Improved Medical Treatment and Surgical Surveillance of Children and Adolescents with Ulcerative Colitis in the United Kingdom

Severity of complications following restorative proctocolectomy in children is related to staging not diagnosis

BACKGROUND

Restorative proctocolectomy (RPC) is performed using a variety of staged procedures for several diseases. Our aim was to assess whether the severity of complications, classified according to Clavien-Dindo, was related to the diagnosis or the procedure.

METHODS

A consecutive series of children receiving an ileoanal pouch was prospectively recorded. Complications were scored by two blinded observers. Major complications were Clavien-Dindo ≥3b. Procedures were classified as: colectomy, proctectomy and pouch or proctocolectomy and pouch. Diagnoses were classified as: ulcerative colitis, familial adenomatous polyposis or other: idiopathic constipation, total colonic Hirschsprung's disease, juvenile polyposis, Crohn's colitis, fibrosing colonopathy or necrotising enterocolitis.

RESULTS

128 children underwent 191 procedures: 61 colectomies, 63 proctectomies and 67 proctocolectomies. 84 children had ulcerative colitis, 20 had FAP and 24 had other indications. Major complications were significantly more likely with proctocolectomy (16/67, 24%) than with either colectomy (4/61, 7%) or proctectomy (8/63, 13%), p = 0.01. There was no association between diagnosis and major complications: ulcerative colitis (18/133, 14%), FAP (5/20, 25%), other (5/38, 13%) p = 0.4. There was no increase in major complications following proctectomy if a major complication had occurred during prior colectomy. Overall, 15% of procedures experienced a major complication. 6/9 stoma related complications required operative intervention.

CONCLUSIONS

The severity of complications after RPC in children is related to use of a two stage rather than three stage sequence of surgery, not the underlying diagnosis.

TYPE OF STUDY

Case control study.

LEVEL OF EVIDENCE

Level III.

Long-term Outcomes of Paediatric Patients Admitted With Acute Severe Colitis- A Multicentre Study From the Paediatric IBD Porto Group of ESPGHAN

BACKGROUND AND AIM

Acute severe colitis [ASC] is associated with significant morbidity in paediatric patients with ulcerative colitis [UC]. Most outcome studies in ASC since tumour necrosis factor alpha [TNFα] antagonists became available have focused on the first year after admission. The aim of this study was to characterise the longer-term outcomes of paediatric patients admitted with ASC.

METHODS

This retrospective study was conducted in 25 centres across Europe and North America. Data on patients with UC aged <18 years, admitted with ASC (defined as paediatric ulcerative colitis activity index [PUCAI] score ≥65) between 2009 and 2011, were collected at discharge and 1, 3 and 5 years after admission. The primary outcome was colectomy-free rates at each time point.

RESULTS

Of the 141 patients admitted with ASC, 137 [97.1%] were treated with intravenous corticosteroids. Thirty-one [22.6%] patients were escalated to second-line therapy, mainly to infliximab. Sixteen patients [11.3%] underwent colectomy before discharge. Long-term follow-up showed colectomy-free rates were 71.3%, 66.4% and 63.6% at 1, 3 and 5 years after initial ASC admission, respectively, and were similar across different age groups. Sub-analysis of colectomy rates in patients with new-onset disease [42.5% of the cohort] yielded similar results. In a multivariate analysis, use of oral steroids in the 3 months before admission, erythrocyte sedimentation rate >70 mm/h, and albumin <2.5 g/dL, were significantly associated with 5-year colectomy risk.

CONCLUSIONS

High colectomy rates were demonstrated in paediatric UC patients admitted with ASC. Additional studies are required to determine whether intensification of anti-TNFα treatment, close therapeutic drug monitoring, and use of new drugs alter this outcome.

Using a Steroid-sparing Tool in Paediatric Inflammatory Bowel Disease to Evaluate Steroid Use and Dependency

OBJECTIVES

The aim of the study was to evaluate the use of steroids within the paediatric inflammatory bowel disease (PIBD) population at a tertiary paediatric centre over a year; to identify cases of steroid dependency; and assess factors associated with steroid excess.

METHODS

The prevalent PIBD population (May 1, 2017-April 30, 2018) were reviewed. Data were collected retrospectively from patient records and entered into an online steroid assessment tool (modified for paediatrics).

RESULTS

A total of 229 patients (181 Crohn disease, 31 ulcerative colitis [UC], and 17 inflammatory bowel disease-unclassified) were included. Of the 229 patients 38 (16.6%) received oral steroids; 12 of 38 (31.6%) receiving >3-month course. Eleven of 38 (28.9%) received >1 steroid course (maximum 2). Of the 229 patients 37 (16.2%) had exclusive enteral nutrition, with 26 of 37 (11.4% total cohort) avoiding steroid use during the study period.Quiescent disease activity had a negative correlation with steroid use (11/127 [8.7%] vs 27/102 [26.5%] P < 0.01), and steroid dependency (3/127 [2.4%] vs 12/102 [11.8%] P < 0.01). Patients with UC were more likely to be steroid dependent (5/31 [16.1%] UC vs 10/198 [5.1%]; P = 0.02); as were network-managed patients (8/11 [72.7%] vs 7/27 [25.9%]; P = 0.01). Fourteen of 15 (93.3%) of steroid-dependent patients had active steroid sparing strategies in place (eg, commencement, switching, or optimization of therapies).

CONCLUSIONS

We have described rates of steroid use and dependency within our PIBD population. Exclusive enteral nutrition served as a steroid sparing tool in 11.4% of the total cohort. Replication of this study in other paediatric centres would allow comparative analysis.