Alimentary tract and pancreas

                  Alimentarni trakt i pankreas 

                              ARCH GASTROENTEROHEPATOL 2000; 19 ( No 3 – 4 ):


           Epidemiologija inflamatornih bolesti creva u jednom delu Beograda

           ( accepted November 3rd, 2000 ) 

            IBD epidemiology in Belgrade

            1Njegica Jojic, 1 Dusan Djurdjevic, 2 Svetlana Milutinovic,  3 Slobodan  Jovicic,

           4 Zoran Kekic,   Mihailo Alic.

1Center for Gastroenterology, 2Human Pathology, 3Radiology, and 4Digestive

Surgery, Zvezdara   Clinical and Hospital Center, Belgrade.

Address correspondence to: Professor Dr Njiegica Jojic

                                                 Zvezdara   Clinical Center

                                                 161 Dimitrija Tucovica St.

                                                YU-11000 Belgrade, Serbia, Yugoslavia

                                                E-mail: [email protected]

Abbreviations used in this article: IBD, inflammatory bowel disease;UC,

ulcerative colitis; CD, Crohn , s disease.


In order to determine the incidence of IBD in one part of Belgrade ( Community of Zvezdara, population 540 000 ), all hospital and outpatient IBD records of  Zvezdara Clinical Center from 1988 to 1998 were reviewed. During that period 187 new IBD cases were registered: 109 ulcerative colitis and 78 Crohn’s disease cases. An average incidence was 3.14 ( 95% confidence interval was 1.78 – 4.5 ) /100 000/ year. In the last few years IBD incidence increases to 4.5 / 100 000 / year. This tendency was characteristic for both diseases, but an increase of Crohn’s disease especially Crohn’s colitis was remarkable. We found that genetic factors and smoking were of lesser importance in the aetiology of IBD in this series.

Key words: epidemiology, IBD.


Epidemiološka ispitivanja inflamatornih bolesti creva ( IBD ) u Jugoslaviji još nisu završena. U ovome radu se prikazuju rezultati retrospektivne studije uradjene u KBC Zvezdara koji obezbedjuje zdravstvenu zastitu dela Beograda u kome zivi 540 000 stanovnika. U periodu od 1988 do 1998 godine ukupno je dijagnostikovano 187 pacijenata obolelih od IBD:109 sa ulceroznim kolitisom ( UC ) i 78 sa Crohnovom bolešću. U periodu ispitivanja incidencija IBD iznosi 3.14    ( 95% interval poverenja je 1.78 -4.5 ) na 100 000 stanovnika godišnje. Zadnih godina ta incidencija je bila veća i iznosila je 4.5/100 000/ godišnje što je značajno povećanje u odnosu na početni period. Uočeno je povećano oboljevanje od obe bolesti, a posebno CD i to pre svega Crohn kolitisa. Kliničkoepidemiološke odike naših pacijenata su slične onima obavljenim od strane drugih regionalnih studija. Ovo ispitivanje je pokazalo da u našoj grupi ispitanika genetski činioci i pušenje nemaju veći značaj u etiologiji IBD.

Ključne reči:epidemiologija, IBD.



Inflammatory bowel disease ( IBD ) classically includes ulcerative colitis (UC) and Crohn’s disease ( CD ). The aetiology of both diseases is unknown. They tend to affect young people, have chronic relapsing course and represent a serious health problem in many developed countries ( 1 ). The geographic incidence of IBD varies. The highest incidence is reported in Northern and Western Europe and North America ( 2,3,4,5,6,7 ). The incidence is lower in Central and Southern Europe ( 8,9,10,11,12,13,14,15 ).

The exact data about the incidence of IBD in this country are lacking. The national epidemiological study for the whole country was not completed yet. There is one estimation that in the whole country with approximately 8 000 000 inhabitants there is  about 1000 patients with UC and 500 patients with Crohn’s disease. 

Here we present the results of epidemiological study of IBD in one part of Belgrade during 11 years period ( January 1988  - December 1998 ).


This study represent the results of the epidemiological survey of IBD in one part of Belgrade ( Community of Zvezdara, population 547 000 ) performed in Zvezdara Clinical Center, referral hospital for the whole community.   Parts of the study group ( 60 000 people ) were war refuges from Bosnia. The majority of population is urban; about 5-10% is rural. The population is racially and religiously homogeneous, 70% of people are Serb - orthodox.

This study includes all hospital and outpatient cases with definitive diagnosis of IBD. All files were reviewed and the following information was retrospectively collected: number of new cases, age, sex, symptoms, extension of inflammation, extraintestinal manifestations, performed operations, complications, smoking habits, and family history. Information’s about Zvezdara Community population were provided by Belgrade Statistical Center. 95% confidence limits were calculated for the number of cases per 100 000 inhabitants.


During the study period 187 new IBD patients were registered: 109 with UC and 78 with CD. The mean annual incidence for both diseases was 3.14 ( 95% confidence interval was 1.78 -4.5 ) cases /100 000 inhabitants/ year. The mean annual incidence of IBD during the whole period was demonstrated on Table 1.  Significant increase in the incidence during the observation period was noticed. In the last few years the incidence was 4.5/ 100 000/ year representing an increase of 73%. Significant rise was observed particularly during 1993 and 1994 for both diseases, UC and CD. For CD, especially Cohn’s colitis this was much more evident.

The main characteristics of our group of patients are presented on Table 2. Regarding sex distributions, there was no difference between males and females: 81 ( 43% ) were males and 106 ( 57% ) females. At the time of diagnosis 70% of patients were below the age of 40. For UC the highest incidence was in the age group 30-39, without second peak after 60.  For CD the highest incidence was in the age group 20-29.

The pattern of anatomic involvement for both diseases is shown on Table 3. For CD this was as follow: terminal ileum with or without caecal involvement ( 40%), ileum and colon ( 25% ), large bowel only ( 24% ), and small intestine ( 11% ). We used Vienna classifications of CD ( 4 ). At the time of diagnosis in CD patients the type of predominant symptoms was related with anatomical location. The most common symptoms were abdominal pain ( 83 % ) and diarrhoea ( 78% ). Table 4. In 23 % of CD patients perianal disease was evident, mostly in colonic CD. The most common changes were fistulae and abscesses. At the end of study 27 ( 34% ) patients were operated, 4 ( 5% ) had second operation. CD was complicated with malignancy in 2 ( 2.5%) cases. One lady suffered of leukemia; the second had small intestinal carcinoma.

Among the patients with UC the most frequent form was distal colitis ( 46 % ) followed by proctitis ( 15 % ), and pancolitis ( 19 %). In 20% of cases disease extent was not recorded. The most frequent clinical symptoms were rectorrhagia ( 87% ) and diarrhoea ( 61% ). Moderately active disease had 60 % of UC patients. Fulminant colitis had only 9 % of cases. Total colectomy was performed in 7 ( 6.4%) patients eventually. Large bowel carcinoma complicating long standing UC was diagnosed in 5 ( 4.6% ) patients.

Extraintestinal manifestations were encountered in 54 ( 29% ) IBD patients, particularly CD cases. Joint manifestation had 31 %, hepatobiliary 7%, skin 5%, ocular 9%, and oral 18% patients. Familial clustering of IBD was observed in 5 ( 2. 9%) patients. Most of them were first-degree relatives. Data regarding smoking habits were available from 46 % of the whole IBD group. There were no significant differences between CD ( smokers: 56% ) and UC ( smokers: 52%) patients. The data about the duration of smoking or the time of giving up were not available. During this period six patients died, two with CD and four with UC.


The incidence of IBD worldwide varies. It is higher in Northern Europe and Scandinavia then in Central and Southern Europe ( 1,3,8,12,13,15 ). In this country national epidemiological study was not completed yet.

We demonstrated that although low, the incidence of IBD is increasing. The mean annual incidence of UC and CD for the whole period was 3.14/ 100 000. At the end of study this rises to 4.5/100 000 ( 73% increase ).  This trend was equally applicable for UC and CD, but an increase of CD incidence especially Crohn , s colitis was much higher. This might reflect greater awareness, improved diagnostics, and changes of operational environmental factor(s). Significant number of war refuges from Bosnia and Croatia with newly diagnosed IBD, specific changes of socio-economic factors and greater exposure to stress were operable.  

The incidence of IBD in this well defined population and their clinico-epidemiological characteristics are in accordance with those reported from another clinical centers from Serbia and neighboring Mediterranean countries (10,11,12,13,14,15,16,18,17). The actual local Belgrade IBD incidence rate is still lower than those reported from Western and Northern Europe, where they are between 6.4 to 11.6 ( 2,4,5,6,7 ). In the Netherlands and Germany they are similarly between 3.1 and 4.0. ( 8,9,10 ).

The increase of incidence rate for UC in this study was mainly restricted to milder cases and left side colitis. But considerable part of UC population was patients with severe pancolitis. An incidence increase of CD was mainly restricted to  Cohn’s colitis and penetrating disease. According to Vienna classifications at the time of diagnosis most patients had A1L1B1 phenotype, which is not too aggressive ( 19 ) . It seems that this subgroup of Crohn’s patients is prevailing in the whole region ( 20 ).  In our study there were no difference between the male and female incidence; most studies are showing male predominance in UC and equal sex distribution in CD ( 4,21 ). The incidence of UC was highest in the age group 30-39, what is in accordance with the majority of other studies ( 4,13 ). We did not observe the second peek incidence of UC after the age 60, what was reported elsewhere ( 4,13 ). We confirmed that at the time of diagnosis the majority of CD patients are below the age of 40 ( 4,5,6,14,15 ).

In this study we found that genetic and environmental factors like smoking did not have any significant role in the aetiology of IBD what is already reported in Greece ( 17 ).




Table 2. The main epidemiological characteristics of IBD


The total number of IBD



N° of  UC patients


N° of CD patients


Mean annual incidence per         per 10000r per  100,000  inhabitants


95% confidence interval



                       81 (43%)


                    106 (57%)

Peak age-related incidence

  for UC


Peak age-related incidence

  for CD


Table 3. The pattern of anatomic involvement for both disease

Cohn’s disease

Ulcerative colitis

T.ileum, cekum

         31 (40%)

Rectum only

          16 (15%)

T.ilum, colon

         20 (25%)

Left -sided colitis

          50 (46%)

Colon only

         19 (24%)


          21 (19%)

Small intestine

           8 (11%)

Not recorded

          22 (20%)


          78 (100%)


        109 (100 %)

Table 4.The frequency of predominant symptoms at the time of diagnosis in the IBD







           69 (61%)

            61 (78%)

Abdominal pain

           32 (29%)

            65 (83%)

Blood in stools

           26 (33%)

            95 (87%)

Extraintestinal  manifest



              54 (29%)



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