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Volume 4, Issue 3, September 2010, Pages 301–311

Clinical practice in Crohn's disease in bordering regions of two countries: Different medical options, distinct surgical events

^a Portuguese Group of Studies of Inflammatory Bowel Diseases, Portugal
^b Hospital de São João, Portugal
^c Faculty of Medicine, Oporto University, Portugal
^d Gastroenterology, University Hospital of Santiago, Santiago de Compostela, Spain
^e EIGA (Inflammatory Bowel Disease Group of Galicia), Spain
^f Hospital Geral de Santo António, Portugal
^g Complexo Hospitalario de Pontevedra, Pontevedra, Spain
^h Centro Hospitalar do Alto Ave, Portugal
ⁱ Arquitecto Marcide Hospital, Ferrol, Spain
^j Hospital S Marcos-Braga, Portugal
^k Xeral Cies Hospital, Vigo, Spain
^l Hospital de Vila Real, Portugal
^m Centro Hospitalar do Vale do Ave — Paredes, Portugal
ⁿ Hospitais da Universidade de Coimbra, Portugal
^o Department of Biostatistics and Informatics — Faculty of Medicine, Oporto University, Portugal

Received 14 September 2009

Revised 2 December 2009

Accepted 2 December 2009

Available online 4 January 2010

Abstract

Contemplating the multifactorial nature of Crohn's disease (CD), the purpose of this study was to compare two neighbouring CD populations from different nations and examine how clinical characteristics of patients can influence therapeutic strategies and consequently different surgical events in routine clinical practice. Cross-sectional study based on data of an on-line registry of patients with CD in northern Portugal and Galicia. Of the 1238 patients, all with five or more years of disease, 568 (46%) were male and 670 (54%) female. The Portuguese and Galician populations were similar regarding Montreal categories, age at diagnosis, and years of follow-up. Galician B2 patients were associated with immunosuppression (OR 3.6; CI 2.2–6.1) and biologic treatment (OR 1.8; CI 1.0–3.1). In both populations ileocolonic disease was associated with immunosuppression and biologic treatment and the penetrating group was linked to immunosuppression. In the north of Portugal 47% and 16% of patients, and in Galicia 63% and 33%, were treated with immunosuppressants and biologic treatment, respectively. In the north of Portugal 44% of patients classified as stricturing behavior were operated without immunomodulation, in contrast to 12% in Galicia. In the latter it was possible to maintain 16% of B2 patients and 40% of B3 patients without surgery with adequate immunosuppression and/or biologic treatment. The delta of surgeries in B2 patients was 8% and in B3 26%.

Conclusions

Stratifying patients according to the Montreal classification identified similar clinical patterns in disparate geographic populations, and revealed that differing medical therapeutic practices may influence the occurrence of surgical events.

Keywords

Crohn's disease;
Portugal;
Galicia;
Southern Europe;
Predictive factors;
Clinical activity;
Surgery;
Biologic treatment;
Immunosuppression

1. Introduction

Crohn's disease (CD) is a chronic inflammatory disease characterized by significant morbidity due to frequent intestinal resections and hospitalizations. Despite major developments in the comprehension of the complex pathophysiology of CD there is still no cure for the disease. Furthermore, hospitalization costs, including surgery, comprise 56%–63% of the total direct costs^1 and 2 as consistently cited in the literature.

Surgery is not a curative option and new lesions can be seen on endoscopy some months following surgery.³ The goal of treatment in CD is, therefore, to slow or even stop this progression. Thus, the choice of drugs in CD must be timely if one considers that longer disease duration inevitably leads to more irreversible damage. This becomes clear when reflecting on the response to azathioprine in adults who as children were treated early^4 and 5 or the response to anti-TNF in individuals with shorter disease duration.⁶

Scandinavian countries exhibit a higher incidence as well as more aggressive behavior when compared to patients from Southern Europe,⁷ nevertheless our group showed recently that rates of aggressive medical therapy and need for surgical interventions are very similar⁸ to the ones obtained from Northern European countries.^{9, 10, 11, 12, 13 and 14}

The north of Portugal and Galicia (North-West of Spain) are two adjacent areas politically separated for the last six centuries. Nonetheless, they are linked due to similar language, culture and traditions. Two independent studies searching for NOD2/CARD15 mutations in CD patients in the north of Portugal and Galicia did not show important genetic differences,^15 and 16 indicating a similar genetic background.

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Clinical practice in Crohn's disease in bordering regions of two countries: Different medical options, distinct surgical events

Abstract

Conclusions

Keywords

1. Introduction