ORIGINAL ARTICLE

Clinical Epidemiology of Ulcerative Colitis in Mexico

A Single Hospital-based Study in a 20-year Period (1987-2006)
Jesus K. Yamamoto-Furusho, MD, PhD, MSc

Background: Ulcerative colitis (UC) is a chronic disease with a

heterogeneous clinical evolution. The prevalence and incidence of
UC vary widely and depend on multiple factors including ethnicity
and geographic location.
Goal: To determine the frequency of new cases of UC and their
clinical characteristics in a large cohort from a referral hospital in
Mexico City.
Study: Patients with conrmed diagnosis of UC were included
during a period between January 1987 and December 2006.
Demographic and clinical data were collected from medical
records.
Results: A total of 848 new cases of UC were diagnosed during a
20-year period. All the patients had endoscopic and histologic
conrmation. The mean of annual new UC cases increased from
28.8 in the rst period (1987 to 1996) to 76.1 in the second period
(1997 to 2006) (P<0.00008). The incidence of new cases increased
2.6-fold comparing both periods of time. This study consisted of
467 females and 382 males, with a mean age at diagnosis
of 31.3 12.3 years. The clinical manifestations were pancolitis
(59.1%), and extraintestinal manifestations (41.5%). Most of the
patients, 762 (89.8%) were taking sulfasalazine or 5-aminosalicylic
acid, 282 (33.3%) used oral or systemic steroids, 237 (28%) were
taking azathioprine.
Conclusions: The frequency of new UC cases has increased
signicantly in the last 10 years in Mexico, largely due to the
unique genetic make-up and the environmental factors (infectious
diseases including parasites) not found in other countries.
Key Words: UC, epidemiology, clinical, Mexico, Latin America

(J Clin Gastroenterol 2009;43:221224)

nammatory bowel disease (IBD) is a group of chronic

inammatory disorders of unknown etiology involving
the gastrointestinal tract and consists of 2 major groups:
Ulcerative colitis (UC) and Crohns disease (CD) that are
clinically characterized by recurrent inammatory involvement resulting in a similar evolution.
The prevalence and incidence of IBD vary widely and
depend on multiple factors, including ethnic background

Received for publication July 4, 2007; accepted April 7, 2008.

From the Inammatory Bowel Disease Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion
Salvador Zubiran, Mexico City, Mexico.
Acknowledgment of grants or nancial support: None.
Author does not have any conict of interest.
Reprints: Jesus K. Yamamoto-Furusho, MD, PhD, MSc, Department of
Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Colonia Seccion XVI,
Tlalpan, C.P. 14000, Mexico D.F., Mexico (e-mail: kazuofurusho@
hotmail.com).
Copyright r 2009 by Lippincott Williams & Wilkins

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and geographic location. The prevalence of IBD is 100 per

100,000 in the general population with 10,000 new cases
diagnosed annually. The incidence of UC is stable with
approximately 10 to 20 per 100,000 per year and a
prevalence of 50 to 100 per 100,000 in the US population.1
Although both sexes are aected similarly,1 the peak onset
of the disease varies with age typically presenting itself
between ages 15 and 25 or between 55 and 65 (bimodal
distribution). Although IBD occurs worldwide, the highest
incidence is among whites, particularly the Ashkenazi
Jewish population of Eastern Europe. Recently, increased
rates of the disease have been reported in regions where the
incidence of UC was thought to be low, such as Asia,
Africa, and Latin America.2 The epidemiology of UC in
Latin America, including Mexico, is still unknown; however, some reports have suggested a lower incidence and
milder course of the disease in Latin America.3
The goal of this study was to determine the frequency
of new cases and clinical characteristics of UC in a large
cohort from a referral hospital in Mexico City.

MATERIALS AND METHODS

Data were collected from medical records during a 20year period from January 1, 1987 to December 31, 2006. A
total of 1049 patients with possible diagnosis of UC were
referred to the Instituto Nacional de Ciencias Medicas y
Nutricion hospital. In the inclusion period, 848 new and
conrmed cases of UC were identied. Two hundred and
one cases were excluded for several reasons: incomplete
medical records, no denitive diagnosis of UC, indeterminate colitis, colonic CD, and microscopic colitis.
All of the patients on the list who were over 18 years of
age were diagnosed and conrmed to have UC. This
database covered both outpatient visits and hospitalizations. Diagnostic codes were based on the National
Adaptation of the International Classication of Diseases
(ICD) with separate code for UC (K51.9).
The diagnosis of UC was carried out by the presence
of the following criteria: a history of diarrhea or blood in
stools, macroscopic appearance by endoscopy and biopsy
compatible with UC, no suspicion of CD on the small
bowel radiograph, ileocolonoscopy, and biopsy.
The Montreal classication of disease extent of UC
was used in all patients.4 All patients were recruited
from several urban areas or cities (Mexico City, Veracruz,
Puebla, Morelia, Toluca, Campeche, La Paz, Pachuca,
Quererato, Guanajuato, and Villahermosa) and rural areas.
Relevant clinical and demographic information in all
UC patients were collected from medical records: sex, age
at diagnosis, familial aggregation, smoking history, previous appendectomy, disease evolution, extension, extraintestinal manifestations, medical or surgical treatment,

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Yamamoto-Furusho

Statistical Analysis
Descriptive statistics are expressed as mean and
standard deviation. New cases of UC were reported yearly
as frequency. Data were analyzed by Student t test for
numerical variables and w2 test for nominal variables. The
P value was 2-tailed and less than 0.05 was considered
statistically signicant. The data analysis was performed
with SSPS version 14.0 for Windows.

RESULTS
A total of 848 patients were diagnosed with UC
between 1987 and 2006 at this hospital. The frequency of
new cases with UC increased over the time (Fig. 1). The
mean of new UC cases increased annually from 28.8 in the
rst period (1987 to 1996) to 76.1 in the second period (1997
to 2006) (P<0.00008). The incidence increased 2.6-fold
comparing both periods of time. The age-group distribution
of the patients were as follows: 21 to 30 years (37.1%); 31 to
40 years (25.5%); 51 to 60 years (12.9%); 41 to 50 years
(10.6%); under 20 years (13.2%) and over 60 years of age
(1.3%) as shown in Figure 2.
During the whole study period (1987 to 2006), 467
female and 382 male patients with UC were analyzed. The
mean age at diagnosis was 31.3 12.3 years; the male to
female ratio (0.9:1.0) was equal. Most of the patients are
residing in urban areas (91.4%) and a total of 775 (91.3%)
patients were nonsmokers and 73 (8.6%) patients were exsmokers. A prior history of appendectomy was revealed in
20 cases (2.35%). Familial aggregation was present in 57
(6.78%) cases (50 patients with rst-degree relatives and

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350
300
Number of cases

and clinical course of disease. The diagnosis of primary

sclerosing cholangitis (PSC) was made based on radiologic
(endoscopic retrograde cholangiopancreatography, magnetic resonance imaging) or histologic criteria.
The year 1987 was selected as the starting point
because the coverage of the hospital register was incomplete
for earlier periods. All cases with unconrmed or wrong
diagnosis were excluded from the study. The duration of
follow-up was at least 5 months since the patient was
diagnosed with UC and all patients had several histologic
examinations. Other causes of colitis including infectious
were excluded. During the follow-up, routine evaluations
were performed for dierent pathogens such as bacteria,
Clostridium dicile, ova, and parasites. All of the patients
with pancolitis and distal colitis underwent routine cancer
surveillance and a biopsy was taken from 4 dierent
segments of the colon every 10 cm; this was performed after
8 and 15 years, respectively after diagnosis of their disease.

250
200
150
100
50
0
< 10

10 to 20

21 to 30

31 to 40

41 to 50

51 to 60

> 60

Age at diagnosis

FIGURE 2. Number of ulcerative colitis patients according to the

age at diagnosis.

7 cases with second-degree relatives aected by UC). The

predominant clinical features of UC patients were: bloody
diarrhea (90%), mucoid diarrhea (45%), abdominal pain
(39%), rectal symptoms (28%), weight loss (21%), and
fever (5%).

Extent of the Disease

The extent of the disease was evaluated by using total
colonoscopy and biopsies were taken from dierent
segments of colon in all cases. The Montreal classication
was used to dene the extent of UC. Of the 848 UC
patients, 492 (59.1%) had pancolitis (E3); 216 (25.5%) had
left-sided colitis (E2); and 130 (15.4%) had proctitis (E1) as
shown in Figure 3. During the follow-up, 216 patients with
initial left-sided colitis, the UC had progressed to pancolitis
in 54 (15%) in a period of 7 2 years. In patients with
proctitis, further progression to left-sided colitis was
observed in 13 patients (10%) in a period of 5 3 years.

Surgery
During this period, 86 (10.1%) of the UC patients
underwent proctocolectomy, 84 patients had pancolitis and
only 2 cases had left-sided colitis. The most common causes
of colectomy were: failed to medical treatment (89.9%),
toxic megacolon (5.6%), perforation (3.7%), cancer
(0.5%), and massive hemorrhage (0.3%). Forty-three
patients underwent colectomy in their rst 5 years since
diagnosis. Four patients developed dysplasia or colorectal
cancer 15 years after the initial diagnosis.

Extraintestinal Manifestations
Three hundred fty-two UC patients (41.5%) had
extraintestinal manifestations that included: arthritis

100
80

Pancolitis (E3)

60

Year 06

Year 05

Year 03

Year 04

Year 01

Year 02

Year 99

Year 00

Year 97

Year 98

Year 96

Year 90

Year 88

Year 89

Year 87

Year 94

Proctitis (E1)
Year 95

20

Year 93

Left-sided colitis
(E2)

Year 91

40

Year 92

Number of New cases

120

FIGURE 1. New cases of ulcerative colitis diagnosed during the

20-year period of study in Mexico.

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FIGURE 3. Distribution of extent of ulcerative colitis in Mexican

patients.
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30

Frequency

25
20
15
10

Ankylosing
spondilitis

Uveitis

Pyoderma

Sacroiliitis

Erythema
nodosum

PSC

Arthropathy

FIGURE 4. Frequency of extraintestinal manifestations in patients

with ulcerative colitis.

(24.4%), PSC (10.5%), erythema nodosum (4.4%), sacroiliitis (3.1%), pyoderma gangrenosum (2.2%), anterior
uveitis (2.0%), and ankylosing spondylitis (1.1%) as shown
in Figure 4.

Medical Treatment
Most of the patients, 762 (89.8%) were taking
sulfasalazine or 5-aminosalicylic acid (5-ASA); 282 (33.3%)
used oral or systemic glucocorticosteroids; 237 (28%) were
taking azathioprine and other treatments (0.5%). Topical
medication was used in 110 patients with proctitis (13%)
based on 5-ASA. Sulfasalazine or 5-ASA was used over the
course of the follow-up. Oral and systemic glucocorticosteroids at dierent points in time and azathioprine was added
during the course of disease (Table 1).

DISCUSSION
To the best of our knowledge, this is the rst Latin
America study that reports the clinical epidemiology in a
large cohort of Mexican patients with UC. Some reports
have suggested a lower incidence and milder course of UC
in Latin America.3 However, the epidemiology and clinical
characteristics are still unknown. Variable incidence and
prevalence rates, and clinical features of UC in dierent
ethnic populations, may provide insight into the pathophysiology of UC. In the developing world, true populationbased registries are hard to nd, and consequently studies
are commonly hospital-based.
An important nding from this study is the increasing
frequency of new UC cases diagnosed in the last decade
in Mexico. The possible explanations of this increased

TABLE 1. Medical Treatment Used in UC Mexican Patients

Sulfasalazine
5-aminosalycilic acid (5-ASA)
Oral and systemic glucocorticosteroids
Azathioprine
6-mercaptopurine
Iniximab
Budesonide
UC indicates ulcerative colitis.

2009 Lippincott Williams & Wilkins

25.5%
64.3%
33.3%
28%
2%
1.17%
0.6%

Clinical Epidemiology of Ulcerative Colitis in Mexico

incidence may be a westernized lifestyle, in terms of dietary

habits and smoking, and also improving the diagnostic
modalities and a lower prevalence of infectious diseases by
worm parasites, where helminth carriage has steadily
declined.5 There is increasing evidence to indicate that
helminth carriage might protect the host from immunologic
disorders. Most helminths stimulate the production of TH2
cytokines [interleukin (IL)-4, IL-5, IL-9, IL-13]. This
mechanism would explain the protective role of helminthes
in TH1-driven disorders such as intestinal inammation.
These results conrmed that the incidence of UC is
increasing in Mexico and it is according to other studies
from Canada, Romania, and Lebanon.68
The present study identied some dierent clinical
characteristics of UC to that reported in white and Asian
populations. In relation to demographic characteristics, the
age of onset for UC (almost equally present in both sexes)
and a high percentage of nonsmokers are similar to the
reports in other countries. However, an interesting nding
was the low frequency (6.78%) of familial aggregation of
UC found in the Mexican population compared with a high
proportion of familial aggregation of UC (13.4% to 15%) in
countries from Northern Europe and the United States.9,10
There are clinical manifestations that may act dierently among the dierent ethnic groups. Previous studies
have shown dierent frequencies regarding the extent of the
disease. In the present study, 59.1% showed pancolitis,
the highest frequency reported up to now. In contrast, the
frequency of pancolitis was lower in other populations such
as China (7.3%),11 Korea (30.9%),12 Iran (18.1%),13 and
European countries (15%).3,1416 In the present study, the
rate of colectomy was 10.1%, which is according to a recent
follow-up studies that reported only 7.5% of the UC
patients had been colectomized during the 5-year period16
but diers from other European studies where the
cumulative risk for colectomy was 20% after 5 years of
evolution of the disease.17
On the other hand, dysplasia and colorectal cancer was
noted in 4 UC patients (0.5%) similar to that reported in the
Iranian and US populations13,18 but higher rates of colorectal cancer have been reported in white populations.19,20
In this study, the frequency of extraintestinal manifestations was 41.5%, which is consistent with that reported
in Western countries between 21% and 41%21 and Indian
population.22 In contrast, low rates were reported in
Chinese (6.1%) and Korean (24.1%) populations with
UC.11,23 In addition, a high frequency (10.5%) of PSC was
found in the Mexican population compared with the
European and North American studies.21,24
The high frequency of pancolitis and PSC was found
at this hospital population can be explained by referral bias
used to admit patients and because it is the biggest
specialized medical center in whole country.
The number of new cases has increased signicantly in
the last decade in Mexico, conrming this tendency in the
world including Latin American countries. Interestingly,
some clinical features of UC are dierent compared with
other populations such as a high frequency of pancolitis and
extraintestinal manifestations (PSC) and also the low rate of
familial aggregation, colorectal cancer, and colectomy.
The diverse clinical patterns of UC in several
geographic regions are inuenced by genetic and environmental factors, whereas a low familial aggregation and high
prevalence of infectious diseases (including parasites) in
Mexico could aect the clinical course of the disease.

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Yamamoto-Furusho

In conclusion, the incidence rate of UC in Mexico has

increased in the last 10 years and UC seems to have dierent
clinical features as compared with other populations.
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