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Compound heterozygous mutations in IL10RA combined with a complement factor properdin mutation in infantile-onset inflammatory bowel disease. Eur J Gastroenterol Hepatol 2018; 30:1491-1496. [PMID: 30199474 DOI: 10.1097/meg.0000000000001247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Inflammatory bowel diseases (IBDs) are chronic and multifactorial diseases resulting from a complex interaction of host genetic factors and environmental stimuli. Although many genome-wide association studies have identified host genetic factors associated with IBD, rare Mendelian forms of IBD have been reported in patients with very early onset forms. Therefore, this study aimed to identify genetic variants associated with infantile-onset IBD. PARTICIPANTS AND METHODS We obtained genomic DNA from whole blood samples of a male patient with infantile-onset IBD and nonconsanguineous Korean parents. Whole-exome sequencing was performed using trio samples. Then, we analyzed the data using susceptibility genes for monogenic forms of IBD and various immunodeficiencies and protein structural analysis. RESULTS The patient who presented with oral aphthous ulcers at the age of 14 days suffered from severe colitis and was refractory to medical treatment. Compound heterozygous mutations in IL10RA (p.R101W; p.T179T) were found in the patient. In addition, a hemizygous mutation in complement factor properdin (CFP) (p.L456V) located on the X-chromosome was detected, inherited from the patient's mother. Protein structural modeling suggested impaired properdin subunit interactions by p.L456V that may hamper protein oligomerization required for complement activation. CONCLUSION This study identified compound heterozygous mutations in IL10RA combined with a hemizygous CFP mutation in infantile-onset IBD by using whole-exome sequencing. CFP p.L456V may exacerbate symptoms of infantile-onset IBD by disturbing oligomerization of properdin.
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Zheng C, Huang Y, Ye Z, Wang Y, Tang Z, Lu J, Wu J, Zhou Y, Wang L, Huang Z, Yang H, Xue A. Infantile Onset Intractable Inflammatory Bowel Disease Due to Novel Heterozygous Mutations in TNFAIP3 (A20). Inflamm Bowel Dis 2018; 24:2613-2620. [PMID: 29788367 DOI: 10.1093/ibd/izy165] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Mutations in tumor necrosis factor alpha-induced protein 3 (TNFAIP3), a key player in the negative feedback regulation of nuclear factor-κB signaling, have recently been recognized as leading to early onset autoinflammatory and autoimmune syndrome. Here, we have reported the phenotypes of 3 infantile onset intractable inflammatory bowel disease (IBD) patients with TNFAIP3 mutations and reviewed previously reported cases to establish phenotypic features associated with TNFAIP3 monogenicity. METHODS From January 1, 2015, to December 31, 2017, we recruited 58 infantile-onset IBD patients. Targeted sequencing and whole-exome sequencing were performed. Sanger sequencing confirmed the variants and determined the parental origin. We followed all the patients with TNFAIP3 mutations in our cohort and analyzed their clinical data. RESULTS Genetic screening in all 58 patients with infantile-onset IBD revealed 44 (75.9%) cases of monogenic disorders, and 3 de novo TNFAIP3 mutations were identified, including 1 nonsense and 2 frame shift mutations. All the mutations resulted in premature stop codon. All 3 patients had multiple systemic involvements, with predominant gastrointestinal diseases. CONCLUSIONS Most infantile-onset IBD was associated with monogenetic mutation, and in addition to the 50 reported genes, other rare genetic variants need to be determined. TNFAIP3 may be an important candidate gene. The treatment of TNFAIP3-associated infantile-onset-IBD was challenging. 10.1093/ibd/izy165_video1izy165.video15789607089001.
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Affiliation(s)
- Cuifang Zheng
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Huang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Ziqing Ye
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yuhuan Wang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Zifei Tang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Junping Lu
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jie Wu
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Zhou
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Lin Wang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiheng Huang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
| | - Haowei Yang
- Department of Radiology, Children's Hospital of Fudan University, Shanghai, China
| | - Aijuan Xue
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children's Hospital of Fudan University, Shanghai, China
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Inflammatory Bowel Disease in the Baby to Baby Boomer: Pediatric and Elderly Onset of IBD. ACTA ACUST UNITED AC 2018; 16:289-305. [PMID: 30006766 DOI: 10.1007/s11938-018-0188-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Early- and late-onset of inflammatory bowel disease (IBD) may perhaps be etiologically distinct and potentially attributed to genetics, environmental or microbial factors. We review disease factors and clinical characteristics, as well as unique management and treatment strategies to consider when caring for the "baby" or "baby boomer" with IBD. RECENT FINDINGS Around 25% of cases of initial diagnosis of IBD is made before the age of 18 years old, and another 15-20% made after the age of 60. Crohn's disease (CD) typically presents as ileocolonic and stricturing or penetrating phenotype among early-onset, whereas among late-onset, it is mainly colonic and inflammatory. Pediatric ulcerative colitis (UC) is mostly pan-colonic versus primarily left-sided among the elderly. Treatment goal for both age groups is primarily symptom control, with growth and development also considered among pediatric patients. Due to alterations in pharmacokinetics, careful monitoring and reduced dose should be considered. A multidisciplinary care team is necessary to ensure better clinical outcomes. Onset of disease at either spectrum of age requires careful management and treatment, with both unique disease- and age-appropriate factors carefully considered.
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Wang XQ, Xiao Y, Xu X, Yu Y, Shan CY, Guo Y, Gong L, Zhou T, Gao SS, Yuan YZ, Wang XJ, Xu CD. Study of disease phenotype and its association with prognosis of paediatric inflammatory bowel disease in China. BMC Pediatr 2018; 18:229. [PMID: 30001197 PMCID: PMC6044010 DOI: 10.1186/s12887-018-1212-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/06/2018] [Indexed: 02/08/2023] Open
Abstract
Background To investigate the unique features of inflammatory bowel disease (IBD) in children, we wanted to identify whether there might be a strong correlation between the disease phenotype and its prognosis at various ages in paediatric patients. Methods We collected data from patients diagnosed with IBD (ulcerative colitis (UC) or Crohn’s disease (CD)) from 2002 to 2016. The diagnosis was made according to the Porto criteria and Paris Classification. Patient characteristics, clinical manifestations and treatments were collected. Risk factors for surgery, mortality and relapse were analysed by Cox proportional hazard models. Results Of the 143 patients, 113 had CD, and 30 had UC; there were 89 males and 54 females with a median age of 9 years (y). Thirteen patients in the 0–2 y group were identified as having mutations in IL-10 receptor A, and this mutation was significantly more common in this age group than in 3–9 and 10–16 y patients. The risk factor for surgery was the B3 phenotype; risk factors for death were age 0–2 y and B3 phenotype; 0–2 y, B3 phenotype and steroid dependency were risk factors for early relapse. Conclusions Clinical manifestations of the onset of IBD in infants and toddlers were extensive and aggressive and were closely associated with early relapse and death. It is of particular interest that some of these patients developed IBD due to monogenic disorders; thus, introduction of genetic testing is essential for these patients.
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Affiliation(s)
- Xin-Qiong Wang
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China
| | - Yuan Xiao
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China
| | - Xu Xu
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China
| | - Yi Yu
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China
| | - Cheng-Yan Shan
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China
| | - Yan Guo
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China
| | - Ling Gong
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China
| | - Tong Zhou
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China
| | - Shen-Shen Gao
- Department of Paediatrics, Ruijin Hospital North, Shanghai Jiao Tong University, School of Medicine, Shanghai, 201821, China
| | - Yao-Zong Yuan
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200025, China
| | - Xiao-Jin Wang
- Department of Biostatistics, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200025, China
| | - Chun-Di Xu
- Department of Paediatrics, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, No. 197, Rui Jin Er Road, Shanghai, 200025, China. .,Department of Paediatrics, Ruijin Hospital North, Shanghai Jiao Tong University, School of Medicine, Shanghai, 201821, China.
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Efficacy and Safety of Adalimumab in Pediatric Ulcerative Colitis: A Real-life Experience from the SIGENP-IBD Registry. J Pediatr Gastroenterol Nutr 2018; 66:920-925. [PMID: 29315163 DOI: 10.1097/mpg.0000000000001883] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the effectiveness and safety of adalimumab (ADA) in children with ulcerative colitis (UC) previously treated with infliximab (IFX). METHODS Retrospective study including children with UC from a national registry who received ADA therapy. The primary endpoint was the rate of corticosteroid-free remission at week 52. Secondary outcomes were the rate of sustained clinical remission, primary nonresponse, and loss of response at weeks 12, 30, and 52 and rate of mucosal healing and side effects at week 52. RESULTS Thirty-two children received ADA (median age 10 ± 4 years). Median disease duration before ADA therapy was 27 months. All patients received previous IFX (43% intolerant, 50% nonresponders [37.5% primary, 42.5% secondary nonresponders], 6.7% positive anti-IFX antibodies). Fifty-two weeks after ADA initiation, 13 patients (41%) were in corticosteroid-free remission. Mucosal healing occurred in 9 patients (28%) at 52 weeks. The cumulative probability of a clinical relapse-free course was 69%, 59%, and 53% at 12, 30, and 52 weeks, respectively. Ten patients (31%) had a primary failure and 5 (15%) a loss of response to ADA. No significant differences in efficacy were reported between not-responders and intolerant to IFX (P = 1.0). Overall, 19 patient (59%) maintained ADA during 52-week follow-up. Seven patients (22%) experienced an adverse event, no serious side effects were observed and none resulted in ADA discontinuation. CONCLUSIONS Based on our data, ADA seems to be effective in children with UC, allowing to recover a significant percentage of patients intolerant or not-responding to IFX. The safety profile was good.
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Abstract
OBJECTIVES The aims of this retrospective study were to describe ulcerative colitis (UC) phenotype at diagnosis and follow-up and to identify possible predictors of severe disease course. METHODS This was a retrospective, single-center study. We reviewed the charts of patients with UC diagnosed between 2 and 18 years at our referral center from January 2007 to January 2016. Laboratory and clinical features at diagnosis, such as disease extent, atypical phenotypes, extraintestinal manifestations, and therapies, and pattern changes during the follow-up, including relapse rate, disease extension, and the cumulative risk for colectomy were collected. RESULTS One hundred eleven patients were enrolled. Atypical phenotypes were identified at diagnosis in 55 out of 111 patients (49.5%). Extraintestinal manifestations were detected in 16 out of 111 (14.4%) at the diagnosis. During the follow-up 60 out of 111 (54%) patients needed to start azathioprine, 9 out of 111 (8.1%) patients started biologic therapy and 10 out of 111 (patients underwent surgery, resulting in a cumulative risk of 8% at 5 years and 16% at 10 years. Steroid refractoriness (hazard ratio: 13.9) and starting of biologic therapy (hazard ratio: 25.3) represented the best predictors for surgery. The cumulative probability of first relapse was 47% at 6 months and 63% at 1 year. Disease extension was reported in 21 out of 70 patients (30%). CONCLUSION Pediatric UC is associated with a severe phenotype and a high percentage of atypical features. Surgery rate seems to be decreased from early reports.
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57
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You JY. [Features and management of very early onset inflammatory bowel disease]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:341-345. [PMID: 29764567 PMCID: PMC7389054 DOI: 10.7499/j.issn.1008-8830.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/27/2018] [Indexed: 06/08/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic nonspecific intestinal inflammatory disease of unknown etiology. This disease includes three main types: Crohn′s disease (CD), ulcerative colitis (UC), and IBD-unclassified (IBD-U). IBD is frequently presented in adults, but in recent years, there is a rising incidence in pediatric populations. Very early onset IBD (VEO-IBD) is a fraction of pediatric IBD, but they have exclusive phenotypic and genetic characteristics such that they are accompanied by severe disease course and resistance to conventional therapy. The purpose of this review is to provide a contemporary overview of the clinical features, pathogenesis, and management of VEO-IBD.
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Affiliation(s)
- Jie-Yu You
- Department of Gastroenterology, Hunan Children′s Hospital, Changsha 410000, China.
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58
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Rialon KL, Crowley E, Seemann NM, Fahy AS, Muise A, Langer JC. Long-term outcomes for children with very early-onset colitis: Implications for surgical management. J Pediatr Surg 2018. [PMID: 29534824 DOI: 10.1016/j.jpedsurg.2018.02.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE The timing of J-pouch surgery following colectomy for children with very early-onset colitis is controversial, with some advocating early reconstruction and others delaying reconstruction because of fear that the colitis may be owing to Crohn's disease (CD). We sought to determine the long-term incidence of CD in this population and whether there may be clinical features that predict the risk of CD. METHODS Children with noninfectious colitis diagnosed prior to age 10, who underwent subtotal colectomy and ileostomy from 2000 to 2015, were reviewed. RESULTS Twenty-five children were identified. Median age at presentation was 5.4years. Four were initially diagnosed with CD (16%), 14 with ulcerative colitis (UC) (56%), and 7 with inflammatory bowel disease unclassified (IBD-U) (28%). Eight eventually had pouch surgery. Five of the children with an initial diagnosis of UC or IBD-U developed findings that changed the diagnosis to CD at a median age of 13.4 (range 10.3 to 16.7) years. None had any indicators of CD at the initial presentation. CONCLUSIONS Approximately one quarter of patients with very early-onset colitis originally diagnosed as UC or IBD-U had a reclassification in diagnosis to CD over time. J-pouch reconstruction should be delayed until adolescence in children with very early-onset colitis. LEVEL OF EVIDENCE 2C.
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Affiliation(s)
- Kristy L Rialon
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Eileen Crowley
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Aodhnait S Fahy
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Aleixo Muise
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jacob C Langer
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada.
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Nordenvall C, Rosvall O, Bottai M, Everhov ÅH, Malmborg P, Smedby KE, Ekbom A, Askling J, Ludvigsson JF, Myrelid P, Olén O. Surgical Treatment in Childhood-onset Inflammatory Bowel Disease-A Nationwide Register-based Study of 4695 Incident Patients in Sweden 2002-2014. J Crohns Colitis 2018; 12:157-166. [PMID: 29029152 DOI: 10.1093/ecco-jcc/jjx132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/19/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS The incidence of childhood-onset [< 18 years] inflammatory bowel disease [IBD] is increasing worldwide, and some studies suggest that it represents a more severe disease phenotype. Few nationwide, population-based studies have evaluated the surgical burden in patients with childhood-onset IBD, and whether the improved medical treatment has influenced the need for gastrointestinal surgery. The aim was to examine whether the surgical treatment at any age of patients with childhood-onset IBD has changed over time. METHODS In a nationwide cohort study we identified 4695 children [< 18 years] diagnosed with incident IBD in 2002-2014 through the Swedish Patient Register [ulcerative colitis: n = 2295; Crohn's disease: n = 2174; inflammatory bowel disease-unclassified: n = 226]. Abdominal [intestinal resections and colectomies] and perianal surgeries were identified through the Swedish Patient Register. The cumulative incidences of surgeries were calculated using the Kaplan-Meier method. RESULTS In the cohort, 44% were females and 56% males. The median age at inflammatory bowel disease diagnosis was 15 years and the maximum age at end of follow-up was 31 years. The 3-year cumulative incidence of intestinal surgery was 5% in patients with ulcerative colitis and 7% in patients with Crohn's disease, and lower in children aged < 6 years at inflammatory bowel disease diagnosis [3%] than in those aged 15-17 years at diagnosis [7%]. Calendar period of inflammatory bowel disease diagnosis was not associated with risk of surgery. CONCLUSION Over the past 13 years, the risk of surgery in childhood-onset inflammatory bowel disease has remained unchanged.
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Affiliation(s)
- Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Center for Digestive Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Oda Rosvall
- Department of Clinical and Experimental Medicine, Linköping University, and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Matteo Bottai
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Petter Malmborg
- Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin E Smedby
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Ola Olén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
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Assa A, Rinawi F, Shamir R. The Long-Term Predictive Properties of the Paris Classification in Paediatric Inflammatory Bowel Disease Patients. J Crohns Colitis 2018; 12:39-47. [PMID: 28961726 DOI: 10.1093/ecco-jcc/jjx125] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/06/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The Paris modification of the Montreal classification for children with inflammatory bowel disease was accepted in 2011. We aimed to investigate the long-term clinical outcomes of patients diagnosed with IBD during childhood in a population-based cohort according to the Paris classification at diagnosis. METHODS The medical records of paediatric inflammatory bowel disease patients, diagnosed from 2000 to 2016, were reviewed retrospectively. Main outcome measures included time to first flare, hospitalisation, surgery, and biologic therapy. RESULTS In Crohn's disease patients [n = 301, median age 14.2 years], colonic location was associated with higher prevalence of extraintestinal manifestations, whereas ileal location and complicated behaviour were associated with anti-Saccharomyces cerevisiae antibody positivity. During a median follow-up of 9.1 years (interquartile range [IQR]of 4.7-12.3), complicated behaviour at diagnosis was associated with increased risk for surgery (hazard ratio[ HR] = 2.7, p < 0.001] and hospitalisation [HR = 1.5, p = 0.01] but not with the risk for flare or stepping-up to biologic therapy. Isolated colonic disease was associated with a decreased risk of surgery [HR = 0.25, p = 0.02]. During a median follow-up of 8.5 years [interquartile range of 5.1-12], in patients with ulcerative colitis [n = 126, median age 13.7 years], severe disease at diagnosis but not disease extent was associated with the risk for colectomy [HR = 3.5, p = 0.002], hospitalisation [HR = 3.3, p < 0.001], flare [HR = 2.4, p < 0.001] and biologic therapy [HR = 2.6, p = 0.001]. CONCLUSIONS The Paris classification for paediatric inflammatory bowel disease has clear predictive properties. Complicated disease and ileal location at diagnosis in Crohn's disease, and severity of disease but not its extension in ulcerative colitis, predict long-term worse outcomes.
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Affiliation(s)
- Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Firas Rinawi
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Colavolpe N, Taylor S, Petit P. Inflammatory Bowel Disease. IMAGING ACUTE ABDOMEN IN CHILDREN 2018:149-165. [DOI: 10.1007/978-3-319-63700-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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62
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Kim KY, Lee EJ, Kim JW, Moon JS, Jang JY, Yang HR, Ko JS. Higher Morbidity of Monogenic Inflammatory Bowel Disease Compared to the Adolescent Onset Inflammatory Bowel Disease. Pediatr Gastroenterol Hepatol Nutr 2018; 21:34-42. [PMID: 29383303 PMCID: PMC5788949 DOI: 10.5223/pghn.2018.21.1.34] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Monogenic inflammatory bowel disease (IBD) patients do not respond to conventional therapy and are associated with a higher morbidity. We summarized the clinical characteristics of monogenic IBD patients and compared their clinical outcomes to that of non-monogenic IBD patients. METHODS We performed a retrospective cohort study of all children <18 years old who were diagnosed with IBD between 2005 and 2016. A total of 230 children were enrolled. Monogenic IBD was defined as a presentation age less than 6 years old with confirmation of a genetic disorder. We subdivided the groups into monogenic IBD (n=18), non-monogenic very early-onset IBD (defined as patients with a presentation age <6 years old without a confirmed genetic disorder, n=12), non-monogenic IBD (defined as all patients under 18 years old excluding monogenic IBD, n=212), and severe IBD (defined as patients treated with an anti-tumor necrosis factor excluding monogenic IBD, n=92). We compared demographic data, initial pediatric Crohn disease activity index/pediatric ulcerative colitis activity index (PCDAI/PUCAI) score, frequency of hospitalizations, surgical experiences, and height and weight under 3rd percentile among the patients enrolled. RESULTS The initial PCDAI/PUCAI score (p<0.05), incidence of surgery per year (p<0.05), and hospitalization per year (p<0.05) were higher in the monogenic IBD group than in the other IBD groups. Additionally, the proportion of children whose weight and height were less than the 3rd percentile (p<0.05 and p<0.05, respectively) was also higher in the monogenic IBD group. CONCLUSION Monogenic IBD showed more severe clinical manifestations than the other groups.
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Affiliation(s)
- Kwang Yeon Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Joo Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ju Whi Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Soo Moon
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ju Young Jang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Brooks AJ, Smith PJ, Lindsay JO. Monitoring adolescents and young people with inflammatory bowel disease during transition to adult healthcare. Frontline Gastroenterol 2018; 9:37-44. [PMID: 29484159 PMCID: PMC5824770 DOI: 10.1136/flgastro-2016-100747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 12/13/2016] [Accepted: 12/15/2016] [Indexed: 02/04/2023] Open
Abstract
The transition of adolescents and young people (AYP) with inflammatory bowel disease (IBD) from paediatric to adult healthcare requires coordination between healthcare care providers to achieve optimum outcomes. Transition into adulthood is a time of major challenges physically, developmentally, emotionally and psychosocially for AYP living with IBD. Healthcare professionals must monitor the AYP progress proactively with attention to each of these parameters throughout the transition period to ensure that milestones are attained, and skills for self-management are formed. Thus, achieving the desired goals in both clinical and pastoral areas requires intensive monitoring from a multidisciplinary team across healthcare providers.
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Affiliation(s)
- Alenka J Brooks
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Philip J Smith
- Centre for Gastroenterology and Hepatology, Royal Free Hospital, London, UK
| | - James O Lindsay
- Bart's Health NHS Trust, The Royal London Hospital, London, UK
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
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Abstract
Very early onset inflammatory bowel disease (VEO-IBD) represents a unique and growing subset of patients with inflammatory bowel disease (IBD). Some VEO-IBD patients present with immunodeficiency and possess loss of function genetic mutations involving immune pathways that cause their IBD. A search for Mendelian causes of IBD is likely most beneficial when the presentation involves extra-intestinal autoimmunity or involves intestinal histopathology that is atypical for IBD. While a subset of these young patients will have highly aggressive courses (and likely present with immunodeficiency), the majority of patients with VEO-IBD appear to have disease courses similar to that of their older counterparts. Most notably, many of these young children will require long courses of immunosuppression simply as a result of the profoundly early presentation-thus increasing their long-term risks of cancer and opportunistic infections.
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Affiliation(s)
- Christopher J Moran
- Harvard Medical School, Department of Pediatrics, 175 Cambridge St, Suite 567, Boston, MA 02114.
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65
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Nasiri S, Kuenzig ME, Benchimol EI. Long-term outcomes of pediatric inflammatory bowel disease. Semin Pediatr Surg 2017; 26:398-404. [PMID: 29126510 DOI: 10.1053/j.sempedsurg.2017.10.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The incidence and prevalence of childhood-onset inflammatory bowel diseases (IBD), including subtypes Crohn's disease and ulcerative colitis, have risen dramatically in recent years, and have emerged globally as important pediatric chronic diseases. Therefore, health care providers are more frequently encountering very young children with IBD, a chronic and incurable condition requiring life-long therapy. These children are living long lives with IBD and therefore knowledge of long-term outcomes is increasingly important to better counsel families and determine the best course of treatment. This review summarizes the current knowledge and literature surrounding long-term outcomes of pediatric IBD, with emphasis on the following areas: need for surgery due to complicated disease behavior, risk of disease remission and recurrence, mental health and psychosocial well-being, educational outcomes, linear growth impairment, cancer risk, and mortality. In addition, we review recent research about predicting negative long-term outcomes in children with IBD.
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Affiliation(s)
- Soheila Nasiri
- Division of Gastroenterology, Hepatology and Nutrition, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Canada K1H 8L1
| | - Mary Ellen Kuenzig
- Division of Gastroenterology, Hepatology and Nutrition, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Canada K1H 8L1; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Canada; Institute for Clinical Evaluative Sciences, Ottawa, Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology and Nutrition, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Canada K1H 8L1; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Canada; Institute for Clinical Evaluative Sciences, Ottawa, Canada; Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
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66
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Current health status and medical therapy of patients with pediatric-onset inflammatory bowel disease: a survey-based analysis on 1280 patients aged 10-25 years focusing on differences by age of onset. Eur J Gastroenterol Hepatol 2017; 29:1276-1283. [PMID: 28877085 DOI: 10.1097/meg.0000000000000956] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE There are inconsistent reports on age-related differences in inflammatory bowel disease (IBD). On the basis of patient information, we describe the clinical presentation and therapy in relation to age at diagnosis in longstanding pediatric IBD. PATIENTS AND METHODS Two surveys were conducted in children and young adults (age: 10-25 years) by pretested postal questionnaires. The main analyses are descriptive, showing proportions and distributions per grouped age of diagnosis. Exploratory logistic regression was used to identify sociodemographic and disease-related factors associated with prognosis. Recent disease course, use of biological therapy, and resecting surgery were chosen as indicators of disease severity. Patients with a diagnosis in infancy (<2 years of age) are presented as a case series. RESULTS Information of 1280 cases was available [804 Crohn's disease (CD), 382 ulcerative colitis (UC), 94 IBD not specified] (response: 44.6 and 49.6%). Stable remission during the preceding year was reported by 675 (56.7%) patients; 825 (60.9%) patients reported feeling currenty well. Anti-tumor necrosis factor therapy was reported by 33% of CD patients and 9.3% of UC patients, immunomodulation in 82.1 and 63.2%, and corticosteroids by 78.4 and 76.1%, respectively (ever use). Age at diagnosis was not associated with indicators of severe disease. Diagnosis in infancy was reported by 37 patients. CONCLUSION Our data do not support age at diagnosis-related differences in prognosis in pediatric-onset IBD.
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Qiu KY, Liao XY, Wu RH, Huang K, Fang JP, Zhou DH. X-linked Hyper-IgM Syndrome: A Phenotype of Crohn's Disease with Hemophagocytic Lymphohistiocytosis. Pediatr Hematol Oncol 2017; 34:428-434. [PMID: 29303623 DOI: 10.1080/08880018.2017.1409301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
X-linked hyper-immunoglobulin M (IgM) syndrome is characterized by recurrent infections, low or undetectable levels of IgG and IgA, and normal to increased serum IgM, and is also rare. It is associated with mutation in the gene encoding CD40 ligand. This study aimed to describe the first international report of hemizygous CD40LG c.542G>A mutation in a 5-year-old boy with a phenotype of Crohn's disease and hemophagocytic lymphohistiocytosis. Also, the clinical implications of this mutation and associated atypical phenotype are discussed.
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Affiliation(s)
- Kun-Yin Qiu
- a Department of Paediatrics , Sun Yat-sen Memorial Hospital, Sun Yat-sen University , Guangzhou , P.R, China.,b Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-sen University , Guangzhou , P.R. China
| | - Xiong-Yu Liao
- a Department of Paediatrics , Sun Yat-sen Memorial Hospital, Sun Yat-sen University , Guangzhou , P.R, China.,b Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-sen University , Guangzhou , P.R. China
| | - Ruo-Hao Wu
- a Department of Paediatrics , Sun Yat-sen Memorial Hospital, Sun Yat-sen University , Guangzhou , P.R, China.,b Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-sen University , Guangzhou , P.R. China
| | - Ke Huang
- a Department of Paediatrics , Sun Yat-sen Memorial Hospital, Sun Yat-sen University , Guangzhou , P.R, China.,b Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-sen University , Guangzhou , P.R. China
| | - Jian-Pei Fang
- a Department of Paediatrics , Sun Yat-sen Memorial Hospital, Sun Yat-sen University , Guangzhou , P.R, China.,b Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-sen University , Guangzhou , P.R. China
| | - Dun-Hua Zhou
- a Department of Paediatrics , Sun Yat-sen Memorial Hospital, Sun Yat-sen University , Guangzhou , P.R, China.,b Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes, Sun Yat-sen University , Guangzhou , P.R. China
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Abstract
Inflammatory bowel disease (IBD), including Crohn disease and ulcerative colitis, is characterized by chronic intestinal inflammation due to a complex interaction of genetic determinants, disruption of mucosal barriers, aberrant inflammatory signals, loss of tolerance, and environmental triggers. Importantly, the incidence of pediatric IBD is rising, particularly in children younger than 10 years. In this review, we discuss the clinical presentation of these patients and highlight environmental exposures that may affect disease risk, particularly among people with a background genetic risk. With regard to both children and adults, we review advancements in understanding the intestinal epithelium, the mucosal immune system, and the resident microbiota, describing how dysfunction at any level can lead to diseases like IBD. We conclude with future directions for applying advances in IBD genetics to better understand pathogenesis and develop therapeutics targeting key pathogenic nodes.
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Affiliation(s)
- Joanna M Peloquin
- Gastrointestinal Unit and Center for the Study of Inflammatory Bowel Disease and.,Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts 02114.,Harvard Medical School, Boston, Massachusetts 02115; , , ,
| | - Gautam Goel
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts 02114.,Harvard Medical School, Boston, Massachusetts 02115; , , ,
| | - Eduardo J Villablanca
- Gastrointestinal Unit and Center for the Study of Inflammatory Bowel Disease and.,Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts 02114.,Harvard Medical School, Boston, Massachusetts 02115; , , ,
| | - Ramnik J Xavier
- Gastrointestinal Unit and Center for the Study of Inflammatory Bowel Disease and.,Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts 02114.,Harvard Medical School, Boston, Massachusetts 02115; , , , .,Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts 02142.,Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139
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Abstract
PURPOSE OF REVIEW Inflammatory bowel disease (IBD) is a multifactorial disease caused by dysregulated immune responses to commensal or pathogenic intestinal microbes, resulting in chronic intestinal inflammation. Patients diagnosed with IBD occurring before the age of 5 are a unique population, known as very early onset (VEO)-IBD and can be phenotypically and genetically distinct from older-onset IBD. We aim to review the clinical presentation of children with VEO-IBD and recent discoveries that point to genomic drivers of disease that may impact our therapeutic decisions. RECENT FINDINGS VEO-IBD is increasing in incidence and is associated with more severe disease, aggressive progression and poor response to most conventional therapies. This article will review the advances in sequencing technology that have led to identification of novel gene variants associated with disease and potentially new targeted therapeutic options. SUMMARY Children with VEO-IBD may present with a different phenotype and more severe disease than older children and adults. Identification of the causal gene or pathways, these children may allow for true precision medicine with targeted therapy and improved disease course.
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Ashton JJ, Ennis S, Beattie RM. Early-onset paediatric inflammatory bowel disease. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:147-158. [PMID: 30169204 DOI: 10.1016/s2352-4642(17)30017-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/08/2017] [Accepted: 06/14/2017] [Indexed: 12/27/2022]
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Prevalence of intestinal complications in inflammatory bowel disease: a comparison between paediatric-onset and adult-onset patients. Eur J Gastroenterol Hepatol 2017; 29:926-931. [PMID: 28471820 DOI: 10.1097/meg.0000000000000896] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Intestinal complications in inflammatory bowel disease indicate active inflammation and typically result in the intensification of therapy. AIM To analyse whether the rates of intestinal complications were associated with age at disease onset. PATIENTS AND METHODS Data from 1506 individuals with Crohn's disease (CD) and 1201 individuals with ulcerative colitis (UC) were obtained from the Swiss inflammatory bowel disease cohort study database, classified into groups on the basis of age at diagnosis (<10, <17, <40 and >40 years of age), and retrospectively analysed. RESULTS In CD patients, the rates of stricturing (29.1-36.2%), abdominal penetrating disease (11.9-18.2%), resectional surgery (17.9-29.8%) and perianal disease (14.7-34.0%) were correlated with disease duration, but not age at diagnosis. However, paediatric-onset CD was associated with higher rates of multiple, rectal and anal strictures and earlier colon surgery. In addition, perianal disease occurred earlier, required earlier surgical intervention, and was more often combined with stricturing and penetrating disease. Finally, anal fissures were more prevalent among younger patients. In UC patients, the rates of progression or extension of disease (0-25.8%) and colectomy (3.0-8.7%) were dependent on disease duration, but not age at disease onset. Paediatric-onset disease was associated with a higher rate of extensive colitis at diagnosis and earlier progression or extension of disease, and nonsurgically treated patients with the youngest ages at onset more frequently required antitumour necrosis factor-α treatments. CONCLUSION The higher rates of intestinal complications, including those of the small and large bowel and in the anal region, in paediatric-onset CD patients point towards a level of inflammation that is more difficult to control. Similar findings were also evident in UC patients.
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72
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Coughlan A, Wylde R, Lafferty L, Quinn S, Broderick A, Bourke B, Hussey S. A rising incidence and poorer male outcomes characterise early onset paediatric inflammatory bowel disease. Aliment Pharmacol Ther 2017; 45:1534-1541. [PMID: 28449214 DOI: 10.1111/apt.14070] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/11/2016] [Accepted: 03/10/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The incidence of paediatric inflammatory bowel disease diagnosed before age 10 years is reportedly increasing, but national data are limited. AIM To characterise the epidemiology, phenotype and clinical outcomes of children diagnosed with inflammatory bowel disease before age 10 years, and compare with data from children diagnosed aged 10-16 years. METHODS A review of all Irish cases of early onset inflammatory bowel disease (diagnosis <10 years, EO-IBD) presenting between January 2000 and December 2014 was undertaken and compared to a cohort of later onset paediatric inflammatory bowel disease patients (diagnosis between 10 and 16 years, LO-IBD). Diagnostic investigations, phenotype, treatments, and long-term clinical and surgical outcomes were analysed. RESULTS One hundred and ninety children (99 male) with EO-IBD were identified; 92 (48%) CD, 77 (41%) UC and 21 (11%) IBDU. The incidence of EO-IBD increased by 0.6 per 100 000 per year (0.8-3.2 per 100 000 per year), with a significant increase in UC by 0.06 per 100 000 per year (P=.02). Males with CD had more upper GI disease (L4a; 48% vs 21%; P=.007), more extensive disease distribution (L3±L4; 31% vs 11%; P=.05) and more severe disease activity at presentation (52% vs 31%; P=.05) than females. Fewer patients with early onset than later onset Crohn's disease had ileocolonic disease (L3; 10% vs 20%; P<.001). More relapses were observed in the first year post-diagnosis in early onset than later onset IBD (1.02 vs 0.5 mean relapses; P<.001). CONCLUSIONS EO-IBD is increasing in incidence. Males have more extensive and severe disease phenotypes, and younger patients have higher relapse rates than older children. Further research to explain these findings is warranted.
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Affiliation(s)
- A Coughlan
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,National Children's Research Centre, OLCHC, Crumlin, Dublin, Ireland
| | - R Wylde
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,Leiden University Medical Centre, Leiden, The Netherlands
| | - L Lafferty
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland
| | - S Quinn
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland
| | - A Broderick
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,Academic Centre for Paediatric Research, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - B Bourke
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,National Children's Research Centre, OLCHC, Crumlin, Dublin, Ireland.,Academic Centre for Paediatric Research, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - S Hussey
- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,National Children's Research Centre, OLCHC, Crumlin, Dublin, Ireland.,Academic Centre for Paediatric Research, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons of Ireland, Dublin, Ireland
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- National Centre for Paediatric Gastroenterology (NCPG), OLCHC, Crumlin, Dublin, Ireland.,National Children's Research Centre, OLCHC, Crumlin, Dublin, Ireland
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Sadigh S, Chopra M, Sury MR, Shah N, Olsen ØE, Watson TA. Paediatric magnetic resonance enteroclysis under general anaesthesia - initial experience. Pediatr Radiol 2017; 47:877-883. [PMID: 28386628 DOI: 10.1007/s00247-017-3836-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/01/2017] [Accepted: 03/09/2017] [Indexed: 10/19/2022]
Abstract
MR enterography is the accepted imaging reference standard for small bowel assessment in inflammatory bowel disease. There is an increasing cohort of children with inflammatory bowel disease presenting at an early age (<5 years) with severe disease. Younger children present a technical challenge for enterography because of the need for sedation/general anaesthesia to allow image optimisation and the need for oral contrast to allow adequate luminal assessment. Through our experiences, MR enteroclysis under general anaesthesia has proven to be a successful imaging technique for the work-up of these patients. In this paper, we present our institutional practice for performing MR enteroclysis under general anaesthesia.
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Affiliation(s)
- Sophie Sadigh
- Department of Paediatric Radiology, Great Ormond Street Hospital NHS Foundation Trust, London, Wc1N 3JH, UK
| | - Mark Chopra
- Department of Paediatric Radiology, Great Ormond Street Hospital NHS Foundation Trust, London, Wc1N 3JH, UK
| | - Michael R Sury
- Department of Paediatric Anaesthetics, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Neil Shah
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Øystein E Olsen
- Department of Paediatric Radiology, Great Ormond Street Hospital NHS Foundation Trust, London, Wc1N 3JH, UK
| | - Tom A Watson
- Department of Paediatric Radiology, Great Ormond Street Hospital NHS Foundation Trust, London, Wc1N 3JH, UK.
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Rinawi F, Assa A, Eliakim R, Mozer-Glassberg Y, Nachmias Friedler V, Niv Y, Rosenbach Y, Silbermintz A, Zevit N, Shamir R. The natural history of pediatric-onset IBD-unclassified and prediction of Crohn's disease reclassification: a 27-year study. Scand J Gastroenterol 2017; 52:558-563. [PMID: 28128677 DOI: 10.1080/00365521.2017.1282008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES A definitive diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) in patients who were initially diagnosed as inflammatory bowel disease-unclassified (IBDU) remains challenging. Our aims were to describe the natural history of pediatric-onset IBDU patients during prolonged period of follow up and to identify associated predictors for CD reclassification among them. MATERIALS AND METHODS In this retrospective single center study, out of 723 patients with pediatric onset IBD, we identified 53 patients (7.3%) diagnosed with IBDU at the Schneider Children's Medical Center of Israel between 1986 and 2013. Potential predictors for CD reclassification including age at diagnosis, gender, clinical manifestations, disease extent and laboratory findings were assessed. RESULTS The median follow-up was 6.8 (± 6.7) years. Reclassification to CD was observed in 24/53 (45%) of patients. The median interval from diagnosis to CD reclassification was 9.4 years. In 58% of these patients, CD reclassification occurred within 5 years from diagnosis. Multivariate Cox models showed that familial history of CD and hypoalbuminemia at diagnosis were significantly associated with CD reclassification (HR 11.3, p = .02 and HR 5.3, p = .03, respectively). All other assessed clinical, laboratory and endoscopic parameters did not serve as predictors for CD reclassification later on. CONCLUSIONS In our cohort, a substantial high proportion of pediatric onset IBDU patients were later re-diagnosed as CD. Only a family history of CD and hypoalbuminemia could predict reclassification among IBDU patients.
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Affiliation(s)
- Firas Rinawi
- a Institute of Gastroenterology, Nutrition and Liver Diseases , Schneider Children's Medical Center of Israel , Petach Tikva , Israel
| | - Amit Assa
- a Institute of Gastroenterology, Nutrition and Liver Diseases , Schneider Children's Medical Center of Israel , Petach Tikva , Israel.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel Aviv , Israel
| | - Rami Eliakim
- b Sackler Faculty of Medicine , Tel-Aviv University , Tel Aviv , Israel.,c Department of Gastroenterology , Sheba Medical Center -Tel Hashomer , Tel Aviv , Israel
| | - Yael Mozer-Glassberg
- a Institute of Gastroenterology, Nutrition and Liver Diseases , Schneider Children's Medical Center of Israel , Petach Tikva , Israel.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel Aviv , Israel
| | - Vered Nachmias Friedler
- a Institute of Gastroenterology, Nutrition and Liver Diseases , Schneider Children's Medical Center of Israel , Petach Tikva , Israel
| | - Yaron Niv
- b Sackler Faculty of Medicine , Tel-Aviv University , Tel Aviv , Israel.,d Department of Gastroenterology , Rabin Medical Center , Petach Tikva , Israel
| | - Yoram Rosenbach
- a Institute of Gastroenterology, Nutrition and Liver Diseases , Schneider Children's Medical Center of Israel , Petach Tikva , Israel
| | - Ari Silbermintz
- a Institute of Gastroenterology, Nutrition and Liver Diseases , Schneider Children's Medical Center of Israel , Petach Tikva , Israel
| | - Noam Zevit
- a Institute of Gastroenterology, Nutrition and Liver Diseases , Schneider Children's Medical Center of Israel , Petach Tikva , Israel.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel Aviv , Israel
| | - Raanan Shamir
- a Institute of Gastroenterology, Nutrition and Liver Diseases , Schneider Children's Medical Center of Israel , Petach Tikva , Israel.,b Sackler Faculty of Medicine , Tel-Aviv University , Tel Aviv , Israel
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Bequet E, Sarter H, Fumery M, Vasseur F, Armengol-Debeir L, Pariente B, Ley D, Spyckerelle C, Coevoet H, Laberenne JE, Peyrin-Biroulet L, Savoye G, Turck D, Gower-Rousseau C. Incidence and Phenotype at Diagnosis of Very-early-onset Compared with Later-onset Paediatric Inflammatory Bowel Disease: A Population-based Study [1988-2011]. J Crohns Colitis 2017; 11:519-526. [PMID: 28453757 DOI: 10.1093/ecco-jcc/jjw194] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/26/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Very-early-onset inflammatory bowel disease [VEO-IBD] is a form of IBD that is distinct from that of children with an older onset. We compared changes over time in the incidence and phenotype at diagnosis between two groups according to age at IBD diagnosis: VEO-IBD diagnosed before the age of 6 years, and early-onset IBD [EO-IBD] diagnosed between 6 and 16 years of age. METHODS Data were obtained from a cohort enrolled in a prospective French population-based registry from 1988 to 2011. RESULTS Among the 1412 paediatric cases [< 17 years], 42 [3%] were VEO-IBD. In the VEO-IBD group, the incidence remained stable over the study period. In contrast, the incidence of EO-IBD increased from 4.4/105 in 1988-1990 to 9.5/105 in 2009-2011 [+116%; p < 10-4]. Crohn's disease [CD] was the most common IBD, regardless of age, but ulcerative colitis [UC] and unclassified IBD were more common in VEO-IBD cases [40% vs 26%; p = 0.04]. VEO-IBD diagnosis was most often performed in hospital [69% vs 43%; p < 10-3]. Rectal bleeding and mucous stools were more common in patients with VEO-IBD, whereas weight loss and abdominal pain were more frequent in those with EO-IBD. Regarding CD, isolated colonic disease was more common in the VEO-IBD group [39% vs 14%; p = 0.003]. CONCLUSIONS In this large population-based cohort, the incidence of VEO-IBD was low and stable from 1988 to 2011, with a specific clinical presentation. These results suggest a probable genetic origin for VEO-IBD, whereas the increase in EO-IBD might be linked to environmental factors.
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Affiliation(s)
- E Bequet
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Lille University Jeanne de Flandre Children's Hospital, University of Lille, Lille, France
| | - H Sarter
- Public Health, Epidemiology and Economic Health, Registre EPIMAD, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France
- Lille Inflammation Research International Center LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - M Fumery
- Gastroenterology Unit, EPIMAD Registry, CHU Amiens Sud, Amiens University Hospital, Amiens, France
| | - F Vasseur
- Biostatistics Unit, EA 2694, Lille University and Hospital, Lille, France
| | - L Armengol-Debeir
- Gastroenterology Unit, EPIMAD Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
| | - B Pariente
- Gastroenterology Unit, Hôpital Huriez, Lille University Hospital, Lille, France
| | - D Ley
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Lille University Jeanne de Flandre Children's Hospital, University of Lille, Lille, France
- Lille Inflammation Research International Center LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - C Spyckerelle
- Paediatric Unit, St Vincent Hospital, Catholic University, Lille, France
| | - H Coevoet
- Gastroenterology Unit, Les Bonnettes Private Hospital, Arras, France
| | - J E Laberenne
- Gastroenterology Unit, General Hospital, Seclin, France
| | - L Peyrin-Biroulet
- Gastroenterology Unit, Inserm U954, Université de Lorraine, Nancy, France
| | - G Savoye
- Gastroenterology Unit, EPIMAD Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
| | - D Turck
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Lille University Jeanne de Flandre Children's Hospital, University of Lille, Lille, France
- Lille Inflammation Research International Center LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - C Gower-Rousseau
- Public Health, Epidemiology and Economic Health, Registre EPIMAD, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France
- Lille Inflammation Research International Center LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
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76
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D'Arcangelo G, Aloi M. Inflammatory Bowel Disease-Unclassified in Children: Diagnosis and Pharmacological Management. Paediatr Drugs 2017; 19:113-120. [PMID: 28150131 DOI: 10.1007/s40272-017-0213-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Inflammatory bowel diseases are chronic disorders of the gastrointestinal tract that include Crohn's disease (CD), ulcerative colitis (UC) and inflammatory bowel disease-unclassified (IBDU). The latter defines a subgroup of patients with clinical and endoscopic evidence of chronic colitis, without specific features of either CD or UC. These patients will possibly be re-classified as having UC or CD during the follow-up, although a significant percentage of them will keep the diagnosis of IBDU. IBDU is the rarest subtype of IBD, both in children and in adults, although it is twice as common among the pediatric population, especially in the younger ages. The diagnosis can only be made after a comprehensive diagnostic work-up, combining clinical history, physical and laboratory examination, upper and lower gastrointestinal endoscopy, with histology and imaging of the small bowel. The therapeutic strategy is borrowed from that of UC and CD, although recent data suggest that IBDU has a lower therapeutic burden with a generally mild disease course and a good response to mesalamine. Since there are only few published data on pediatric IBDU, and no guidelines on its management are available, this review aims at summarizing the most recent evidence for the diagnostic work-up with a specific focus on medical and surgical options in the treatment of IBDU.
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Affiliation(s)
- Giulia D'Arcangelo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Marina Aloi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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Multicentric Case-Control Study on Azathioprine Dose and Pharmacokinetics in Early-onset Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:628-634. [PMID: 28296824 DOI: 10.1097/mib.0000000000001051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Early-onset inflammatory bowel disease (IBD) is generally aggressive, with a high probability of complications and need of surgery. Despite the introduction of highly effective biological drugs, treatment with azathioprine continues to be important even for early-onset IBD; however, in these patients azathioprine response seems to be reduced. This study evaluated azathioprine doses, metabolite concentrations, and their associations with patients' age in children with IBD treated at 6 tertiary pediatric referral centers. METHODS Azathioprine doses, metabolites, and clinical effects were assessed after at least 3 months of therapy in 17 early-onset (age < 6 yr, cases) and 51 nonearly-onset (aged > 12 and <18 yrs, controls) patients with IBD. Azathioprine dose was titrated on therapeutic efficacy (response and adverse effects). Azathioprine metabolites and thiopurine methyltransferase activity were determined by high-performance liquid chromatography with ultra violet-vis detection (HPLC-UV) methods. RESULTS Frequency of patients in remission was similar among early-onset and control groups, respectively (82% and 84%, P value = 0.72). Early-onset patients required higher doses of azathioprine (median 2.7 versus 2.0 mg·kg·d, P value = 1.1 × 10). Different doses resulted in comparable azathioprine active thioguanine nucleotide metabolite concentrations (median 263 versus 366 pmol/8 × 10 erythrocytes, P value = 0.41) and methylmercaptopurine nucleotide concentrations (median 1455 versus 1532 pmol/8 × 10 erythrocytes, P value = 0.60). Lower ratios between thioguanine nucleotide metabolites and azathioprine doses were found in early-onset patients (median 98 versus 184 pmol/8 × 10 erythrocytes·mg·kg·d, P value = 0.017). Interestingly, early-onset patients presented also higher thiopurine methyltransferase activity (median 476 versus 350 nmol methylmercaptopurine/mg hemoglobin/h, P-value = 0.046). CONCLUSIONS This study demonstrated that patients with early-onset IBD present increased inactivating azathioprine metabolism, likely because of elevated activity of the enzyme thiopurine methyltransferase.
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Mutations in Interleukin-10 Receptor and Clinical Phenotypes in Patients with Very Early Onset Inflammatory Bowel Disease: A Chinese VEO-IBD Collaboration Group Survey. Inflamm Bowel Dis 2017; 23:578-590. [PMID: 28267044 DOI: 10.1097/mib.0000000000001058] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Interleukin-10 (IL10) signaling plays an important role in the pathogenesis of very early onset inflammatory bowel disease (VEO-IBD) in children. However, little is known about the role of the IL10 axis in children with VEO-IBD in China. METHODS The Chinese VEO-IBD Collaboration Group was created to collect clinical and genetic data from patients deficient in IL10 and the IL10 receptor. High-throughput sequencing was performed to identify mutations in these genes. RESULTS We identified 32 compound heterozygous mutations and 9 homozygous mutations in IL10 receptor subunit alpha and 1 homozygous mutation in IL10 receptor subunit beta. Among these mutations, 10 novel mutations were identified, and 6 pathogenic mutations had been previously described. In patients with IL10 receptor subunit alpha mutations, c.301C>T (p.R101RW) and c.537 G>A (p.T179T) were the most common mutations. For 88.1% of the patients, the initial symptom was diarrhea, with a time of onset of 10.4 ± 8.0 days. Oral ulcers were the first symptom in 23.8% of the patients, with a time of onset of 9.7 ± 2.8 days. Extraintestinal manifestations included perianal abscesses (22/42), perianal fistulas (23/42), oral ulcers (20/42), and recurrent eczema (15/42). Twelve patients underwent enterostomy. These patients also had lower average Z scores in height-for-age and weight-for-age. Various treatment strategies were used, including fecal microbiota transplantation; however, only hematopoietic stem cell transplantation was efficacious. CONCLUSIONS This study identified genotypes and phenotypes of Chinese VEO-IBD infants with IL10 receptor mutations. Our study expands the current knowledge on the involvement of the IL10 axis in patients with VEO-IBD.
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Abstract
The incidence of inflammatory bowel disease (IBD) has increased steadily worldwide, both in adult and in children; approximately 25% of IBD patients are diagnosed before the age of 18. The natural history of IBD is usually more severe in children than in adults, and can be associated with linear growth impairment, delayed puberty onset, reduced bone mass index, malnutrition, and the need for surgery. Biological therapies, especially blocking tumor necrosis factor-α (TNFα), have radically modified the treatment strategies and disease course of IBD in children. In particular, drugs such as Infliximab and Adalimumab are routinely used in the treatment of pediatric IBD. The role of Infliximab and Adalimumab in the management of pediatric IBD has been recently updated in the Consensus guidelines of ECCO/ESPGHAN. Data regarding short-term and long-term efficacy and safety of these drugs in children, and the effects of "top-down" and "step-up" strategies, are lacking. In this paper, the authors will review current indications, efficacy, and safety of biological therapy in pediatric IBD patients, evaluating all articles published after ECCO/ESPGHAN guidelines publication. The authors carried out a systematic search through MEDLINE through PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) Embase, CINAHL, Cochrane Library, and gray literature, from January 2013 to January 2016. Anti-TNFα has been shown to be effective and safe to maintain remission and to achieve mucosal healing. Multicenter trials based on large sample size cohorts are needed to better clarify long-term efficacy of anti-TNFα and the real incidence of treatment-related complications in pediatric IBD.
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Subramanian S, Ekbom A, Rhodes JM. Recent advances in clinical practice: a systematic review of isolated colonic Crohn's disease: the third IBD? Gut 2017; 66:362-381. [PMID: 27802156 DOI: 10.1136/gutjnl-2016-312673] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/05/2016] [Accepted: 09/06/2016] [Indexed: 12/13/2022]
Abstract
The genetics of isolated colonic Crohn's disease place it approximately midway between Crohn's disease with small intestinal involvement and UC, making a case for considering it as a separate condition. We have therefore systematically reviewed its epidemiology, pathophysiology and treatment. Key findings include a higher incidence in females (65%) and older average age at presentation than Crohn's disease at other sites, a mucosa-associated microbiota between that found in ileal Crohn's disease and UC, no response to mesalazine, but possibly better response to antitumour necrosis factor than Crohn's disease at other sites. Diagnostic distinction from UC is often difficult and also needs to exclude other conditions including ischaemic colitis, segmental colitis associated with diverticular disease and tuberculosis. Future studies, particularly clinical trials, but also historical cohorts, should assess isolated colonic Crohn's disease separately.
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Affiliation(s)
- Sreedhar Subramanian
- Institute of Translational Medicine, University of Liverpool, The Henry Wellcome Laboratory, Liverpool, UK
| | - Anders Ekbom
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Jonathan M Rhodes
- Institute of Translational Medicine, University of Liverpool, The Henry Wellcome Laboratory, Liverpool, UK
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81
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Cuív PÓ, Begun J, Keely S, Lewindon PJ, Morrison M. Towards an integrated understanding of the therapeutic utility of exclusive enteral nutrition in the treatment of Crohn's disease. Food Funct 2017; 7:1741-51. [PMID: 26948398 DOI: 10.1039/c5fo01196e] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crohn's disease (CD) is a chronic disease characterized by episodic and disabling inflammation of the gastrointestinal tract in genetically susceptible individuals. The incidence and prevalence of CD is rising rapidly across the world emphasising that disease risk is also influenced by environmental and lifestyle factors, as well as the microbial community resident in the gut. Childhood-onset CD is associated with an aggressive disease course that can adversely impact patient growth and development. There is no cure for CD however new onset and recurrent cases of paediatric CD are often responsive to exclusive enteral nutrition (EEN) treatment. EEN treatment involves the exclusive consumption of an elemental or polymeric formula for several weeks and it is well established as a primary intervention strategy. EEN treatments typically achieve remission rates of over 80% and importantly they are associated with a high rate of mucosal healing, far superior to steroids, which is prognostic of improved long-term health outcomes. Furthermore, they are safe, have few side effects, and improve nutritional status and linear growth. Surprisingly, despite the utility of EEN our understanding of the host-microbe-diet interactions that underpin clinical remission and mucosal healing are limited. Here, we review the current state of knowledge and propose that the induction of autophagy, in addition to modulation of the microbiota and coordinated effects on inflammation and epithelial cell biology, may be critical for the therapeutic effects associated with EEN. A better understanding of EEN treatment will provide new opportunities to restore gut homeostasis and prolong periods of remission, as well as provide new insights into the factors that trigger and perhaps prevent CD.
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Affiliation(s)
- Páraic Ó Cuív
- The University of Queensland Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, QLD 4102, Australia.
| | - Jakob Begun
- Mater Research Institute, The University of Queensland, Brisbane, QLD 4102, Australia and School of Medicine, The University of Queensland, Brisbane, QLD 4102, Australia and Department of Gastroenterology, Mater Health Services, Brisbane, Australia
| | - Simon Keely
- School of Biomedical Science and Pharmacy, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia and Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Peter J Lewindon
- The University of Queensland, Department of Paediatrics and Child Health, Lady Cilento Children's Hospital, QLD 4101, Australia
| | - Mark Morrison
- The University of Queensland Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, QLD 4102, Australia.
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Kammermeier J, Dziubak R, Pescarin M, Drury S, Godwin H, Reeve K, Chadokufa S, Huggett B, Sider S, James C, Acton N, Cernat E, Gasparetto M, Noble-Jamieson G, Kiparissi F, Elawad M, Beales PL, Sebire NJ, Gilmour K, Uhlig HH, Bacchelli C, Shah N. Phenotypic and Genotypic Characterisation of Inflammatory Bowel Disease Presenting Before the Age of 2 years. J Crohns Colitis 2017; 11:60-69. [PMID: 27302973 PMCID: PMC5885808 DOI: 10.1093/ecco-jcc/jjw118] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Inflammatory bowel disease [IBD] presenting in early childhood is extremely rare. More recently, progress has been made to identify children with monogenic forms of IBD predominantly presenting very early in life. In this study, we describe the heterogeneous phenotypes and genotypes of patients with IBD presenting before the age of 2 years and establish phenotypic features associated with underlying monogenicity. METHODS Phenotype data of 62 children with disease onset before the age of 2 years presenting over the past 20 years were reviewed. Children without previously established genetic diagnosis were prospectively recruited for next-generation sequencing. RESULTS In all, 62 patients [55% male] were identified. The median disease onset was 3 months of age (interquartile range [IQR]: 1 to 11). Conventional IBD classification only applied to 15 patients with Crohn's disease [CD]-like [24%] and three with ulcerative colitis [UC]-like [5%] phenotype; 44 patients [71%] were diagnosed with otherwise unclassifiable IBD. Patients frequently required parenteral nutrition [40%], extensive immunosuppression [31%], haematopoietic stem-cell transplantation [29%], and abdominal surgery [19%]. In 31% of patients, underlying monogenic diseases were established [EPCAM, IL10, IL10RA, IL10RB, FOXP3, LRBA, SKIV2L, TTC37, TTC7A]. Phenotypic features significantly more prevalent in monogenic IBD were: consanguinity, disease onset before the 6th month of life, stunting, extensive intestinal disease and histological evidence of epithelial abnormalities. CONCLUSIONS IBD in children with disease onset before the age of 2 years is frequently unclassifiable into Crohn's disease and ulcerative colitis, particularly treatment resistant, and can be indistinguishable from monogenic diseases with IBD-like phenotype.
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Affiliation(s)
- Jochen Kammermeier
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK,Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Robert Dziubak
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Matilde Pescarin
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Suzanne Drury
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK,NE Thames Regional Genetics Laboratory, Great Ormond Street Hospital, London, UK
| | - Heather Godwin
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Kate Reeve
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | | | - Bonita Huggett
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Sara Sider
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Chela James
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Nikki Acton
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Elena Cernat
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Marco Gasparetto
- Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
| | - Gabi Noble-Jamieson
- Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
| | - Fevronia Kiparissi
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Mamoun Elawad
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Phil L. Beales
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Neil J. Sebire
- Department of Histopathology, Great Ormond Street Hospital, London, UK
| | - Kimberly Gilmour
- Department of Immunology, Great Ormond Street Hospital, London, UK
| | - Holm H. Uhlig
- Transitional Gastroenterology Unit, Nuffield Department of Medicine and Department of Paediatrics, University of Oxford, UK
| | - Chiara Bacchelli
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Neil Shah
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
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83
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Kim JY, Park DI, Han DS, Huh KC, Lee CK, Shin JE, Kim JH, Kim YS, Jung Y, Jung SA, Song HJ, Jang HJ, Kim YH, Hong SN. Comparing the clinical outcomes of young-onset and adult-onset ulcerative colitis: a multi-center Korean Association for the Study for Intestinal Diseases study. Korean J Intern Med 2017; 32:69-78. [PMID: 27338135 PMCID: PMC5214714 DOI: 10.3904/kjim.2014.262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 11/10/2014] [Accepted: 09/01/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to compare the clinical features and outcomes of ulcerative colitis (UC) according to the age of onset in Korea. METHODS A total of 1,141 patients who were diagnosed with UC between July 1987 and November 2013 at 11 tertiary hospitals were enrolled. The baseline disease characteristic and disease state at onset, treatment during the disease course were retrospectively reviewed among patients with young-onset (YO, < 20 years) and adult-onset (AO, ≥ 20 years). Severe outcome was defined as use of intravenous (IV) steroids, infliximab, immunosuppressant, or UC-related operation. RESULTS There were 55 YO patients (mean age, 17.8 ± 2.4) and 1,086 AO patients (mean age, 43.0 ± 13.6). High Mayo scores (7.7 ± 3.0 vs. 5.6 ± 2.7, p = 0.000), extensive UC (52.7% vs. 25.8%, p = 0.000) and IV steroid (41.8% vs. 18.0%, p = 0.000), immunosuppressant (47.3% vs. 26.9%, p = 0.002), and infliximab (20.0% vs. 7.2%, p = 0.001) use were more frequent in the YO than in the AO group. According to multivariate analysis, severe outcomes were related to YO disease (hazard ratio [HR], 2.18; 95% confidence interval [CI], 1.27 to 3.71), body mass index < 23 kg/m2 (HR, 1.46; 95% CI, 1.07 to 2.00), severe (HR, 2.29; 95% CI, 1.36 to 3.38), and moderate (HR, 2.48; 95% CI, 1.67 to 3.67) disease, extensive UC (HR, 2.90; 95% CI, 1.79 to 4.69), UC-related admission (HR, 63.89; 95% CI, 20.41 to 200.02), and oral steroid use (HR, 0.51; 95% CI, 0.39 to 0.67). CONCLUSIONS UC with YO presented with more advanced clinical features at onset and more severe outcomes than the AO. YO cases require careful management and intense treatment strategies.
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Affiliation(s)
- Ji Yeon Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence to Dong Il Park, M.D. Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Korea Tel: +82-2-2001-2059 Fax: +82-2-2001-2049 E-mail:
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Kyu-Chan Huh
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Chang Kyun Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Jae Hak Kim
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
| | - You Sun Kim
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Asan, Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyun Joo Song
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Hyun Joo Jang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Young-Ho Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung No Hong
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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84
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Abstract
BACKGROUND Data describing the incidence and the risk factors for surgical interventions in pediatric Crohn's disease (CD) is inconsistent. Our aim was to describe the rates of intestinal surgery and to identify associated risk factors in a large cohort of children with CD. METHODS Medical charts of 482 children with CD from the Schneider Pediatric Inflammatory Bowel Disease cohort who were diagnosed between 1981 and 2013 were carefully reviewed retrospectively. RESULTS Of 482 patients, 143 (29.7%) underwent intestinal surgery with a median follow-up time of 8.6 years (range, 1-30.5). Kaplan-Meier survival estimates of the cumulative probability of CD-related intestinal surgery were 14.2% at 5 years and 24.5% at 10 years from diagnosis. Of these, 14% needed more than one operation. Multivariate Cox models showed that isolated ileal disease (hazard ratio [HR] 2.39, P = 0.008), complicated behavior (penetrating or stricturing) (HR 2.44, P < 0.001) and higher severity indices, at diagnosis, including Harvey-Bradshaw (HR 1.06, P = 0.009) and short Pediatric Crohn's Disease Activity Index (HR 1.02, P = 0.001) were associated with increased risk for intestinal surgery. Age, gender, family history of CD, early introduction of immunomodulators, treatment with anti-tumor necrosis factor α, or diagnosis before the year 2000 did not affect the risk of bowel surgery. CONCLUSIONS Ileal location, complicated behavior, and higher disease activity indices at diagnosis are independent risk factors for bowel surgery, whereas anti-tumor necrosis factor α treatment and diagnosis during the "biological era" are not associated with diminished long-term surgical risk.
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85
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Rinawi F, Assa A, Hartman C, Mozer Glassberg Y, Nachmias Friedler V, Rosenbach Y, Silbermintz A, Zevit N, Shamir R. Evolution of disease phenotype in pediatric-onset Crohn's disease after more than 10 years follow up-Cohort study. Dig Liver Dis 2016; 48:1444-1450. [PMID: 27637153 DOI: 10.1016/j.dld.2016.08.118] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/11/2016] [Accepted: 08/14/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pediatric-onset Crohn's disease (CD) is a heterogeneous disorder which is subjected to progression and complications in a substantial proportion of patients. AIMS We aimed to assess the progression in pediatric-onset CD phenotype on long term follow up. METHODS Medical charts of pediatric onset CD patients with at least 10 years follow-up were analyzed retrospectively. Disease phenotype was determined at diagnosis and during follow up at different time points. Phenotype was determined according to the Paris classification. The impact of possible predictors on phenotype progression was assessed as well as the association between different therapeutic regimens during disease course and phenotype progression. RESULTS Progression of disease location, behavior, and perianal involvement was observed in 20%, 38% and 20% of patients, respectively, after a median follow-up of 16.4 (±4.4) years. Microscopic ileocolonic disease at diagnosis was significant predictors for progression of disease extent. Treatment with anti tumor necrosis factor-ɑ agents and number of flares per years of follow-up were associated with progression of disease extent, behavior and perianal involvement. CONCLUSION Disease extent, behavior and prevalence of perianal disease change significantly over time in pediatric-onset CD. In our cohort, most clinical, laboratory and endoscopic parameters do not serve as predictors for long-term disease progression.
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Affiliation(s)
- Firas Rinawi
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel.
| | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Corina Hartman
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Yael Mozer Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel
| | - Vered Nachmias Friedler
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel
| | - Yoram Rosenbach
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel
| | - Ari Silbermintz
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
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86
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Nambu R, Hagiwara SI, Kubota M, Kagimoto S. Difference between early onset and late-onset pediatric ulcerative colitis. Pediatr Int 2016; 58:862-6. [PMID: 26833925 DOI: 10.1111/ped.12935] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 12/30/2015] [Accepted: 01/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Early onset pediatric ulcerative colitis (EO-UC) is distinguished from late-onset pediatric ulcerative colitis (LO-UC) by the effects of genetic predisposition, but there have been few reports on the clinical features of EO-UC in Asia. METHODS To describe and compare the presentation and disease course of EO-UC (age range, 0-7 years) with those of LO-UC (age range, 8-15 years), we retrospectively analyzed 63 children with UC who had been diagnosed between January 2004 and March 2014 at Saitama Children's Medical Center in Japan. RESULTS Ten patients (16%) had EO-UC, and 53 (84%) had LO-UC. All patients in the EO-UC group and 70% in the LO-UC group had pancolitis (P = 0.05). The period from onset to diagnosis was 9.0 ± 14.1 months for EO-UC and 2.6 ± 3.5 months for LO-UC (P < 0.01). The prevalence of extra-intestinal complications at diagnosis was significantly higher for EO-UC than for LO-UC (50% vs 11%, respectively; P < 0.01). There were no significant differences in the use of corticosteroids, immunomodulators, immunosuppressants, or surgical risk between the groups but, in the EO-UC group, only one patient was treated with cytapheresis and none was treated with anti-tumor necrosis factor (TNF-α) antibodies. CONCLUSIONS The EO-UC group had a higher incidence of pancolitis, longer diagnostic delay, and more extra-intestinal manifestations than the LO-UC group. Diagnosis and treatment may therefore be slightly more difficult for EO-UC than for LO-UC.
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Affiliation(s)
- Ryusuke Nambu
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan.
| | - Shin-Ichiro Hagiwara
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
| | - Mitsuru Kubota
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
| | - Seiichi Kagimoto
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
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87
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Abstract
BACKGROUND The objectives of this multicenter national study were to compare the clinical phenotype of early-onset inflammatory bowel disease (IBD) (EO-IBD) with IBD in older children and to examine whether there is any variability in consanguinity rate and familial aggregation in EO-IBD compared with later onset IBD. METHODS A retrospective analysis was performed on children aged 0 to 14 years with IBD in 17 centers located in geographically distinct regions in Saudi Arabia, from 2003 to 2012. Data of patients with EO-IBD (0 to <6 yrs) were compared with those with later onset IBD (6-14 yrs). Moreover, we evaluated differences in clinical pattern of infantile or toddler onset IBD subgroup (0-3 yr) as compared with those presenting in older children. RESULTS Of 352 IBD patients identified during the 10-year study period, 76 children (21.6%) younger than 6 years were diagnosed with IBD. Among the Crohn's disease (CD) group, infantile or toddler onset CD subgroup showed a more frequent isolated colonic involvement (L2) than later-onset group (57% versus 20%; P = 0.002). Positive family history was significantly more common in the infantile or toddler onset ulcerative colitis subgroup (29.4% versus 4.2% in later onset ulcerative colitis; P < 0.0001). The consanguinity rate was significantly higher in the infantile or toddler onset CD subgroup as compared with later onset CD group (57.1% versus 25.3%; P = 0.04). CONCLUSIONS In conclusion, EO-IBD exhibits a unique clinical phenotype with a strikingly higher familial aggregation in early-onset ulcerative colitis. Our data suggest a significant genetic impact on the onset of CD in the very young children.
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88
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Abstract
BACKGROUND We aimed at describing the efficacy of azathioprine (AZA) in pediatric ulcerative colitis, comparing the outcomes of early (0-6 months) versus late (6-24 months) initiation of therapy. METHODS Children with ulcerative colitis treated with AZA within 24 months of diagnosis were included. Corticosteroid (CS)-free remission and mucosal healing (MH), assessed by endoscopy or fecal calprotectin, at 12 months were the primary outcomes. Patients were also compared for CS-free remission and MH, need for treatment escalation or surgery, number of hospitalizations, and adverse events during a 24-month follow-up. RESULTS A total of 121 children entered the study (median age 10.5 ± 4.0 years, 59% girls). Seventy-six (63%) started AZA between 0 and 6 months (early group) and 45 (37%) started between 6 and 24 months (late group). Seventy-five percent and 53% of patients in the early and late group, respectively, received CS at the diagnosis (P = 0.01). CS-free remission at 1 year was achieved by 30 (50%) of the early and 23 (57%) of the late patients (P = 0.54). MH occurred in 37 (37%) patients at 1 year, with no difference between the 2 groups (33% early, 42% late; P = 0.56). No difference was found for the other outcomes. CONCLUSIONS Introduction of AZA within 6 months of diagnosis seems not more effective than later treatment to achieve CS-free remission in pediatric ulcerative colitis. MH does not depend on the timing of AZA initiation; however, because of the incomplete comparability of the 2 groups at the diagnosis and the use of fecal calprotectin as a surrogate marker of MH, our results should be further confirmed by prospective studies.
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Capriati T, Cardile S, Papadatou B, Romano C, Knafelz D, Bracci F, Diamanti A. Pediatric inflammatory bowel disease: specificity of very early onset. Expert Rev Clin Immunol 2016; 12:963-72. [DOI: 10.1080/1744666x.2016.1184571] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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90
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Abstract
To date, there have been many advances in inflammatory bowel disease (IBD) imaging in every cross-sectional imaging modality, particularly in children. The main emphasis in pediatric IBD imaging is on robust and reproducible measures of small bowel Crohn's disease inflammation, accurate diagnosis of IBD-related complications, and minimizing radiation burden to the patient, as repeat imaging is necessary over the course of their disease. In this article, we discuss the current state-of-the-art imaging techniques, in addition to routine fluoroscopy, including MR and CT enterography and bowel ultrasound. We also present the emerging use of new methods to characterize disease severity and distinguish active inflammation from fibrosis such as diffusion-weighted imaging, bowel elastography, and contrast-enhanced ultrasound. The diagnostic performance of particular examinations, their strengths and weaknesses, and role in IBD management will be discussed. Although these advanced imaging techniques applied to children are similar to those performed in adults, special considerations related to their application in pediatric patients will also be reviewed.
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91
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Gasparetto M, Guariso G, Pozza LVD, Ross A, Heuschkel R, Zilbauer M. Clinical course and outcomes of diagnosing Inflammatory Bowel Disease in children 10 years and under: retrospective cohort study from two tertiary centres in the United Kingdom and in Italy. BMC Gastroenterol 2016; 16:35. [PMID: 26976427 PMCID: PMC4791934 DOI: 10.1186/s12876-016-0455-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 03/09/2016] [Indexed: 12/22/2022] Open
Abstract
Background Most children with Inflammatory Bowel Disease (IBD) are diagnosed between 11 and 16 years of age, commonly presenting with features of typical IBD. Children with onset of gut inflammation under 5 years of age often have a different underlying pathophysiology, one that is genetically and phenotypically distinct from other children with IBD. We therefore set out to assess whether children diagnosed after the age of 5 years, but before the age of 11, have a different clinical presentation and outcome when compared to those presenting later. Methods Retrospective cohort study conducted at two European Paediatric Gastroenterology Units. Two cohorts of children with IBD (total number = 160) were compared: 80 children diagnosed between 5 and 10 years (Group A), versus 80 children diagnosed between 11 and 16 (Group B). Statistical analysis included multiple logistic regression. Results Group A presented with a greater disease activity (p = 0.05 for Crohn’s disease (CD), p = 0.03 for Ulcerative Colitis (UC); Odds Ratio 1.09, 95 % Confidence Interval: 1.02–1.1), and disease extent (L2 location more frequent amongst Group A children with CD (p = 0.05)). No significant differences were observed between age groups in terms of gastro-intestinal and extra-intestinal signs and symptoms at disease presentation, nor was there a difference in the number of hospitalisations due to relapsing IBD during follow-up. However, children in Group A were treated earlier with immunosuppressants and had more frequent endoscopic assessments. Conclusion While clinicians feel children between 5 and 10 years of age have a more severe disease course than adolescents, our analysis also suggests a greater disease burden in this age group. Nevertheless, randomized trials to document longer-term clinical outcomes are urgently needed, in order to address the question whether a younger age at disease onset should prompt per se a more “aggressive” treatment. We speculate that non-clinical factors (e.g. genetics, epigenetics) may have more potential to predict longer term outcome than simple clinical measures such as age at diagnosis. Electronic supplementary material The online version of this article (doi:10.1186/s12876-016-0455-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco Gasparetto
- Cambridge University Hospitals, Addenbrooke's, Department of Paediatric Gastroenterology, Hepatology and Nutrition, Box 116 Level 8, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Graziella Guariso
- Padova University Hospital, Department of Women and Children's Health, Unit of Paediatric Gastroenterology, Padova, 35128, Italy
| | - Laura Visona' Dalla Pozza
- Padova University Hospital, Department of Women and Children's Health, Unit of Epidemiology and Community Medicine, Padova, 35128, Italy
| | - Alexander Ross
- Cambridge University Hospitals, Addenbrooke's, Department of Paediatric Gastroenterology, Hepatology and Nutrition, Box 116 Level 8, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Robert Heuschkel
- Cambridge University Hospitals, Addenbrooke's, Department of Paediatric Gastroenterology, Hepatology and Nutrition, Box 116 Level 8, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Matthias Zilbauer
- Cambridge University Hospitals, Addenbrooke's, Department of Paediatric Gastroenterology, Hepatology and Nutrition, Box 116 Level 8, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
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92
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Ognibene NMG, Basile M, Di Maurizio M, Petrillo G, De Filippi C. Features and perspectives of MR enterography for pediatric Crohn disease assessment. Radiol Med 2016; 121:362-77. [PMID: 26838591 DOI: 10.1007/s11547-015-0613-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/01/2015] [Indexed: 02/07/2023]
Abstract
The aim of this paper is to provide indications for performing magnetic resonance enterography (MRE) in Crohn's disease (CD), the essential technical elements of MRE techniques and typical findings in patients with CD. Patients suffering from CD frequently require cross-sectional imaging. By performing MRE, it is possible to obtain results comparable to those obtained with endoscopy in terms of identifying and assessing disease activity and better than other cross-sectional imaging techniques, such as CT, in the evaluation of the fibrosis and complications of disease. The MR imaging of diffusion MR is a technique which enables medical staff to add important additional information and which may replace the use of intravenous contrast agents in the near future. Magnetic resonance enterography is an accurate tool for assessing bowel disease and the various complications associated with CD. The lack of exposure to non-ionizing radiation is an important advantage of this imaging technique, especially in the case of pediatric patients. Familiarity with common and pathognomonic imaging features of CD is essential for every clinician involved in the treatment of inflammatory bowel disease and the care of patients.
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Affiliation(s)
- Noemi Maria Giovanna Ognibene
- Radiodiagnostic and Oncological Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Massimo Basile
- Pediatric Radiology, Meyer Children's University Hospital, Florence, Italy
| | - Marco Di Maurizio
- Pediatric Radiology, Meyer Children's University Hospital, Florence, Italy
| | - Giuseppe Petrillo
- Radiodiagnostic and Oncological Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Claudio De Filippi
- Pediatric Radiology, Meyer Children's University Hospital, Florence, Italy.
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93
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Clinical Presentation and Five-Year Therapeutic Management of Very Early-Onset Inflammatory Bowel Disease in a Large North American Cohort. J Pediatr 2015; 167:527-32.e1-3. [PMID: 25982142 DOI: 10.1016/j.jpeds.2015.04.045] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/23/2015] [Accepted: 04/16/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To evaluate the presentation, therapeutic management, and long-term outcome of children with very early-onset (VEO) (≤ 5 years of age) inflammatory bowel disease (IBD). STUDY DESIGN Data were obtained from an inception cohort of 1928 children with IBD enrolled in a prospective observational registry at multiple centers in North America. RESULTS One hundred twelve children were ≤ 5 years of age with no child enrolled at <1 year of age. Of those, 42.9% had Crohn's disease (CD), 46.4% ulcerative colitis (UC), and 10.7% had IBD-unclassified. Among the children with CD, children 1-5 years of age had more isolated colonic disease (39.6%) compared with 6- to 10-year-olds (25.3%, P = .04), and 11- to 16-year-olds (22.3%, P < .01). The change from a presenting colon-only phenotype to ileocolonic began at 6-10 years. Children 1-5 years of age with CD had milder disease activity (45.8%) at diagnosis compared with the oldest group (28%, P = .01). Five years postdiagnosis, there was no difference in disease activity among the 3 groups. However, compared with the oldest group, a greater proportion of 1- to 5-year-olds with CD were receiving corticosteroids (P < .01) and methotrexate (P < .01), and a greater proportion of 1- to 5-year-olds with UC were receiving mesalamine (P < .0001) and thiopurine immunomodulators (P < .0002). CONCLUSIONS Children with VEO-CD are more likely to have mild disease at diagnosis and present with a colonic phenotype with change to an ileocolonic phenotype noted at 6-10 years of age. Five years after diagnosis, children with VEO-CD and VEO-UC are more likely to have been administered corticosteroids and immunomodulators despite similar disease activity in all age groups. This may suggest development of a more aggressive disease phenotype over time.
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94
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Pediatric IBD-unclassified Is Less Common than Previously Reported; Results of an 8-Year Audit of the EUROKIDS Registry. Inflamm Bowel Dis 2015; 21:2145-53. [PMID: 26164665 DOI: 10.1097/mib.0000000000000483] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inflammatory bowel disease-unclassified (IBD-U) is diagnosed in ∼10% of pediatric and adolescent onset IBD patients. The EUROKIDS registry (2004) initiated by the Porto IBD working group of ESPGHAN prospectively monitors diagnostic workup of newly diagnosed pediatric and adolescent onset IBD patients. We aimed to describe diagnostic workup, phenotype, and change of diagnosis over time in pediatric IBD-U patients. METHODS Data were collected on children from 52 centers across 20 European countries and Israel, diagnosed with IBD from May 2005 through November 2013. Full endoscopy plus small bowel radiology was considered complete diagnostic workup. Participating centers reporting IBD-U patients were queried in 2014 for follow-up data. RESULTS IBD-U was the provisional first diagnosis in 265 of 3461 children (7.7%) (91/158 [58%] with pancolitis; 140 [53%] male), diagnosed more frequently under the age of 10 (median age 12.3 years, 89 [34%] under 10 years). Half (48%) had undergone complete diagnostic workup. Lack of small bowel radiology was the prevailing reason for incomplete workup. As a result of reinvestigations (endoscopy in 54%, radiology in 38%) during a median follow-up of 5.7 years (interquartile range, 2.5-7.8), a change in diagnosis from IBD-U to Crohn's disease (12%) or ulcerative colitis (20%) was reported. CONCLUSIONS Only half of patients reported as IBD-U in EUROKIDS had undergone complete diagnostic workup. Follow-up with reinvestigations resulted in a reduction of IBD-U rate to 5.6%. A diagnosis of IBD-U becomes less likely in case of complete diagnostic workup. Implementation of clear diagnostic criteria will further reduce the rate of IBD-U in the future.
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95
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Machtaler S, Knieling F, Luong R, Tian L, Willmann JK. Assessment of Inflammation in an Acute on Chronic Model of Inflammatory Bowel Disease with Ultrasound Molecular Imaging. Am J Cancer Res 2015; 5:1175-86. [PMID: 26379784 PMCID: PMC4568446 DOI: 10.7150/thno.13048] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 07/16/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Ultrasound (US) molecular imaging has shown promise in assessing inflammation in preclinical, murine models of inflammatory bowel disease. These models, however, initiated acute inflammation on previously normal colons, in contrast to patients where acute exacerbations are often in chronically inflamed regions. In this study, we explored the potential of dual P- and E-selectin targeted US imaging for assessing acute inflammation on a murine quiescent chronic inflammatory background. METHODS Chronic colitis was induced using three cycles of 4% DSS in male FVB mice. Acute inflammation was initiated 2 weeks after the final DSS cycle through rectal administration of 1% TNBS. Mice at different stages of inflammation were imaged using a small animal ultrasound system following i.v. injection of microbubbles targeted to P- and E-selectin. In vivo imaging results were correlated with ex vivo immunofluorescence and histology. RESULTS Induction of acute inflammation resulted in an increase in the targeted US signal from 5.5 ± 5.1 arbitrary units (a.u.) at day 0 to 61.0 ± 45.2 a.u. (P < 0.0001) at day 1, 36.3 ± 33.1 a.u. at day 3, returning to levels similar to control at day 5. Immunofluorescence showed significant increase in the percentage of P- and E-selectin positive vessels at day 1 (P-selectin: 21.0 ± 7.1% of vessels; P < 0.05; E-selectin: 16.4 ±3.7%; P < 0.05) compared to day 0 (P-selectin: 10.3 ± 5.7%; E-selectin: 7.3 ± 7.0%). CONCLUSIONS Acute inflammation can be accurately measured in a clinically relevant murine model of chronic IBD using ultrasound molecular imaging with a dual P- and E- selectin-targeted contrast agent.
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Abstract
Inflammatory bowel diseases are characterized by a chronic relapsing course, high morbidity and impaired quality of life. Their incidence is rising, and about 25% of cases are diagnosed in pediatric age. Anti-TNF-α antibodies, such as infliximab and adalimumab (ADA), are usually administered in patients refractory to conventional therapies. However, increasing evidence suggests that they can be introduced earlier in the course of the disease, especially in patients with aggressive and extensive disease since diagnosis. ADA is a fully human anti-TNF-α antibody recently approved for pediatric Crohn's disease not only in patients unresponsive to infliximab, but also as a first-line anti-TNF-α therapy. In this review, we aim to summarize the current knowledge on the use of ADA in pediatric Crohn's disease and to discuss open issues regarding safety as well as future perspectives.
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Affiliation(s)
- Federica Nuti
- Pediatric Unit, Vimercate Hospital, Vimercate, Italy
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97
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Abstract
Inflammatory bowel disease (IBD) is a multifactoral disease caused by dysregulated immune responses to commensal or pathogenic microbes in the intestine, resulting in chronic intestinal inflammation. An emerging population of patients with IBD occurring before the age of 5 represent a unique form of disease, termed Very Early Onset (VEO)-IBD, which is phenotypically- and genetically-distinct from older-onset IBD. VEO-IBD is associated with increased disease severity, aggressive progression and poor responsiveness to most conventional therapies. Further investigation into the causes and pathogenesis of VEO-IBD will help improve treatment strategies, and may lead to a better understanding of the mechanisms that are essential to maintain intestinal health or provoke the development of targeted therapeutic strategies to limit intestinal disease. Here we discuss the phenotypic nature of VEO-IBD, the recent identification of novel gene variants associated with disease, and functional immunologic studies interrogating the contribution of specific genetic variants to the development of chronic intestinal inflammation.
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Key Words
- inflammatory bowel disease
- very early onset inflammatory bowel disease
- whole exome sequencing
- mucosal immunology
- adam17, a disintegrin and metalloproteinase domain 17
- cgd, chronic granulomatous disease
- col7a1, collagen, type vii, α1
- cvid, common variable immunodeficiency
- foxp3, forkhead box protein 3
- gucy2, guanylate cyclase 2
- gwas, genomewide association studies
- ibd, inflammatory bowel disease
- il, interleukin
- ilc, innate lymphoid cells
- ilc3, group 3 innate lymphoid cells
- iga, immunoglobulin a
- ikbkg, inhibitor of κ light polypeptide gene enhancer in b cells, kinase of, γ
- ipex, immunodysregulation, polyendocrinopathy, and enteropathy, x-linked
- mhcii, major histocompatibility complex class ii
- nemo, nuclear factor-κb essential modulator
- rag, recombination-activating gene
- stat, signal transducer and activator of transcription
- tnf, tumor necrosis factor
- treg, regulatory t cell
- ttc7a, tetratricopeptide repeat domain-containing protein 7a
- veo-ibd, very early onset inflammatory bowel disease
- wasp, wiskott-aldrich syndrome protein
- wes, whole exome sequencing
- xiap, x-linked inhibitor of apoptosis protein
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98
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Nonanesthesia magnetic resonance enterography in young children: feasibility, technique, and performance. J Pediatr Gastroenterol Nutr 2015; 60:754-61. [PMID: 25996792 DOI: 10.1097/mpg.0000000000000712] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The aim of the present study was to demonstrate the effectiveness and cost savings of a nonanesthesia approach to magnetic resonance enterography (MRE) in 14 young pediatric patients (age 4-7 years) with clinically suspected early-onset inflammatory bowel disease using an MRE protocol. METHODS MRE was performed using a combination of an abbreviated imaging protocol, magnetic resonance imaging video goggles, and Child Life Services support. MRE results were correlated with both colonoscopy and pathology results using Pearson correlation coefficient. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS MRE was performed successfully in 13 of 14 patients (age range 4 years 0 months to 7 years 6 months). MRE findings matched with results in 12 of 13 patients in whom colonoscopy was successfully performed. Both MRE and colonoscopy demonstrated a high specificity (100%) and a positive predictive value (100%), but a low sensitivity (43%) and a negative predictive value (50%). CONCLUSIONS MRE can be successfully performed in children ages 4 to 7 years using this approach. In addition to decreased risks to the child, the lack of anesthesia also offers a potential overall cost reduction.
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99
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Managing paediatric acute severe ulcerative colitis according to the 2011 ECCO-ESPGHAN guidelines: Efficacy of infliximab as a rescue therapy. Dig Liver Dis 2015; 47:455-9. [PMID: 25733340 DOI: 10.1016/j.dld.2015.01.156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 01/22/2015] [Accepted: 01/28/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effectiveness of medical therapy in paediatric acute severe colitis is scarcely described. We aimed to assess the efficacy of infliximab in children prospectively enrolled at Sapienza University of Rome between May 2010 and 2012. METHODS Clinical assessment and laboratory data were recorded at admission and at day 3 and 5. All patients received corticosteroids; infliximab was administered in refractory patients. Colectomy rate was assessed at 2-year follow-up. RESULTS Thirty-one patients (mean age 10.6±4.9 years, 52% females) were included: 21 responded to corticosteroids (68%), 10 were refractory and received infliximab (32%). Among the latter, 2 required urgent colectomy (20%); 80% responded, however 50% of these required elective colectomy during follow-up. Patients refractory to corticosteroids showed a significantly shorter interval from ulcerative colitis diagnosis to acute severe colitis compared to responders (7.4±9.6 vs. 23.1±21.6 months, respectively; p=0.01), and a higher rate of colectomy at follow-up (50% vs. 14%, respectively; p=0.007). More than 2 courses of corticosteroids before acute severe colitis were predictive of surgical need (OR 4.4). CONCLUSION Despite its short-term efficacy, infliximab did not modify the long-term surgical rate of paediatric acute severe colitis in our cohort. Children with an early severe colitis commonly need a second-line therapy, whilst frequent courses of corticosteroids are predictive of a poor outcome.
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100
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Curcumin and inflammatory bowel disease: potential and limits of innovative treatments. Molecules 2014; 19:21127-53. [PMID: 25521115 PMCID: PMC6271352 DOI: 10.3390/molecules191221127] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 02/08/2023] Open
Abstract
Curcumin belongs to the family of natural compounds collectively called curcuminoids and it possesses remarkable beneficial anti-oxidant, anti-inflammatory, anti-cancer, and neuroprotective properties. Moreover it is commonly assumed that curcumin has also been suggested as a remedy for digestive diseases such as inflammatory bowel diseases (IBD), a chronic immune disorder affecting the gastrointestinal tract and that can be divided in two major subgroups: Crohn’s disease (CD) and Ulcerative Colitis (UC), depending mainly on the intestine tract affected by the inflammatory events. The chronic and intermittent nature of IBD imposes, where applicable, long-term treatments conducted in most of the cases combining different types of drugs. In more severe cases and where there has been no good response to the drugs, a surgery therapy is carried out. Currently, IBD-pharmacological treatments are generally not curative and often present serious side effects; for this reason, being known the relationship between nutrition and IBD, it is worthy of interesting the study and the development of new dietary strategy. The curcumin principal mechanism is the suppression of IBD inflammatory compounds (NF-κB) modulating immune response. This review summarizes literature data of curcumin as anti-inflammatory and anti-oxidant in IBD, trying to understand the different effects in CD e UC.
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