bowel disease: epidemiology and management in an English general practice population.Aliment Pharmacol Ther. 2000; 14: 1553-1559Crossref PubMed Scopus (152) Google Scholar and North America.4Loftus C.G. Loftus Jr, E.V. Harmsen W.S. et al.Update on the incidence and prevalence of Crohn's disease and ulcerative colitis in Olmsted County, Minnesota, 1940-2000.Inflamm Bowel Dis. 2007; 13: 254-261Crossref PubMed Scopus (225) Google Scholar, 5Bernstein C.N. Wajda A. Svenson L.W. et al.The epidemiology of inflammatory bowel disease in Canada: a population-based study.Am J Gastroenterol. 2006; 101: 1559-1568Crossref PubMed Scopus (192) Google Scholar In those regions, such high incidences may indicate common etiologic factors. The incidence of UC is greater than that of CD, except in Canada5Bernstein C.N. Wajda A. Svenson L.W. et al.The epidemiology of inflammatory bowel disease in Canada: a population-based study.Am J Gastroenterol. 2006; 101: 1559-1568Crossref PubMed Scopus (192) Google Scholar, 6Pinchbeck B.R. Kirdeikis J. Thomson A.B. Inflammatory bowel disease in northern Alberta An epidemiologic study.J Clin Gastroenterol. 1988; 10: 505-515Crossref PubMed Google Scholar, 7Bernstein C.N. Blanchard J.F. Rawsthorne P. et al.Epidemiology of Crohn's disease and ulcerative colitis in a central Canadian province: a population-based study.Am J Epidemiol. 1999; 149: 916-924Crossref PubMed Google Scholar and several areas of Europe,8Gunesh S. Thomas G.A. Williams G.T. et al.The incidence of Crohn's disease in Cardiff over the last 75 years: an update for 1996–2005.Aliment Pharmacol Ther. 2008; 27: 211-219Crossref PubMed Scopus (26) Google Scholar, 9Molinie F. Gower-Rousseau C. Yzet T. et al.Opposite evolution in incidence of Crohn's disease and ulcerative colitis in Northern France (1988-1999).Gut. 2004; 53: 843-848Crossref PubMed Scopus (114) Google Scholar, 10Latour P. Louis E. Belaiche J. Incidence of inflammatory bowel disease in the area of Liege: a 3 years prospective study (1993-1996).Acta Gastroenterol Belg. 1998; 61: 410-413PubMed Google Scholar, 11Ott C. Obermeier F. Thieler S. et al.The incidence of inflammatory bowel disease in a rural region of Southern Germany: a prospective population-based study.Eur J Gastroenterol Hepatol. 2008; 20: 917-923Crossref PubMed Scopus (25) Google Scholar although this has been changing over the past 20 years. Canterbury County, New Zealand, has among the highest incidence of CD (16.5/100,000 people)12Gearry R.B. Richardson A. Frampton C.M. et al.High incidence of Crohn's disease in Canterbury, New Zealand: results of an epidemiologic study.Inflamm Bowel Dis. 2006; 12: 936-943Crossref PubMed Scopus (112) Google Scholar; IBD has emerged in countries in which it had rarely been previously reported, including South Korea, China, India, Iran, Lebanon, Thailand, the French West Indies, and North Africa.13Yang S.K. Hong W.S. Min Y.I. et al.Incidence and prevalence of ulcerative colitis in the Songpa-Kangdong District, Seoul, Korea, 1986-1997.J Gastroenterol Hepatol. 2000; 15: 1037-1042Crossref PubMed Scopus (77) Google Scholar, 14Sood A. Midha V. Sood N. et al.Incidence and prevalence of ulcerative colitis in Punjab, North India.Gut. 2003; 52: 1587-1590Crossref PubMed Scopus (83) Google Scholar, 15Edouard A. Paillaud M. Merle S. et al.Incidence of inflammatory bowel disease in the French West Indies (1997-1999).Gastroenterol Clin Biol. 2005; 29: 779-783Crossref PubMed Google Scholar In these countries, the occurrence of UC preceded that of CD by about 10 years. In some countries, such as Japan, the incidence of IBD was initially low but has recently increased.16Thia K.T. Loftus Jr, E.V. Sandborn W.J. et al.An update on the epidemiology of inflammatory bowel disease in Asia.Am J Gastroenterol. 2008; 103: 3167-3182Crossref PubMed Scopus (121) Google Scholar The overall incidence of IBD can be broken down into several geographic zones: those with a high incidence, those with a moderate incidence, those with low incidence 15 years ago but where incidence has constantly increased, and those with unknown incidence (Figure 1) (Table 1, Table 2).Table 1Incidence and Prevalence of CDCountryDates of studies (references)Incidence (/105)Prevalence (/105)Japan197499Ishikawa M. Watanabe H. Yamagishi G. et al.Crohn's disease, non-specific ulcers of the small intestine, and idiopathic proctocolitis in a Japanese university hospital from 1954 to 1974.Tohoku J Exp Med. 1976; 118: 97-109Crossref PubMed Google Scholar0.085.81991100Morita N. Toki S. 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