Journal of Crohn's and Colitis (2010) 4, 532536

available at www.sciencedirect.com

Ulcerative colitis in the county of Uppsala 19452007

Incidence and clinical characteristics
A. Rnnblom a,, S.-M. Samuelsson b , A. Ekbom c
a

Department of Internal Medicine, Uppsala University Hospital, Uppsala, Sweden

Department of Social Medicine, Uppsala University, Uppsala, Sweden
c
Anders Ekbom, Clinical Epidemiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden
b

Received 30 January 2010; received in revised form 9 March 2010; accepted 9 March 2010

KEYWORDS
Ulcerative colitis;
Epidemiology;
Incidence

Abstract
Objective: The incidence of ulcerative colitis has increased in many parts of the world during the
second part of the twentieth century. In the county of Uppsala in the middle part of Sweden, the
epidemiology of ulcerative colitis has been studied during two different time periods, 19451964
and 19651983. These figures have now been compared to the present day situation, 20052007.
Method: The incidence figures in the two first studies were the results of retrospective studies
but the figures from 2005 to 2007 were generated prospectively. The clinical characteristics
during 19451964 were described according to the Montreal classification and a comparison
between the first and third study periods could therefore be done.
Results: During the study period, the population of the county increased from 146 000 to 323 270
inhabitants. The crude incidence of ulcerative colitis increased from 2 to 19.2 new cases per
100 000 inhabitants/year. The age distribution was remarkably stable when the first 20 years was
compared with the last 3 years (mean age 36 vs. 38.1 and range 284 vs. 384) except for those
below 11 years of age.
Conclusion: Between 1945 and 2007 the incidence of UC in the County of Uppsala increased from
2 to 19.2 new cases/100 000. The increase affected all age groups except those below 11 years of
age.
2010 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

Corresponding author. Magtarmmottagningen, Akademiska sjukhuset, 751 85 Uppsala, Sweden. Tel.: +46 186114425; fax: +46 18515938.
E-mail address: Anders.ronnblom@akademiska.se (A. Rnnblom).
1873-9946/$ - see front matter 2010 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.crohns.2010.03.003

Ulcerative colitis, incidence

Summary box
What is already known:
The incidence of ulcerative colitis has increased in
most parts of the world during the second part of last
century.
Individuals in the age interval 2030 years are most
commonly affected.
A secondary incidence peak among elderly men is
commonly described.

What is new:
The increase in incidence of ulcerative colitis has
continued in the new century.
This increases affects all age groups except those
below 11 years of age.
The clinical characteristics of the disease has been
stable during more than 60 years.

Clinical consequences:
The search for the probable environmental factor(s)
causing this increase must continue.

533
simoideoscopy and barium enema. Cases were identified by
scrutinising registers at the three hospitals in the county as
well as clinical notes from GPs and private practitioners.
Departments of Medicine, Surgery, Pediatrics, and Infectious
Diseases were included, and the reports of all barium enemas
during the study period were checked. After a reexamination
of the X-ray reports and the histopathological specimens,
seven cases of Crohn's disease were excluded from the
material, and 220 patients were left.
The second period in this study was a part of a large
retrospective regional study4 including the Uppsala Health care
region with a population of about 1.3 million. A similar method
of case finding was used; all possible cases from the Inpatient
Registry were checked, records from the Department of Clinical
Pathology were reviewed and the diagnostic criteria were
based upon those of Garland for definite and probable cases.7
The third period (20052007) was a prospective study in
the county of Uppsala where case finding was based on a
continuous check of every visit at the Section of Gastroenterology and Hepatology as well as all colonoscopies
performed during the study period. All new cases from the
Department of Pediatrics where all new cases are primarily
taken care of as inpatients are included. The same methods
were used in the other hospital in the county. The diagnostic
criteria were: a history compatible with UC but not
necessarily with a duration of 6 weeks6 and an endoscopical
picture compatible with UC and histopathological findings
not contradicting the diagnosis.

1. Introduction

3. Statistics

The epidemiology of IBD has been studied in many parts of the

world since the latter part of the twentieth century. There
are, however, only a few reports describing the epidemiology
from the same area for more than 50 years; Crohn's disease
(CD) in Cardiff 193120051 and ulcerative colitis (UC) and CD in
Olmsted county 19402000.2 The epidemiology of UC in the
county of Uppsala has previously been studied during two
different time periods, 194519643 and 19651983.4 The
former of these studies was a very careful clinical study with
clinical descriptions making it possible to characterise the
material according to the Montreal classification.5
The aim of the present study is to compare the earlier
incidence figures with the present situation and to compare
the clinical forms of the disease during the different epochs
with respect to clinical severity at presentation, delay in
diagnosis, extent of disease and clinical course during the
first years after diagnosis.

Population data by age and sex for each year were obtained
from the Swedish Population Statistics Registry (http://
www.scb.se). Comparison between the first and last study
period was performed with the 2-test.
The study was approved by the local Ethics Committee at
Uppsala University.

2. Patients and methods

The county of Uppsala is located in the middle of Sweden
north of Stockholm, the capital of Sweden. The majority of
the population is living in the university town of Uppsala
which is dominated by the University Hospital and the
University. The population of the county has increased from
146 000 to 323 270 inhabitants in 19452007.
The diagnostic criteria during the first 20 years of the
study were those of Evans and Acheson6 and the study
was retrospective. The diagnostic methods used were rigid

4. Results
During the first 20 years of the study period, 220 new cases of
UC were identified, to be compared with 165 during the last
3 years, corresponding to an increase from 2 to 19.2 new
cases/100 000 within the same geographical area, Fig. 1.
Gender, age and clinical characteristics at presentation are
described in Table 1.
A comparison between the first and last study periods
demonstrates that the diagnostic delay between start of
symptoms and diagnosis has been shortened, and that the
distribution of different severity forms has changed, i.e.
during the latter period a smaller proportion of cases with
severe disease activity were found. The extension of
inflammation at diagnosis was similar but the incidence
increased dramatically and evenly in different age groups
except for those below 11 years of age, Fig. 2. When the age
standardised incidence figures were analysed with respect to
gender, a second peak could be observed, more prominent
for males than females, and at higher age for males, Fig. 3.
A relapse-free course after the first attack followed 15%
and 12% of the patients respectively after 1 and 3 years in the

534

A. Rnnblom et al.

Table 1

Clinical characteristics during the first and last study period.

Male/female
Age, years (mean, median, range)
Time before diagnosis. (%)
-Within 1 year
-1-3 year
-more than 3 years
Extension (%)
-Proctitis
-Left side colitis
-Extensive colitis
-At least left side
Severity (%)
-Mild
-Moderate
-Severe

1945-1964

2005-2007

(n = 220)

(n = 165)

1,1
E1; 32 36 2-86*
E2-3; 38 43 6-89**

1,2
38,2 35,0 3-84

70
12
18

93
2
5

51
21
28

32
25
35
7

74
19
7

58
40
3

2test P = 0,0001

2test P = NS

2test P b 0,0001

*Age at first symptoms, ulcerative proctitis and **ulcerative colitis respectively.

first study group. Corresponding figures for patients

recruited in 20052007 were 34% and 12%.

5. Discussion
We have demonstrated that within a defined Swedish
geographical area, the incidence of UC during a period of
60 years has increased in all age groups with exception for
the youngest. During this period, the demographical characteristics of the affected individuals have been remarkably
stable. Clinical differences were the shorter delay between
start of symptoms and diagnosis during the latter period as
well as a dominance of individuals with a moderate severity
of the disease.
Since there are no pathognomonic findings that give the
diagnosis for ulcerative colitis, different criteria have been
used during different time periods. The criteria of Evans and

Fig. 1

Incidence of UC in Uppsala county 1945-2007.

Acheson6 state that the symptoms must have been present

for at least 6 weeks, but in the last study period 50 out of 165
patients got their diagnosis within 4 weeks, making the
6 week criterion difficult to use. In the ECCO criteria of UC8
no definite time with symptoms is required. As can be seen in
Table 1, there was also a general shortening of the time
between start of symptoms and the meeting with the doctor,
between the study periods. This could be the explanation for
the lower proportion of severe cases during the latter period.
Time before first relapse has been reported to vary in
different studies. In the first part of our study, 85%
experienced their first relapse within 1 year, which is similar
to the 81% reported by Edwards and Truelove.9 In the
Norwegian IBSEN study,10 the corresponding figure was 52%;
and in our later period, 66% suffered a relapse within 1 year.
A lower recurrence rate within the first year could indicate
more prevalent use of prophylactic treatment. After 3 years,
88% had experienced at least one relapse in both the first and
the last parts of our study, very similar to the report from
Edwards and Truelove, (87%),9 indicating that the natural
course of the disease has been similar during different time

Fig. 2

Age standardised incidence of UC in Uppsala County.

Ulcerative colitis, incidence

535
in smoking followed by a marked decrease.16,17 This pattern
may explain part of the increase in incidence but other
environmental factors are probably more important.

6. Conclusion

Fig. 3

Age standardised male, female.

periods and in different regions. The patients during the first

20 years of this study were utterly well described making it
possible to use the Montreal classification to compare them
with the present day situation. However, the extension of
the disease process beyond the most distal part was
determined with barium enemas.
The major limitation of the present study is the retrospective nature of the first two study periods compared to the
prospective last period. The longer follow up time inherent in a
retrospective study will ensure that patients with a misdiagnosis will be identified leading to a higher incidence in a
prospective study. On the other hand undiagnosed patients
will be identified in a retrospective study to a higher degree
than in a prospective one. Moreover, the use of endoscopes
was limited to rigid sigmoideoscopes during the early years,
and flexible endoscopes during the later periods. Taken
together, these circumstances indicate that the observed
increase in incidence is true, and not only due to an increased
diagnostic accuracy or differences in the study design.
An update from Loftus et al.2 regarding the epidemiology
of UC and Crohn's disease in Olmsted County between 1940
and 2000 reports similar figures for the first part of the study
period (19401970), but the incidence figure stabilises
thereafter, in contrast to Uppsala county where the postwar
increase has continued until today, except for children b 11
which is similar to a pediatric report from Sweden.11
The reason for this increase in incidence is not known. The
historical variation in the incidence of IBD has in a recent
review been appointed as the first of The 10 remaining
mysteries of inflammatory bowel disease12. One of several
possible environmental factors discussed in this review is
changes in diet. This assumption has been strengthened by a
recent report that demonstrates the correlation of linoleic
acid intake and incidence of UC in a big nested casecontrol
study among 203 193 European men and women.13 The
highest quartile of intake of linoleic acid was associated
with an increased risk of UC with an odds ratio = 2.49 (95%
CI = 1.23 to 5.07, p = 0.01). It was estimated that 30% of cases
could be attributed to having dietary intakes higher than the
lowest quartile of linoleic acid intake. In Sweden, the intake
of dietary n-6 polysaturated fatty acids increased until the
beginning of the 1990s and has been rather stable thereafter,
indicating that part of the observed increase in incidence
could be attributed to this factor.14 In an adjacent
geographical area of Sweden the incidence of UC increased
from 3,3 to 14,9 between 1963 and 1987.15 It has been
speculated that this increase in incidence could be related to
the concomitant smoking pattern in society, i.e. an increase

Within a defined geographical area, the incidence of

ulcerative colitis during a 63 year period, increased from 2
to 19.2/100 000. All age groups except those b 11 were
affected.

Acknowledgements
The study was supported by grants from the Uppsala
University Hospital Research Foundation and the Uppsalarebro Regional Research Council.

References
1. Gunesh S, Thomas GA, Williams GT, Roberts A, Hawthorne AB.
The incidence of Crohn's disease in Cardiff over the last
75 years: an update for 19962005. Aliment Pharmacol Ther
2008;27(3):2119.
2. Loftus CG, Loftus Jr EV, Harmsen WS, Zinsmeister AR, Tremaine
WJ, Melton III LJ, et al. Update on the incidence and prevalence
of Crohn's disease and ulcerative colitis in Olmsted County,
Minnesota, 19402000. Inflamm Bowel Dis 2007;13(3):25461.
3. Samuelsson S-M. Ulcerative colitis in the county of Uppsala
194564. Clinical, epidemiological and socio-medical aspects.
Uppsala: Uppsala University; 1976.
4. Ekbom A, Helmick C, Zack M, Adami HO. The epidemiology of
inflammatory bowel disease: a large, population-based study in
Sweden. Gastroenterology 1991;100(2):3508.
5. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The
Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 2006;55(6):74953.
6. Evans JG, Acheson ED. An epidemiological study of ulcerative
colitis and regional enteritis in the Oxford area. Gut 1965;6(4):
31124.
7. Garland CF, Lilienfeld AM, Mendeloff AI, Markowitz JA, Terrell
KB, Garland FC. Incidence rates of ulcerative colitis and Crohn's
disease in fifteen areas of the United States. Gastroenterology
1981;81(6):111524.
8. Stange EF, Travis SPL, Vermeire S, Reinisch W, Geboes K,
Barakauskiene A, et al. European evidence-based consensus on
the diagnosis and management of ulcerative colitis: definitions
and diagnosis. J Crohn's Colitis 2008;2(1):123.
9. Edwards FC, Truelove SC. The course and prognosis of ulcerative
colitis. Gut 1963;4:299315.
10. Solberg IC, Lygren I, Jahnsen J, Aadland E, Hoie O, Cvancarova
M, et al. Clinical course during the first 10 years of ulcerative
colitis: results from a population-based inception cohort (IBSEN
Study). Scand J Gastroenterol 2009;44(4):43140.
11. Lindberg E, Lindquist B, Holmquist L, Hildebrand H. Inflammatory bowel disease in children and adolescents in Sweden, 1984
1995. J Pediatr Gastroenterol Nutr 2000;30(3):25964.
12. Colombel JF, Watson AJ, Neurath MF. The 10 remaining
mysteries of inflammatory bowel disease. Gut 2008;57(4):
42933.
13. Hart AR. Linoleic acid, a dietary N-6 polyunsaturated fatty acid,
and the aetiology of ulcerative colitisa European Prospective
Cohort Study. Gut 2009.

536
14. Becker W, Haglund M, Wretling S. Fat and fat acids in the
Swedish food (Fett och fettsyror i den svenska kosten). Report,
No.: 17. National Food Administration; 2008.
15. Tysk C, Jarnerot G. Ulcerative proctocolitis in Orebro, Sweden.
A retrospective epidemiologic study, 19631987. Scand J
Gastroenterol 1992;27(11):94550.

A. Rnnblom et al.
16. Tysk C, Jarnerot G. Has smoking changed the epidemiology of
ulcerative colitis? Scand J Gastroenterol 1992;27(6):50812.
17. de Leone A, Giaquinto S, Riegler G. Suspension of smoking is a
risk factor for ulcerative colitis (UC) diagnosed after an acute
myocardial infarction (AMI). Journal of Crohn's and colitis; 2009.
p. 215.