Ulcerative Colitis in Turkey" Clinical Review of Sixty Cases* HAMDI AKTAN,
M.D.,
ZAVER PAYKOC,
M.D.,
A T I L L A ERTAN, M . D .
From the Department of Gastroenterology, University of Ankara School of Medicine, Yiiksek Ihtisas HospilaI, d nkara, Turkey
TABLE I. Age Distribution (60 Patients)
IT IS STILL a common belief, even among T u r k i s h clinicians, that ulcerative colitis is rare in Turkey. T h i s almost certainly has been due to the lack of T u r k i s h reports in the national and foreign medical literature.i, ~1 Sixty cases collected since 1960 in the D e p a r t m e n t of Gastroenterology of the Ankara University Medical School indicate that ulcerative colitis is not so rare as has been believed. Therefore, the provision of information about the clinical picture and incidence of the disease in T u r k e y seems timely and worthwhile.
Age (years)
N m n b e r of patients
0-9 10.19
4
2O--29
11
30.39
17
40-49
11
50.59
10
60-69
5
70-79
2
three patients were from central Anatolia, 16 from the Black Sea coastal region, and nine each from eastern and western Anatolia; the remaining five patients had been born outside T u r k i s h frontiers (three in Cyprus). All patients were of the Turkish race. I n all cases, etiologic factors causing specific colitides were excluded by bacteriologic and parasitologic investigations. T h e course of the disease was followed up by repeated endoscopic examinations, and in 42 cases rectal biopsies were performed more than once. Fifty eight patients had barium-enema examinations at least once. T w o patients -were admitted at terminal stages; their conditions did not permit radiologic examination. Follow-up periods are presented in T a b l e 2. In 19 patients the entire colon, in 17 the left colon, and in 24 only the rectum and sigmoid colon were involved. Gravity of the clinical pictures was classed as mild
Clinicat Material Fifty-eight of the 60 patients presented were inpatients and two were outpatients. Because of recurrences four patients were readmitted three times and eight patients twice each. Twenty-six patients were women (43.4 per cent) and 34 were men (56.6 per cent). At first admission, the pa* tients' ages ranged from 17 to 77 years with an average of 42.7 years. In 17 patients the disease had its onset after 50 years of age. Age distribution by decades is presented in T a b l e 1. Seven patients were living in villages at the time of the onset of ulcerative colitis and until they sought medical advice at our Department; 53 patients were city dwe~lers, witia var:.'ous occapations. Twenty* Received for publication J u n e 13, 1969. R e p r i n t requests should be addressxxl to Dr. H a m d i Aktan, Ytiksek Ihtisas Hospital, Ankara, Turkey.
62 Dis. Col. & Rect. J-am-Feb. 1970
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ULCERATIVE COLITIS IN TURKEY
in 26 cases (43.3 per c e n t ) , m e d i u m in 22 (36.6 per cent), and severe in 12 (20.0 per cent). A l t h o u g h in some cases the follow-up period was too short for an exact assessment, the clinical courses of our patients are tabulated in T a b l e 3. I m p o r t a n t symptoms of the patients in o u r series are listed in T a b l e 4. I n 15 of the 60 cases (25.0 per cent) the radiologic appearance of the colon was normal. I n 42 (70.0 per cent) the haustral markings had disappeared. I n 13 (21.6 per cent) ulcers were present. I n 12 (20.0 per cent) the colon had a lead-pipe appearance; in 12 (20.0 per cent) it had a saw-tooth appearance. I n seven (11.6 per cent) polyposis was found. I n three (5.0 per cent) the l u m e n was a b n o r m a l l y narrow. Complications are listed in T a b l e 5. Of I8 patients with p seudopolyposis, one had a mild clinical course, while eight h a d m o d e r a t e and nine had severe courses. T h e time from onset of symptoms to appearance of pseudopolyposis was less than a year in five cases, and more than two years in the rest (more than five years in five). N o cancer was detected a m o n g 25 patients who had h a d the disease for at least two years (three more than ten years). I n addition to conventional medical treatment of patients in w h o m the disease was of mild or m o d e r a t e intensity, 14 patients u n d e r w e n t surgical procedures. T h e need for surgical treatment was deter-
TABLE2. Follow-up Periods (60 Patients) Follow-up (years)
Number of patients
< 1 I-2 2-3 34 4-5 >5
33~ 2 8 5 3 9
~" Eleven p a t i e n t s died soon after a d m i s s i o n and are i n c l u d e d in the less-than-one-year group.
6~
"I'AlU,lC3. Classification According to Clinical Course (60 Patients) Clinical course Cases w i t h relapses a nd remissions Cases w i t h m i l d relapses Cases w i t h m e d i u m a n d / o r severe relapses
Patients Number Per cent
32
53.3
13
21.6
C hroni c c o n t i n u o u s cases
9
15.0
Acute f u h n i n a t i n g cases
6
I0.0
TABLE4. Distribution of Symptoms (60 Patients) Symptoms
Number of patients
Mucus and blood in stools
60
A1)dominal pa i n
57
~Veigh t loss
56
Anemia
47
Fever
39
T e n e s m us
33
m i n e d by i n a d e q u a t e or unsuccessful response to medical therapy o r . severe complications. I n eight patients total colectomy or a sphincter-saving type of subtotal colectomy was performed; two of them were in g o o d condition a n d apparently cured at the time oL writing, more than two years after the operations. T h e rem a i n i n g six patients died in the immediate postoperative period. T h e clinical pictures and histories in o u r cases were definite e n o u g h to identify the disease as ulcerative colitis, as opposed to bacillary or amebic dysenteries, It is noteworthy that some of o u r patients were living in regions where dysentery is common, and the local doctors have acquired the h a b i t of using antiamebic or anti-infective medicines empiricaEy in t,eating such conditions, tndeed, in 16 of o u r cases (26.6 per cent) emetine h a d been given before the correct diagnosis could be established in o u r d e p a r t m e n t .
A K T A N , ET AL.
64 TABLE 5.
Complications (60 Patients) N u m b e r of patients
Complications Hemorrhoids
22
Pseudopolyposis
18
Hepatic involvement
12
Massive bleeding
I0
Stenosis of the rectum or colon
6
Arthritis
5
Renal involvement
3
Perforation of the colon
2
Anal fissure
2
Per cent
$6.6 30.0 20.0 16.6 I0.0 8.3 5.o 3.~ 3.3
Acute toxic dilatation of the colon
1
1.5
Erythema nodosum
1
1.6
Iridocyclitis
1
1.,6
Pyoderma gangrenosum
1
1.fi
Comment As is the case in m a n y o t h e r countries, ulcerative colitis is not a reportable disease in T u r k e y , and therefore it is not possible to determine the countrywide incidence. I n o u r series, the incidence of the disease in inpatients was 11.0 per 10,000 patients. Ulcerative colitis was disclosed by 1.05 per cent of 5,71l rectosigmoidoscopic examinations. However, o u r cases represent a highly selected group, i n a s m u c h as the D e p a r t m e n t of Gastroenterology governs the admission policy of the hospital. Probably this is the reason o u r incidence is higher than those reported for other countries.3.6, 7 Most cases have their onset in the third a n d f o u r t h decades of life in w o m e n a n d in the fourth a n d fifth decades in men. At the time of onset of symptoms, o u r youngest patient was I5 years old a n d o u r oldest, 78 years oId. Patients in w h o m the onset occurred at or after the age of 50 years comprise 98.3 per cent of o u r series. T h u s , a l t h o u g h the average life expectancy is
Dis. CoI. & Reet. Jam-Feb. 1970
shorter in T u r k e y than in m a n y western countries, T u r k i s h people are generally older when they develop ulcerative colitis. A l t h o u g h o u r hospital facilities are shared equally by rural a n d u r b a n patients, there were only seven villagers in our uIcerative colitis series, s u p p o r t i n g the impression of others that ulcerative colitis is more c o m m o n a m o n g city dwellers, z, 1_, Unlike o t h e r p u b l i s h e d series, s. 9, 11 o u r 60 cases i n c l u d e d no instance in which the colitis was limited to the right colon and terminal ileum. As it is k n o w n that this particular localization of the disease manifests as fever a n d general s y m p t o m s rather than a clinical picture of dysentery, it is conceivable that these cases m i g h t not have been referred to us. O n the o t h e r hand, cases in which the p a t h o l o g y is confined to the anterior wall of the rectum, w i t h o u t general s y m p t o m s or evidence of progression h i g h e r in tile colon, are not rare a m o n g o u r patients. T h i s type of localization is not u n a n i m o u s l y accepted as being indicative of ulcerative colitis exclusively, so patients w h o h a d it have not been i n c l u d e d in the series. Most of o u r patients have been reluctant to undergo surgical treatment. Of the 14 patients for w h o m total colectomy was d e e m e d advisable, six refused colostomy on religious and esthetic grounds. C o n t i n u o u s soiling of the surface of the body is considered i m p r o p e r and creates deep concern a m o n g the Moslem believers with regard to the rules of cleanliness required for religious practice. Summary I n this p a p e r a series of 60 cases oE ulcerative colitis seen since 1960 at the D e p a r t m e n t of G a s t r o e n t e r o l o g y of the University of A n k a r a School of Medicine is p r e s e n t e d . S y m p t o m a t o l o g y , clinical courses and complications of the disease in this T u r k i s h series are discussed.
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ULCERATIVE COLITIS IN TURKEY
References 1. Acheson, E. D.: Epidemiology of ulcerative colitis and regional enteritis. I n Badenoch, J., and B. R. Brooke (editors): Recent Advances in Gastroenterology. London, Churchill Ltd., 1965, pp. 202-226. 2. Acheson, E. I)., and M. D. Nefzger: Ulcerative colitis in the United States Army in 1944. Epidemiology: Comparison between patients and controls. Gastroenterology 44:7, 1963. 3. Almy, T. P., and A. G. Plaut: Ulcerative colitis: A report of progress, based upon the recent literature. Gastroenterology 49: 295, 1965. 4. Avery Jones, F.: Some observations on idiopathic procto-colitis. Gastroenterologia 93: 107, 1960. 5. Bockus, H. L., J. L. A. Roth, E. Buchman, M. Kalser, \V. R. Staub, A. Finkelstein, and A. Valdes-Dapena: Life history of non-specific ulcerative colitis: Relation of prognosis to anatomical and clinical wn'ieties. Gastroenterologia 86: 549, 1956.
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6. Carleson, R., B. Fristedt, and J. Philipson: Ulcerative colitis; a follow-up investigatima of a 20-year primary material. Acta Med. Scand. 172: 647, 1962. 7. Chojecki, Z.: Quoted by Almy, T. P., and A. G. Plaut.S 8. Edwards, F. C., and S. C. Truelovc: The course aml prognosis of ulcerative colitis. Gut 4: 299, 1963. 9. Evans, J. G., and E. D. Acheson: An epidemiological study of ulcerative colitis and regional enteritis in the Oxford area. Gut 6:311, 1965. 10. Farmer, R. G., and C. H. Brown: Ulcerative proctitis: Course and prognosis. Gastreenterology 5 h 219. 1966. 11. Roth, J. L. A.: Ulcerative colitis. In Bockus, H. L. (editor) : (;astroenterology. Ed. 2. Philadelphia. W. B. Saunders Company, 1964, vol. 2, pp. 816-892. 12. }gigley, R. D.. and B. P. MacLaurin: A study of ulcerative colitis in New Zealand, showing a low incidence in Maoris. Brit. Med. J. 2: 228, 1962.
Memoirs VaUCHaN', GEORCE DE,XNIS, R i c h m o n d , Virginia; b o r n July 21, 1919, R i c h m o n d , Virginia; Medical College of Virginia 1939; i n t e r n s h i p C ~ O Hospital, t-Iuntington: residency T e m p l e University Hospital, P h i l a d e l p h i a ; served with the U.S. Navy in W o r l d W a r II. Dr. V a u g h a n was elected to menfl)ership in the A m e r i c a n Proctologic Society in 1948 a n d was elevated to Fellowship in 1961. He was a d i p l o m a t e of/ the A m e r i c a n B o a r d of C o l o n a n d Rectal S u r g e r y Fellow of the A m e r i c a n College of/Surgeous, a n d m e m b e r of the A m e r i c a n Medical Association, S o u t h e r n Medical Association, Medical Society of Virginia, R i c h m o n d Academy of Medicine, a n d past p r e s i d e n t of/ the P i e d m o n t P r o c t o l o g i c Society. He was on the staff of R i c h m o n d M e m o r i a l a n d R e t r e a t for the Sick Hospitals; Assistant Clinical Professor of Surgery, Medical College of/ Virginia. Dr. V a u g h a n d i e d S e p t e m b e r 17, 1969.
BUTTER, JOHN ROBINSON', St. Petersburg, Florida; b o r n J a n u a r y 9, 1917, M i n n e apolis, M i n n e s o t a ; University of/ M i n n e s o t a Medical School 1941; i n t e r n s h i p W a y n e C o u n t y (Michigan) G e n e r a l H o s p i t a l ; served w i t h U.S. A r m e d Forces in "World W a r ~I. Dr. B u t t e r j o i n e d the A m e r i c a n Proctologic Society in 1931 a n d was elected to Associate Fellowship in !956. He was a Fellow of the A m e r i c a n College of Surgeons. a n d a m e m b e r of the A m e r i c a n Medical Association, Florida Medical Association, P i n e l l a C o u n t y Medical Society, S o u t h e r n Medical Association, a n d Florida Proctologic Society; oi1 the staff at M o u n d Park, St. A n t h o n y ' s a n d Palms of P a s a d e n a Hospitals. Dr. B u t t e r died S e p t e m b e r 5, 1969.