Inflammatory bowel disease: how relevant for Brazil?
The term inflammatory bowel disease (IBD) encompasses such disorders as idiopathic ulcerative colitis (IUC) and Crohn's disease (CD), characterized as recurrent and immune-mediated, with the intestine as the target organ and chronic inflammatory process as the principal event.
The etiology remains unknown and is probably multi-factorial. It is believed that genetically predisposed individuals interact with environmental factors (probably triggers for the disease), sparking an uncontrolled immune response that gives rise to a chronic intestinal inflammatory process. Progression of the disease can involve perforations, obstructions, and even intestinal tumors. The limited modifications in the evolution of IBD with treatment, and its emergence in young individuals tend to cause a major impact on work capacity, quality of life, and socioeconomic issues for patients and families.
IBD prevalence increased rapidly in the industrialized countries in the latter half of the 20th century, tending to stabilize. CD incidence is 5 cases per 100 thousand inhabitants/year in the United States and Europe, with a prevalence of 50/100 thousand, while IUC prevalence is 12/100 thousand inhabitants in the United States.
In developing countries where Western lifestyle is spreading, the corresponding rates are increasing and indicate an environmental influence in the genesis of IBD. Prevalence, incidence, and mortality rates in Brazil are still unknown, although regional reports have described an increase in the number of new cases of CD as compared to IUC.
The disease mainly affects individuals in their teens and twenties and presents a diverse range of symptoms, severity, and extra-intestinal manifestations. The most frequent clinical picture includes chronic diarrhea, abdominal pain, and rectal bleeding, which also occur in various other prevalent diseases in Brazil such as bacterial, parasitic, and viral intestinal infections. Diagnostic difficulties arise both in the formulation of the clinical hypothesis and in the investigative process. The lack of a single gold standard test requires the association of clinical data with serological, radiological, endoscopic, and histological tests to reach a diagnosis. Even this entire armamentarium may be insufficient to produce a diagnosis, and only the natural evolution of the disease can help the clinician.
There is still no cure, but the emergence of new biological drugs points to a reduction in the morbidity of IBD by controlling the cells and immune mediators involved in the inflammation, thus preventing its perpetuation. However, the chronic and costly use of drugs has a major socioeconomic impact on Brazil's Unified National Health System, which currently releases medication for some 12 thousand patients.
While aiming to analyze the public health impact of IBD in Brazil, we have observed a lack of the following: systematic data collection on patients in the principal referral centers, prevalence and incidence estimates for the country, long-term follow-up of patient cohorts, and economic assessments of the direct costs (tests, drugs, medical services, and hospitalizations) and indirect ones (early retirement, absenteeism) generated by the disease. In this context, the Brazilian Expert Group for Studies on Inflammatory Diseases was formed with the purpose of promoting epidemiological studies, performing a national census on IBD with diagnostic and therapeutic guidelines, and helping facilitate government agencies in relation to releasing medication for the treatment of IBD, all of which ultimately aims to improve patient care.
Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.