Environmental risk factors and Crohn's disease: a population-based, case-control study in Spain.

BACKGROUND: The pathogenesis of inflammatory bowel disease probably involves an interaction between genetic and environmental factors: cigarette smoking, appendectomy and oral contraceptives have been the factors most frequently linked to its aetiology AIM: To analyse the association between known environmental risk factors and development of Crohn's disease in the community of Aragón, Spain. PATIENTS AND METHODS: A case-control, population-based study has been carried out. All patients diagnosed with Crohn's disease in the community of Aragón from 1st February 1992 to 31st January 1995 were prospectively included. The Lennard Jones criteria were used to define the cases and selected controls among the healthy population matched with patients for age, sex and rural/urban habitat. Statistical analysis included multivariate analysis using conditional logistic regression, testing 38 different models. RESULTS: A total of 103 patients were diagnosed with Crohn's disease in Aragón from 1st February, 1992 to 31st January, 1995. Of these 62 patients (60.2%) with Crohn's disease were smokers, compared with 42 (40.8%) controls (p<0.001). Cigarette smoking is considered a risk factor for Crohn's disease with an odds ratio of 3.09 (95% confidence interval, 1.58-6.05). After multivariate analysis, the positive association is maintained. A dose-dependent relation could not be demonstrated. No statistical differences (p=0.50) were detected in the analysis of previous appendectomy. Use of oral contraceptive acts as a risk factor with a p=0.048; odds ratio 2, 8, 95% confidence interval: 1.009-7.774; but this association disappears in the multivariate analysis. Eight patients had a family history (3 first degree and 5 second degree relatives) versus none of the controls (p=0.002). Of the variables studied for childhood hygiene none appeared significant. CONCLUSION: Smoking, family history, and oral contraceptive use, appear as risk factors for developing Crohn's disease in univariate analysis, but only smoking remains significant in all models of multivariate analysis.

[Incidence of inflammatory bowel disease in Aragon: outcome of a prospective population-based study]. / Incidencia de la enfermedad inflamatoria intestinal en Aragon: resultados de un estudio prospectivo y poblacional.

OBJECTIVE: To identify every new case of ulcerative colitis (UC) (including ulcerative proctitis), Crohn's disease (CD) and indeterminate colitis (IC) in Aragon, in Spain (population: 1,189,000, area: 47,719 km2) and to compare the incidence in this region with that in the rest of Spain and Europe. PATIENTS AND METHODS: We designed a prospective, population-based study based on inception cohorts. During a 3-year predetermined period (1st February 1992-31st January 1995) we identified every new case of inflammatory bowel disease in Aragon by checking the records in all the hospitals, outpatient clinics and private practices in this region. RESULTS: The overall adjusted incidence rate per 100,000 inhabitants/year was 7.2 for UC (a figure lower than the average for Europe) and 3.9 for Crohn's disease (a rate similar to that of Southern Europe). These rates are much higher than those previously described in Spanish studies, probably due to the design and methods used as well as to a real increase in the incidence of CD in Spain. The age and sex pattern was similar to those other studies. CONCLUSIONS: The incidence rates for inflammatory bowel disease in Aragon are higher than those previously described, the incidence of UC being inferior to that of Europe. Nevertheless, the incidence of CD is similar the average for southern Europe, which suggests that there has been a recent increase in the incidence of this disease in Aragon.

[The debut of Crohn's disease as a gastrocolic fistula]. / Inicio de enfermedad de Crohn como fístula gastrocólica.

The case of a 66-year-old women admitted for the study of chronic diarrhea and an important deterioration in her general state is reported. Following the study undertaken the presence of a gastrocolic fistula was observed without clarifying the nature of the same thereby leading to surgical treatment. Anatomopathologic analysis confirmed the presence of a gastrocolic fistula in relation to Crohn's disease. The origin of these fistulas is usually neoplastic and the presentation as a complication of an inflammatory disease is very infrequent.

Effect of parenteral omeprazole and ranitidine on gastric pH and the outcome of bleeding peptic ulcer.

The pharmacotherapy of bleeding peptic ulcer is directed at attempting to keep the gastric pH above the proteolytic range for pepsin. In this randomized, prospective, open clinical trial we have compared the effects and outcome of omeprazole versus ranitidine in patients with bleeding peptic ulcer. Of 219 consecutive patients with upper gastrointestinal bleeding, 51 (23.2%) had an ulcer with endoscopic predictors of rebleeding at the time of diagnosis. These 51 patients were selected at random to receive either omeprazole (80 mg bolus and 40 mg/12 h i.v.) or ranitidine (50 mg/4 h i.v.). No endoscopic therapy was performed at the time of diagnosis. Twenty of these patients with duodenal ulcer (n = 10 omeprazole, n = 10 ranitidine) underwent 24-h gastric pH monitoring. Both groups were homogeneous in all clinical and endoscopic parameters. No differences in blood transfusion units, time of hospitalization, the lowest hematocrit measured, and mortality rates were observed between the groups. However, omeprazole reduced the number of rebleeding episodes (p = 0.1) and the need for surgery (3.8% vs. 22.7%; p = 0.05). Omeprazole also reduced the amount of time the gastric pH was < 6 (15.3 +/- 5.9% vs. 61.8 +/- 5.6%, p < 0.0001). We conclude that parenteral omeprazole is much more effective than ranitidine in keeping the gastric pH above the proteolytic range for pepsin in bleeders and that this might explain a better outcome in a subset of patients with bleeding peptic ulcers treated with parenteral omeprazole.

[Inflammatoru bowel disease in Aragón: a more and more frequent diagnosis]. / Enfermedad inflamatoria intestinal en Aragón: un diagnóstico cada vez más frecuente.

OBJECT: To study the frequency of inflammatory bowel disease in our area. MATERIAL AND METHODS: A retrospective, hospital-based analysis identifying potential cases, with a posterior study of case records following a predefined protocol, according to international standards in diagnosis. PATIENTS: All patients with a confirmed diagnosis of Crohn's disease, ulcerative colitis, or indeterminate colitis established between 1975 and 1992 at our Hospital. RESULTS: 222 cases (ulcerative colitis: 109; Crohn's disease 93; indeterminate colitis 20) were identified and a clear trend for an increased incidence was found for the three diagnoses; with annual incidence below 1 for them all in the 1975-1977 period versus 3.66; 3.33; and 1 respectively in the 1990-1992 period. This trend was evident both for ulcerative colitis and Crohn's disease. CONCLUSIONS: The global frequency of inflammatory bowel disease has increased in the last years in Zaragoza (Spain), and its incidence in now very similar to that reported in northern European countries. Possible factors associated with this phenomenon should be pursued in future studies.

[Deficiency polyneuropathy secondary to immunoproliferative disease of the small intestine]. / Polineuropatía carencial secundaria a enfermedad inmunoproliferativa de intestino delgado.

We report a new case of immunoproliferative small intestinal disease with neurological involvement expressed as deficiency polyneuropathy. In spite of non identifiable plasmatic paraprotein, the use of immunohistochemical techniques showed the characteristic proliferation in the intestinal mucosa of plasma cells with a prevalence of IgA cells, which define this disease.

[Gastric emptying of solids, acid secretion and tobacco in duodenal ulcer]. / Vaciamiento gástrico de sólidos, secreción ácida y tabaco en la úlcera duodenal.

We study in a group of patients with endoscopically diagnosed duodenal ulcer (19; 17 males) and controls (11; 7 males) the gastric emptying of solids through scintigraphy and gastric acid secretion by standard tests. In the same way we investigated prospectively some clinical data, specially smoking habits. As a whole, patients with duodenal ulcer showed an emptying of solids slightly faster than controls (T 1/2-minutes-: 85.4 +/- 28.6 in patients with duodenal ulcer versus 116.9 +/- 46.5 in controls, p less than 0.03). However, most of our patients (15 of 19 or 79%) were found to have a normal emptying rate. No correlation was found between secretory outputs and gastric emptying. Smokers with duodenal ulcer had a faster emptying that non-smokers with duodenal ulcer (T 1/2 74.8 +/- 30.05 vs. 99.91 +/- 19.86; p = 0.05).

[Gammagraphy with labeled leukocytes as an activity and extension index of Crohn disease]. / Gammagrafía con leucocitos marcados como índice de actividad y extensión de la enfermedad de Crohn.

The knowledge of the location and extent of bowel involment and disease activity can be an important aspect on the evaluation of inflammatory bowel disease. Thirty five patients of Crohn's disease (CD) have been studied in this sense. We performed a total of 44 scintigraphic examinations using 99mTc-HMPAO labeled leukocytes and the results were compared with several clinical-biological indexes and with radiology and endoscopy. The Tc scan was the most sensitive (84.3%) and specific (100%) activity index and showed an excellent correlation with radiology and/or endoscopy in the assessment of extent of disease. Leukocyte scanning brought useful information for the management of stenosis in CD.

[The epidemiological aspects of Crohn's disease in Zaragoza]. / Aspectos epidemiológicos de la enfermedad de Crohn en Zaragoza.

Crohn's disease (CD) incidence is characterized by a wide variability in different countries. In our area it hasn't developed yet any epidemiologic study about this disease. We have reviewed fifty-four new cases diagnosed in Zaragoza University Clinical Hospital (Spain) during the period 1974-1988. The most striking facts were that the incidence of Crohn's Disease increased steadily during the 15-year period studied and the existence of a statistical association between smoking and CD. Other features were similar those previously described in the literature.