Inflammatory bowel disease in children and adolescents: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition

Probiotics: The scientific evidence in the context of inflammatory bowel disease

Inflammatory bowel disease (IBD) generally comprises Crohn's disease (CD) and ulcerative colitis (UC), and their main characteristic is the intestinal mucosa inflammation. Although its origin is not yet fully known, there is growing evidence related to genetics, intestinal microbiota composition, and the immune system factors such as precursors for the initiation and progression of intestinal conditions. The use of certain probiotic microorganisms has been touted as a possible and promising therapeutic approach in reducing the risk of inflammatory bowel disease, specifically ulcerative colitis. Several mechanisms have been proposed to explain the benefits of probiotics, indicating that some bacterial strains are able to positively modulate the intestinal microbiota and the immune system, and to produce metabolites with anti-inflammatory properties. The aim of this paper is to bring together the various results and information, based on scientific evidence, that are related to probiotics and inflammatory bowel disease, emphasizing the possible mechanisms involved in this action.

Fibroblast growth factor 23 contributes to diminished bone mineral density in childhood inflammatory bowel disease

BACKGROUND

Diminished bone mineral density (BMD) is of significant concern in pediatric inflammatory bowel disease (IBD). Exact etiology is debatable. The recognition of fibroblast growth factor 23 (FGF23), a phosphaturic hormone related to tumor necrosis factor alpha (TNF-α) makes it plausible to hypothesize its possible relation to this pathology.

METHODS

In this follow up case control study, BMD as well as serum levels of FGF23, calcium, phosphorus, alkaline phosphatase, creatinine, parathyroid hormone, 25 hydroxy vitamin D3 and 1, 25 dihydroxy vitamin D3 were measured in 47 children with IBD during flare and reassessed in the next remission.

RESULTS

Low BMD was frequent during IBD flare (87.2%) with significant improvement after remission (44.7%). During disease flare, only 21.3% of patients had vitamin D deficiency, which was severe in 12.8%. During remission, all patients had normal vitamin D except for two patients with Crohn's disease (CD) who remained vitamin D deficient. Mean value of serum FGF23 was significantly higher among patients with IBD during flare compared to controls. It showed significant improvement during remission but not to the control values. 1, 25 dihydroxy vitamin D3, FGF23, serum calcium and urinary phosphorus were significant determinants of BMD in IBD patients.

CONCLUSIONS

We can conclude that diminished BMD in childhood IBD is a common multifactorial problem. Elevated FGF23 would be a novel addition to the list of factors affecting bone mineral density in this context. Further molecular studies are warranted to display the exact interplay of these factors.

Aspectos epidemiológicos das doenças intestinais inflamatórias na macrorregião de saúde leste do Estado de Minas Gerais

A doença de Crohn e a colite ulcerativa são entidades clínicas distintas, porém relacionadas, que se incluem no grupo das doenças intestinais inflamatórias. Esse artigo trata-se de um estudo epidemiológico a fim de descrever a produção do conhecimento em doenças inflamatórias intestinais, levando em consideração os casos de internações registrados, decorrentes do agravamento da doença, nas unidades de saúde da macrorregião de saúde leste do Estado de Minas Gerais. As doenças inflamatórias intestinais são consideradas um dos grandes problemas da população moderna, uma vez que geram repercussões importantes na qualidade de vida de seus portadores, acarretando alterações no âmbito social, psicológico e profissional. Durante o período de 1998 a 2005, foram registradas 363 internações hospitalares, em função das doenças intestinais inflamatórias, distribuídas em 184 e 179 casos nos gêneros masculino e feminino, respectivamente. Em função da escassez de estudos e do número de internações na macrorregião leste do Estado de Minas Gerais, pesquisas devem ser conduzidas a fim de delinear o perfil dos pacientes portadores de doenças inflamatórias intestinais, bem como detectar as possíveis alterações biopsicossociais a fim de promover uma assistência multiprofissional, humanizada e baseada em evidências.

An update on the epidemiology of inflammatory bowel disease in Asia

A rising trend in the incidence and prevalence of inflammatory bowel disease (IBD) in Asia has been recognized for the past two decades. It has been postulated that this phenomenon may be related to the westernization of lifestyles, including changes in dietary habits and environmental changes such as improved sanitation and industrialization. Previously we reported that the incidence and prevalence rates of IBD in Asia were low compared with the West, but there was a notably rising secular trend. In this review, we summarize the recent epidemiological data in Asia, characterize the clinical features, risk factors and genetic susceptibility of Asian IBD patients, and compare these to those of Western IBD patients. In the past decade, the incidence and prevalence of IBD reported across Asia, particularly in East Asia, has continued to increase. Familial clustering is generally uncommon in East Asia but appears to be higher in West Asia. The genetic susceptibilities in Asian IBD patients differ from those of White patients, as NOD2/CARD15 mutations are much less common. The clinical phenotypes and complication rates of Asian IBD resemble the White population in general, but with some differences, including lower surgical rates, higher prevalence of males, and higher prevalence of ileocolonic involvement among East Asian Crohn's disease patients, and a low frequency of primary sclerosing cholangitis among IBD patients in East and Southeast Asia.

US estimates of hospitalized pediatric patients with ulcerative colitis: implications for multicenter clinical studies

BACKGROUND

The optimal clinical management of children hospitalized with ulcerative colitis (UC) is evolving. There are limited data quantifying the number of pediatric patients with UC admitted to hospitals in the United States. We analyzed the Kids' Inpatient Database (KID, 2003), to estimate the distribution of hospitalized children with UC and estimate sample sizes available for clinical research.

METHODS

We limited our analysis to subjects age less than 18 years. We defined cases of UC as discharge records associated with an ICD-9 code of 556.0-556.9 in the first position. We defined colectomy as principal procedure code of 45.8. We generated weighted estimates for these analyses. To estimate the relationship between number of patients and number of hospitals necessary for clinical trials, we generated 1000 simulated datasets.

RESULTS

A total of 2311 UC cases were identified. The mean age at admission was 13.1 (standard error [SE] 0.1) years, and 9% (SE 0.9%) underwent colectomy during their hospitalization. 1008 UC cases were treated at high-volume hospitals; the majority of these children were treated at children's hospitals. Simulation studies suggest that approximately 5 high-volume hospitals would be necessary to generate sample sizes necessary for a pilot clinical trial of refractory UC.

CONCLUSIONS

Approximately half of all young patients hospitalized with UC in the US were treated at a limited number of high-volume hospitals, and approximately 5 such centers would be adequate for pilot clinical trials of hospitalized patients with refractory UC.

Epidemiology of inflammatory bowel disease in a German twin cohort: results of a nationwide study

BACKGROUND

Genetic predisposition as a cause of inflammatory bowel disease (IBD) has been proven by both family and twin studies and genetic variants associated with the disease have been identified. The aim of our study was to determine the concordance rates for IBD in German twin pairs and to evaluate clinical characteristics of concordant and discordant twin pairs.

METHODS

Patients with IBD were asked to participate and complete a questionnaire that contained questions about zygosity, demographic data, and medical history.

RESULTS

A total of 189 twin pairs in which at least 1 member had IBD were recruited (68 monozygotic and 121 dizygotic pairs). Within monozygotic pairs, 11 out of 31 (35%) were concordant for Crohn's disease (CD) and 6 out of 37 (16%) for ulcerative colitis (UC). Two of the 58 (3%) dizygotic pairs with CD and 1 out of 63 (2%) dizygotic pairs with UC were concordant for the disease. In 14 out of 20 (70%) discordant monozygotic CD pairs and 25 out of 31 (81%) discordant monozygotic pairs with UC, the first-born was affected by IBD. For discordant dizygotic twins, the first in birth order had IBD in 33 out of 56 (59%) pairs with CD and 40 out of 62 (64.5%) pairs with UC.

CONCLUSIONS

This study confirms a stronger genetic influence in CD than in UC. The high preponderance in being affected of the first-born twin and the fact that concordance was only 35% for CD and 16% for UC monozygotic twins highlight the important role of environmental trigger factors.

Azathioprine maintains first remission in newly diagnosed pediatric Crohn's disease

6-Mercaptopurine (6-MP) maintains remission in pediatric Crohn's disease (CD). Azathioprine, a prodrug of 6-MP, is used for maintenance of remission of CD in Europe. We evaluated to what extent azathioprine is used in newly diagnosed pediatric CD patients and whether maintenance of remission differed between patients using azathioprine or not. Charts of children (diagnosed 1998-2003, follow-up > or = 18 mo) were reviewed. Active disease was defined as Pediatric Crohn's Disease Activity Index (PCDAI) greater than 10 or systemic corticosteroid use. Remission was defined as PCDAI 10 or less without use of corticosteroids. Eighty-eight children (55M/33F, age 12 +/- 3 yr) were included. Seventy-two (82%) patients received azathioprine during the follow-up period (38 +/- 17 mo). Patients diagnosed after 2000 received azathioprine significantly earlier during the course of disease compared with those diagnosed earlier (median, at 233 vs. 686 days; P < 0.05). At initial presentation, moderate-severe disease activity and prescription of corticosteroids were more prevalent in patients using azathioprine compared with nonazathioprine patients (75% vs. 52%; P < 0.05; and 89% vs. 58%; P < 0.005, respectively). Duration of corticosteroid use was longer in patients receiving azathioprine (232 vs. 168 days; P < 0.005). Median maintenance of first remission in patients who initially used corticosteroids, however, was longer in patients receiving azathioprine compared with nonazathioprine patients (PCDAI, 544 vs. 254 days, P = 0.08; corticosteroid free, 575 vs. 259 days, P < 0.05, respectively). We conclude that, since 2000, azathioprine is being introduced earlier in the treatment of newly diagnosed pediatric CD patients. The use of azathioprine is associated with prolonged maintenance of the first remission.

Epidemiology of inflammatory bowel diseases in childhood

Inflammatory Bowel Disease (IBD) is common in most industrialised countries and childhood IBD accounts for nearly 30% of total cases. Various studies, mostly from Europe and USA have reported epidemiological characteristics of childhood IBD. The incidence figures vary greatly from region to region and within a region over time. Almost all reported studies have documented an increase in the incidence, mainly of Crohn's disease over the last few decades. The reasons for the increase are not clear but epidemiological observations have led to many postulates. Incidence in developing countries is perceived to be low, but limited data suggest that it may not be as uncommon as previously thought. IBD can occur at any age but is rare in infancy. Among childhood IBD, early onset IBD appears to be different epidemiologically and is characterised by predominance of colonic involvement and high positive family history. It has become apparent that only about 25% of childhood Crohn's disease presents with classical triad of abdominal pain, diarrhoea and weight loss. Pediatricians should be aware of atypical manifestations and should maintain high index of suspicion. Though epidemiological studies of childhood IBD done so far have contributed towards understanding of IBD, they have differed in study design, population, time period, age group and case definitions. Unfortunately there are no uniform, clear diagnostic criteria which are evidence based. To address this problem, recently the IBD working group of European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) has published "The Porto Criteria" which details a consensus based diagnostic criteria for the diagnosis of childhood IBD. This should bring uniformity in ascertainment of newly diagnosed IBD cases. An European multicentre prospective database has also been established to facilitate future epidemiological studies.

Children with early-onset inflammatory bowel disease (IBD): analysis of a pediatric IBD consortium registry

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.

Estrogen receptor-alpha, sexual dimorphism and reduced-size liver ischemia and reperfusion injury in mice

Estrogen (E(2)) exerts its effect on target organs principally by interacting with specific estrogen receptors (ER) such as ER-alpha or ER-beta. The role that these E(2) receptors play in mediating the protective effects observed in RSL+I/R induced injury remains to be defined. To study the role of ER-alpha, we anesthetized female and male wild type (wt; C57Bl/6) and ER-alpha-deficient (alphaERKO) mice and subjected them to 70% liver ischemia for 45 min followed by resection of the remaining 30% nonischemic lobes and reperfusion of the ischemic tissue. For some experiments, wt and alphaERKO male mice were injected with E(2). Survival was monitored on a daily basis while liver injury was assessed by quantifying serum alanine aminotransferase (ALT) levels and histopathology. Hepatic eNOS mRNA levels were evaluated using semi-quantitative RT-PCR. Our data showed that untreated females or males treated with E(2) survived RSL+I/R surgery indefinitely whereas all male mice given vehicle died within 3-5 days following surgery. This protective effect was diminished in alphaERKO female mice such that only 40% of alphaERKO females survived 7 d following RSL+I/R. Furthermore, liver injury was significantly higher in alphaERKO females compared with their wt counterparts and similar to those seen in wild type males and alphaERKO males. The protective effect observed in wild type females or E(2) treated males correlated well with increases in hepatic eNOS message whereas both male and female alphaERKO mice exhibited significantly lower levels of eNOS mRNA. We conclude that this protection may in part be due to the E(2)/ER-alpha-mediated activation of eNOS.

Consensus and controversy in the management of pediatric Crohn disease: an international survey

OBJECTIVES

Treatment options for patients with Crohn disease (CD) have expanded, but the use of some of these options in pediatric patients remains controversial. The authors evaluate current trends in treatment and areas of consensus or controversy.

METHODS

An international survey of certified pediatric gastroenterologists was conducted using an e-mail questionnaire in an attempt to evaluate management of active Crohn disease, attitudes toward four types of therapy, and prevalence of testing for osteopenia and 6-thioguanine levels.

RESULTS

One hundred sixty-seven physicians from the United States, Canada, Western Europe, and Israel were included. The majority of North American physicians (71%) prefer to use conventional steroids and azathioprine (AZA) before nutritional therapy or budesonide for patients with mild to moderately active disease, versus 21% of Western Europeans (P < 0.001). Western Europeans prefer nutritional therapy followed by budesonide or steroids for those with mild or moderate disease. Only 4% of North American gastroenterologists use nutritional therapy frequently versus 62% of their Western European colleagues (P < 0.001). Infliximab was thought to be effective for steroid-unresponsive disease by almost all physicians surveyed, although its efficacy as a maintenance therapy was rated higher by North American physicians than by their Western European and Israeli colleagues (P < 0.01). Bone mineral density is routinely evaluated by about 45% of physicians in Western Europe and North America.

CONCLUSIONS

Attitudes toward current therapies vary significantly by region, with North Americans strongly favoring corticosteroids followed by immunomodulatory therapy, and Western Europeans favoring nutritional therapy or budesonide and the avoidance of conventional corticosteroids.