| Part1 The epidemiological characteristics of inflammatory bowel disease in Yunnan province:a population-based studyObjective:To investigate the clinical epidemiological characteristics of the inflammatory bowel disease (IBD) including ulcerative colitis (UC) and crohn’s disease (CD) in Yunnan province so as to guide the clinical diagnosis and treatment of IBD.Methods:Our research group has screened the cases of IBD before January 1,1998. The study population was the permanent residents lived in Yunnan province. From January 1,1998 to December 31,2013, all newly diagnosed IBD patients were collected, which were divided into three groups:IBD group, UC group and CD group. The respective prevalence, incidence, general information, clinical characteristics, treatment and prognosis were collected and made a statistical analysis.Results:1. The crude incidence and prevalence of UC and CD has markedly increased during the last 16 years in Yunnan province. The respective crude prevalence rate of IBD, UC and CD was 0.246 per 100 000 inhabitants,0.241 per 100 000 inhabitants and 0.005 per 100 000 inhabitants in 1998. However, in 2013, it increased to 7.453 per 100 000 inhabitants,7.035 per 100 000 inhabitants and 0.418 per 100 000 inhabitants respectively. Similarly, the crude incidence rate of IBD, UC and CD in Yunnan province was 0.068 per 100 000 inhabitants,0.068 per 100 000 inhabitants and 0 per 100 000 inhabitants in 1998. While that increased to 1.152 per 100 000 inhabitants,1.075 per 100 000 inhabitants and 0.077 per 100 000 inhabitants in 2013.2. Different regions had different prevalence. There are 16 prefectures in Yunnan province. Among those, in 2013, the highest crude prevalence of IBD was 14.086 per 100 000 inhabitants in Yuxi prefecture, followed by Honghe Prefecture and Kunming (crude prevalence 14.006 per 100 000 inhabitants,11.932 per 100 000 inhabitants). The highest crude prevalence of UC was 13.505 per 100 000 inhabitants in Honghe prefecture, followed by Yuxi Prefecture and Kunming (crude prevalence 13.367 per 100 000 inhabitants,11.157 per 100 000 inhabitants). The highest crude prevalence of CD was 0.775 per 100 000 inhabitants in Kunming, followed by Yuxi, Qujing Prefecture and Honghe prefecture (crude prevalence 0.719 per 100 000 inhabitants,0.502 per 100 000 inhabitants and 0.501 per 100 000 inhabitants).3. In Yunnan province, differences were observed in the crude prevalence rate for IBD, UC and CD among nationalities. In 2013, the crude prevalence of the ethnic minorities for IBD, UC and CD in Yunnan province was lower than the Han nationality. In the Han nationality, that were 9.463 per 100 000 inhabitants,8.918 per 100 000 inhabitants and 0.545 per 100 000 inhabitants in 2013 and in the ethnic minorities, that were 3.444 per 100 000 inhabitants,3.278 per 100 000 inhabitants and 0.166 per 100 000. Among the 18 nationalities, The Han nationality has the highest crude prevalence rate of IBD and UC (9.463 per 100 000 inhabitants and 8.918 per 100 000 inhabitants), followed by the Hui patients (8.563 per 100 000 inhabitants,7.720 per 100 000 inhabitants), Man patients (7.092 per 100 000 inhabitants,7.092 per 100 000 inhabitants) and Bai patients (5.271 per 100 000 inhabitants,5.083 per 100 000 inhabitants). CD patients were only recorded in 9 nationalities. The Tibetan has the highest crude prevalence rate (1.376 per 100000 inhabitants), followed by the Hui and Han nationality (0.842 per 100 000 inhabitants,0.545 per 100 000 inhabitants).4. From January 1,1998 to December 31,2013, all the 3 419IBD patients, including 3 225 UC patients and 194 CD patients were collected in Yunnan province. UC patients were significantly more than CD patients,16.82 compared to 1. IBD, UC and CD patients characterized by male gender predominance (male:female ratio 1.23:1,1.21:land 1.49:1 respectively). There were no differences among the genders (P=0.182). The age at onset for UC and CD were 46.61±15.03 years and 38.77±17.04 years respectively. Patients with CD were more likely to be younger (P<0.01). The peak age of UC and CD onset was around 40 to 49 years and at 30 to 39 years. There were no the second smaller peak obviously. Patients of A2 were significantly more than Al and A3 (55.67% of A2, P<0.05), based on the Montreal Classification.5. In UC patients, there were more office workers (35.44%,143/3225), more mental workers (43.75%,1411/3225), urban dwellers (49.30%,1590/3225) and more cases with middle school education (38.39%,1238/3225). While CD patients were more common in peasants (39.69%,77/194), manual workers (52.58%, 102/194), urban dwellers (36.60%,71/194) and with more elementary education (36.60%,71/194). At diagnosis, there were 19.44%smokers in UC, and 24.74% in CD. The number of smokers in UC is lower than in CD (P=0.030).6. A family history was present in 0.40%(13/3225) UC patients. While absent in CD.7. More UC and CD cases were less than 5 years. Presenting complaints of the majority of UC patients were diarrhea (93.61%,3019/3225), mucous diarrhea (91.44%,2949/3225) and bloody stools (84.34%,2720/3225) and that for CD were abdominal pain (96.39%,187/194), diarrhea (58.25%,113/194) and bloody stools (40.21%,78/194). Systemic symptoms were more in CD (P<0.01). CD patients were more likely to be with low hemoglobin levels, increased PLT levels, fast blood sedimentation and decreased albumin than UC patients (P<0.01).8. Of UC patients,49.00%(1580/3225) had left-sided colitis (E2). The largest group of CD patients (50.52%,98/194) had disease in the small bowel and colon (L3). There was no patient affected upper gastrointestinal disease alone. The disease was nonstricturing, nonpenetrating (B1) in 50.52% (98/194), with concomitant perianal disease (P) in 1.55% (3/194). More patients had active IBD at diagnosis. And more were moderate.9. Extraintestinal manifestations of CD were more common than UC (P=0.001). Approximately 8.99% of UC patients (290 in 3225 UC patients) had extraintestinal manifestations of disease, such as arthritis/arthralgia (117,3.63%), skin disorders (46,1.43%), eye disorders (45,1.40%), hepatobiliary diseases (42, 1.30%) and oral ulcers (35,1.09%). A total of 16.49% of CD patients (32 in 194 CD patients) had one of major extraintestinal diseases. Oral ulcers (12,6.19%) was more frequent (P<0.01), followed by arthritis/arthralgia (6,3.09%) and skin disorders (6,3.09%).1.55% and 1.03% CD patients had hepatobiliary diseases and eye disorders respectively. In UC patients,4.09% of patients had complications (132/3225), including severe bleeding (53,1.64%), intestinal obstruction (45,1.40%), carcinoma of colon (14,0.43%), toxic megacolon (9, 0.28%). Complications were more frequent in CD compared to UC (P<0.001), which occurred in 24.23% (47/194) CD patients, had a high rate of intestinal obstruction (29/194,14.95%) and followed by anal fistula (7/194,3.61%) and intestinal perforation (6/194,3.09%).10. In UC and CD patients, Medication was the main treatment. There were more CD patients required for intestinal surgery (CD to UC:0.90% to 42.00%, P<0.001). The most commonly prescribed medications were aminosalicylic acid in UC and CD (74.71%,1988/2661; 85.18%,138/162). Medication treatment was more effective in UC patients than in CD patients.During the follow-up period, most of IBD patients had good prognosis. Nine UC patients (0.28%) and three CD patients (1.55%) died, there was more likely to have higher mortality in CD (P=0.023).Conclusions:1. The crude prevalence and incidence of IBD, UC, and CD in Yunnan province increased noticeably during the last 16 years, which showed lower than that reported from other developed regions in China, and were far lower than the West. UC patients were significantly more than CD patients.2. Differences were observed in the crude prevalence of IBD, UC, and CD among regions and nationalities in Yunnan province. For 16 prefectures, the highest crude prevalence of IBD was that in Yuxi prefecture, followed by Honghe prefecture and Kunming. The highest of UC was that in Honghe prefecture, followed by Yuxi Prefecture and Kunming. The highest of CD was that in Kunming, followed by Yuxi, Qujing and Honghe prefecture. In 2013, the crude prevalence of the ethnic minorities for IBD, UC and CD in Yunnan province were lower than the Han nationality. Among the 18 nationalities, the Han nationality has the highest crude prevalence rate of IBD and UC, followed by the Hui patients, Man patients and Bai patients. CD patients were only recorded in 9 nationalities. The Tibetan has the highest crude prevalence rate, followed by the Hui and Han nationality.3. Patients with UC and CD in Yunnan province had their own characteristics. On the whole, the clinical course of which were less aggressive with less extraintestinal manifestations and complications compared to developed countries and those were consistent with other Asian countries.Part 2 Environmental factors in inflammatory bowel disease in Yunnan province:a nested case-control studyObjective:To examine environmental risk and protective factors prior to patients developing IBD (including UC and CD) in Yunnan province in a nested case-control study, which would help early prevention from this disease.Methods:A nested case-control study was conducted. The cohort population for UC was the permanent residents lived in Kunming and Qujing Prefecture in Yunnan province ruling out the confirmed cases before January 1,2008. Similarly, the cohort population for CD was the permanent residents lived in Yunnan province excluding the patients with CD before January 1,2008. Regular follow-up was carried out for each cohort and the newly diagnosed cases (including UC and CD cases) were recruited from January 1,2008 to December 31,2013. Controls, respectively, who were drawned from the same population and geography, matched sex and age with 1:4 case-control and were likely to be representative of the general population. Environmental factors were completed by using questionnaire at diagnosis. The questionnaire consisted of nearly 40 items. Some questions were based on relevant domestic and foreign epidemiologic studies. Exposure rates to environmental factors were compared with odds ratios (OR) with 95% confidence intervals (CI).Results:1.15 items were found to be related to UC. Of those, having allergies (OR 4.489; 95%CI 3.078 to 6.545), had intestinal infectious disease (OR 1.766; 95%CI 1.262 to 2.471) and using antibiotics frequently (OR 2.231; 95%CI 1.352 to 3.680) before the age of 14 years, taking non-steroidal anti-inflammatory drugs other than aspirin less than 1 month before diagnosis (OR 2.893; 95%CI 1.609 to 5.202), brain work (OR 1.823; 95%CI 1.307 to 2.544), occupational stress (OR 1.732; 95% CI 1.141 to 2.628), dining not on time more than 3 times a week (OR 2.087; 95% CI 1.394 to 3.127), eating fried foods (OR 1.900; 95%CI 1.223 to 2.952), salted foods (OR 1.665; 95%CI 1.076 to 2.576) or foods stored in the refrigerators (OR 1.868; 95%CI 1.290 to 2.704) more than 3 times a week were associated with increased risk of UC. While smoking (OR 0.679; 95%CI 0.485 to 0.951), regular physical activity 1 to 2 times a week (OR 0.555; 95%CI 0.391 to 0.788) and more than 3 times a week (OR 0.452; 95%CI 0.309 to 0.660), drinking tea (OR 0.367; 95%CI 0.275 to 0.488), eating sweets (OR 0.697; 95%CI 0.494 to 0.982) and eating fruits 1 to 2 times a week (OR 0.475; 95%CI 0.282 to 0.801), especially consumption of fruits more than 3 times a week (OR 0.445; 95%CI 0.274 to 0.723) were protective for the development of UC in Yunnan Province.2. There were only 3 environmental factors associated with CD. Appendectomy before diagnosis (OR 2.848; 95%CI 1.444 to 4.217) and dining not on time more than 3 times a week (OR 1.876; 95%CI 1.807 to 3.236) increased the risk of CD. Regular physical activity 1 to 2 times a week (OR 0.0.350; 95%CI 0.131 to 0.937) and more than 3 times a week (OR 0.505; 95%CI 0.217 to 1.090) were associated with reducing development of CD.Conclusions:1. Our results indicated the environmental factors had been identified as the indispensable part in the development of IBD. UC may be more susceptible to the environmental factors compared to CD.2. We reported for the first time in a nested case-control study in Yunnan province. UC and CD shared only two the same environmental factors. Regular physical activity was a protective factor, while dining not on time acted as the risk factor in UC and CD. Some dietary habits, life style, occupational factors and childhood factors may play important roles in IBD, especially in UC. Such as having allergies, having intestinal infectious disease and using antibiotics frequently before the age of 14 years, eating fried foods and so on may increase the risk of UC. While drinking tea may decrease the risk of UC. Appendectomy before diagnosis may be an independent risk factor of CD.Part 3 Relapse factors in inflammatory bowel disease in Yunnan province:a prospective case-control studyObjective:We aimed to investigate whether diet, lifestyle habits and clinical features had relationship to clinical relapse in inflammatory bowel disease(IBD, including UC and CD), which would help guide treatment and prevent relapse.Methods:A prospective case-control study was performed with UC patients in remission stage from Kunming and Qujing Prefecture in Yunnan province and CD patients in Yunnan province diagnosed between January 1,2008 and December 31, 2013. Participants should meet some conditions such as age between 14-80 years, inactive stage consistently more than 1 month, diagnosed by non-surgical method and so on. Cases were followed up for 1 year or for a shorter period if they had a relapse.Related datas were collected about diet, lifestyle habits and clinical features. During the follow-up period,459 UC participants including 310 relapsed and 102 non-relapsed and 99 CD participants containing 68 relapsed and 31 non-relapsed were analyzed using logistic regression analysis.Results:1. The factors associated with a high risk of relapse in UC were occupational stress (OR 2.322; 95%CI 1.186 to 4.546), The presence of severe disease at diagnosis (OR 2.621; 95%CI 1.020 to 6.737), the initial requirement for steroid use (OR 3.171; 95%CI 1.605 to 6.265). While the female (OR 0.387; 95%CI 0.227 to 0.659), a history of appendectomy (OR 0.225; 95%CI 0.082 to 0.617), maintenance therapy in remission (OR 0.444; 95%CI 0.261 to 0.755), older age (OR 0.946; 95%CI 0.925 to 0.968), higher levels of albumin at diagnosis (OR 0.923; 95%CI 0.880 to 0.969) and smoking before the end of the follow-up (OR 0.521; 95%CI 0.278 to 0.975) were independent predictive factors decreasing the relapse of UC. Other items in relapse and non-relapse cases like different dietary habits were not significant predictors.2. Multivariate logistic regression analysis retained that blood in stools was significant a predictor of relapse (OR 4.094; 95%CI 1.324 to 12.660), older age at diagnosis was protective for the recurrence of CD (OR 0.956; 95%CI 0.932 to 0.990). The initial requirement for steroid use (OR 2.890; 95%CI 1.032 to 8. 093) were significant predictors of relapse in CD.Conclusions:1. Of all the factors, older age at diagnosis was associated with a decreased risk of relapse in patients with UC and CD. The initial requirement for steroid use was the common independent risk factor related to relapse.2. Occupational stress, the presence of severe disease at diagnosis may associate with increased risk of relapse in UC. Blood in stools was significant a predictor of relapse in CD. While the female, smoking, a history of appendectomy, maintenance therapy in remission stage, higher levels of albumin acted as protective factors related to relapse of UC. |
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