I refer to the interesting study by Alreheili et al.[1] published in this Journal. It is well-known that inflammatory bowel disease (IBD) is associated with a variety of extraintestinal manifestations (EIMs) that could produce greater morbidity than the underlying intestinal disease and might even be the initial presentation of IBD. The authors mentioned that during the 10-year study period (2001–2011) in a single-center in the Kingdom of Saudi Arabia (KSA), EIMs were reported in 21 (31.8%) of 66 patients.[1] These included osteoporosis/osteopenia (n = 11), peripheral joint inflammation (n = 9), primary sclerosing cholangitis (n = 5), erythema nodosum (n = 2), sacroiliitis (n = 2), ankylosing spondylitis (n = 2), pyoderma gangrenosum (n = 1), and uveitis/episcleritis (n = 1).[1] Interestingly, this reported prevalence of EIMs appeared higher than that previously reported in KSA. For instance, Hasosah et al.[2] reported that during the 7-year study period (2005–2012) in a single center, only one child (8%) with skin involvement (pyoderma gangrenosum) was observed among 12 pediatric IBD patients. AlSaleem et al.[3] noted that during the 9-year study period (2003–2012) involving 188 pediatric IBD patients from 15 medical centers from different regions in KSA, EIMs were reported in only 6 (4%) patients, namely arthritis (n = 3) and skin rash (n = 3). I presume that the differences in the reported prevalence and pattern of EIMs in the study by Alreheili et al.[1] and that reported in other Saudi studies[2,3] could be plausibly explained by a number of factors.
First, there were variations in the size of the studied population, study period, and the number of settings. This could importantly affect the accuracy of results. Second, there is a correlation between IBD severity and likelihood to have EIMs where increased IBD severity was found to be associated significantly with the occurrence of any EIMs (P < 0.001).[4] Third, the incidence of EIMs both before and after diagnosis of IBD differs markedly by the duration of the disease. The cumulative incidence of EIMs was reported to be 9% at 1 year, 19% at 5 years, and 29% at 15 years after diagnosis.[5] Fourth, the potential roles of different genetic and environmental influences related to Saudi pediatric population as well as undetermined factors in enhancing the development of EIMs must not be overlooked.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest
REFERENCES
- 1.Alreheili KM, Alsaleem KA, Almehaidib AI. Natural history and outcome of inflammatory bowel diseases in children in Saudi Arabia: A single-center experience. Saudi J Gastroenterol. 2018;24:171–6. doi: 10.4103/sjg.SJG_490_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hasosah MY, Sukkar GA, Alsahafi AF, Kutbi SY, Alzabn AA, Jacobson K. Pediatric inflammatory bowel disease in the western region of Saudi Arabia. A retrospective analysis. Saudi Med J. 2013;34:651–3. [PubMed] [Google Scholar]
- 3.AlSaleem K, El Mouzan MI, Saadah OI, AlSaleem B, Al-Hussaini A, Hassosa M, et al. Characteristics of pediatric ulcerative colitis in Saudi Arabia: A multicenter national study. Ann Saudi Med. 2015;35:19–22. doi: 10.5144/0256-4947.2015.19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Dotson JL, Hyams JS, Markowitz J, LeLeiko NS, Mack DR, Evans JS, et al. Extraintestinal manifestations of pediatric inflammatory bowel disease and their relation to disease type and severity. J Pediatr Gastroenterol Nutr. 2010;51:140–5. doi: 10.1097/MPG.0b013e3181ca4db4. [DOI] [PubMed] [Google Scholar]
- 5.Jose FA, Garnett EA, Vittinghoff E, Ferry GD, Winter HS, Baldassano RN, et al. Development of extraintestinal manifestations in pediatric patients with inflammatory bowel disease. Inflamm Bowel Dis. 2009;15:63–8. doi: 10.1002/ibd.20604. [DOI] [PMC free article] [PubMed] [Google Scholar]