Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 28, 2019; 25(8): 989-1001
Published online Feb 28, 2019. doi: 10.3748/wjg.v25.i8.989
Two-year delay in ulcerative colitis diagnosis is associated with anti-tumor necrosis factor alpha use
Ho Suk Kang, Ja Seol Koo, Kang Moon Lee, Dae Bum Kim, Ji Min Lee, Yoon Jae Kim, Hyuk Yoon, Hyun Joo Jang
Ho Suk Kang, Department of Internal Medicine, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, South Korea
Ja Seol Koo, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan 15355, South Korea
Kang Moon Lee, Dae Bum Kim, Ji Min Lee, Department of Internal Medicine, The Catholic University of Korea, St. Vincent’s Hospital, Suwon 16247, South Korea
Yoon Jae Kim, Department of Gastroenterology, Gachon Graduate School of Medicine Gil Medical Center, Incheon 21565, South Korea
Hyuk Yoon, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, South Korea
Hyun Joo Jang, Division of Gastroenterology, Department of Internal Medicine, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, South Korea
Author contributions: Koo JS designed the study; Koo JS, Kang HS, Kim DB, Lee JM, Kim YJ, Yoon H and Jang HJ performed the data collection; Kang HS analyzed the data and wrote the manuscript; Kim DB, Lee JM, Kim YJ, Yoon H and Jang HJ revised the manuscript for important intellectual content; Lee KM supervised the study; all authors have read and approved the final version to be published.
Institutional review board statement: This study was conducted with the approval of the ethics committee of Hallym University Sacred Heart Hospital in Anyang, South Korea, IRB No. 2016-I607.
Informed consent statement: The need for informed consent was waived.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Ja Seol Koo, MD, PhD, Professor, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Jeokgeum-ro 123, Danwon-gu, Ansan-si, Gyeonggi-do 15355, South Korea.
Telephone: +82-31-4124853 Fax: +82-31-4125582
Received: December 11, 2018
Peer-review started: December 11, 2018
First decision: January 23, 2019
Revised: January 30, 2019
Accepted: February 15, 2019
Article in press: February 16, 2019
Published online: February 28, 2019
Research background

Ulcerative colitis (UC) is diagnosed by clinical, endoscopic, and histologic findings because there is no definite diagnosis index. Therefore, differentiating it from other diseases of the intestines, such as acute gastroenteritis or irritable bowel syndrome is often difficult, and its diagnosis is often delayed. Recent studies have shown that early control of inflammatory bowel disease (IBD) affects the quality of life and the disease course, including its prognosis.

Research motivation

Most studies of a diagnostic delay for IBD were focused on Crohn’s disease. There have been reports of clinical factors involved in the diagnostic delay of UC, but there is a lack of information regarding whether this delay affects the prognosis and treatment of UC. Diagnostic delay and its impact on Western and Asian populations may be significantly different owing to genetic or environmental factors; therefore, it is necessary to examine the results according to countries or regions.

Research objectives

We aimed to identify the delay in diagnosis (time from the first symptoms to UC diagnosis) that affected treatment and prognosis. We also evaluated the risk factors and clinical significance of a diagnostic delay for UC in South Korean patients.

Research methods

This retrospective study was based on patient data collected from six university-affiliated hospitals located in South Korea from January 2006 to December 2016. We analyzed the medical records of 718 patients who visited the outpatient clinic in 2016, had a definite diagnosis of UC, and were available for follow-up for more than 6 mo. One hundred sixty-seven patients were excluded from the study because of incomplete medical record data regarding the first day of symptoms. To determine the prognostic factors, the use of anti-tumor necrosis factor alpha (TNFα) drugs, the hospital admission history due to acute flare-ups, frequent admission, surgery associated with UC, and the clinical remission state at the latest follow-up were obtained from the medical records. The diagnostic interval was defined as the time from the first symptom until UC diagnosis. We divided the patients into the early and delay groups according to several diagnostic interval criteria (3 mo, 6 mo, 12 mo, 18 mo and 24 mo. Then, we compared the two groups according to the demographic and clinical characteristics to determine the diagnostic delay having a clinical impact.

Research results

The days from first symptoms to UC diagnosis were 223.28 ± 483.15 (median, 69); 75% of patients were diagnosed within 195 d. The use of anti-TNFα drugs at the 3-mo diagnostic interval was insignificantly prevalent in the early group (34/314; 10.6%) and the delay group (16/229; 7.0%); however, the use of anti-TNFα drugs by the early group and delay group started to decrease at the 18-mo diagnostic interval. Finally, at the 24-mo diagnostic interval, it was significantly higher in the delay group (8/42; 35.7%) than in the early group (42/509; 8.3%) (P = 0.019). Anti-TNFα free-survival rates between the early and delay groups according to the 24-mo diagnostic interval were significantly different (P = 0.034). Therefore, it was determined that 24 mo was the diagnostic delay cutoff point for poor outcomes. According to the multivariate logistic regression analysis, independent risk factors predictive of a diagnostic delay of 24 mo were age < 60 years [odd ratio (OR) = 14.778, 95% confidence interval (CI): 1.731-126.121, P = 0.014], smoking history (OR = 2.688, 95%CI: 1.239-5.747, P = 0.012), and misdiagnosis of hemorrhoids (OR = 11.066, 95%CI: 3.596-34.053, P=0.000).

Research conclusions

We found that the ≥ 24-mo diagnostic delay group more frequently used anti-TNFα compared to the < 24-mo delay group. We also found that risk factors for a 24-mo delay were age < 60 years, smoking history, and misdiagnosis of hemorrhoids by a physician.

Research perspectives

Prospective studies are needed to reduce recall bias for important clinical studies such as the first day of UC-related symptoms.