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West African Journal of Medicine Vol. 32, No. 1 January–March, 2013

Department of Medicine, University of Ghana Medical School, Box 4236, Korle-bu, Accra, Ghana.*Correspondence: Timothy N.A. Archampong, Gastroenterology Unit, Department of Medicine, University of Ghana Medical School, Box4236, Korle-bu, Accra, Ghana. E-mail: [email protected]; [email protected]: CD, Crohns Disease; IBD, Inflammatory Bowel Disease; KBTH, Korle-Bu Teaching Hospital; t1, February, 1997 – March, 2004;t2, April, 2004 – August, 2011; UC, Ulcerative Colitis.

Inflammatory Bowel Disease in Accra: What New Trends?

Maladie Inflammatoire Intestinale: quelles sont les nouvelles tendances?

T. N. A. Archampong*, K. N. Nkrumah

STRUCTURED ABSTRACTBACKGROUND: Inflammatory bowel disease (IBD) has beenmore common in Western Europe and North America. InitiallyIBD had been thought to be low in incidence among Sub-Saharan Africans. However, it is now being increasinglyrecognised in patients of African descent.OBJECTIVE: A comparative assessment of the patterns of IBDin Accra from 1997 to 2011.METHODS: This study used a retrospective design to accessclinical details of follow-up patients attending theGastroenterology Unit of the Korle-Bu Teaching Hospital,Accra between February, 1997 and May, 2011. It was acomparative seven-year review of clinical presentations of IBDbetween April, 2004 – August, 2011 (t2) and February, 1997 –March, 2004 (t1) for changing patterns of disease in tertiarycare.RESULTS: Twenty-eight (28) new IBD patients were seen inthe Gastroenterology Clinic, KBTH with IBD during 2004 –2011 (t2) in comparison to 17 patients over1997 – 2004 (t1).Presentations of severe diarrhoea were 70.4% and 55.6% in(t1) and (t2) respectively. Eighty-two percent (82%) of patientswith IBD in (t2) had a severely inflamed colon on the indexcolonoscopy. Most patients (70–80%) responded to medicaltherapy (steroids, sulfasalazine) with no colon resections forsteroid-refractory colitis.CONCLUSION: Although relatively uncommon, IBD recordeda 65% rise in incidence over the study periods with a malepreponderance. Most patients with IBD were presenting latewith severe clinical and endoscopic features of disease yetmedically responsive. Non-specific (indeterminate) colitisgained prominence in (t2). WAJM 2013; 32(1): 40–44.

Keywords: Inflammatory, bowel, trends, Accra, Ghana,Africans, non-specific colitis.

RÉSUMÉ STRUCTURÉCONTEXTE: La maladie inflammatoire de l’intestin (MII) a étéplus courante en Europe de l’ouest et en Amérique du Nord.Son incidence a été considérée comme étant basse chez lesAfricians au sud du Sahara. Toutefois, elle est à présent deplus en plus reconnue chez les originaires d’Afrique.OBJECTIF: Une évaluation comparative des particularités dela MII à Accra de 1997 à 2011.MÉTHODES: Une étude rétrospectivea évalué les donnéescliniques et du suivi des patients de l’unité de Gastroentérologiede l’Hôpital Universitaire de Korle Bu (HUKB), Accra entreFévrier 1997 et Mai 2011. Il s’agissait d’une revue comparativesur des périodes de 7 ans des aspects cliniques de MII entreles périodes Avril 2004 – Août 2011 (t2) et Février 1997 – Mars2004 (t1) afin d’évaluer les changements d’aspect de la maladiedans une structure tertiaire.RÉSULTATS: Vingt huit (28) nouveaux cas de MII ont été vusà la clinique de Gastroentérologie de l’HUKB dans la période2004 – 2011 (t2) en comparaison des 17 cas dans la période1997 – 2004 (t1). Un tableau de diarrhée sévére a été observédans 70,4% et 55,6% respectivement en (t1) et (t2). Quatre vingtdeux pour cent (82%) des patients avec une MII en (t2) avaientun colon sévèrement inflammatoire lors de la colonoscopie. Laplus part des patients (70-80%) avaient une bonne réponse autraitement médical (stéroïdes, sulfasalazine) sans notion derésection pour les colites réfractaires aux stéroïdes.CONCLUSION: Bien que relativement rare, la MII avait eu uneaugmentation de son incidence de 65% au cours de la périoded’étude avec une prépondérence masculine. La plus part despatients se présentaient tardivement avec un tableau cliniquesévère mais des aspects endoscopiques encore compatiblesavec un traitement médical. La colite non-spécifique(indéterminée) était prédominante en (t2). WAJM 2013; 32(1):40–44.

Mots Clés: Inflammatoire, intestin, tendances, Accra, Ghana,Africains, colite non spécifique.

WEST AFRICAN JOURNAL OF MEDICINE

ORIGINAL ARTICLE

West African Journal of Medicine Vol. 32, No. 1 January–March, 2013 41

T. N. A. Archampong and K. N. Nkrumah Inflammatory Bowel Disease in Accra

INTRODUCTIONInflammatory bowel disease (IBD)

is characterised by non-specific chronicrelapsing inflammation of the gastro-intestinal tract and extra-intestinalmanifestations of unknown aetiology andpartly understood pathogenesis.1,2

Current hypothesis indicate that thegenesis of IBD may be polygenic andmulti-factoral. The chronic inflammationmay result from a dysfunctional gutimmune system in response to agenetically determined failure to processcertain commensal antigens.3,4 Two sub-types are clinically recognized, ulcerativecolitis (UC) and Crohn’s disease (CD).1

IBD has been more common in the highlydeveloped countries of Northern/Western Europe and North America, witha prevalence of 30 to 200/100,000 for UC,1.2 to 106/100,000 for CD and anincidence of 0.5 to 24.5/100,000 UC and0.1 to 16/100,000 CD.5 Initially IBD hadbeen thought to be low in incidenceamong Sub-Saharan Africans.1,6 This wasmainly because of the relatively sporadiccases reported from the continent incomparison to the larger numbersreported from North America and WesternEuropean countries.7 However, it is nowbeing increasingly recognised in patientsof African descent.6

The community prevalence of IBDin Ghana is not known. Between 1997 and2004, 17 cases of IBD were identified inthe tertiary referral centre, Korle-Buteaching Hospital, Accra.8 Seventy-fivepercent of these cases were confirmedas ulcerative colitis.8 In this cohort ofcases, males were affected more thanfemales with the majority of casesoccurring before the age of 50 yrs.8

Pyoderma gangrenosum was the maindermatological manifestation of IBD seenin Korle-Bu, Accra.8 This has beenreported in other studies in Sub-SaharanAfrica.9–11It is felt that there is a significantpopulation of patients with chronicdiarrhoea diseases in the community,usually treated as bacterial or parasiticinfections.8This contributes to a longdelay in diagnosis and subsequentmanagement.8,12 This study will assessclinical presentations of IBD to comparecases between 2004–2011 and 1997–2004for changing patterns of disease.

METHODSThis study used a retrospective

design to access clinical details from caserecords of new and follow-up patientswith confirmed IBD at the Gastro-enterology Unit of the Korle-Bu TeachingHospital, Accra between 1997 and2011.The Gastroenterology Unit runs aweekly afternoon Outpatient Clinic andsees approximately 60 patients each clinicsession. The focus of the study was acomparative review of clinical presenta-tions of IBD between April, 2004 –August, 2011 and February, 1997 –March, 2004 for changing patterns ofdisease and outcomes in theGastroenterology Unit, KBTH,the maintertiary referral centre in Accra. The period(February, 1997 – March, 2004) and (April,2004 – August, 2011) were referred to as(t1) and (t2) respectively. This study tookplace between Septemberand December,2011. All authors complied with therequirements and principles of theHelsinki Declaration during thisdescriptive study. The exercise wasundertaken with particular care to avoidpatient identifiable information on thestudy instrument. The study survey wasstructured with specific questions tocapture data on age, sex, duration ofsymptoms, initial stool frequency, stoolconsistency, stool appearance, colonicendoscopic examination, colonichistology and clinical outcome followingtherapeutic intervention. One-hundredand seventy-five (175) case files withgastroenterological conditions werereviewed, excluding liver relateddiseases. Comparative data wereexpressed as proportions and presentedin table-format and figures.

RESULTSTwenty-eight (28) new patients were

seen in the Gastroenterology Clinic,

KBTH with IBD during 2004 – 2011 (t2)in comparison to 17 patients over the 1997– 2004 (t1) year-period. During (t2),Seventy-One percent (71%) were maleswhile 28.6% were females. Table 1illustrates the comparative ages of thestudy periods: the 20–30 year groupbeing the most prominent over the studyperiod.

During (t2), 50% of patientspresented 1–5 years after theirsymptoms, however there was areduction in patients with symptoms over5 years in duration (21.4%); Figure 1.

Patients presenting with severediarrhoea (more than 6 episodes ofdiarrhoea per day) were 70.6% and 57.1%in (t1) and (t2) respectively; Figure 2.Fewer patients were presenting withmilder forms of diarrhoea (less than 4episodes of diarrhoea per day) in bothstudy periods; 11.8%, and 10.7% in (t1)and (t2) respectively. Majority, approxi-mately 88% of patients presented withstool frequency over 4 times per day inboth study periods with the appearanceblood-stained in 85–95% of cases.Eighty-two percent 82% of patients withIBD in (t2) had a severely inflamed colonon the index lower GI endoscopy.

Treatment regimes for acute IBDflares varied between Prednisolone 20–40mg daily and/or sulfasalazine 1gmtwice/three times daily. Excluding non-compliant and defaulting patients, 82%and 71% responded to prednisolone andsulfasalazine respectively. No operationswere recorded for steroid-refractorycolitis.

Eighty-nine-percent 89% of patientsdiagnosed during (t2) were alivefollowing this period in relation to 71%at the end of (t1).

Table 2 demonstrates the differenttypes of histologically-confirmed IBD inthe study populations. Ulcerative colitis

Table 1: The Age Distribution of IBD Cases at the Korle-Bu Teaching Hospital(KBTH) over the Study Period (1997 – 2011)

Age-Group (yrs) t1 1997 – 2004: n(%) t2 2004 – 2011: n (%)< 20 yrs 4 (23.5) 2 (7.1)20 – 30 3 (17.6) 11 (39.3)31 – 40 4 (23.5) 7 (25.0)41 – 50 3 (17.6) 3 (10.7)51 – 60 2 (11.8) 3 (10.7)>60 yrs 1 (5.9) 2 (7.1)



was the commonest;however non-specific (indeterminate) chronic colitiswas significantly more prevalent in (t2).

Table 3 shows the distribution ofextra-gastrointestinal (GI) manifestationsof IBD. In (t1), pyoderma gangrenosum,the main extra-GI feature occurred in17.6%. (t2) had a diverse presentation ofextra-GI features with clubbing 7%,conjunctivitis 3.6%, mouth-ulcers 3.6%,sacro-ilitis 7% and arthopathy 21%.

DISCUSSIONThere has been a 65% increase in

incidence of IBD during ( t2) incomparison with (t1). This may imply anincreased awareness of the condition.However reports suggest an increase inthe incidence of IBD world-wide over thepast two decades, but its spread has beenslowing down in highly affectedcountries such as Western Europe andNorth America.12,13 On the contrary, thetraditionally low incidence areas such asEastern Europe14 and Asia15 have seen arapid increase in the incidence of IBD.16

For instance Western Hungary saw itsincidence rate rise from 1.66/100,000(1977–1981) to 11.01/100,000 (1997-2001)in UC, and from 0.41 to 4.68 in CD,respectively.17 It has also been suggestedthat there is likely to be a significantundiagnosed community burden ofinflammatory bowel disease in Ghana;recognised cases representing a tip of theice-berg.8 There is however, limitedinformation on time-trend related studiesin Africa. The rise in incidence at theTertiary Centre in Accra may be part ofan increasing pattern in relatively lowincidence areas suggesting an emergingcommon environmental factor res-ponsible for its prominence. More maleswere affected in both study periodschronologically with the male: femaleratios of 1.83 and 2.38 in (t1) and (t2)respectively. This pattern of malepreponderance was also reported inrelatively low incidence areas such asIndia12 for Crohns Disease and EasternEurope for UC.14

The age distribution Table, 1,showed a peak between age 20–30 yearsin (t2), 39.3%; this was different fromthe preceding (t1) period which hadan even spread of cases over most yeargroups and without clear peaks. IBD

Table 2: The Histological Distribution of IBD cases seen at the Korle-Bu TeachingHospital (KBTH) over the Study Period (1997 – 2011)

Histologic Diagnosis t11997 – 2004: n (%) t22004 – 2011: n (%)Ulcerative Colitis 12 (70.6) 12 (42.9)Non-specific Chronic Colitis 1 (5.9) 14 (50.0)Crohns Colitis 2 (11.8) 2 (7.1)Unspecified 2 (11.8) –

Table 3: The Extra-Intestinal Manifestations of IBD at the Korle-Bu Teaching Hospital(KBTH)

Extra-GI characteristics t11997 – 2004: n(%) t22004 – 2011: n(%)Pyoderma gangrenosum 3 (17.6) 2 (7.1)Arthralgia 1 (5.9) 6 (21.4)Clubbing – 2 (7.1)Sacro-ilitis – 2 (7.1)Aphthous mouth ulcers – 1 (3.6)Conjunctivitis – 1 (3.6)

Figure 1: A Comparative View of IBD Symptom-duration at Presentation: (t1) vs (t2)

(t1) : 02/1997 –03/2004, less than

1 yr, 29.4%

(t1) : 02/1997 –03/2004, 1 -- 5

yrs, 29.4%

(t1) : 02/1997 –03/2004, more

than 5 yrs, 41.2%

(t2) : 04/2004 –08/2011, less than

1 yr, 28.6%

(t2) : 04/2004 –08/2011, 1 -- 5

yrs, 50.0%

(t2) : 04/2004 –08/2011, more

than 5 yrs, 21.4%

Prev

alen

ce (%

)

(t1) : 02/1997 – 03/2004

(t2) : 04/2004 – 08/2011

(t1) : 02/1997 –03/2004, less than

4/day, 11.8%

(t1) : 02/1997 –03/2004, 4 -- 6 per

day, 17.6%

(t1) : 02/1997 –03/2004, more

than 6/day, 70.6%

(t2) : 04/2004 –08/2011, less than

4/day, 10.7%

(t2) : 04/2004 –08/2011, 4 -- 6 per

day, 32.1%

(t2) : 04/2004 –08/2011, more

than 6/day, 57.1%

Prev

alenc

e (%)

(t1) : 02/1997 – 03/2004

(t2) : 04/2004 – 08/2011

Figure 2: A Comparative View of IBD Stool frequency at Presentation: (t1) vs (t2)



43

often exhibits a bi-modal peak ofincidence, usually mid-adolescent-30year group and then 50–60 year groupsrespectively.13,18

Most patients with IBD werepresenting late with severe symptoms ofdiarrhoea and endoscopic colitis basedon cases seen 1–5 years after symptomonset. This implies that the IBD patients’illness behaviour may not have changedsignificantly. Patients tolerate theirsymptoms, often trying varioustreatments including local herbal regimesprior to clinical consultations.8 Thispattern of severe delayed clinicalpresentation of IBD yet medical responseto therapy and low surgical interventionhas also been reported in Sudan19 and astudy involving Blacks in South Africa.20

This may signify a peculiar clinicalparadox in these traditionally low-incidence populations.

Non-specific (indeterminate) colitiswas significantly more prevalent in (t2)compared with (t1). Some studies havereported definitive diagnoses of eitherCD or UC in 40–50% following serologicanalysis, anti-neutrophil cytoplasmicantibodies (ANCA) or anti-Saccharomyces cervisiae anti-bodies,21–23 however, serologic markerstend to have low sensitivity for IBD.24

Patients have reportedly developed UCor CD over follow up23with approximately80% ulcerative colitis.23,25 Whether thiscohort of IBD patients in Accrarepresents indeterminate colitis or a pre-ulcerative colitis stage will be determinedby further longitudinal studies.

Extra-GI manifestations haveevolved and broadened through thestudy periods to include clubbing, mouthulcers, sacro-ilitis and arthralgia during(t2). The latter being the most prevalentduring this period as reported in otherstudies.26,27 Arthropathy was amanifestation in 21% of cases during thisperiod, similar to data from otherEuropean centres (20–50% of IBDcases).28–30

This study location in Accra mayreflect a different demographic popula-tion to the community however itsuggests emerging trends given thesignificantly delayed presentations andstresses the importance of its awarenesslocally. This phenomenon provides a

basis for further community and tertiary-based-investigation into the patho-genesis of IBD as it gains significance inGhana.

CONFLICT OF INTERESTNone.

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