|Year : 2014 | Volume
| Issue : 1 | Page : 16-19
Clinicopathological features of inflammatory bowel disease in Benin City, Nigeria
Darlington Ewaen Obaseki, Gerald Dafe Forae
Department of Pathology, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||13-Jun-2014|
Dr. Gerald Dafe Forae
Department of Pathology, University of Benin Teaching Hospital, PMB - 1111, Benin City
Source of Support: None, Conflict of Interest: None
Background: Conventionally, inflammatory bowel disease (IBD) is considered to be more common in western countries. Nevertheless, it is relatively rare in most developing countries. Aim: The purpose of this study is to determine the frequency and morphological patterns of IBD in Benin City, Nigeria, and to compare our findings with the reports from other centers. Materials and Methods: The study is a four-year analysis of 32 histologically confirmed cases of IBD, presenting at the University of Benin Teaching Hospital (UBTH) and a private specialist gastroenterology hospital, based in Benin City, Southern Nigeria. Both centers serve as referral centers to most hospitals in South-Southern Nigeria. All suspected patients were examined with rectosigmoidoscopy and colonoscopy after obtaining consent. These specimens were formalin-fixed, paraffin-embedded, sectioned at 3-5 microns, and stained with hematoxylin and eosin (H and E). Results: In this four-year study, there were a total of 78 suspected cases, of which 32 were histologically confirmed IBD cases. Among the 32 patients, 14 (43.8%) were cases of Crohn's disease (CD), while 12 (37.5%) were cases of ulcerative colitis (UC). The remaining six patients (18.7%) were with indeterminate colitis (IC). A total of 21 males and 11 females presented, giving a ratio of 1.9:1, with a mean age of 51.1 years ± 7.2 standard deviation (SD). In CD, seven cases constituting 53.9%, had ileocolonic involvement. In UC, six cases involved left-sided colitis, accounting for 50%. Conclusion: IBD was twice more common in males than females, with majority of involvement in both the colonic and ileo-colonic anatomic sites. However, there is a slight higher preponderance of CD than UC in this environment.
Keywords: Crohn′s disease, inflammatory bowel disease, ulcerative colitis
|How to cite this article:|
Obaseki DE, Forae GD. Clinicopathological features of inflammatory bowel disease in Benin City, Nigeria. Int J Adv Med Health Res 2014;1:16-9
| Introduction|| |
Inflammatory bowel disease (IBD) consisting of Crohn's disease (CD) and ulcerative colitis (UC) have generated immense interest in gastroenterology and pathology researches. This is so because of the wide geoethnical variation in its incidence globally. Conventionally, IBD is considered to be more common in western countries, precisely in North America and North and western Europe.  Yet, recent reports have shown an increase in the incidence rates in Asia, South America, and Eastern Europe, previously considered to have a low prevalence. , However, such an assertion cannot be made for Africa, including Nigeria, due to the inadequate information on IBD, as only few reports are available, mainly case reports, consisting of a handful of cases.  Nevertheless, such reports, if well figured out, can form the basis for a comprehensive national data, as well as provide first-hand information for assessing the pattern of the disease in our locale.
Globally the incidence rate of IBD, UC, and CD is 396 per 100,000, 0.5-24.5 per 100,000, and 0.1-16 per 100,000, respectively. , Although IBD affects all age groups, studies have it that two peaks in the age group have been noted. The primary peak in the age group occurs in young people of 15 to 40 years and the secondary peak is seen more commonly at 50 to 60 years. 
The main objective of this study is to observe the frequency and histological patterns of IBD in Benin City, Nigeria, and its environs and to correlate our findings with the published data of other researchers and institutions.
| Materials and Methods|| |
Study design and setting
The study was a four-year analysis of 78 suspected patients of inflammatory bowel diseases, presenting at the University of Benin Teaching Hospital (UBTH) and a private specialist gastroenterology hospital, based in Benin City, Southern Nigeria, where the samples were scrutinized for study. The UBTH, Benin City Center, serves as a referral hospital to most hospitals in Southern Nigeria. All suspected patients were examined with rectosigmoidoscopy and colonoscopy, after obtaining consent. Among these suspected cases only 32 cases were histologically confirmed to have IBD. Information regarding the age, clinical history, digital rectal examination and endoscopic findings, and clinical diagnosis, was obtained from the medical records and histopathological request cards/surgical daybooks.
Specimen sampling and laboratory procedures
These specimens were received and examined at the UBTH and Biogenics Histopathology Diagnostic Center, Benin City, Nigeria, from January 2008 to December 2012. This center is one of the only two private centers in the Benin City metropolis and Edo State offering histopathology services. All specimens were formalin-fixed, paraffin-embedded, sectioned at 3-5 microns, and stained with hematoxylin and eosin stains. The results obtained were analyzed with respect to age, clinical presentation frequency, extent of disease on endoscopy, and IBD histopathological patterns
All cases with missing haematoxylin and eosin (H and E) slides and paraffin-embedded tissue blocks, all cases with incomplete biodata of the suspected patients, and human immunodeficiency virus (HIV) patients were excluded.
The data were entered into Microsoft excel, transferred, and expressed as a percentage for categorical variables, and the mean/standard deviation for a continuous variable, using Version 16 Statistical Packaging for Social Sciences (SPSS), Chicago, Illinois, USA.
| Results|| |
In this four-year study, a total of 32 cases of inflammatory bowel disease were encountered. All the patients were Nigerians. Among the 32 patients with IBD, 14, accounting for 43.8%, were cases of CD, while 12 patients, constituting 37.5%, were cases of UC. The remaining six patients (18.7%) were IC. A total of 21 males and 11 females were seen, giving a ratio of 1.9:1 for males and females, respectively. The age range was 25-66 years, while the mean age for all IBD cases was 51.1 ± 7.2 SD years. There was no significant difference in the mean age of diagnosis in men when compared to their female counterparts for CD and UC, as seen in [Table 1]. The majority of cases of IBD, constituting 13 (40.6%), occurred between 51 and 60 years [Table 2]. This was followed by 41-50 years, accounting for eight cases (25%). Only one case (3.2%) was seen in the 21-30 year range, while no case was diagnosed below 20 years.
Clinical presentation and treatment
The clinical presenting patterns of CD included non-bloody diarrhea and fever in four cases (28.6%), while two cases (21.4%) had abdominal pain [Table 3]. The clinical presentation of UC included abdominal pain, fever, and bloody diarrhea in five (41.6%), three (25%), and two (16.7%) cases, respectively. In IC, two cases had bloody diarrhea and fever (33.3%). The time that elapsed between the onset of symptoms and diagnosis mostly ranged between three months and five years.
For CD, seven cases constituting 53.9% had ileocolonic involvement [Table 4]. This was followed by only colonic involvement, accounting for four cases (30%). For UC, six out of the 12 cases involved left-sided colitis, accounting for 50%. Three cases had pancolitis (25%), while colorectal and anorectal involvement constituted two (16.7%) and one (8.3%) case, respectively. In cases of IC, left-sided colitis accounted for four out of the six cases (66.6%), while colonic and ileocolonic involvement accounted for one case (16.7%) each. Only two of the 32 IBD patients (6.2%) had dysplasia.
|Table 4: Extent of anatomical involvement of Crohn's disease and ulcerative colitis on colonoscopy|
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The patients were treated with supportive therapy, systemic steroids, salazopyrine, 5-ASA derivatives, azathioprine, and metronidazole in combinations of various regimens.
| Discussion|| |
In the past, very few studies were available that discussed the prevalence and incidence of IBD in a non-Caucasian series. Some of these studies have shown a low incidence of IBD in Africa and other developing countries.  The reason for this low incidence in Nigeria, and indeed in Africa, is partly attributable to the dearth of adequate information. The present study comprising of 32 cases of IBD in our locale has confirmed the prevalence of this disease entity in our environment, as opposed to previous anecdotal allusions to the contrary. However, this incidence is low when compared to other gastrointestinal diseases. Nevertheless, this report and other African studies have shown a slight increase in the incidence of IBD in Africa and other developing countries against previous opinion.  The reason for this increased incidence is partly attributed to increased awareness of the disease in our environment, the utilization of modern medicine and modern endoscopic procedures, and a higher diagnostic index of suspicion. ,
In this study 32 patients were diagnosed with IBD over a four-year period, giving an average of eight cases per year. This study is the first on IBD in Benin City and has the highest number of histologically confirmed cases reported so far, in Nigeria. However, there are few recent cases reported in different parts of Nigeria, from Lagos (Senbanjo et al.), Zaria (Ukwenya et al.), and Ife (Alatise et al.), where one, four, and twelve cases, respectively, have been documented. ,, Reported cases of IBD in the west African subregion are extremely rare, as there are very few cases, thus, it is difficult to make any comparison with our neighboring countries, except the very few cases in Ghana by Nkrumah et al. and two cases of Crohn's disease in Senegal, respectively. ,
The average incidence of IBD in this study is similar to reports on the blacks of African descent living in Jamaica, where an average of 10 cases is documented yearly. , However, this is sharply in contrast to reports from North America and North-western Europe, where a very high frequency of the disease has been documented.  Nevertheless, in other parts of the world, including Asia, South America, and Eastern Europe, the frequency of IBD is on the increase, almost catching up with the western figures. This is due to improvement of endoscopic technologies, including double-ballooned endoscopy and selective enterography, impacting more specialized care to patients. In Africa, the situation is very different, as most cases still go unreported. This is largely due to the state of gastroenterology practice, the paucity of specialists (gastroenterologists and pathologists), and the high cost of endoscopic procedures in the few centers where they are available. This state of affairs forces most indigent patients to seek alternative solutions (both traditional and religious alternative care) for their gastrointestinal complaints. Besides, the few studies done in Africa are biased by shortcomings in methodology, as most of the cases are hospital-based retrospective studies, as compared to other parts of the world, where prospective population-based studies are conducted. Again other environmental and genetic factors cannot also be ruled out for the discrepancy between Africa and western world. ,
In this study, the male to female ratio of IBD is 1.9:1. This is contrary to the reports of other researchers in western countries and globally, where the male to female ratio is always almost equal, with a slight male preponderance occasionally. ,,,,, The reason for this discrepancy cannot be ascertained. Nevertheless, some minority reports from Asia and Ghana have documented a higher male to female preponderance, although not as high as our observation in Benin City, Nigeria. In our report, there is rarity of dysplasia, as only two cases had additional histological features of dysplasia. However, this observation is similar to reports by Nkrumah et al.  and other reports from south Africa, where dysplastic changes and malignant transformation are rare among Africans. 
In this study, IBD is uncommon before the first decade of life, as most of the cases here have occurred in the middle and elderly age groups. This report is in contrast to most researches, where a majority of cases occur in adolescent and young adults, between the ages of 15 and 40 years. ,, Again, in most studies, only 10% of the cases have occurred in patients greater than 60 years of age. 
Studies have shown that CD may affect any part of the gastrointestinal tract, from the anus to the mouth, with most cases presenting as skip lesions. In this study, most of the cases present as ileocolitis and colitis. This is similar to studies from other parts of the world, where a majority of the cases present as ileocolitis, colitis, and ileitis.  However, this varies from the report of Penn et al.  , where a majority of the cases involved the colon. The reason attributed to this difference is that both the environmental and dynamic nature of the lesion can involve other parts of the gut with time.
The classification of UC depends on the anatomical site of involvement. These include pancolitis, proctitis, and left-sided colitis (involving the sigmoid colon, with or without involvement of the descending colon). A minority of patients may also develop backwash ileitis. In the present study, left-sided colitis was 50%, while pancolitis was 25%. This is similar to reports of other researchers where left-sided colitis was the most commonly encountered lesion. ,, Specifically, studies done in the African-American Jamaican series have revealed 44 and 31% left-sided colitis and pancolitis, respectively. In this study the prevalence of extraintestinal manifestation was low, as only 8% presented with athralgia. This is in contrast to studies done by Torres et al.  and Kochhar et al.,  where extraintestinal involvement had been relatively high.
The relatively low incidence of IC among the IBD cases observed in these studies is similar to reports by other researchers. ,,
| Conclusion|| |
In this study, IBD was twice more common in males than females, with the majority of involvement in the ileocolonic and colonic regions. However, there is a slightly higher preponderance of CD than UC in this environment.
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[Table 1], [Table 2], [Table 3], [Table 4]