Chronic inflammatory bowel diseases (IBD) are characterized by persistent inflammation of the gastrointestinal tract, evolving through periods of exacerbation and remission [1][2]. Ulcerative colitis (UC) refers to an inflammatory condition, primarily affecting the mucosa, which begins in the rectum and can extend in a continuous manner to varying lengths of the proximal colon [3]. Crohn’s disease (CD) is a granulomatous inflammation that may affect all layers of the intestinal wall, often discontinuously involving the colon and/or small intestine or any other segment of the digestive tract [4].

These two colonic diseases can sometimes be difficult to distinguish, in which case the term “indeterminate colitis” is used.

Although their pathogenesis is not fully understood, it is currently considered that IBD results from an inappropriate intestinal immune response to bacterial antigens of the gut microbiota in genetically predisposed individuals, influenced by environmental factors [5][6].

While widely studied in Western countries, these disorders remain under-documented in sub-Saharan Africa, notably in Senegal [7]-[10]. This knowledge gap limits our understanding of the true impact of IBD in this region and hinders the development of appropriate management strategies.

Today, it is important to better understand IBD in our local context, especially given that rapid changes in lifestyle and diet in sub-Saharan Africa could influence both the incidence and clinical presentation of IBD [11].

It is in this context that we undertook the present study at Idrissa Pouye General Hospital (HOGIP) with the objective of better characterizing the epidemiological, diagnostic, therapeutic, and outcome aspects of IBD in our setting.

In our series, the prevalence of inflammatory bowel diseases (IBD) was 0.27%. This figure, although low compared to Western data, confirms the increasing diagnosis of IBD in sub-Saharan Africa, particularly in Senegal. Historically, the first Senegalese cases were reported by Carayon et al. in 1968 [12], followed by a series of 14 ulcerative colitis (UC) cases published by Aubry et al. in 1984 [13], and then another series of 32 cases by Diouf et al. in 2010 [9].

More recently, a hospital prevalence of 0.87% for UC was reported in 2020 in the same department [7], while the prevalence of Crohn’s disease (CD) was 0.027% at the Principal Hospital of Dakar over a 16-year period in 2017 [8]. These data confirm the apparent rarity of these pathologies, but also their increasing recognition in the African context.

Other studies in sub-Saharan Africa support this trend. In Burkina Faso, Bougouma described 20 cases of UC over 11 years [14]. In Ghana, Archampong reported 45 cases of IBD in Accra from 1997 to 2011, with an overall hospital prevalence of 0.06% [15].

Conversely, in the Maghreb region, prevalences are markedly higher, as shown by Elazzaoui’s study, which reported a global prevalence of 5.3% over 7 years, with 2.8% for CD and 2% for UC [16].

In Europe, IBD reaches markedly higher levels. Data from the EPIMAD registry analyzed by Gower-Rousseau indicates a CD prevalence ranging from 8.3 to 214 per 100,000 inhabitants, and UC between 21.4 and 294 per 100,000 inhabitants [2]. In North America, the prevalence of UC is 286 per 100,000 in the United States and CD is 319 per 100,000 in Canada [17].

These disparities reflect a well-established north-south epidemiological gradient. Nevertheless, the current trend in sub-Saharan Africa appears to be increasing. Our cohort of 64 cases represents, to our knowledge, the largest series reported in West Africa to date, reflecting not only improved diagnostic capacity but also an increased need to structure care and raise clinician awareness of these emerging pathologies. This development may also be explained by lifestyle changes. Urbanization seems to play a key role [5][6]. In our cohort, 44 patients (68.75%) lived in urban areas, suggesting a possible influence of environmental and dietary changes on the emergence of IBD. These changes may alter the gut microbiota and promote chronic intestinal inflammation.

The mean age of our patients was 37 years, ranging from 13 to 74 years, consistent with literature data. In Senegal, Gueye et al. reported a similar mean age of 36 years [7]. Comparable results were found in other countries: 34 years in Algeria [18], 38 years in Israel [19], and 41 years in Spain [5]. These figures confirm that IBD are diseases of young adults, with a peak frequency between the second and fourth decades.

No family history of IBD was reported in our cohort, contrasting with international data where 6 to 21% of patients have a family history [19]-[21]. This absence might be due to lack of knowledge or failure to collect genealogical information in our context rather than a true absence of a genetic factor. Future prospective studies should incorporate structured genealogical questionnaires to improve the collection of family history and provide a more accurate assessment of the familial contribution to inflammatory bowel disease in our setting. Nevertheless, the involvement of genetic factors in IBD is well established. The relative risk of developing CD is multiplied by 8 among first-degree relatives, and by 4 for UC. This risk progressively decreases with second- and third-degree relatives [22][23].

Active smoking was found in 9 patients (14%). This finding aligns with literature data [6][24]. The role of tobacco in IBD is paradoxical and well documented since the work of Harries in 1982. Indeed, smoking is a recognized risk factor for CD, whereas it appears to have a protective effect against UC [25]. Among patients with CD, smoking is associated with a more aggressive disease course, an increased relapse risk, more frequent use of corticosteroids and immunosuppressants, and a higher rate of surgery. Although the exact mechanism remains to be elucidated, one hypothesis is the alteration of the gut microbiota induced by tobacco components [24][26].

In our series, the mean diagnostic delay was 36 months [12 - 60] for Crohn’s disease and 41 months [3 - 84] for ulcerative colitis. These figures are in line with observations from other sub-Saharan African countries, where the mean delay varies between 24 and 36 months [14][27][28]. In contrast, these delays are considerably longer than those reported in Western countries. A systematic review conducted in England reported a median diagnostic delay of 12 months for CD and 8 months for UC in adults [29]. More broadly, Nishani, in a meta-analysis including 101 studies, reported a mean diagnostic delay of 3 months in high-income countries versus 16 months in developing countries [30].

Several factors may explain this diagnostic delay in Africa. Late healthcare seeking is partly due to a lack of financial resources and the absence of universal health coverage. Moreover, the high frequency of parasitic colitis often leads to diagnostic wandering. Finally, the scarcity of gastroenterologists, pathologists, and adequate technical platforms complicates rapid and reliable diagnosis.

This diagnostic delay in our region also has important clinical consequences, partly explaining the severity of endoscopic lesions observed at diagnosis. In our series, 19 patients (30%) presented with severe acute colitis, often revealing the disease, and three patients (16%) died.

Extra-intestinal manifestations were found in 23 patients (18 with UC and 5 with CD), with peripheral arthritis in 8 patients.

These extra-digestive manifestations, which are diverse and sometimes even indicative of the disease, can pose diagnostic challenges when they precede intestinal involvement or therapeutic issues when they evolve independently. Their clinical spectrum ranges from minor manifestations to severe, sometimes fatal, forms. They are more frequent as digestive involvement extends [31][32].

Ano-perineal lesions (APL) were present in 5 patients (55%). They are common in CD, with an incidence varying from 4 to 52% according to studies [33]. APL may be clinically initial in 8 to 30% of cases (22% in our series), and are often challenging to diagnose. These lesions can precede diagnosis by several years. Spontaneous evolution is rarely favorable. They represent a severity factor for CD, often requiring surgery in our region, especially with the absence of biologics [34].

All patients underwent ileocolonoscopy, revealing at least one lesion in each case. The lesion distribution varied according to the type of IBD, consistent with the literature; left-sided colitis predominated in UC patients, while ileocolic disease was most frequent in those with CD [20][35][36]. Lesion distribution along the digestive tract closely depends on the nature of the disease. Although no individual endoscopic lesion is pathognomonic for IBD, their topographical arrangement combined with macroscopic appearance strongly guides diagnosis. It is within this scope that the Montreal classification, a revision of the Vienna classification, has been widely adopted in gastroenterological practice [37].

An important point concerns gastroduodenal involvement in Crohn’s disease. In our series, gastroduodenal involvement was observed in 22% of patients, corresponding to only two of the nine patients with Crohn’s disease included in our study. Although the sample size was small, this finding suggests that upper gastrointestinal involvement may occur in our setting. However, this result should be interpreted with caution because of the limited sample size. Larger studies are needed to confirm the true prevalence of gastroduodenal involvement in our population. Therefore, systematic esophagogastroduodenoscopy (EGD) with gastric and duodenal biopsies is recommended for every new CD patient, even when the mucosa appears macroscopically normal [38].

From a therapeutic perspective, the combination of corticosteroids with maintenance treatment by mesalazine, sulfasalazine, and immunosuppressants enabled clinical remission in 49 patients (76.5%). No patient received biologic therapy. In our series, three patients with APL required surgical management. Two patients died following surgery indicated for toxic megacolon complicated by colonic perforation; emergency surgery could not be performed in time.

In developing countries, the introduction of biologics, particularly anti-TNF agents, has significantly transformed the management of patients with IBD refractory to conventional treatments such as corticosteroids and immunosuppressants. These maintenance therapies afford better disease control by reducing hospitalization rates, facilitating corticosteroid withdrawal, promoting mucosal healing, and decreasing the need for surgery. However, in our context, where biologics—including anti-TNFs (infliximab, adalimumab) and cyclosporine—are not routinely available, therapeutic options remain limited.

Surgery thus remains an essential therapeutic alternative in managing severe or complicated forms of IBD. It should be considered in cases of failure of intensive medical treatment (intravenous corticosteroids), in patients with APL refractory to medical therapy, or in patients presenting with severe acute colitis and deterioration of general condition [39]-[41].

In our series, 13 surveillance colonoscopies were performed in long-term monitored patients. The absence of neoplasia but the presence of high-grade dysplasia in 3 patients highlights the preventive value of screening colonoscopy in this high-risk population for colorectal cancer, even in the absence of evocative symptoms.

Indeed, endoscopic surveillance is recommended in patients with extensive UC or colonic CD evolving for more than 8 years, even in the absence of symptoms.

Chromo-colonoscopy (or virtual chromoendoscopy when unavailable) should be performed every 1 to 3 years, depending on disease duration, inflammatory activity, and the presence of associated risk factors (family history of colorectal cancer, primary sclerosing cholangitis, prior dysplasia) [42][43].

Chronic inflammatory bowel diseases, long considered rare in sub-Saharan Africa, are now increasingly diagnosed, notably due to improved accessibility to endoscopic examinations. To the best of our knowledge, based on the currently available published literature from West Africa, this represents the largest reported series to date. This confirms that IBD predominantly affects young adults, with a male predominance. The frequent diagnostic delay in our context leads to a substantial proportion of severe forms, such as severe acute colitis.

Management remains constrained, particularly by the unavailability of biologic therapies, making surgery sometimes unavoidable. Our work also emphasizes the importance of screening, especially through surveillance colonoscopy, to identify dysplastic lesions and prevent the development of colorectal cancers, which are serious complications of advanced disease forms.

Chronic inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn’s disease, have long been considered rare in sub-Saharan Africa, with only sporadic cases historically reported. In recent years, there has been increasing recognition and diagnosis of IBD in Africa, although the reported prevalence remains markedly lower than in Western countries. Access to endoscopic and modern diagnostic resources has been limited in many African settings, contributing to diagnostic delays and underreporting of cases. Patterns of disease in Africa are believed to be influenced by environmental, dietary, and genetic factors, but regional data remain sparse.

Provides the largest documented series of IBD cases in West Africa to date (64 cases), thereby expanding the epidemiological understanding of IBD in this region. This demonstrates that IBD primarily affects young adults with a slight male predominance and highlights a significant diagnostic delay (average 36 - 41 months). Reveals a high rate of severe presentations, such as acute severe colitis, and emphasizes that extra-intestinal manifestations and ano-perineal lesions are frequent in this population. Shows therapeutic challenges due to limited access to biologic agents, leading to greater reliance on corticosteroids and surgery. This underlines the necessity for increased awareness, structured care pathways, and regular surveillance (colonoscopy), given the risk of dysplasia and colorectal cancer even in this emerging IBD population.