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Nallapaneni P, Picoraro JA. Diagnosis and Treatment of Pouch Disorders in Children: A Systematic Review. Dis Colon Rectum 2024; 67:S115-S124. [PMID: 38422401 DOI: 10.1097/dcr.0000000000003317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Restorative proctocolectomy and IPAA have become the surgical procedure of choice in pediatric patients with medically refractory colitis or familial adenomatous polyposis. OBJECTIVE This systematic review aims to assess the diagnosis and treatment of pouch disorders in pediatric patients who undergo IPAA. DATA SOURCES A literature search was performed using MEDLINE, Google Scholar, and Embase for all publications describing outcomes of pediatric IPAA. STUDY SELECTION Studies between January 1, 2000, and September 7, 2022, published in English were included. Studies were excluded on the basis of title, abstract, and full-length review. INTERVENTIONS IPAA. MAIN OUTCOME MEASURES Pouch disorders described include anastomotic leaks, pouch strictures, pouch failure, pouchitis, cuffitis, and de novo Crohn's disease of the pouch. RESULTS Thirty-three studies were included in this review, all of which were retrospective in nature. The outcomes of 2643 pediatric patients were included in the 33 studies. LIMITATIONS Management is largely informed by clinical practices in adult patients with scant data on treatment efficacy in children. CONCLUSIONS The reported incidence of disorders of the pouch in children varies widely and is likely attributable to differences in definitions and follow-up periods across studies. Pouchitis was the most frequently described outcome. The overall rate of pouch failure in children is relatively low, with de novo Crohn's disease of the pouch being the most significant risk factor. Multicenter prospective studies are needed in the pediatric population to accurately identify risk factors, standardize the assessment of pouch complications, and determine effective treatment strategies. See video from the symposium .
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Affiliation(s)
- Padmini Nallapaneni
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
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Szigeti R, Kellermayer R. Immunotherapy withdrawal by step-down to mesalamine in pediatric patients with ulcerative colitis. JPGN REPORTS 2024; 5:97-100. [PMID: 38756120 PMCID: PMC11093912 DOI: 10.1002/jpr3.12048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/04/2023] [Accepted: 01/14/2024] [Indexed: 05/18/2024]
Abstract
Objective Parents and pediatric patients with ulcerative colitis (UC) who progressed to systemic immunotherapy are concerned about lifelong risks from such treatments. There is limited knowledge about withdrawal of such agents and step-down (SD) to enteral 5-aminosalicylic acid (mesalamine) before transitioning to adult care. Methods We studied nine pediatric cases with moderate to severe UC who after a median of 2.18 years of clinical remission on systemic immunotherapy stepped down to oral mesalamine treatment. Results Average follow-up time from SD was 3.49 years. Five patients (55.5%) had sustained remission (without any flare noted) after SD during follow-up. Sustained clinical remission was 88.9% (8/9) at 1 year, 87.5% (7/8) at 2 years, and 66.7% (4/6) at 3 years after SD. Out of those tested (one patient was not tested), 62.5% (5/8) had fecal calprotectin <50 μg/g. Four out of six patients examined (66.6%) had mucosal healing on post-SD colonoscopy. Conclusion We propose that SD to mesalamine can be a reasonable therapeutic consideration for pediatric patients with UC before transitioning to adult gastroenterology care. Shared decision-making is important before such treatment changes.
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Affiliation(s)
- Reka Szigeti
- Department of Pathology and Genomic MedicineHouston Methodist HospitalHoustonTexasUSA
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's HospitalBaylor College of MedicineHoustonTexasUSA
- USDA/ARS Children's Nutrition Research CenterHoustonTexasUSA
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Ochoa B, McMahon L. Surgery for ulcerative colitis. Semin Pediatr Surg 2024; 33:151404. [PMID: 38615424 DOI: 10.1016/j.sempedsurg.2024.151404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Ulcerative colitis (UC) has a more severe presentation and rapid progression in pediatric patients, resulting in a greater need for surgical intervention compared to adults. Though medical management of UC has advanced with new biologic therapies, surgery continues to play an important role when disease progresses in the form of worsened or persistent symptoms, hemodynamic instability, or sepsis. The goals of surgical management are to restore intestinal continuity with a functional pouch when possible. While the literature has been growing regarding studies of pediatric patients with UC, high level of evidence studies are limited and most recommendations are based on adult studies. Similar to adults, pediatric patients who have ileal pouches created require surveillance for recurrent disease and cancer surveillance. Unique issues for pediatric patients include monitoring of growth and appropriate transition to adult care after adolescence. This review includes indications for surgical management, overview of staged surgical approaches, and the technical details of the three-stage approach.
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Affiliation(s)
- Brielle Ochoa
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, Arizona, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, Arizona, USA.
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Greene AC, Mankarious MM, Finkelstein A, El-Mallah JC, Kulaylat AS, Kulaylat AN. Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis. J Surg Res 2024; 295:399-406. [PMID: 38070253 DOI: 10.1016/j.jss.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/21/2023] [Accepted: 11/08/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes. METHODS Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay. RESULTS The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference. CONCLUSIONS There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Adam Finkelstein
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Jessica C El-Mallah
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Audrey S Kulaylat
- Division of Colon and Rectal Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania.
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Hope E, Kuronen-Stewart C, Wilson DC, Henderson P, Clark C. The Impact of Biologic Therapies on Rate of Colectomy in Paediatric-onset Ulcerative Colitis - A Population-Based Cohort Study. J Pediatr Surg 2024; 59:230-234. [PMID: 37981545 DOI: 10.1016/j.jpedsurg.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 10/11/2023] [Indexed: 11/21/2023]
Abstract
AIM Biologic therapies have been associated with reduced rate of colectomy in ulcerative colitis (UC) in adults, but data are limited in paediatric-onset UC. Our aim was to define the rate of colectomy in paediatric-onset UC, including post-transition into adult care, and to evaluate the impact of biologic therapies on rate of colectomy. METHOD All prevalent patients diagnosed with paediatric-onset UC in South-East Scotland were identified from a prospectively accrued database at our regional tertiary centre. Patients exposed to biologics or surgery were identified and further data collected from health records. Kaplan-Meier analysis was used to calculate cumulative risk of colectomy over time. RESULTS 145 prevalent patients were identified between 2000 and 2021. Median follow-up was 7.9 years (IQR 4.1-13.1). 23 patients (16 %) underwent a colectomy. 50/145 (34 %) patients received biologic therapy, and 13/23 (57 %) patients who underwent colectomy received biologics. The cumulative risk of colectomy across the whole cohort at 1, 5, and 10 years was 3 %, 13 % and 16 %, respectively. Patients exposed to biologics had a higher colectomy rate at 5 and 10 years (22 % and 34 %). Patients in the pre-biologic era (2000-2008) had non-significantly reduced time from diagnosis to colectomy (2.4 vs 3.7 years, p = 0.204). CONCLUSION We have defined the 1-, 5-, and 10-year colectomy rate in a population-based cohort of Paediatric-onset UC patients. Patients who received biologic therapy had a significantly increased risk of colectomy. Increased severity of disease in these patients may account for the greater colectomy risk. LEVEL OF EVIDENCE Level 1.
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Affiliation(s)
- Emma Hope
- Department of Paediatric Surgery, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Cameron Kuronen-Stewart
- Department of Paediatric Surgery, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK.
| | - David C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK; Department of Child Life and Health, University of Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK; Department of Child Life and Health, University of Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Claire Clark
- Department of Paediatric Surgery, Royal Hospital for Children and Young People, Edinburgh, 50 Little France Crescent, Edinburgh, EH16 4TJ, UK
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Kumar M, Harvey RN, Osei SK, Fatima A, Menning AZ, Akay B, Brahmamdam P, Stallion A, Novotny NM. The Evolving Effectiveness of Biologics in Avoiding Surgery in Children With Ulcerative Colitis: At what Nutritional Cost? Am Surg 2023; 89:5584-5591. [PMID: 36869696 DOI: 10.1177/00031348231161701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
BACKGROUND Pediatric ulcerative colitis (UC) treatment has changed dramatically with the introduction of multiple biologics. The goal of this study was to determine the effectiveness of these new biologics on achieving remission, nutritional impact, and eventual need for surgery in children. METHODS We retrospectively analyzed hospital records of UC patients (ages 1-19) seen at a pediatric gastroenterology clinic between January 2012 andAugust 2020. Patients were divided into groups: 1) medically without biologics or surgery; 2) patients treated with one biologic; and 3) patients treated with multiple biologics 4)patients that underwent colectomy. RESULTS There were 115 UC patients with a mean follow-up of 5.9 ± 3.7 years (1 month-15.3 years). PUCAI score at diagnosis was mild in 52 patients (45%), moderate in 25 (21%), and severe in 5 (4.3%). PUCAI score for 33 patients (29%) could not be calculated. There were 48 (41.3%) in group 1 with 58% remission, 34 (29.6%) in group 2 with 71% remission, 24 (20.8%) in group 3 with 29% remission, and only 9 (7.8%) in group 4 with 100% remission. The majority (55%) of surgical patients had colectomy within the first year of diagnosis. BMI improved after surgery (P = 0.001). The change from one biologic to others did not improve nutrition over time. DISCUSSION New biologics are changing the landscape in maintaining remission from UC. The current need for surgery is much lower than previously published studies. In medically refractive UC, nutritional status only improved after surgery. Addition of another biologic for medically refractory ulcerative colitis in order to avoid surgery must take into account the positive impact surgery has on nutrition and disease remission.
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Affiliation(s)
- Mohineesh Kumar
- Department of Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
| | - Rachel N Harvey
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
| | - Samuel K Osei
- Department of Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
| | - Ayesha Fatima
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
- Section of Pediatric Gastroenterology, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Alexander Z Menning
- Department of Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
| | - Begum Akay
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
- Section of Pediatric Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Pavan Brahmamdam
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
- Section of Pediatric Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Anthony Stallion
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
- Section of Pediatric Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Nathan M Novotny
- Oakland University William Beaumont School of Medicine, Oakland, MI, USA
- Section of Pediatric Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
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Green Z, Beattie RM, Ashton JJ. Recent developments in the assessment and management of inflammatory bowel disease in childhood: a narrative review. Transl Pediatr 2023; 12:1853-1874. [PMID: 37969128 PMCID: PMC10644027 DOI: 10.21037/tp-23-210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/15/2023] [Indexed: 11/17/2023] Open
Abstract
Background and Objective The landscape of paediatric inflammatory bowel disease (pIBD) continues to evolve in an era of increasing incidence. There have been rapid developments in understanding, as we begin to perceive IBD as a spectrum of conditions, alongside advancements in monitoring and treatment. The objective of this article was to provide an overview of recent advances and challenges in the management of pIBD, with a focus on sustainable healthcare, personalised therapy, genomics, new drugs and avenues for future optimisation. Methods We present a narrative review that synthesises and summarises recent research (2017-2022) related to pIBD. We undertook a structured search of the literature (PubMed and Medline) and additional articles were identified through manual searches of reference lists. Evidence tables were compiled for disease outcomes. Key Content and Findings In this review we outline current practice, integrating clinical guidelines and contemporary research. We discuss initial investigations (including suggested threshold for paediatric faecal calprotectin), specialist investigations for disease monitoring [with reference to video capsule endoscopy (VCE) and therapeutic drug levels] and outline new and established treatment options. Biomarkers and genomic testing are examined as important tools for individualising care and identifying potential therapeutic targets, including for top-down therapy. Despite these advances, significant challenges remain, including the need for further research to understand the mechanisms of disease and the translation of these advances into real-world improvements in practice. Conclusions Recent advances in understanding of the pathogenesis of pIBD, alongside genomic and pharmacological developments have added more tools to the armamentarium for the treatment of these conditions and highlighted ongoing areas of research need.
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Affiliation(s)
- Zachary Green
- Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
- Department of Paediatric Gastroenterology, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
| | - Robert Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
| | - James J. Ashton
- Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
- Department of Human Genetics and Genomic Medicine, University of Southampton, Southampton, UK
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Carman N, Picoraro JA. Advances in Endoscopy for Pediatric Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2023; 33:447-461. [PMID: 36948755 DOI: 10.1016/j.giec.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Endoscopic characterization of pediatric inflammatory bowel disease (IBD) has developed in accordance with advances in treatment and improved understanding of disease progression and complications. Reliable and consistent endoscopic reporting practices and tools continue to evolve. The roles of endoscopic ultrasonography, capsule endoscopy, and deep enteroscopy in the care of children and adolescents with IBD are beginning to be clarified. Opportunities for therapeutic intervention with endoscopy in pediatric IBD, including endoscopic balloon dilation and electroincision therapy, require further study. This review discusses the current utility of endoscopic assessment in Pediatric Inflammatory Bowel Disease, as well as emerging and evolving techniques to improve patient care.
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Affiliation(s)
- Nicholas Carman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, University of Ottawa, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Sickkids Inflammatory Bowel Disease Centre, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH17-105, New York, NY 10032, USA; NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY 10032, USA
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Mansuri I, Wang S, Rufo PA, Liu E, Chan C, Bousvaros A. Efficacy and Safety of Sulfasalazine Suspension in Children With Ulcerative Colitis. J Pediatr Gastroenterol Nutr 2023; 76:460-467. [PMID: 36576855 DOI: 10.1097/mpg.0000000000003698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sulfasalazine (SZ) is commonly used to treat pediatric ulcerative colitis (UC). SZ can be compounded into a suspension form which is beneficial for children with difficulty swallowing a pill. Despite being utilized for over 40 years, there is a lack of published data on the efficacy and safety of SZ suspension in children with UC. Recently, third-party payors have begun refusing to pay for SZ suspension due to lack of data. METHODS In this retrospective study, we reviewed the electronic medical records of patients ages <18 years diagnosed with UC from June 1999 to December 2019 at Boston Children's Hospital and treated with SZ suspension as a first-line agent. We obtained demographics, clinical, and endoscopic data to measure outcomes at 1 year and long term. RESULTS Of 57 patients treated with SZ suspension, 52 (91%) had a follow-up and 26 of 52 (50%) remained in steroid-free remission at 1 year. Two patients were switched to SZ tablets due to nonmedical reasons and 11 (21%) required rescue treatment (2 infliximab, 1 tacrolimus, 8 6-mercaptopurine/azathioprine) within a year. Three required colectomy within a year and 5 in long term. Four (8%) developed nonserious adverse reactions and switched to 5-aminosalicylates (5-ASA) by 1 year. The median duration of long-term follow-up was 36 months (range, 2-205 months) with 28 requiring treatment escalation in long term. CONCLUSIONS SZ suspension is a safe and effective treatment for UC in children with difficulty swallowing a pill. The 1-year remission rate on this treatment is comparable to 5-ASA utilized in children.
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Affiliation(s)
- Ishrat Mansuri
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Sophia Wang
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Paul A Rufo
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Enju Liu
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Christina Chan
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Athos Bousvaros
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
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Patel H, Karam L, Kellermayer R. A Single-Center Study of Long-Term Effectiveness of Vedolizumab in Anti-TNF Refractory Pediatric Inflammatory Bowel Disease. JPGN REPORTS 2023; 4:e276. [PMID: 36915867 PMCID: PMC10004749 DOI: 10.1097/pg9.0000000000000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 10/01/2022] [Indexed: 05/14/2023]
Abstract
Vedolizumab is an anti-α4β7 integrin antibody that has been used successfully in the treatment of adult-onset inflammatory bowel diseases (IBDs: Crohn disease [CD] and ulcerative colitis [UC]). Its off-label use in the pediatric IBD (PIBD) population is increasing, but knowledge on durability beyond 6 months of treatment is limited. Methods A real-life, single-center, retrospective study of PIBD patients treated with vedolizumab was performed. Data on demographics, prior and concomitant treatments, and disease activity were obtained at 14 weeks, 26 weeks, 1 year, and 2 years of therapy. Primary outcome was corticosteroid- and other biologic-free remission (based on pediatric ulcerative colitis activity index [PUCAI]). Results Thirty-nine patients were studied. By 1 year, 65% of CD and 68% of UC patients continued on vedolizumab therapy. Corticosteroid- and other biologic-free remission was 29% in CD and 16% in UC. By 2 years, 36% of CD and 47% of UC patients continued therapy. Corticosteroid- and other biologic-free remission was 21% in CD and 40% in UC. By 2 years, 80% of CD and 100% of UC patients were on intensified treatment regimen compared to the manufacturer guidance. Nine patients (23%) required surgical intervention within 26 months of starting vedolizumab indicating the severity of IBD in this cohort. Conclusions Vedolizumab is a useful therapeutic modality in PIBD patients refractory to anti-TNF therapy, although with declining effectiveness by 2 years. Intensified treatment regimens are associated with long-term durability. Larger prospective trials in children are warranted.
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Affiliation(s)
- Halee Patel
- From the Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX
| | - Lina Karam
- From the Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX
| | - Richard Kellermayer
- From the Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX
- Children’s Nutrition and Research Center, Houston, TX
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Picoraro JA, Shen B. The Pediatric Pouch Deserves Precision. Inflamm Bowel Dis 2022; 28:1469-1471. [PMID: 35040991 DOI: 10.1093/ibd/izab321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
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Kellermayer R, Chang A, Patel K. Sirolimus (Rapamycin) Induced Mucosal Healing in Anti-Tumor Necrosis Factor Refractory Pediatric Ulcerative Colitis. JPGN REPORTS 2022; 3:e183. [PMID: 37168909 PMCID: PMC10158451 DOI: 10.1097/pg9.0000000000000183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/20/2022] [Indexed: 05/13/2023]
Abstract
Sirolimus (rapamycin) has been sparsely reported in the treatment of pediatric ulcerative colitis (PUC). Mucosal healing has not been examined in responders to the drug. We describe a case of infliximab refractory PUC where rapamycin induced sustained clinical remission along with mucosal healing. We conclude that rapamycin should be positioned into the expanding treatment repertoire of PUC.
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Affiliation(s)
- Richard Kellermayer
- Section of Pediatric Gastroenterology, Texas Children’s Hospital Baylor College of Medicine
- USDA/ARS Children’s Nutrition Research Center
| | | | - Kalyani Patel
- Department of Pathology, Baylor College of Medicine, Houston, TX
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Gordon IO, Abushamma S, Kurowski JA, Holubar SD, Kou L, Lyu R, Rieder F. Paediatric Ulcerative Colitis Is a Fibrotic Disease and Is Linked with Chronicity of Inflammation. J Crohns Colitis 2021; 16:804-821. [PMID: 34849664 PMCID: PMC9228908 DOI: 10.1093/ecco-jcc/jjab216] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/20/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Intestinal fibrosis has recently been characterised in adult ulcerative colitis and may affect motility, diarrhoea, and the symptom of urgency. We aimed to charactersze the presence of fibrosis in paediatric patients with ulcerative colitis, and its link to severity and chronicity of mucosal inflammation, as well as clinical factors of severity. METHODS We performed a single-centre cross-sectional study in children ages 1-18 years with ulcerative colitis, undergoing colectomy or proctocolectomy. Tissue cross-sections were derived from proximal, mid, and distal colon and rectum, and inflammation and fibrosis were graded based on previously developed scores. Clinical data were collected prospectively. RESULTS From 62 patients, 205 intestinal sections were evaluated. Median age at diagnosis was 13 years, 100% had extensive colitis, and all resections were done for refractory disease. The presence, chronicity, and degree of inflammation were linked with the presence of fibrosis. Thickness of the muscularis mucosa was also linked with presence and chronicity of inflammation. The overall submucosal fibrosis burden was associated with prior anti-tumour necrosis factor use. CONCLUSIONS Paediatric patients with ulcerative colitis exhibit colorectal submucosal fibrosis and muscularis mucosa thickening, which correlate with the presence, chronicity, and degree of mucosal inflammation. Fibrosis should be recognised as a complication of paediatric ulcerative colitis, and ulcerative colitis should be considered a progressive disease.
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Affiliation(s)
- Ilyssa O Gordon
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Suha Abushamma
- Department of Gastroenterology, Washington University School of Medicine, Barnes Jewish Hospital, St Louis, MO,USA
| | - Jacob A Kurowski
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lei Kou
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Corresponding author: Florian Rieder, MD, Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, 9500 Euclid Avenue – A3, Cleveland, OH, 44195, USA. Tel.: +1 [216] 445 4916; fax: +1 [216] 636 0104;
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14
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Affiliation(s)
- Nathan S Rubalcava
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, 1540 East Hospital Drive SPC 4217, Ann Arbor, MI 48109 - 4217, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, 1540 East Hospital Drive SPC 4217, Ann Arbor, MI 48109 - 4217, USA; Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, Ann Arbor, MI 48109, USA.
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15
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Colman RJ, Dhaliwal J, Rosen MJ. Predicting Therapeutic Response in Pediatric Ulcerative Colitis-A Journey Towards Precision Medicine. Front Pediatr 2021; 9:634739. [PMID: 33681110 PMCID: PMC7925616 DOI: 10.3389/fped.2021.634739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/08/2021] [Indexed: 12/12/2022] Open
Abstract
Ulcerative colitis (UC) is a disabling disease, characterized by chronic inflammation of the colon, with a rising prevalence worldwide in the pediatric age group. Although UC presents in children with varying severity, disease extent, and comorbidities, initial treatment is essentially uniform, consisting of 5-aminosalicylate drugs with corticosteroid induction for those with moderately to severely active disease. With the advent of anti-tumor necrosis factor (TNF) biologic therapy and several new biologics and small-molecule drugs for UC, precision medicine approaches to treatment are needed to more rapidly achieve sustained remission, restore quality of life, normalize development, and limit exposure to toxic corticosteroids in children with UC. Here, we review available data on clinical, biochemical, histopathologic, and molecular predictors of treatment response in UC. We also address known predictors and special treatment considerations in specific relevant scenarios such as very-early-onset UC, acute severe UC, ileal pouch anal anastomosis, and UC with concomitant primary sclerosing cholangitis. The review concludes with a prediction of how machine learning will integrate multimodal patient data to bring precision medicine to the bedside of children with UC in the future.
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Affiliation(s)
- Ruben J Colman
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Jasbir Dhaliwal
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Michael J Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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