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Predictors of Perianal Fistula Healing in Children With Newly Diagnosed Crohn Disease. J Pediatr Gastroenterol Nutr 2022; 75:709-716. [PMID: 36399175 DOI: 10.1097/mpg.0000000000003595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Perianal fistulas are among the most severe complications of Crohn disease, but limited data regarding their outcomes are available in children. Our objective was to determine predictors of perianal fistula healing among pediatric patients newly diagnosed with Crohn disease. METHODS This single-center retrospective study followed patients with perianal fistulas at Crohn disease diagnosis until fistula healing. Time to healing was analyzed using Cox proportional hazard regression models considering relevant covariates including patient demographics, disease characteristics, medical therapies [no anti-tumor necrosis factor (TNF)α therapy, anti-TNFα therapy ±therapeutic drug monitoring], and perianal surgical procedures including fistulotomy, fistulectomy, removal of perianal lesions, seton placement, and incision and drainage. RESULTS Of 485 patients identified, 107 (22%) had a perianal fistula at Crohn disease diagnosis. Multivariate analysis identified that perianal fistulotomy, fistulectomy, and lesion removal [hazard ratio (HR) 0.46; P = 0.028], non-White race (HR 0.30, P < 0.01), and male sex (HR 0.42; P = 0.02) were associated with delayed fistula healing. Faster fistula healing was associated with treatment with anti-TNFα with therapeutic drug monitoring (HR 1.78, P = 0.009). There were no other differences in healing by treatment. CONCLUSIONS Fistulotomy, fistulectomy, and perianal lesion removal as well as non-White race were associated with delayed fistula healing. Anti-TNFα therapy was associated with faster fistula healing when combined with therapeutic drug monitoring, compared to all other medical treatment groups, including anti-TNFα therapy without therapeutic drug monitoring.
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Cho YJ, Kwon H, Kwon YJ, Kim KM, Oh SH, Kim DY. Efficacy and safety of autologous adipose tissue-derived stem cell therapy for children with refractory Crohn's complex fistula: a Phase IV clinical study. Ann Surg Treat Res 2021; 101:58-64. [PMID: 34235117 PMCID: PMC8255577 DOI: 10.4174/astr.2021.101.1.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/10/2021] [Accepted: 03/30/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose Autologous adipose tissue-derived stem cells (ASCs) have been proposed for patients with refractory Crohn disease, but research is lacking in pediatric patients. This Phase IV study evaluated the efficacy and safety of ASCs in children with refractory Crohn's fistulae. Methods Patients with a refractory Crohn's fistula who did not have conventional therapy for more than 3 months or with a recurrent complex Crohn's fistula were included. All patients were at least 14 years old. Patients with infection, poor condition, or active Crohn disease with a disease activity index of 450 and above were excluded. Five patients were treated with ASCs from 2014 to 2015 in Asan Medical Center. ASC administration was adjusted according to fistula size (1 mL per cm2). We evaluated the efficacy and safety 8 weeks after injection and followed patients for 6 months. Results Fistulae were healed in 4 patients by 8 weeks after ASC injection. Of these 4 patients, 1 had complete fistula closure and sustainability after 6 months. The other 3 with healing effects had less than 50% fistula closure by 6 months. None of these 4 patients have persistent fistulae. One patient had no healing effect, and seton ligation was performed 8 months after ASC injection. There were no adverse effects related to ASC administration. Conclusion ASC therapy is a simple and well-tolerated therapeutic option for children with refractory Crohn's complex fistulae. Complete closure was well-sustained. However, more data from a larger number of patients are needed.
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Affiliation(s)
- Yu Jeong Cho
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunhee Kwon
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Jae Kwon
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
The incidence of paediatric Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Surgical intervention is required during childhood in approximately 25% of children diagnosed with CD, and for 10% of those diagnosed with UC. Although there is evidence that the rate of surgical intervention undertaken in children is decreasing since the introduction of biologic therapy, this may only represent a delay rather than true reversal of the risk of surgery. Surgery for CD is not curative and limited resection is the key principle thus preserving bowel length. For UC, subtotal colectomy is relatively curative; ileo-anal pouch anastomosis can be performed to restore bowel continuity.
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Affiliation(s)
- Arun Kelay
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
| | - Lucinda Tullie
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
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Adler J, Jary HK, Eder SJ, Dong S, Brandt E, Haraga JK, Dombkowski KJ. Identifying perianal fistula complications in pediatric patients with Crohn's disease using administrative claims. PLoS One 2019; 14:e0219893. [PMID: 31412045 PMCID: PMC6693740 DOI: 10.1371/journal.pone.0219893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 07/04/2019] [Indexed: 12/18/2022] Open
Abstract
Background Although perianal fistulas occur commonly in pediatric Crohn’s disease (CD), evaluations of health services have been limited since no validated claims-based methods exist for identifying cases. Objective To develop and validate accurate case definitions for perianal fistulas among pediatric patients with CD from administrative claims. Methods Retrospective cohort study in which we developed and tested candidate case definitions for perianal fistula. Patients (age 5–21 years between 2005–2012) with CD enrolled in Michigan Medicaid with healthcare at University of Michigan were identified via claims. Medical records were obtained from all identified patients, whose entire records were abstracted. Medical record evidence for perianal fistula was considered the “gold standard” against which candidate case definitions were compared. The reference case definition of perianal fistula (ICD9 565.1) and candidate case definitions were evaluated. Results Of 843 patients identified via claims, 274 (33%) met CD criteria for inclusion. The true perianal fistula rate among CD patients was 18% (n = 49). The top-performing candidate case definition identified 15% (n = 42), had sensitivity of 77.6%, specificity of 98.2%, positive predictive value (PPV) 90.5%, negative predictive value (NPV) 95.3%, and area under receiver operator characteristic curve (ROC) of 0.88. In contrast, the reference case definition identified 9% (n = 26), sensitivity 51.0%, specificity 99.6%, PPV 96.2%, NPV 90.3%, and had an area under ROC of 0.75. Conclusions We demonstrated that it is feasible to use administrative claims data to accurately identify pediatric patients with perianal fistula complications. Claims-based case definitions were found to be highly accurate through medical record review, providing a high degree of confidence for future studies where chart review is not feasible. These claims-based methods can be applied to claims data in other settings for the evaluation of health services utilization as well as to assess the comparative effectiveness of prevention and treatment strategies.
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Affiliation(s)
- Jeremy Adler
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, Michigan, United States of America
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor Michigan, United States of America
- * E-mail:
| | - Hannah K. Jary
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor Michigan, United States of America
| | - Sally J. Eder
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, Michigan, United States of America
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor Michigan, United States of America
| | - Shiming Dong
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor Michigan, United States of America
| | - Emily Brandt
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor Michigan, United States of America
| | - Jessica K. Haraga
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor Michigan, United States of America
| | - Kevin J. Dombkowski
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor Michigan, United States of America
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Abstract
BACKGROUND Although perianal complications of Crohn disease (CD) are commonly encountered in clinical practice, the epidemiology of perianal CD among populations of children is poorly understood. We sought to characterize the prevalence of perianal disease in a large and diverse population of pediatric patients with CD. METHODS We conducted retrospective analyses from a prospective observational cohort, the ImproveCareNow Network (May 2006-October 2014), a multicenter pediatric inflammatory bowel disease quality improvement collaborative. Clinicians prospectively documented physical examination and phenotype classification at outpatient visits. Perianal examination findings and concomitant phenotype change were used to corroborate time of new-onset perianal disease. Results were stratified by age, sex, and race and compared across groups with logistic regression. Cumulative incidence was estimated using Kaplan-Meier analyses and compared between groups with Cox proportional hazard regression models. RESULTS The registry included 7076 patients with CD (41% girls). Missing/conflicting entries resulted in 397 (6%) patient exclusions. Among the remaining 6679 cases, 1399 (21%) developed perianal disease. Perianal disease was more common among boys (22%) than girls (20%; P = 0.013) and developed sooner after diagnosis among those with later rather than early onset disease (P < 0.001). Perianal disease was also more common among blacks (26%) compared with whites (20%; P = 0.017). Asians with later onset CD developed perianal disease earlier in their disease course (P = 0.01). There was no association between disease location or nutritional status at diagnosis and later development of perianal disease. CONCLUSIONS In this large multicenter collaborative, we found that perianal disease is more common among children with CD than previously recognized. Differences in the development of perianal disease were found across racial and other subgroups. Treatment strategies are needed to prevent perianal disease development.
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Amil-Dias J, Kolacek S, Turner D, Pærregaard A, Rintala R, Afzal NA, Karolewska-Bochenek K, Bronsky J, Chong S, Fell J, Hojsak I, Hugot JP, Koletzko S, Kumar D, Lazowska-Przeorek I, Lillehei C, Lionetti P, Martin-de-Carpi J, Pakarinen M, Ruemmele FM, Shaoul R, Spray C, Staiano A, Sugarman I, Wilson DC, Winter H, Kolho KL. Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2017; 64:818-835. [PMID: 28267075 DOI: 10.1097/mpg.0000000000001562] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.
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Affiliation(s)
- Jorge Amil-Dias
- *Department of Pediatrics, Centro Hospitalar, S. João, Porto, Portugal †Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia ‡The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel §Department of Pediatrics, Hvidovre University Hospital, Hvidovre, Denmark ||Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland ¶Department of Pediatric Gastroenterology, University Hospital Southampton, Southampton, UK #Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland **Department of Pediatrics, University Hospital Motol, Prague, Czech Republic ††Queen Mary's Hospital for Children, Epsom and St Helier NHS Trust, Surrey ‡‡Chelsea and Westminster Hospital, London, UK §§Paris-Diderot Sorbonne-Paris-Cité University and Robert Debré Hospital, Paris, France ||||Pediatric Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, Ludwig Maximilians-University, Munich, Germany ¶¶St George's, University of London, London, UK ##Boston Children's Hospital and Harvard Medical School, Boston, MA ***Department NEUROFARBA, University of Florence - Meyer Hospital, Florence, Italy †††Unit for the Comprehensive Care of Pediatric Inflammatory Bowel Disease, Hospital Sant Joan de Déu, Barcelona, Spain ‡‡‡Department of Pediatric Gastroenterology, Necker Enfants Malades University Hospital, Sorbonne Paris Cité University, Paris Descartes University, Institut IMAGINE - INSERM U1163, Paris, France §§§Pediatric Gastroenterology Institute, Ruth Children's Hospital, Rambam Medical Center, Haifa, Israel ||||||Department of Pediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK ¶¶¶Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy ###Department of Pediatric Surgery, Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK ****Child Life and Health, University of Edinburgh, Scotland, UK ††††MassGeneral Hospital for Children, Harvard Medical School, Boston, MA ‡‡‡‡Children's Hospital, University of Helsinki, Helsinki, Finland
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Seemann NM, King SK, Elkadri A, Walters T, Fish J, Langer JC. The operative management of children with complex perianal Crohn's disease. J Pediatr Surg 2016; 51:1993-1997. [PMID: 27692346 DOI: 10.1016/j.jpedsurg.2016.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/12/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND/PURPOSE Perianal Crohn's disease (PCD) can affect both quality of life and psychological wellbeing. A subset of pediatric patients with complex PCD require surgical intervention, although appropriate timing and treatment regimens remain unclear. This study aimed to describe a large pediatric cohort in a tertiary center to determine the range of surgical management in children with complex PCD. METHODS A retrospective review of children requiring operative intervention for PCD over 13 years (2002-2014) was performed. PCD was divided into simple and complex based on the type of surgical procedure, and the two groups were compared. RESULTS The 57 children were divided into two groups: the simple group (N=43) underwent abscess drainage ± seton insertion alone, and the complex group (N=14) underwent loop ileostomy ± more extensive surgery. In the complex group, females were more predominant (57% of complex vs 30% of simple), and the average age at diagnosis was lower. Anti-TNF therapy was utilized in 79.1% of simple and 100% of complex PCD. All 14 complex patients underwent a defunctioning ileostomy, with 7 requiring further operations (subtotal colectomy=4, proctocolectomy ± anal sparing=5, plastic surgery reconstruction with perineal flap/graft=4). CONCLUSION Complex PCD represents a small but challenging subset of patients in which major surgical intervention may be necessary to alleviate the symptoms of this debilitating condition. LEVEL OF EVIDENCE retrospective case study with no control group - level IV.
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Affiliation(s)
- Natashia M Seemann
- Division of General and Thoracic Surgery, Hospital for Sick Children, Department of Surgery, University of Toronto
| | - Sebastian K King
- Division of General and Thoracic Surgery, Hospital for Sick Children, Department of Surgery, University of Toronto
| | - Abdul Elkadri
- Division of Gastroenterology, Hospital for Sick Children, Department of Pediatrics, University of Toronto
| | - Thomas Walters
- Division of Gastroenterology, Hospital for Sick Children, Department of Pediatrics, University of Toronto
| | - Joel Fish
- Division of Plastic and Reconstructive Surgery, Hospital for Sick Children, Department of Surgery, University of Toronto
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Department of Surgery, University of Toronto.
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Zwintscher NP, Shah PM, Argawal A, Chesley PM, Johnson EK, Newton CR, Maykel JA, Steele SR. The impact of perianal disease in young patients with inflammatory bowel disease. Int J Colorectal Dis 2015; 30:1275-9. [PMID: 25994782 DOI: 10.1007/s00384-015-2251-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perianal disease is a potentially significant source of morbidity for patients with inflammatory bowel disease (IBD). We sought to identify the impact of perianal disease on IBD outcomes in children, adolescents, and young adults. METHODS We studied 12,465 inpatient admissions for patients ≤20 years old with IBD in 2009 using the Kids' Inpatient Database (KID). Patients were stratified by their principal diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). Perianal disease (perianal abscess, anal fissure, or anal fistula), complex fistulas (rectourethral, rectovaginal, or enterovesical), and growth failure were defined by ICD-9 codes. Logistic regression was performed adjusting for CD or UC, gender, age, need for surgical intervention, fistulas, or growth failure. RESULTS Of the 511 (4.1%) patients with perianal disease, 480 had CD (94%, p < 0.001). Girls were less likely to suffer perianal disease (OR = 0.63, CI 0.52-0.76, p < 0.001). Those with perianal disease were more likely to suffer complex fistulas (OR = 3.5, CI 1.98-6.20, p < 0.001) but less likely to suffer enteroenteral fistulas (OR = 0.30, CI 0.15-0.63, p = 0.001) than those without perianal disease. Perianal disease did not increase the incidence of growth failure (p = 0.997) but doubled the likelihood of an operation of any type during admission (p < 0.001). Additionally, patients with perianal disease spent on average 1.29 more days in the hospital (7.45 vs. 6.16 days, p < 0.001) and accrued $5838 extra in hospital charges (p = 0.005). CONCLUSIONS Perianal disease in younger patients is associated with a longer length of stay, higher hospital charges, and increased rates of both perineal and abdominal operative procedures. These data support the notion that, similar to adults, the presence of perianal disease in pediatric Crohn's patients is associated with a more severe course.
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Dotson JL, Kappelman MD, Chisolm DJ, Crandall WV. Racial disparities in readmission, complications, and procedures in children with Crohn's disease. Inflamm Bowel Dis 2015; 21:801-8. [PMID: 25742396 PMCID: PMC4366277 DOI: 10.1097/mib.0000000000000325] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Racial disparities in care and outcomes contribute to mortality and morbidity in children; however, the role in pediatric Crohn's disease is unclear. In this study, we compared cohorts of black and white children with Crohn's disease to determine the extent race is associated with differences in readmissions, complications, and procedures among hospitalizations in the United States. METHODS Data were extracted from the Pediatric Health Information System (January 1, 2004-June 30, 2012) for patients with 21 years or younger hospitalized with a diagnosis of Crohn's disease. White and black cohorts were randomly selected in a 2:1 ratio by hospital. The primary outcome was time from index hospital discharge to readmission. The most frequent complications and procedures were evaluated by race. RESULTS There were 4377 patients. Black children had a shorter time to first readmission and higher probability of readmission (P = 0.009) and a 16% increase in risk of readmission compared with white children (P = 0.01). Black children had longer length of stay and higher frequency of overall and late (30-d to 12-mo postdischarge) readmissions (P < 0.001). During index hospitalization, more black children had perianal disease and anemia (P < 0.001). During any hospitalization, black children had higher incidence of perianal disease, anemia, and vitamin D deficiency, and greater number of perianal procedures, endoscopies, and blood product transfusion (P < 0.001). CONCLUSIONS There are differences in hospital readmissions, complications, and procedures among hospitalized children related to race. It is unclear whether these differences are due to genetic differences, worse intrinsic disease, adherence, access to treatment, or treatment disparities.
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Affiliation(s)
- Jennifer L. Dotson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- The Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Michael D. Kappelman
- University of North Carolina at Chapel Hill, Department of Pediatrics, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - Deena J. Chisolm
- The Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Wallace V. Crandall
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
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Diaz M, Patel DeZure C, Cordova J, Lo A, Azzam R. A 15-year-old girl with fever and abdominal pain. Pediatr Ann 2015; 44:e49-52. [PMID: 25806729 DOI: 10.3928/00904481-20150313-08] [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: 11/20/2022]
Abstract
We present a case of a previously healthy 15-year-old girl with fever, right lower quadrant pain, and hip pain. Her history was notable for a recent laparoscopic appendectomy that was complicated by the development of intraabdominal abscesses. She reported normal bowel movements and good appetite on a regular diet, although she did endorse a recent 5-kg weight loss. Further investigation and examination revealed a diagnosis of Crohn's disease with recurrent psoas muscle abscess as the etiology of her pain and fevers. Psoas abscess is a rare complication of Crohn's disease, and vague presenting symptoms may complicate its diagnosis. This case demonstrates the importance of maintaining a broad differential diagnosis when treating a child presenting with abdominal pain and fever.
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Combination biological and surgical therapy in an adolescent presenting with highly destructive perianal Crohn disease. J Pediatr Gastroenterol Nutr 2010; 51:784-6. [PMID: 20601909 DOI: 10.1097/mpg.0b013e3181d32728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Corbett SL, Walsh CM, Spitzer RF, Ngan BY, Kives S, Zachos M. Vulvar inflammation as the only clinical manifestation of Crohn disease in an 8-year-old girl. Pediatrics 2010; 125:e1518-22. [PMID: 20457677 DOI: 10.1542/peds.2009-1829] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recognition of Crohn disease in children who present with cutaneous vulvar lesions as their initial clinical manifestation is often difficult. We report here the case of an 8-year-old girl with chronic vulvar edema, which on biopsy revealed granulomatous inflammation of the vulva. Further investigation and biopsy of the terminal ileum demonstrated similar findings and was consistent with a diagnosis of Crohn disease.
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Affiliation(s)
- Shannon L Corbett
- Department of Pediatrics, Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8
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Rosen MJ, Moulton DE, Koyama T, Morgan WM, Morrow SE, Herline AJ, Muldoon RL, Wise PE, Polk DB, Schwartz DA. Endoscopic ultrasound to guide the combined medical and surgical management of pediatric perianal Crohn's disease. Inflamm Bowel Dis 2010; 16:461-8. [PMID: 19637325 PMCID: PMC2871764 DOI: 10.1002/ibd.21067] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Perianal fistulas are a debilitating manifestation of Crohn's disease (CD) in the pediatric population and present a management challenge. The aims of this study were to describe our experience using endoscopic ultrasound (EUS) to guide management of perianal CD (PCD) in a pediatric population, and determine whether using EUS to monitor healing after seton placement improves outcomes. METHODS We conducted a retrospective study of 2 cohorts: pediatric subjects with PCD who underwent EUS and pediatric subjects who underwent seton placement between 2002 and 2007. RESULTS In all, 25 children underwent a total of 42 EUS procedures. Of 28 EUSs performed to evaluate suspected perianal disease, complex fistulizing disease was identified in 15 (54%). Setons were placed after most EUSs demonstrating complex fistulizing disease and after none demonstrating superficial or no fistulizing disease. Of 14 EUSs performed to monitor healing around a seton, 7 (50%) demonstrated persistent peri-seton inflammation. Setons were more often left in place after an EUS revealing persistent inflammation (86% versus 0%), and the patients were more likely to have a biologic initiated or changed (57% versus 0%). Among all subjects who underwent seton placement, time from seton removal to recurrence was longer for those followed by EUS compared to those followed by physical exam only; however, we were not powered to test for statistical significance. CONCLUSIONS EUS to guide the combined medical and surgical management of PCD is feasible in the pediatric population. Larger prospective studies are needed to determine if EUS-directed management improves outcomes in pediatric patients with PCD.
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Affiliation(s)
- Michael J. Rosen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University School of Medicine, Nashville, TN
| | - Dedrick E. Moulton
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University School of Medicine, Nashville, TN
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Walter M. Morgan
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Stephen E. Morrow
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Alan J. Herline
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Roberta L. Muldoon
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Paul E. Wise
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - D. Brent Polk
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University School of Medicine, Nashville, TN
| | - David A. Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University School of Medicine, Nashville, TN
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Keljo DJ, Markowitz J, Langton C, Lerer T, Bousvaros A, Carvalho R, Crandall W, Evans J, Griffiths A, Kay M, Kugathasan S, LeLeiko N, Mack D, Mamula P, Moyer MS, Oliva-Hemker M, Otley A, Pfefferkorn M, Rosh J, Hyams JS. Course and treatment of perianal disease in children newly diagnosed with Crohn's disease. Inflamm Bowel Dis 2009; 15:383-7. [PMID: 19023863 DOI: 10.1002/ibd.20767] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND We sought to characterize perianal disease and its treatment in pediatric patients newly diagnosed with Crohn's disease. METHODS Data were obtained from the Pediatric Inflammatory Bowel Disease (IBD) Collaborative Group Registry, a prospective, multicenter observational registry recording clinical and laboratory outcomes in children under 16 years of age newly diagnosed with IBD. Patients with Crohn's disease were selected who had data on perianal disease and at least 24 months of follow-up. The records of patients with a Pediatric Crohn's Disease Activity Index perianal subscore greater than 0 were reviewed, and patients with abscesses or fistulas were selected. The therapies used and the course of their perianal disease were then assessed. RESULTS Of the 276 patients identified, 41 had perianal lesions within 30 days of diagnosis. Thirteen of these had skin tags and fissures only, whereas 28 had fistulas and/or abscesses. The latter lesions resolved by 1 year in 20 patients, and 8 had chronic/recurrent perianal disease persisting for more than 1 year following diagnosis. Patients with fistulizing disease were much more likely to be treated and were treated earlier with antibiotics, infliximab, and immunomodulators than were nonfistulizing patients. Patients who developed chronic perianal disease were more likely to have low body mass indices and required more perianal surgery than did patients whose perianal disease resolved. CONCLUSIONS Approximately 10% of newly diagnosed pediatric patients with Crohn's disease will have perianal fistulas and/or abscesses at the time of diagnosis. Most of these will resolve within a year with medical therapy alone.
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Affiliation(s)
- David J Keljo
- Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15213, USA.
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15
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White JM, O'Connor S, Winter HS, Heyman MB, Kirschner BS, Ferry GD, Cohen SA, Baldassano RN, Smith T, Clemons T, Gold BD. Inflammatory bowel disease in African American children compared with other racial/ethnic groups in a multicenter registry. Clin Gastroenterol Hepatol 2008; 6:1361-9. [PMID: 18848910 PMCID: PMC3273485 DOI: 10.1016/j.cgh.2008.07.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2005] [Revised: 07/03/2008] [Accepted: 07/25/2008] [Indexed: 01/12/2023]
Abstract
BACKGROUND & AIMS Few epidemiologic investigations characterize inflammatory bowel disease (IBD) in non-Caucasian children. Our study compared IBD characteristics between African Americans and non-African Americans enrolled in a multicenter pediatric IBD registry with endoscopic- and pathology-based diagnosis. METHODS The study retrieved data entered from January 2000 to October 2003 on children 1 to 17 years old, inclusive, followed by a consortium of academic and community US pediatric gastroenterology practices. Analyses examined racial/ethnic differences by comparing the proportions of African Americans and non-African Americans in the following categories: each diagnostic disease classification (any IBD, Crohn's disease, ulcerative colitis, indeterminate colitis); age group (<6 y, 6-12 y, or >12 y) at diagnosis or symptom onset; presence of extraintestinal manifestations, Z-scores for height and weight, immunomodulatory therapy, anatomic disease location, and abnormal hemoglobin, albumin, or sedimentation rate at diagnosis. RESULTS A total of 1406 patients had complete data, 138 (10%) of whom were African American. African Americans more often were older than 12 years of age at diagnosis (52% vs 37%; odds ratio [OR], 1.82; 95% confidence interval [95% CI], 1.28-2.59) and symptom onset (46% vs 30%; OR, 1.99; 95% CI, 1.40-2.84); had Crohn's disease (78% vs 59%; OR, 2.36; 95% CI, 1.56-3.58); and had a low hemoglobin level at diagnosis (39% vs 17%; OR, 3.15; 95% CI, 1.92-5.17). CONCLUSIONS IBD in African American children and adolescents presents more commonly with Crohn's disease and at older ages compared with non-African Americans. Racial/ethnic differences in the epidemiology of IBD, particularly Crohn's disease, among American youths require further investigation.
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Affiliation(s)
| | | | | | - Melvin B. Heyman
- Pediatrics, University of California, San Francisco, San Francisco, CA
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Mardini HE, Schwartz DA. Treatment of perianal fistula and abscess: Crohn’s and non-Crohn’s. ACTA ACUST UNITED AC 2007; 10:211-20. [PMID: 17547859 DOI: 10.1007/s11938-007-0014-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The management of perianal abscesses and fistulas is relatively straightforward in most cases and based on a sound knowledge of the anatomy of the anorectum and adherence to established medical and surgical principles. Asymptomatic fistulas should not be treated, whereas abscesses require surgical drainage under general anesthesia. Fistula treatment includes drainage of any associated sepsis and eradication of the fistula track to prevent recurrence while preserving sphincter integrity. A small percentage of anal abscesses and fistulas are complex and very challenging to manage, particularly in conditions such as rectovaginal fistulas and abscesses and/or fistulas complicating Crohn's disease. Treatment strategies in these situations rely on an accurate clinical assessment of the degree of rectal inflammation and perianal pathology. Treatment should combine aggressive medical therapy (antibiotics, immunomodulators, and anti-tumor necrosis factor antibody treatment) and minimal surgical interventions. Patients with proctitis have a significantly lower healing rate and a significantly higher complication rate with aggressive surgical interventions.
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Affiliation(s)
- Houssam E Mardini
- David A. Schwartz, MD Director, Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, 1501 TVC, Nashville, TN 37232, USA.
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Hart AL, Plamondon S, Kamm MA. Topical tacrolimus in the treatment of perianal Crohn's disease: exploratory randomized controlled trial. Inflamm Bowel Dis 2007; 13:245-53. [PMID: 17206671 DOI: 10.1002/ibd.20073] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The aim of this study is to evaluate the efficacy of topical tacrolimus in treating perianal Crohn's disease. METHODS Nineteen patients, stratified into 7 with ulcerating, and 12 with fistulizing, perianal Crohn's disease were randomized to topical tacrolimus 1 mg/g (1 g ointment twice a day [bid]) or placebo for 12 weeks. Sixteen patients had been on, or were currently taking, azathioprine/6-MP, and 6 had received infliximab. The primary outcome in ulcerating disease was global improvement in perianal/anal lesions, as assessed by the attending physician; for fistulas, it was reduction of > or =50% of actively draining fistulas on 2 consecutive visits. Blood tacrolimus levels and adverse events were assessed. RESULTS Three of 4 patients treated with topical tacrolimus for ulcerating disease improved compared with none of 3 in the placebo group. Complete healing was not achieved. In fistulizing disease, topical tacrolimus was not beneficial. Two tacrolimus-treated patients developed perianal abscesses, 1 after improvement in fistula drainage. Adverse events were otherwise infrequent and mild. Whole blood tacrolimus levels were detectable in only 2 patients and were low. CONCLUSIONS These preliminary data suggest that topical tacrolimus is effective and safe in the treatment of perianal or anal ulcerating Crohn's disease. This therapy is unlikely to be beneficial in fistulizing perianal Crohn's disease, although a larger study is required to confirm this.
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Serour F, Gorenstein A. Characteristics of perianal abscess and fistula-in-ano in healthy children. World J Surg 2006; 30:467-72. [PMID: 16467979 DOI: 10.1007/s00268-005-0415-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Probably because of the low frequency, perianal abscess (PA) and fistula-in-ano (FIA) in children older than 2 years have not been investigated except in those with a predisposing condition such as Crohn's disease. This study aims to summarize our experience about the characteristics and treatment of PA and FIA in healthy children. METHODS The charts of all children older than 24 months of age treated for PA and/or FIA from 1990 to 2003 were reviewed. RESULTS We found 40 patients, 37 of them boys (92.5%), ranging from 2 to 14 years of age (average: 7.19 years). At the first examination, the diagnosis was PA in 36 patients (mean age: 6.8 years; range: 2.3-13 years), and FIA in 4 patients (mean age: 10.8 years; range: 6-14 years). The primary local treatment of PA was drainage (needle aspiration in 26 patients, and incision and drainage in 4 patients) and local care in 6 patients. All patients received antibiotics. Overall, 29 children (80.6%) had primary cure of the abscess. Evolution included recurrent abscess in 3 patients (8.3%) and FIA in 4 patients (11.1%). Crohn's disease was diagnosed in only one boy with an abscess of long duration. No patient developed a new PA in another location or a recurrent FIA. Four male patients aged 6 to 14 years (range: 7.1 years) had a FIA of long duration. One patient underwent a fistulectomy. Crohn's disease was found in three other children and treated conservatively. CONCLUSION Drainage of PA by needle aspiration associated with antibiotics is effective in children older than 2 years of age with a low rate of evolution toward FIA. Associated pathology must be ruled out in children with FIA.
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Affiliation(s)
- Francis Serour
- Department of Pediatric Surgery, The Edith Wolfson Medical Center, Halokhamim Street 62, P.O. Box 5, Holon, 58100, Israel.
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19
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Affiliation(s)
- Balgopal Eradi
- Pediatric Surgery, Bristol Royal Hospital for Children, Bristol, United Kingdom
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20
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Heyman MB, Kirschner BS, Gold BD, Ferry G, Baldassano R, Cohen SA, Winter HS, Fain P, King C, Smith T, El-Serag HB. Children with early-onset inflammatory bowel disease (IBD): analysis of a pediatric IBD consortium registry. J Pediatr 2005; 146:35-40. [PMID: 15644819 DOI: 10.1016/j.jpeds.2004.08.043] [Citation(s) in RCA: 346] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the characteristics of inflammatory bowel disease (IBD) in young patients. STUDY DESIGN Uniform data were collected from a cohort of patients with IBD who were enrolled from January 2000 to November 2002 at six pediatric centers (Pediatric IBD Consortium). RESULTS Of 1370 children in the registry, the mean age at IBD diagnosis was 10.3 +/- 4.4 years; 54% were male, and 86% were white. Diagnosis was confirmed in 87 (6.1%) under 3 years of age, 211 (15.4%) before 6 years, 654 (47.7%) at 6 to 12 years, and 505 (36.9%) at 13 to 17 years. More than 63% of children younger than 8 years of age had isolated colonic disease, whether Crohn disease, ulcerative colitis (UC), or indeterminate colitis. Conversely, only 35% of those 8 years of age or older had isolated colonic disease ( P < .0001). Overall, 29% had one or more family members with IBD. The subgroup of children younger than 3 years of age with UC had the highest prevalence of first-degree relatives with IBD (44%). CONCLUSIONS This demographically diverse pediatric IBD cohort revealed age-related variation in the distribution of IBD phenotype, with a high prevalence of isolated colonic disease in young children. Positive family history was especially common in young patients with UC.
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Affiliation(s)
- Melvin B Heyman
- UCSF Children's Hospital, University of California, San Francisco, CA 94143, USA.
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Saadah OI, Oliver MR, Bines JE, Stokes KB, Cameron DJS. Anorectal strictures and genital Crohn disease: an unusual clinical association. J Pediatr Gastroenterol Nutr 2003; 36:403-6. [PMID: 12604983 DOI: 10.1097/00005176-200303000-00020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Omar I Saadah
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
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22
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Hill DA, Dehner LP, Gow KW, Pappo AS, Crawford D, Pflaumer SM, Furman WL, Hayes-Jordan AA, McDermott MB. Perianal rhabdomyosarcoma presenting as a perirectal abscess: A report of 11 cases. J Pediatr Surg 2002; 37:576-81. [PMID: 11912514 DOI: 10.1053/jpsu.2002.31613] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND PURPOSE The organs and soft tissues of the pelvis are some of the most common primary sites for rhabdomyosarcoma (RMS) in children and adolescents. In most cases a mass is detectable on clinical examination, and the initial concern is focused on the possibility of a neoplasm. The current report concerns 11 patients, each presented with a painful perineal-perianal mass suggesting an abscess to the extent that each one of these patients was treated initially with antibiotics or incision and drainage for several weeks to months before the pathologic diagnosis of RMS was established. METHODS The authors reviewed the clinical histories of all patients with perirectal/perianal RMS from their respective institutions to identify cases in which the initial clinical diagnosis or impression was that of a perirectal abscess. Pathologic material was reviewed in all cases. RESULTS Eleven patients, 7 of whom were girls, ranged in age from 1 to 16 years at diagnosis (median age, 14 years). Fever accompanied the clinical presentation in 2 patients. None of the patients had a past medical history of illness that may have predisposed them to a perirectal abscess, although one patient had a family history of inflammatory bowel disease. Duration of symptoms ranged from 1 month to 1 year (mean, 4.6 months). Each patient presented with a tender perianal/perineal nodule or mass. Inguinal adenopathy was present in 6 patients at diagnosis. White blood cell counts ranged from 6,600/mm(3) to 24,500/mm(3). LDH levels ranged from 414 to 3,432 U/L. The average time from presentation to pathologic diagnosis of RMS was 2.1 months. Nine of the 11 cases showed an alveolar pattern. All were high-stage disease. Of 7 patients with follow-up longer than 1 year, 2 (29%) are alive without disease. CONCLUSION This report presents the need to consider the possibility of a malignant neoplasm, in this case RMS, in a child or adolescent with a putative perirectal abscess that fails to respond in the expected manner to incision and drainage and antibiotic therapy.
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Affiliation(s)
- D Ashley Hill
- Department of Pathology, St Jude Children's Research Hospital and University of Tennessee, Memphis TN, USA
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23
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Affiliation(s)
- Sandra Kim
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Clinical Outcome and Pharmacokinetics After Addition of Low-Dose Cyclosporine to Methotrexate: A Case Study of Five Patients with Treatment-Resistant Inflammatory Bowel Disease. Inflamm Bowel Dis 2000. [DOI: 10.1097/00054725-200011000-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
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25
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Affiliation(s)
- D Pashankar
- Division of Gastroenterology, British Columbia's Children's Hospital, Vancouver, Canada
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Jeshion WC, Larsen KL, Jawad AF, Piccoli DA, Verma R, Maller ES, Baldassano RN. Azathioprine and 6-mercaptopurine for the treatment of perianal Crohn's disease in children. J Clin Gastroenterol 2000; 30:294-8. [PMID: 10777191 DOI: 10.1097/00004836-200004000-00018] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Numerous adult studies show a 30-65% response rate to azathioprine (AZA) or 6-mercaptopurine (6-MP) for significant perianal Crohn's disease. The aim of this study was to evaluate whether these drugs healed pediatric perianal Crohn's disease. Records of pediatric Crohn's patients were retrospectively reviewed for significant perianal disease treated with AZA or 6-MP for > or =6 months. The patient's perianal disease was reviewed and evaluated for fistulas, drainage, induration, and tenderness. In addition, the patients were given a score using the Irvine Perianal Disease Activity Index (PDAI). Patients were retrospectively scored upon initiation of treatment and after six months of therapy. Possible scores ranged from 0-20. Twenty patients met the study criteria. Five patients were considered treatment failures. One patient required a colostomy after 1.5 months of therapy, one developed pancreatitis, and three were noncompliant with therapy. Of the remaining 15 patients who were treated for > or =6 months, 67% had an improvement in drainage, 73% in tenderness, 60% in induration, and 40% in fistula closure. The mean Irvine PDAI was 7.67 +/- 2.19 initially and 4.40 +/- 1.72 after six months of therapy. The improvement was statistically significant (p < 0.001). AZA and 6-MP are effective treatments for healing significant perianal Crohn's disease in pediatrics.
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Affiliation(s)
- W C Jeshion
- Division of Gastroenterology and Nutrition, Children Hospital of Philadelphia, Pennsylvania 19104, USA
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Ierardi E, Principi M, Rendina M, Francavilla R, Ingrosso M, Pisani A, Amoruso A, Panella C, Francavilla A. Oral tacrolimus (FK 506) in Crohn's disease complicated by fistulae of the perineum. J Clin Gastroenterol 2000; 30:200-2. [PMID: 10730928 DOI: 10.1097/00004836-200003000-00015] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
We describe the cases of two patients with Crohn's disease affected by severe perineal fistulae resistant to conventional therapies, successfully treated with FK 506, a new immunomodulatory drug. It is well absorbed from diseased bowel and preliminary experiences have indicated its short-term use in complicated Crohn's disease. The first patient was a 24-year-old male with perineal fistula and severe skin ulceration (8 cm of external opening diameter). He had undergone colectomy and ileostomy because of severe pancolitis refractory to medical treatment and had been treated with azathioprine and metronidazole. Two months after starting FK 506, a dramatic improvement made further surgical operation unnecessary. Local and general benefit was observed during the following 26 months, until FK 506 was withdrawn. The second patient was a 28-year-old male with a diagnosis of ulcerative pancolitis changed to Crohn's disease two months after the onset of a perineal fistula, recurring despite drainage procedures, steroid therapy, and total parenteral nutrition. FK 506 was administered for two months with a complete healing of fistula. Successively, it was stopped and corticosteroids (associated to enteral nutrition) were given because of recurrent rectal bleeding. Our experience encourages the use of oral FK 506 in complicated Crohn's disease and suggests the possibility of a long-term primary therapy other than the use as a "bridge" to other treatments.
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Affiliation(s)
- E Ierardi
- Department of Emergency and Organ Transplantation, University of Bari, Italy
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Lowry PW, Weaver AL, Tremaine WJ, Sandborn WJ. Combination therapy with oral tacrolimus (FK506) and azathioprine or 6-mercaptopurine for treatment-refractory Crohn's disease perianal fistulae. Inflamm Bowel Dis 1999; 5:239-45. [PMID: 10579116 DOI: 10.1097/00054725-199911000-00001] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Our aim was to report the clinical experience with combination treatment using tacrolimus and either azathioprine (AZA) or 6-mercaptopurine (6MP) in patients with Crohn's disease (CD) perianal fistulae. The medical records of all patients with Crohn's disease perianal fistulae seen at the Mayo Clinic from 1996-1998 who were treated with tacrolimus were reviewed. Clinical response was classified as: complete response, partial response, and nonresponse. Eleven patients were treated with oral tacrolimus for a mean duration of 22 weeks. The initial oral dose of tacrolimus ranged from 0.15 to 0.31 mg/kg/day. Azathioprine or 6MP was continued in combination with tacrolimus in seven patients and initiated simultaneously with tacrolimus in four patients. All patients improved clinically, seven had a complete response, and four had a partial response. The mean time to initial improvement was 2.4 weeks, and the mean time to complete response was 12.2 weeks. The most frequent adverse events were nausea, paresthesias, nephrotoxicity, and tremor. Patients with nephrotoxicity had a significantly higher mean initial tacrolimus dose (0.31 mg/kg/day) compared with patients who did not have nephrotoxicity (0.25 mg/kg/day) (p = 0.035); however, there was not a statistically significant association between the starting dose or mean blood level and clinical response. Combination therapy with oral tacrolimus and AZA or 6MP may be effective treatment for CD perianal fistulae. Higher initial tacrolimus doses increase the risk of nephrotoxicity without improving clinical response.
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Affiliation(s)
- P W Lowry
- Inflammatory Bowel Disease Clinic, Mayo Clinic, Rochester, Minnesota 55905, USA
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Ogunbi SO, Ransom JA, Sullivan K, Schoen BT, Gold BD. Inflammatory bowel disease in African-American children living in Georgia. J Pediatr 1998; 133:103-7. [PMID: 9672520 DOI: 10.1016/s0022-3476(98)70187-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We describe the clinical characteristics of inflammatory bowel disease (IBD) African-American compared with non-African-American children. We identified 172 children with IBD; forty-nine (29%) were African-American. Median symptom duration before IBD diagnosis in African-American children (6 months) was shorter than that of non-African-American children (10 months). The most frequent presenting symptom was hematochezia (ulcerative colitis) and abdominal pain (Crohn's disease) in both racial groups. The estimated incidence of Crohn's disease in African-Americans ranged from 7 per 100,000 to 12 per 100,000, whereas the observed incidence in those with ulcerative colitis was between 5 and 7 per 100,000 during the 10 years of the study. Our pilot study suggests that IBD may be more common in African-American children than previously reported. Prospective population-based studies would be useful to determine whether inheritable factors linked with ethnicity are associated with IBD.
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Affiliation(s)
- S O Ogunbi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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31
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Egan LJ, Sandborn WJ, Tremaine WJ. Clinical outcome following treatment of refractory inflammatory and fistulizing Crohn's disease with intravenous cyclosporine. Am J Gastroenterol 1998; 93:442-8. [PMID: 9517654 DOI: 10.1111/j.1572-0241.1998.00442.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine outcome following treatment of refractory Crohn's disease with intravenous (i.v.) cyclosporine (CYA). METHODS The medical records of 18 patients with refractory Crohn's disease treated with i.v. CYA were reviewed. Nine patients had refractory inflammatory Crohn's disease and nine patients had complex fistulizing Crohn's disease. All patients were initially treated with i.v. CYA (4 mg/kg/day). Patients who responded were converted to standard oral CYA. Patient outcomes were classified as complete response, partial response, or nonresponse. RESULTS Four of nine patients with severe inflammatory Crohn's disease and seven of nine patients with fistulizing Crohn's disease had a partial response to i.v. CYA. Four of four responding patients in the inflammatory group and four of six responding patients in the fistulizing group (plus one initial nonresponder) maintained or improved their response during oral CYA therapy. After discontinuing oral CYA, all four patients in the inflammatory group and five of seven patients in the fistulizing group relapsed despite 1-17 wk of concomitant treatment with azathioprine or 6-mercaptopurine (AZA/6MP). Two patients who received overlapping CYA and AZA/6MP for 17 and 23 wk maintained long-term responses. CYA toxicity was minimal: reversible nephrotoxicity (n = 2), headache (n = 2), oral candidiasis (n = 1), paresthesia (n = 2). CONCLUSIONS I.v. CYA appears to benefit both refractory inflammatory and fistulizing Crohn's disease. Most patients who respond to i.v. CYA will maintain their response during oral CYA therapy. However, the majority of these patients relapse when oral CYA is discontinued, probably because of inadequate duration of overlap with the slow acting maintenance drugs, AZA/6MP.
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Affiliation(s)
- L J Egan
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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