Mortality and causes of death in patients with inflammatory bowel disease: A nationwide register study in Finland

Background and aimIncreased mortality has been reported in Crohn's disease (CD) but mostly not in ulcerative colitis (UC). We evaluated the overall and cause-specific mortality in a nationwide cohort of patients with inflammatory bowel disease (IBD) in Finland.MethodsA total of 21,964 patients with IBD (16,649 with UC and 5315 with CD) from the Special Reimbursement register were diagnosed 1987–1993 and 2000–2007 and followed up to the end of 2010 by collating these figures with the national computerized Cause-of-Death Register of Statistics Finland. In each cause-of-death category, the number of deaths reported was compared to that expected in general population, and expressed as a standardized mortality ratio (SMR).ResultsOverall mortality was increased among patients with CD (SMR 1.33, 95% confidence interval 1.21–1.46) and UC (1.10, 1.05–1.15). SMR was significantly increased for gastrointestinal causes in CD (6.53, 4.91–8.52) and UC (2.81, 2.32–3.34). Patients with UC were found also to have increased SMR from pulmonary (1.24, 1.02–1.46) and cardiovascular disease (1.14, 1.06–1.22) and cancers of the colon (1.90, 1.38–2.55), rectum (1.79, 1.14–2.69) and biliary tract (5.65, 3.54–8.54), whereas SMR from alcohol-related deaths was decreased (0.54, 0.39–0.71). Patients with CD had a significantly increased SMR for pulmonary diseases (2.01, 1.39–2.80), infections (4.27, 2.13–7.63) and cancers of the biliary tract (4.51, 1.23–11.5) and lymphoid and hematopoietic tissue (2.95, 1.85–4.45).ConclusionsIn this Finnish nationwide study increased overall mortality in both CD and UC was observed. The excess mortality of 14 % in IBD is mainly due to deaths related to inflammation in the gut.     

Inflammatory bowel disease is not a risk factor for cardiovascular disease mortality: results from a systematic review and meta-analysis

OBJECTIVES: Inflammation in general, and C-reactive protein (CRP) in particular, are closely associated with atherosclerosis. Similarly, the risk of cardiovascular (CV) disease is increased in several systemic inflammatory diseases. The purpose of this study was to examine whether inflammatory bowel disease (IBD) increases CV mortality, an indirect surrogate for CV disease incidence. METHODS: A systematic review of studies on CV mortality rates in patients with IBD published between 1965 and 2006 was performed. Studies were included for analysis if they reported data on CV-disease-specific standardized mortality ratios (SMRs) for Crohn's disease (CD) and/or ulcerative colitis (UC). A meta-analysis of SMRs from included studies was performed. RESULTS: The review ultimately included 11 studies. Overall there were 4,532 patients with CD and 9,533 patients with UC. SMR point estimates ranged from 0.7 to 1.5 for patients with CD and 0.6-1.1 for patients with UC. There was not a statistically significant increase in CV SMR for either CD or UC in any study. However, two studies demonstrated a statistically significant decrease in CV SMR for UC. Finally, the meta-SMR for CD was 1.0 (95% CI 0.8-1.1) and the meta-SMR for UC was 0.9 (95% CI 0.8-1.0). CONCLUSIONS: IBD is not associated with increased CV mortality. Although CV mortality is a suboptimal surrogate for CV disease incidence, this finding provides indirect evidence against an association between IBD and CV disease.     

Survival and causes of death in patients with inflammatory bowel disease: a population-based study.

Relative survival up to December 31, 1986 was analyzed for all patients diagnosed with ulcerative colitis (UC) (n = 2,509) and Crohn's disease (CD) (n = 1,469) within the Uppsala Region, Sweden 1965-1983. After 10 years survival was 96% of that expected for UC and CD. Patients with ulcerative proctitis, left-sided colitis, and pancolitis at diagnosis had relative survival rates of 98%, 96%, and 93% respectively. Survival did not differ by extent at diagnosis for patients with CD. After including prevalent cases, 684 deaths occurred compared with 481.1 expected deaths [standardized mortality ratio (SMR) = 1.4; 95% confidence interval (CI) = 1.3-1.5]. Inflammatory bowel disease was the main reason for this excess mortality. Colorectal cancer increased mortality (50 deaths observed vs. 15.2 expected). Death from other cancers were not greater than expected. Obstructive respiratory diseases, especially bronchitis, emphysema, and asthma increased mortality SMR = 1.5 (95% CI = 1.1-2.2) in UC. Cerebrovascular disease mortality occurred less often than expected (SMR = 0.7; 95% CI = 0.5-1.0). Mortality for other diseases and groups of diseases was close to that expected.     

Low mortality in ulcerative colitis and Crohn's disease in three regional centers in England

OBJECTIVES: Recent epidemiological studies suggest that mortality rates for inflammatory bowel disease (IBD) are similar to those of the general population. However, most of this work has been done in referred populations or larger urban centers. We intended to estimate mortality rates for ulcerative colitis (UC) and Crohn's disease (CD) in three British district general hospital practices in Wolverhampton, Salisbury, and Swindon. METHODS: Consecutive patients with CD or UC were identified from 1978 to 1986 and followed prospectively. Demographic data, date and cause of death or health status at December 31, 1993 were used to estimate standardized mortality ratios (SMRs) and 95% confidence intervals. RESULTS: Sixty-four deaths occurred in 552 patients (UC 41 of 356; CD 23 of 196). The overall SMRs were 103 [95% confidence interval (CI): 79-140] for UC and 94 (95% CI: 59-140) for CD. The respective SMRs were higher only in the first year after diagnosis at 223 (95% CI: 99-439; p = 0.02) and 229 (74-535; p = 0.056), and even then, most subjects died from non-IBD causes (5 of 13). Nonsurvivors were significantly older than survivors in both UC and CD (p < 0.01). The SMR was also significantly greater during a severe first attack of UC at 310 (95% CI: 84-793; p = 0.04). Patients with perianal or colonic CD had an increased SMR [396 (95% CI: 108-335; p = 0.02) and 164 (95% CI: 82-335; p = 0.02)] respectively, partly related to the older mean age (52 vs 32 yr, p < 0.001). CONCLUSIONS: Mortality rates are not increased in IBD compared with the general population. However, older patients may be at increased risk of dying from other causes early in the disease clinical course.     

General and cancer specific mortality of a population based cohort of patients with inflammatory bowel disease: the Florence study

Background—A population basedepidemiological study identified all the patients diagnosed withulcerative colitis (UC) or Crohn's disease (CD) resident in theFlorence area in the period 1978-1992.
Aims—To assess the mortality of unselectedpatients with inflammatory bowel disease (IBD) in a Mediterranean country.
Methods—Overall, 920 patients (689 UC and 231 CD)were followed until death or end of follow up (31 December 1996).Information on vital status was available for all except eight patients(0.9%); 70 deaths were identified (23 in patients with CD and 47 inpatients with UC). Expected deaths were estimated on the basis of five year age group, gender, and calendar year national mortality rates. Standardised mortality ratios (SMR) and 95% confidence intervals were calculated.
Results—General mortality was significantly lowerthan expected in UC (SMR 0.6; 95% confidence interval 0.4 to 0.8), dueto a reduced number of cardiovascular and, possibly, smoking related deaths. Cancers of the respiratory tract were significantly reduced inUC but tended to be increased in patients with CD. These latter patients had not only an increased cancer mortality but also a 40%increased risk of dying for all causes already evident in the firstfive year follow up period and persisting thereafter. In contrast, inpatients with UC, SMRs were initially very low but tended to increasesteadily over the follow up period. Gastrointestinal deaths wereparticularly increased in patients with CD, but only moderately inthose with UC. Overall, there was some evidence of a twofold increasedmortality for colorectal cancer, the risk being highest for rectalcancers in patients with UC. A non-significant excess of deaths due tohaemolymphopoietic malignancies and suicides was also observed.
Conclusions—This study, the first in aMediterranean country, supports the existence of two divergentmortality patterns for patients with UC and CD, possibly explained bydifferences in smoking habits and by a greater severity of CD.

     

Survival and cause specific mortality in patients with inflammatory bowel disease: a long term outcome study in Olmsted County, Minnesota, 1940-2004

BACKGROUND AND AIMS: We followed a population based cohort of patients with inflammatory bowel disease (IBD) from Olmsted County, Minnesota, in order to analyse long term survival and cause specific mortality. Material and METHODS: A total of 692 patients were followed for a median of 14 years. Standardised mortality ratios (SMRs, observed/expected deaths) were calculated for specific causes of death. Cox proportional hazards regression was used to determine if clinical variables were independently associated with mortality. RESULTS: Fifty six of 314 Crohn's disease patients died compared with 46.0 expected (SMR 1.2 (95% confidence interval (CI) 0.9-1.6)), and 62 of 378 ulcerative colitis (UC) patients died compared with 79.2 expected (SMR 0.8 (95% CI 0.6-1.0)). Eighteen patients with Crohn's disease (32%) died from disease related complications, and 12 patients (19%) died from causes related to UC. In Crohn's disease, an increased risk of dying from non-malignant gastrointestinal causes (SMR 6.4 (95% CI 3.2-11.5)), gastrointestinal malignancies (SMR 4.7 (95% CI 1.7-10.2)), and chronic obstructive pulmonary disease (COPD) (SMR 3.5 (95% CI 1.3-7.5)) was observed. In UC, cardiovascular death was reduced (SMR 0.6 (95% CI 0.4-0.9)). Increased age at diagnosis and male sex were associated with mortality in both subtypes. In UC but not Crohn's disease, a diagnosis after 1980 was associated with decreased mortality. CONCLUSIONS: In this population based study of IBD patients from North America, overall survival was similar to that expected in the US White population. Crohn's disease patients were at increased risk of dying from gastrointestinal disease and COPD whereas UC patients had a decreased risk of cardiovascular death.     

High and increasing prevalence of inflammatory bowel disease in Finland with a clear North–South difference

Background and aimInflammatory bowel disease (IBD) prevalence has increased and a North–South gradient has been reported. We estimated the nationwide prevalence of IBD, ulcerative colitis (UC) and Crohn's disease (CD) in 1993, and prevalence of IBD in 2008, and assessed the geographical distribution of IBD in Finland. In addition, we investigated the vitamin D levels in a study population from a large, nationally representative health examination survey, the Health 2000 Survey.MethodsThe register study for prevalences included all patients who had special reimbursement of medications for IBD in the years 1993 (n = 10,958) and 2008 (31,703). The study for D-vitamin measurement consisted of 6134 persons who had participated in the Health 2000 Survey.ResultsThe nationwide point prevalence of IBD in 1993 was 216 per 100,000 inhabitants, and 595 in 2008. In 1993, the prevalence of UC (177) was fourfold higher than the prevalence of CD (38). The prevalence of IBD and UC in Finland increased from South to North. For CD, no geographical variation could be demonstrated. In the Health 2000 survey, vitamin D levels were lower in Northern than in Southern Finland.ConclusionsFinland belongs to high prevalence area of IBD and this prevalence has increased nearly threefold during the past 15 years. A clear North–South gradient has been shown for IBD and UC, but not for CD. Slightly lower vitamin D levels in Northern Finland may be associated with the observed higher prevalence of IBD there.     

Overall and cause-specific mortality in ulcerative colitis: meta-analysis of population-based inception cohort studies

OBJECTIVES: It remains debated whether patients with ulcerative colitis (UC) are at greater risk of dying and whether a possible alteration in mortality can be attributed to specific causes of death. We aimed to clarify this issue by conducting a meta-analysis of population-based inception cohort studies on overall and cause-specific mortality in patients with UC. METHODS: The MEDLINE search engine and abstracts from international conferences were searched for relevant literature by use of explicit search criteria. STATA meta-analysis software was used to calculate pooled risk estimates (SMR, standardized mortality ratio, observed/expected deaths) of overall mortality and specific causes of death and to conduct metaregression analyses of the influence of specific variables on SMR. RESULTS: Ten papers fulfilled the inclusion criteria, reporting SMRs varying from 0.7 to 1.4. The overall pooled estimate was 1.1 (95% confidence interval [CI] 0.9-1.2, P= 0.42). However, greater risk of dying was observed during the first years of follow-up, in patients with extensive colitis, and in patients from Scandinavia. Metaregression analysis showed an increase in SMR by increasing cohort size. UC-related mortality accounted for 17% of all deaths. Mortality from gastrointestinal diseases, nonalcoholic liver diseases, pulmonary embolisms, and respiratory diseases was increased whereas mortality from pulmonary cancer was reduced. CONCLUSIONS: The overall risk of dying in patients with UC did not differ from that of the background population, although subgroups of patients were at greater risk of dying. The cause-of-death distribution seemed to differ from that of the background population.     

Changes in clinical characteristics, course, and prognosis of inflammatory bowel disease during the last 5 decades: a population-based study from Copenhagen, Denmark

BACKGROUND: It remains uncertain whether the increasing incidence of inflammatory bowel disease (IBD) during the last decades has been accompanied by an alteration in the presentation, course, and prognosis of the disease. To answer this question, 3 consecutive population-based IBD cohorts from Copenhagen, Denmark (1962-2005), were assessed and evaluated. METHODS: Phenotype, initial disease course, use of medications, cumulative surgery rate, standardized incidence ratio of colorectal cancer (CRC), and standardized mortality ratio (SMR) were compared in the 3 cohorts, which had a total of 641 patients with Crohn's disease (CD) and 1575 patients with ulcerative colitis (UC). RESULTS: From 1962 to 2005, the proportion of IBD patients suffering from CD increased (P < 0.001), time from onset of symptoms to diagnosis of CD decreased (P = 0.001), and median age at diagnosis of UC increased (P < 0.01). The prevalence of upper gastrointestinal involvement and pure colonic CD varied significantly between cohorts. UC patients diagnosed in the 1990s had a higher prevalence of proctitis, received more medications, and had a milder initial disease course than did previous patients. The surgery rate decreased significantly in CD but not in UC. The risk of CRC in IBD was close to expected over the entire period, whereas the mortality of patients with CD increased (overall SMR, 1.31; 95% CI, 1.07-1.60). CONCLUSIONS: Despite variations in the presentation and initial course of IBD during the last 5 decades, its long-term prognosis remained fairly stable. Treatment of IBD changed recently, and future studies should address the effect of these changes on long-term prognosis.     

Risk factors for inflammatory bowel diseases according to the “hygiene hypothesis”: A case–control,multi-centre,prospective study in Southern Italy

BackgroundUlcerative colitis (UC) and Crohn's disease (CD) are inflammatory bowel diseases (IBD) of unknown aetiology. The ‘hygiene hypothesis’ (HH) suggests that several hygiene-related factors may have contributed to the increased incidence of IBD. The aim of the study was to evaluate risk factors for IBD related to HH in a cohort of IBD patients from the south of Italy.MethodsWe prospectively performed a one-year, questionnaire-based, case–control, multi-centre study focusing on the principal risk factors for IBD according to HH. We investigated the main surrogate markers of HH (helmintic infections and antibiotics in childhood; breastfeeding; family size/sibship;urban upbringing; personal and domestic hygiene in childhood) in UC and CD patients, in comparison with a control group of healthy subjects. In addition, the traditional risk factors for IBD were also recorded.ResultsThe study population included 527 cases of UC, 468 CD and 562 controls. None of the surrogate risk factors of HH was significantly associated with IBD. On the contrary, the traditional risk factors confirmed their statistical significance in this IBD population. Familial aggregation: OR 4.07 for UC; OR 4.83 for CD; smoking: OR 0.38 for UC; OR 1.40 for CD; appendectomy: OR 0.28 for UC; OR 1.61 for CD.ConclusionEven though risk factors associated to the HH have been proposed as a possible explanation for the increasing calendar trend of IBD incidence, their role does not appear to be statistically significant. Familial aggregation, smoking habits and appendectomy still remain the main risk factors associated with IBD.     

Un estudio descriptivo de la enfermedad inflamatoria intestinal en un centro de atención terciario egipcio

Introduction and aimsInflammatory bowel disease (IBD) is a group of chronic intestinal disorders that trigger prolonged inflammation of the digestive tract. Its incidence and prevalence appear to be increasing in the African population and in Egypt. The present study aims to highlight the pattern and management of IBD in Egyptian patients.Materials and methodsTwo hundred patients with IBD were assessed for ulcerative colitis (UC), through the Mayo score, and for Crohn's disease (CD), with the Crohn's disease activity index (CDAI).ResultsMedian patient age was 35 years, with a predominance of females. UC was more common than CD (88% and 12%, respectively) and severity was moderate, in the majority of cases. Most UC patients had left-sided lesions, whereas ileitis was the most common finding (37.5%) in the CD patients. Proctitis was the least common finding in both diseases and Crohn's fistulizing disease was detected in 4.1% of the patients. Interestingly, peripheral arthropathy was the most common extraintestinal manifestation in the IBD patients (70%) and axial arthropathy was the least common (6%). Severe ocular or mucocutaneous involvement was very rare. Finally, biologic treatment was prescribed to 15.4% of the UC patients and 20.8% of the CD patients.ConclusionsAlthough the clinical presentation of IBD in Egypt is comparable to that reported worldwide, diagnoses were found to be delayed. There were fewer cases of CD than UC, but more mild-to-moderate disease severity. The surveillance of patients with IBD must continue and awareness of the disease in the Egyptian medical community needs to increase. A national registry must be established, multicenter studies need to be conducted, and molecular diagnostics is recommended.     

Original research: Direct costs of inflammatory bowel diseases in a Finnish tertiary-level clinic

BackgroundInflammatory bowel disease (IBD), Crohn’s disease (CD) and ulcerative colitis (UC) are chronic diseases associated with a high and continuous economic burden. The introduction of biologics has changed the distribution of costs over the past two decades, and there are no recent studies on direct costs in Finland. This study aimed to estimate the direct healthcare costs of these diseases in a tertiary-level clinic.MethodsThe data were collected during a 1-year period of patients with IBD visiting Turku University Hospital. Patients were included if they lived in the hospital district area and were over 18 years old. This comprised an IBD group of 2208 patients, including 794 cases of CD and 1414 cases of UC. A sex-matched and age-matched control group was collected for comparison. Direct costs were collected during a 1-year study period from the hospital records.ResultsTotal direct costs per patient with IBD in a tertiary-level clinic were €4223 annually. IBD-generated direct costs were estimated to total €3981 per patient annually. Patients with IBD who were given infliximab had €9157 higher direct healthcare costs per patient annually than patients with IBD with no infliximab medication. Direct healthcare costs generated in a tertiary-level gastroenterological clinic averaged €1652 per patient with IBD annually. On average, patients with CD had €1111 higher direct healthcare costs annually than patients with UC.ConclusionsThe direct healthcare costs of IBD were significant, almost 17-fold higher compared with a control group. Patients with IBD administered with biologics had significantly higher costs. Patients with CD had higher annual infliximab costs than patients with UC.     

The risk of colorectal cancer in patients with inflammatory bowel diseases in Finland: A follow-up of 20 years

Background and aimsData on the relative risk of colorectal cancer in inflammatory bowel diseases (IBD) are inconsistent. To prevent the development of cancer, endoscopic facilities should be targeted correctly. We report here the results of a 20-year follow-up in Finland and evaluate the efficacy of endoscopic surveillance in cancer prevention.MethodsThe data were based on an IBD register in our catchment area in 1986–2007. The population-based cohort comprised 1915 patients, 1254 with ulcerative colitis, 550 with Crohn's disease and 111 with inflammatory bowel unclassified. Colorectal cancer cases were obtained from the IBD register; the colorectal cancer figures in the respective population were obtained from the Finnish Cancer Registry.ResultsColorectal cancer was found in 21 patients, the standardized incidence ratio (SIR) being 1.83 (95% confidence interval (CI) 1.13–2.79) for IBD. Colorectal cancer risk was 3.09 (CI 1.50–5.75) for extensive UC, and 3.62 (CI 2.00–11.87) for Crohn's disease affecting the colon. Eleven (52%) of the colorectal cancer cases were TNM stage 3 or 4. In the same observation period 10 colectomies with ileoanal anastomosis were performed with the indication of cancer risk in ulcerative colitis; of these 10 patients only two had no additional risk factors for colorectal cancer, for example primary sclerosing cholangitis, pseudopolyposis or active disease.ConclusionsThe risk of colorectal cancer in the cohort was only moderately increased. In the absence of additional risk factors, endoscopic surveillance was of limited benefit. We therefore suggest intensive endoscopy surveillance to be targeted on patients with definite risk factors.     

Mortality and extraintestinal cancers in patients with primary sclerosing cholangitis and inflammatory bowel disease

IntroductionPrimary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) frequently co-occur. PSC is associated with increased risk for colorectal cancer (CRC). However, whether PSC is associated with increased risk of extraintestinal cancers or affects mortality in an IBD cohort has not been examined previously.MethodsIn a multi-institutional IBD cohort of IBD, we established a diagnosis of PSC using a novel algorithm incorporating narrative and codified data with high positive and negative predictive value. Our primary outcome was occurrence of extraintestinal and digestive tract cancers. Mortality was determined through monthly linkage to the social security master death index.ResultsIn our cohort of 5506 patients with CD and 5522 patients with UC, a diagnosis of PSC was established in 224 patients (2%). Patients with IBD–PSC were younger and more likely to be male compared to IBD patients without PSC; three-quarters had UC. IBD–PSC patients had significantly increased overall risk of cancers compared to patients without PSC (OR 4.36, 95% CI 2.99–6.37). Analysis of specific cancer types revealed that a statistically significant excess risk for digestive tract cancer (OR 10.40, 95% CI 6.86–15.76), pancreatic cancer (OR 11.22, 95% CI 4.11–30.62), colorectal cancer (OR 5.00, 95% CI 2.80–8.95), and cholangiocarcinoma (OR 55.31, 95% CI 22.20–137.80) but not for other solid organ or hematologic malignancies.ConclusionsPSC is associated with increased risk of colorectal and pancreatobiliary cancer but not with excess risk of other solid organ cancers.     

Postoperative mortality after surgery for inflammatory bowel disease in the era of biological agents: A population-based study in Southern Europe

Background: Despite the efficacy of biological agents, surgery is still required for a large percentage of patients with inflammatory bowel disease (IBD).AimsTo assess the postoperative mortality rates and associated risk factors in IBD patients in a population-based setting in the era of biological agents.MethodsThis is a population-based longitudinal study including all patients diagnosed with IBD in Catalonia who underwent intestinal resection or colectomy between 2007 and 2016, identified from the Catalan Health Surveillance System database. Logistic regression was used to calculate the adjusted odds ratio for postoperative in-hospital and 30-day mortality. Data for Crohn's disease (CD) and ulcerative colitis (UC) were analysed separately.ResultsA total of 1,660 interventions for CD (69%) and 738 for UC (31%) were performed at 55 centres. In-hospital and 30-day postoperative mortality rates were 2.1% and 2.5% for CD, and 5.4% and 6.4% for UC, respectively. In the multivariate logistic regression analysis, comorbidity was associated with in-hospital and 30-day postoperative mortality in CD and UC, whereas age was only associated with mortality in CD and a non-laparoscopic surgical approach with UC.ConclusionsIn the era of biologicals, the postoperative mortality rate for IBD depends mostly on co-morbidities and age.     

Treatment patterns and intensification within 5 year of follow-up of the first-line anti-TNFα used for the treatment of IBD: Results from the VERNE study

BackgroundAnti-TNFα represent one of the main treatment approaches for the management of inflammatory bowel diseases (IBD). Therefore,the evaluation of their treatment patterns over time provides valuable insights about the clinical value of therapies and associated costs.AimsTo assess the treatment patterns with the first anti-TNFα in IBD.MethodsRetrospective, observational study.Results310 IBD patients were analyzed along a 5-year follow-up period. 56.2% of Crohn's disease (CD) patients started with adalimumab (ADA), while 43.8% started with infliximab (IFX). 12.9% of ulcerative colitis (UC) patients initiated with ADA, while 87.1% initiated with IFX. Treatment intensification was required in 28.9% of CD and 37.1% of UC patients. Median time to treatment intensification was shorter in UC than in CD (5.3 vs. 14.3 months; p = 0.028). Treatment discontinuation due to reasons other than remission were observed in 40.7% of CD and 40.5% of UC patients, although, in UC patients there was a trend to lower discontinuation rates with IFX (36.6%) than with ADA (66.7%). Loss of response accounted for approximately one-third of discontinuations, in both CD and UC.ConclusionsAround one-third of IBD biologic-naive patients treated with an anti-TNFα required treatment intensification (earlier in UC) and around 40% discontinued the anti-TNFα due to inappropriate disease control.     

Causes of death in patients with peptic ulcer perforation: a long-term follow-up study

BACKGROUND: Survival is lower in ulcer perforation patients than in the general population. This study assesses the causes of death in patients treated for peptic ulcer perforation. METHODS: Cause-specific mortality in a population-based cohort of 817 patients treated for ulcer perforation in western Norway during the period 1962-1990 was compared with cause-specific population death rates. Analyses were based on observed and expected mortality curves for major causes of death and on standardized mortality rates (SMRs). Cox regression models were used to analyse possible differences on the basis of sex, birth cohort, surgical procedure, and ulcer location. RESULTS: Ulcer perforation patients experienced increased mortality from neoplasms (SMR = 1.8; 95% confidence interval (CI) = 1.4-2.1), lung cancer (SMR = 3.6; 95% CI = 2.3-4.9), circulatory diseases (SMR = 1.3; 95% CI = 1.1-1.6), ischaemic heart disease (SMR = 1.3; 95% CI = 1.03-1.6), and respiratory diseases (SMR = 1.9; 95% CI = 1.3-2.6). Postoperative deaths accounted for 38% of all excess deaths. Death from recurrent peptic ulcer was increased also in subjects who survived the 1st year after the perforation (SMR = 5.8; 95% CI = 1.2-10.4) but accounted for only a few deaths. The increase in mortality from lung cancer was higher in subjects born after 1910 than in patients of older generations. Excess mortality from lung cancer and from circulatory diseases was higher in male than in female patients. CONCLUSIONS: Increased mortality in ulcer perforation patients could mainly be attributed to smoking-related diseases. This is indirect evidence that smoking may be an important aetiologic factor for ulcer perforation.     

Disease Outcome in Inflammatory Bowel Disease: Mortality,Morbidity and Therapeutic Management of a 796-Person Inception Cohort in the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD)

Background: The course of inflammatory bowel diseases (IBD) has mainly been studied using different methods in single patient cohorts. The aim of the present study was to assess clinical aspects of disease outcome in a population-based cohort of IBD patients over a 4-year period in multiple centres across Europe. Methods: A total of 796 patients with IBD diagnosed in 10 centres between October 1991 and October 1993, registered at the EC IBD study centre (98% of the original cohort), participated in the study. Investigators filled out a standard follow-up form containing questions on the method of follow-up, vital status of the patient, change in diagnosis, extraintestinal manifestations, medical and surgical treatment, and physician's global assessment of disease activity. Results: Complete relief of the complaints was reported in 255 (48%) patients with ulcerative colitis (UC), 9 (50%) with indeterminate colitis (IC), but only in 87 (35%) of patients with Crohn disease (CD). Improvement was reported in 195 (37%) patients with UC, 113 (45%) with CD and 6 (33%) with IC. During the 4-year follow-up period, 23 patients died (14 UC, 8 CD, and 1 IC). The mean age at death was 69.3 years (s, 14.9 years). The deaths of three patients were recorded as directly due to IBD. Conclusions: With the present approach to therapeutic management the short-term outcome of patients with IBD seems to be favourable in 10 medical centres in the north and south of Europe. However, more detailed studies including both objective and subjective measures are necessary.     

Thromboembolic events and cardiovascular mortality in inflammatory bowel diseases: A meta-analysis of observational studies

ObjectivePatients with inflammatory bowel disease (IBD) are at increased risk of having venous thromboembolism. The magnitude of this risk has yet to be determined. The question of whether IBD patients have an increased risk of arterial thromboembolism and cardiovascular (CV) mortality remains controversial.DesignWe searched MEDLINE, Cochrane Library, EMBASE and international conference abstracts and included all controlled observational studies that evaluated the incidence of venous and/or arterial thromboembolic events (TE) and CV mortality in adult IBD.Results33 studies enrolling 207,814 IBD patients and 5,774,898 controls and capturing 3,253,639 hospitalizations of IBD patients and 936,411,223 hospitalizations of controls reported a risk of arterial and/or venous TE or CV mortality were included. The risk of venous TE was increased in IBD patients compared to the general population (RR, 1.96; 95% CI, 1.67–2.30) contrary to the risk of arterial TE (RR, 1.15; 95% CI, 0.91–1.45). There was an increased risk of deep venous thrombosis (RR, 2.42; 95% CI, 1.78–3.30), pulmonary embolism (RR, 2.53; 95% CI, 1.95–3.28), ischemic heart disease (RR, 1.35; 95% CI, 1.19–1.52) and mesenteric ischemia (RR, 3.46; 95% CI, 1.78–6.71). Differences in methodology were great between studies resulting in a significant heterogeneity in all previous analysis. CV mortality in IBD patients was not increased compared to the general population (SMR, 1.03; 95% CI, 0.93–1.14).ConclusionThe risk of TE is increased in patients with IBD. This difference is mainly due to an increased risk of venous TE. There is no increased risk of arterial TE or CV mortality in IBD patients, but an increased risk of both ischemic heart disease and mesenteric ischemia.     

Long-term survival among patients operated upon for peptic ulcer disease

BACKGROUND: Although surgery has been used widely for treating peptic ulcer disease, there is conflicting evidence with respect to subsequent life expectancy and the determinants of mortality. Our aim was to compare long-term survival in a large, population-based cohort of operated patients with that expected in the general population. METHODS: We followed 471 Rochester, Minnesota residents who had surgery for peptic ulcer at the Mayo Clinic during 1956-85 for a total of 6174 person-years. Patients were followed through their complete (inpatient and outpatient) medical records in the community until death or last clinical contact and death certificates were obtained for all who succumbed. We compared observed survival and cause-specific death rates in this cohort with expected values and identified the determinants of short (30 day) and long-term mortality. RESULTS AND CONCLUSIONS: Survival was worse than expected, but excess deaths were confined to those with perforated ulcers (42 deaths observed; 18.8 expected). Independent predictors of death included age, male gender, emergency operation, gastric ulcer and cigarette smoking. Most deaths were due to heart disease and cancer, but only those due to digestive diseases (standardized mortality ratio (SMR) 3.8, 95% CI 2.4-5.7) and respiratory diseases (SMR 1.9, 95% CI 1.3-2.7) were increased compared to expected figures. Overall survival was reduced in this cohort but was normal among those whose ulcers were not perforated. However, the data suggest an adverse role for alcohol and smoking in these patients.