Diagnostic delay of pediatric inflammatory bowel disease in Saudi Arabia-the community, the physicians, and the disease: Where's the hold-up?

To the Editor,

We read with great interest the study by El Mouzan et al., looking at diagnostic delay of pediatric inflammatory bowel disease in Saudi Arabia.[1] The authors concluded that there was a significantly longer delay in diagnosing Crohn's disease (CD) compared to ulcerative colitis (UC), 8 months vs. 5 months (P< 0.001). Ileal location was the only significant risk factor identified for the delay among CD patients (P = 0.040). The authors proposed different measures to be considered in order to reduce this delay including public education, education of general physicians, and evaluation of the referral system from primary health care (PHC) physicians to gastroenterologists.

A study by Saadah[2] evaluating the clinical pattern of Crohn's disease in pediatric age group in Saudi Arabia found that CD has a wide spectrum of clinical presentations. Diarrhea was the most common symptom (88.5%). However, nonspecific symptoms such as weight loss and anorexia were common as well, 84.4% and 80.2%, respectively. In addition, extraintestinal manifestations were common among this age group occurring in 24% of the patients. Oral manifestations including angular cheilitis, aphthous ulcers, and mucogingivitis were the commonest (18.6%).

Furthermore, ileal CD has several mimickers including infectious, inflammatory, and malignant diseases as well as drug-induced enterocolopathy which require thorough work-up to reach the correct diagnosis.[3]

These aforementioned factors may explain the diagnostic delay among CD patients and in particular, those with ileal disease as seen in this study. Accordingly, the measures suggested by the authors to reduce the delay in diagnosis are not enough to ensure early identification of the disease. Easy access to proper endoscopic and radiographic evaluation is an important variable that ought to be considered.

The authors found a significant diagnostic delay in Interval I (patient-related delay), defined as duration from symptoms onset to physician consultation compared to Interval II (physician-related delay), defined as duration from physician consultation to final diagnosis, in both CD and UC, median was 6 vs. 0.6 months (P< 0.001) in CD and 2.4 vs. 0.8 months (P = 0.008) in UC. However, adding an interval to measure the duration from PHC physician evaluation until the referral to the gastroenterologist would be of great value to judge the referral time more precisely.

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Conflicts of interest

There are no conflicts of interest.