The prevalence of Crohn's disease -...
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CLINICAL GASTROENTEROLOGY The prevalence of Crohn's disease in the Israeli Kibbutz population YARON NIV, MD Y Ntv. Prevalence of Crohn's disease in the Israeli Kibbutz population. Can J Gastroenterol 1991 ;5(3 ):91-93. An ep idemiol og i ca l stud y o f Crohn' s disease was performe<l in 2 79 Israe li Kibbutzim (rural co mmunities) (populat io n 12 L,403 ). The prevalence on December 31, 1987 was 25.53 per 100,000 pop ula- tion. When the data were st ratifie<l according to ethnic group, the highest point preva lence was found in Asian/African-born Jews (41.76 per 100,000 popula- unn), greater than in Israe li-bo rn, or European/American -bo rn Kibbut z membe rs (38.92 and 17 .35 cases per 1 00,000 population, respect ively) . There were l5 women and 16 men (female co mal e ratio 0.94 ). The average age of patients was 45 years in the survey year, and 35 years at diagnosis. Termina l ileitis was found in69%, ileoco li tis in 19%, and co litis in 12%. Probable comp li cat ions ofCrohn's disea.L were observed in 10 cases (32%). Anemia was demons trated in two cases (6%). The high rate of Cro hn' s disease prevalence among Israeli- born versus European/American-born Kibbutz members may point to a role for environmen- tal factors in the etiology of the disease. Key Words: Crolm's disease, IBO, Prevalence Prevalence de la maladie de Crohn clans la population du kibboutz israelien RESUME: On a effectue une e tu<le cpidemiologique sur la maladie de Crohn Jans 279 kibbo ut zim o u fe rmes co llectives (soit une population de 121 403 personnes). Le 31 decembre 1987, la prevalence etait de 25,53 pour 100 000 habitants. Se lon les do nnees st rat ifiees d'apres les groupes ethn iques, les cas l es plus nombreux se trouvaient parmi !es] uifs d'origine africaine/asiatique ( 41, 76 pour I 00000 habitants), compares aux Israe liens d'origine ou aux membres n atifs J'Europe ou d'Amer i que (38,92 et 17 , 35 cas pour 100 000 h ab itants, respect ive- ment). II y avait 15 femmes et 16 ho mmcs (rapport de 0,94). L'age moyen des patients ecait <le 45 ans pendant l'annee de l'enque te et de 35 ans au mome nt du diagnostic. Soixante-neuf pour cent des malades souffra ie nc c.l'un e ileite ter- minale, 19 % d'une ileoco lite, et 12 % d'une co lite. On a re l eve des complicatio ns probables de la maladie d eCrohnd ans lO cas (32 % ). Deuxcas (6 %) presentaient une anemie. Le taux de prevalence el cve de la maladie de Crohn c hez !es mcmbres Jes kibbo utzim natif s d'lsrael, par rapport aux personnes originaires d'Europe et J'Amerique, la isse soup~o nn er le role de certains facteurs env ironnemencaux Jans l'etiologie c.lc la malad ie. Gastroenterology Unit, Rebecca Si eff liovemment Hospital, Safed, l. 1rael Correspondence and reprincs: Dr Y Niv, Gmtroenterology Unii, Rebecca Sieff Govemment H ospital , Saf ed. I srael Received for publicaiion Jam wry 3. 1 991. Accepced March 25. / 99 / CAN J GASTROENTEROI VOi 5 NO 3 MAY/JUNE 199 1 T l IE PREVALl:.NCE OF CRO! IN'S DIS- ease varies in <lifferen t area5 of th e world, and is repone<l to be high a mon g peoples of Eu ropean or igin. The high anc.l variable inci<lence and preva lence of Crohn's dbease in Jews can possibly be explained by an i nteracti on of ge ne - tic and enviro nmenta l factors. In all countries surveyed the prevalence is 10 to 70 cases per 100,000 population, three to eight times more common among Jews compare<l to non-Jews (1- 12). An overall increase in inci<lcnce an<l prevalence in many recent studies was shown for Crohn's J iscase (13, 15). In Israel. Crohn's disease is four times more prevalent among As hkenazi Jews than a mon g non-Ashkenazim, with a greatly increased frequency among Is- raeli Jews born in Europe or the U n ited Scates. Nevertheless, the preva l ence in the l atte r group is three to 10 times lower than among Jews living o uts id e Israel (16-20). As a high incidence and prevalence of ulcerative co litis was found in mem- bers of a Kibb ut z (an Is raeli rural com- munit y) (2 l ), a survey of all of the Kibbutzim in Israel was performed to de tennine the Crohn 's disease poi nt pre- val ence in th is particular population. PATIENTS AND METHODS A commu nity-based survey was con- ducte<l. T he ILJcal physician of every Kibbutz was a<ldressed by mail and te l ephone and his or her agreement to parti cipate in t his survey was obtai ned. A questionnaire co ncerni ng Cro hn' s 91
Transcript of The prevalence of Crohn's disease -...
CLINICAL GASTROENTEROLOGY
The prevalence of Crohn's disease in the Israeli Kibbutz population
YARON NIV, MD
Y Ntv. Prevalence of Crohn's disease in the Israeli Kibbutz population. Can J Gastroenterol 1991 ;5(3 ):91-93. An epidemio logical study of Crohn's disease was performe<l in 2 79 Israeli Kibbutzim (rural communities) (population 12 L,403 ). The prevalence on December 31, 1987 was 25.53 per 100,000 population. When the data were stratifie<l according to ethnic group, the highest point prevalence was found in Asian/African-born Jews (41.76 per 100,000 populaunn), greate r than in Israeli-born , or European/American-born Kibbutz members (38.92 and 17.35 cases per 100,000 population, respectively) . There were l 5 women and 16 men (female co male ratio 0.94 ). The average age of patients was 45 years in the survey year, and 35 years at diagnosis. Terminal ileitis was found in69%, ileocoli tis in 19%, and colitis in 12%. Probable complications ofCrohn's disea.L were observed in 10 cases (32%). Anemia was demonstrated in two cases (6%). The high rate of Crohn's disease prevalence among Israeli-born versus European/American-born Kibbutz members may point to a role for environmental factors in the etiology of the disease.
Key Words: Crolm's disease, IBO, Prevalence
Prevalence de la maladie de Crohn clans la population du kibboutz israelien
RESUME: O n a effectue une etu<le cpidemiologique sur la maladie de Crohn Jans 279 kibboutzim o u fermes collectives (soit une population de 121 403 personnes). Le 31 decembre 1987, la prevalence etait de 25,53 pour 100 000 habitants. Selon les donnees stratifiees d'apres les groupes ethniques, les cas les plus nombreux se trouvaient parmi !es] uifs d'origine africaine/asiatique ( 41, 76 pour I 00000 habitants), compares aux Israelie ns d'origine ou aux membres natifs J'Europe ou d'Amerique (38 ,92 et 17 ,35 cas pour 100 000 habitants, respectivement). II y avait 15 femmes et 16 hommcs (rapport de 0,94). L'age moyen des patients ecait <le 45 ans pendant l'annee de l'enque te e t de 35 ans au moment du diagnostic. Soixante-neuf pour cent des ma lades souffra ienc c.l'une ileite terminale, 19 % d'une ileocolite, et 12 % d'une colite. On a re l eve des complications probables de la maladie deCrohndans lO cas (32 %). Deuxcas (6 % ) presentaient une anemie. Le taux de prevalence e lcve de la maladie de Crohn chez !es mcmbres Jes kibboutzim natifs d 'lsrael, par rapport aux personnes originaires d'Europe et J'Amerique, la isse soup~onner le role de certains facteurs environnemencaux Jans l'etiologie c.lc la maladie.
Gastroenterology Unit, Rebecca Sieff liovemment Hospital, Safed, l.1rael Correspondence and reprincs: Dr Y Niv, Gmtroenterology Unii, Rebecca Sieff Govemment
Hospital , Saf ed. Israel Received for publicaiion Jam wry 3. 1991. Accepced March 25. / 99 /
CAN J GASTROENTEROI VOi 5 NO 3 MAY/JUNE 199 1
T l IE PREVALl:.NCE OF CRO! IN'S DIS
ease varies in <lifferent area5 of the world, and is repone<l to be high among peoples of European origin. The high anc.l variable inci<lence and prevalence of Crohn's dbease in Jews can possibly be explained by an interaction of genetic and environmental factors. In all countries surveyed the prevalence is 10 to 70 cases per 100,000 populat ion, three to eight t imes more common among Jews compare<l to non-Jews (1-12). An overall increase in inci<lcnce an<l prevalence in many recent studies was shown for Crohn's J iscase (13, 15).
In Israel. Crohn's d isease is four times more prevalent among Ashkenazi Jews than among non-Ashkenazim, with a greatly increased frequency among Israeli Jews born in Europe or the U n ited Scates. Nevertheless, the prevalence in t he latter group is three to 10 times lower than among Jews living outside Israel ( 16-20) .
As a high incidence and prevalence of ulce rative colitis was found in members of a Kibbutz (an Israeli rural community) (2 l ), a survey of a ll of the Kibbutzim in Israel was performed to detennine the Crohn's disease point prevalence in this particular population.
PATIENTS AND METHODS A community-based survey was con
ducte<l. T he ILJcal physician of every Kibbutz was a<ldressed by mail and telephone and his or her agreement to participate in this survey was obtained. A questionnaire concerning Crohn's
91
NIV
TABLE 1 Point prevalence of Crohn's disease in the Kibbutz population of Israel (1987)
Population Crohn's disease Prevalence base coses (coses/100,000 population)
Sex Men 60.400 Women 61.003
Origin Israel 30.831 Asia/ Africa 7,184 Europe/ America 74.938 Unknown 8.450
Total 121.403
TABLE 2 Clinical data
Number of patients 31 Age (years)
Average 45 Range 11 to 76
Disease duration (years) Average 10 Range l to 29
Extent of inflammatory process (coses) Terminal Ileitis 11 Colitis 2 lleocolitls 3 Unknown 15
Diagnosis during surgery 2
TABLE 3 Complica,1ons and associated syndromes (cases)
Anemia (hemoglobin < 10 g/dl) 2 Socroileitis l Ankylosing spondylitis l Pyodermo gongrenosum 1 Rectovag1nal fistula l lleocecol fistula l Anal fistula l Anal abscess l Stomotitls aphtoza l Duodenal ulcer l Hyperthyroidism l
TABLE 4 Treatment of Crohn's disease (cases)
Medical Systemic steroids 10 Solazopyrine 7 Metronldozole 4 Azathioprine 2 Systemic steroids + salazopyrine 3 Systemic steroids+ metronidazole l Systemic steroids + azothioprine l Salazopyrlne + metronldazole 2 No medical therapy 1
Surgical Partial resection of terminal Ileum 2 Appendectomy 2 Thyroldectomy l Vagotomy and pyloroplosty l Gastric partitioning 1
16 2649 15 24.59
12 38.92 3 41.76
13 17.35 3 35.50
31 25.53
J1sease patients was then sent to the physic ian, including informaLiun on sex, age, origin, place of diagnosis ,md folll1w-up, cxlelH of tbe inl1ammatory process, dinical speLrrum, therapy, complicmions of Lhe d isease and t reatment. Ninety-nine per cent of the addressed physicians cooperated with rhe author and completed and returned the 4uestionnaire. lnformaLion on the population was obtained from the Kibbutz clinic, since all Kibbutz members are insured for medical purposes by the same company. December 31, 1987 was des ignated as the point prevalence dace. When calculat ing prevalence rates, t he emire population of the Kibbutzim was considered at rn,k; denominator data on ethnic groups were derived from Kibbutz clmic records. A ll patients diagnosed as suffe ring from Crohn's di ease and who were residents of the Kibbutz on December 3 1, 1987 were included in determination of prevalence. Only cases with a defin ite diagnosis of Cnihn 's disease made in a recogmzed hospital gastroenterology un it were accepted into the study. The data were collected and investigated by the author, and when incomplete, the fami ly physician was again contacted. The data were studie<l carefully to ensure that no patient with Crohn's disease represented a duplicate case.
RESULTS General demographic d ata: The total populauon of 279 Kibbutz im on the prevalence Jay was 121,403 Jewish residents. St ratification by place of birth was Europe/America 62%, Israel 25%, and Asia/Africa 6% (Table l ).
P revalence: Thin y-s1x Crohn 's diseasl.' panenrs were residents of t he Kibbutzim on the pre\'alence day. Patients whod1J not fulfil I res1Je1ll y criteria ( three rem porary residents) and those whose d1ag noses we re not conf I rmcd in ,1 gastroenternlogy cl inic (two cases) were excluded.
Thus, 31 cases were 111cluded in thl.' sruJy (Tahlc l ). There were 15 wnn1l'n and 16 men (femn le to male rat1n 0.94 ). The prevalence was 2 5. 5 3 per l 00,000 populauon. The pre\'aleille m men wa, slightly higher than that in women. A breakdown of prevalenle races by eth nic group is given in Tahlc I. Thi.' highest prevalenu· was demonstratl.'J in Asian/Alrican-hmn Kibhu tz mem hers and, in decreasing order, 111 hracl1 born and European/American-born Kibbutz members. C linical da ta: The average nge of
patients in the year of th is survey wr1s 45 years, and at Lhe ume of diagnosis 35 years (Table 2). Terminal ileitis wa, found in 69%, ilcocolitis in 19%, and colitb in 12%. Probable complicatiom of Crohn's disease were observed in 10 cases (32%) (Tahle 3). Anemia wa1 demonstrated 111 two cases (6%) Therapy is described in Table 4. Com· pl ication.s or side effects of therapy were not demonstrated.
DISCUSSION Roth et al ( 22) suggested that
American Jewish patients with mflam matory bowel d isease represented ,I
nonrandom genetically predisposed subset of the Jewish popu lation. Thc1· founJ a sigmficant excess nf patient~ of midd le European origin relative to chose of Poli~h or Russian origm. The genetic influence 1s not supponed by Fireman ct al ( I 3 ), who founJ a decrease in d ifference between prevalence of original migrant group, in bracli Jews of central lsmcl. The prevalence in European/Amcricanbom Jews increa~ed from 13.27 to
26.05 cases per 100,000 population, and 111 Asian/African-born Israeli Jew, from 1.69 to 12.37 cases per 100,000 populat1on from 1970 to 1980 ( l.96, fold versus 7 .32-fold, respectively). Thu~. the increase of Crohn's Ji ea~e prevalence m A~ian/Afncan-hom II-
92 CAN J GASTROFNTEROI Vm 5 No 3 MJ\Y/jUNF 1991
raeli Jews was almost four times that in European/American-born Israe li Jews. Asian/American-bo rn Kibbutz mem bers had a higher point prevalence of Crohn's disease than the others, and the prevalence ra te in Israeli -born members exceedeJ that in European/ American-born memhers. However, most of the Jsrae li-bom Kibbutz memhers were of European/American origin, either first or second generation in Israel. Thus, it is no t clear whether environmental factors play a more im portant role than genet ic factors. S ince the peak incidence of Cro hn's disease occurs in the second and third decades of life, and European/American- and Asian/African-horn groups may be older than Israeli -born patients, these results become even more significant.
The present survey is a communi tybased study, and includes most of the patients with proven Crohn's Jisease in
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2. Evans JG, Acheson ED. An epidemiological ~tudy of ulcerative colitis and regional enteritis in the Oxford area. Gut 1965;6: 111 -24.
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a given population. As the level of medical care in the Kibbu tz is somewhat above average Israeli family medicine, and as every Kibbutz has its own clinic, the author believes that a lmost every C rohn's disease case could be t raced. People with known Crohn's disease canno t become members of a Kibbutz, since the criteria for accepting new members are very strict , and inc lude 'perfect health'. The high prevalence noted in this study may relate also to the very steady Kibbutz population allowing inclusion of some cases with delayed diagnoses. Some cases may possibly have been added in a colorecral screening program of fecal nccult blood testing, as secondary prevention of cancer is very popular in the Kibbutzim. Mayberry et al (23 ) found two cases of Crohn's disease out o f 481 patients screened via feca l occult blood test .
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CAN j GASTROENTEROL VOL 5 No 3 MAY/JUNE 199 l
Crohn's in Israeli Kibbutzim
Only two patients (6.5%) required surgery in a mean follow-up of lO years. This percen tage b very low anJ may demonstrate the conservative therapeut ic ,lpproach towards Crohn '~ disease in Israe l.
T he author could nm find any cases of cancer after an average J isease duration of IO years. Thb fi nd ing is in agreement with another braeli populat ion-based survey, which found only one case of Gmcer m 365 cases of Crohn's disease (24 ).
T he author suggests that the in
crease in Crohn's disease prevalence in Isrne li -born Jewish Kibbutz members provides some support for environmental factors playing a role in disease expression. Ethnic groups merging into a homogeneous people become similar in their food and life patterns, and the epidemio logical characteristics of Crohn's disease may change accordingly.
18. Gilm T, Grossman A, Fireman Z, Rozcn P. Inflammatory bowel disca,c in Jews. Front G.1strnintcst Res 1986; 11: I ,5-40.
19. Grossman A, Fireman Z, Lilos P, I lacohcn D, Gilat T. Epidemiology of IBD in central bract 1970- 1980. h raeli Gastrrn:nterological Association, l lerzlia 1987. (Ahst )
20. Donaldson RM Jr. Crohn's dbcasc. In: Slcisrnger Ml I, Fordtran JS, eds. Gastrointest inal Diseases, 4th edn. Phi ladclplm: WB Saunders, 1989: 1327.
21. Niv Y, Ahuksis G. The prevalence of ulcerative colit is in the Israel i Kibbu tz popu lation. J Clin Gastrocnrcrol. (In press)
22. Roth MP, Petersen GM, McElrcc C, Fe ldman E, Rmtcr JI. Geographic origins of Jewish patients with inflammatory bowel disease. Gastrocnterology 1989;97 :900-4.
23 . Mayberry J F, Ballanryne KC, Hardcastle JD, Mangham C, Pye G. Epidemiological study of asympromatic inflammatory howel disease: The identi fication of cases during a screening programme for colorectal cancer. Gut 1989; 30:481 -3.
24. Fireman Z, Gross1m111 A, Lilos P, ct al. Intestinal cancer in patients with Crohn's Jisease. A population study in central Israel. Scand J G::tstroenterol I 989;24:346-50.
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