Inflammatory bowel disease in Pakistan: Low prevalence or underdiagnosis?

Abstract

Inflammatory bowel disease (IBD) has a low prevalence in the Global South, including Pakistan. While genetics and gut flora, influenced by diet and the environment, can contribute to this, we are exploring the possibility of underdiagnosis. Lack of facilities trained in IBD, scarcity of medications, limited health insurance for specialist referral and the current epidemic of abdominal tuberculosis could be the cause. The increasing diagnosis of IBD among Pakistani immigrants and colorectal carcinoma among the young population might be the result of this. Timely referrals by primary care physicians to gastroenterologists, along with the growing use of newer technologies such as abdominal ultrasound for diagnosis can help mitigate the challenge of low or late diagnosis of this chronic condition.

Key Words: Inflammatory bowel disease; Crohn’s disease; Ulcerative colitis; Pakistan; Third world country

Core Tip: We wanted to shed light on the low prevalence of inflammatory bowel disease in Pakistan, which is due to many factors; the main one being underdiagnosis. There is a need to incorporate newer diagnostic modalities along with educating the general physicians about the disease and when to refer these patients to specialists.

TO THE EDITOR

Inflammatory bowel disease (IBD) is a chronic, relapsing, noninfectious disorder of the gastrointestinal tract. It is a spectrum of diseases, with Crohn's disease (CD) and ulcerative colitis (UC) at its two ends.

PATHOGENESIS

The exact cause of this condition is not fully understood, but it is believed to be a result of a combination of genetic factors, environmental triggers, and immune responses. This leads to an abnormal reaction of the body's innate and adaptive immune responses to gastrointestinal bacteria and food antigens. Diagnosing IBD includes a combination of clinical symptoms, endoscopic findings, radiology, macroscopic evidence, and histology. Underdiagnosing IBD can lead to complications, with CD manifesting as strictures, abscesses and fistulae, and UC posing a risk factor for colorectal carcinoma[1,2].

PREVALENCE IN SOUTH ASIA

Among South Asian countries, India has the highest incidence of patients diagnosed with IBD[3]. To date, there has been no epidemiological study for IBD in Pakistan, hence little is known about the exact extent or severity of the disease in Pakistan[4].

REASON FOR UNDERDIAGNOSIS

Lack of healthcare facilities, shortage of IBD-trained gastroenterologists and nursing staff, financial constraints, and limited health insurance contribute to IBD being underdiagnosed. This, coupled with limited early colonoscopy referrals and self-medication with over-the-counter antibiotics, hints at a possible hidden burden of IBD in our population[2].

The current tuberculosis (TB) epidemic in our region makes it challenging to differentiate between CD and intestinal TB because both are chronic granulomatous disorders with similar clinical presentations and endoscopic and histological features[2]. Akhtar et al[1] mentioned in their cross-sectional study investigating the factors contributing to the diagnosis of IBD in one center in Pakistan that ~40% of people diagnosed with CD had taken anti-TB therapy. This may also end up with physicians favoring diagnosing abdominal TB due to availability bias. Moreover, misdiagnosing or delaying the diagnosis of either condition may result in serious complications with poor morbidity.

The underdiagnosis of IBD may also contribute to the increasing incidence of colorectal cancer (CRC) in Pakistan. In one epidemiological study investigating IBD across Asia, Park and Cheon[5] highlighted that South Asians including Pakistanis show an increasingly high prevalence of UC compared to Europeans in a survey conducted in the UK with a ratio of 135 to 90.8 cases. The prevalence of CD was lower than in Europeans within the same community with a prevalence of 33.2 to 75.8 cases. This finding was confirmed by Akhtar et al[1], who reported 238 cases of UC compared to 22 cases of CD among 270 patients in a study conducted in one clinical site located in Pakistan[5]. It has been estimated that half of the new cases of CRC in Pakistan occur in young patients and present as advanced stages of cancer. Additionally, since over 80% of the Pakistani population is under 40 years old, the number of people at risk of developing early-onset CRC in Pakistan is higher compared to the rest of the world[6].

While always thought of as a disease of the West, the increasing incidence of IBD among first and second-generation immigrants in western countries also indicates how the lack of enhanced diagnostic facilities plays a role in its current low prevalence in Pakistan. Park and Cheon[5] shed light on the increasing incidence of IBD in Pakistani immigrants compared to native white Europeans in the UK. However, the impact of environmental factors should also be investigated concerning immigration-related changes in the gut microbiome[5]. Numerous studies of IBD have been conducted in different cities in Pakistan; however, there are still no collective epidemiological data on IBD.

CONCLUSION

More attention must be given to the diagnosis and management of IBD in Pakistan. Recent literature suggests the use of intestinal ultrasound for diagnosing IBD. This noninvasive and cost-effective modality could be a stepping stone in addressing the underdiagnosis of this disease in Pakistan. Primary care physicians encountering patients with chronic gastrointestinal issues should prioritize educating them about IBD and advising them on when to seek specialist referrals. Access to medications including biological agents and treatments including interleukin inhibitors and Janus kinase inhibitors should be made available at lower cost in resource-limited countries like Pakistan. These measures have the potential to enhance the quality of life for individuals experiencing chronic unexplained gastrointestinal issues due to IBD in Pakistan.