Published online Feb 28, 2019. doi: 10.3748/wjg.v25.i8.989
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
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.
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.
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.
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.
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).
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.
Prospective studies are needed to reduce recall bias for important clinical studies such as the first day of UC-related symptoms.