Inflammatory bowel disease: Working Group report of the second World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition

EARLY AND LONG-TERM OUTCOME OF SURGICAL INTERVENTION IN CHILDREN WITH INFLAMMATORY BOWEL DISEASE

Background:

Although children with inflammatory bowel disease (IBD), disease control is possible through medical procedures, but surgical intervention is indicated in some cases.

Aim:

To evaluated long-term surgical outcomes in children with IBD.

Methods:

This retrospective cohort study was done on 21 children suffering IBD with surgical indication admitted to a referral children hospital in Tehran in 2019. The baseline information was collected by reviewing the recorded files and children were followed-up to assess surgical outcome.

Results:

The rate of early complications after surgery was 47.6%; they included intestinal perforation in 4.8%, peritonitis in 4.8%, wound infection in 23.8%, pelvic abscesses in 14.3%, deep vein thrombosis in 4.8%, intestinal obstruction in 9.5%, pancreatitis in 9.5% and anal fissure in 4.8%. The mean duration of follow-up for patients was 6.79±4.24 years. The rate of delayed complications during follow up was 28.6%. Accordingly, long-term free-complication survival rate during 5-10 years after surgery was 92.3% and 56.4%, respectively. Among the early features, lack of prior drug treatment and bleeding as indication for surgery, were two predictors of long-term surgical complications.

Conclusion:

Standard surgery in the treatment of IBD in children with surgical indication is associated with favorable outcome, although short- and long-term surgical complications are also predictable.

Particularities of Crohn's disease in pediatric patients: current status and perspectives regarding imaging modalities

A consensus on the best imaging modality evaluating inflammatory bowel disease in the pediatric population is lacking and it is often unclear which modality to choose in specific clinical circumstances. Children with inflammatory bowel disease are exposed to ionizing radiation from multiple imaging studies performed at initial diagnosis, throughout treatment and during the follow-up period. This paper discusses the value of different imaging techniques in pediatric patients with inflammatory bowel disease and gives a review of the literature. In addition, particular features of inflammatory bowel disease in children including the predilection of affected segments in the gastrointestinal tract are highlighted. Based on current literature knowledge, we encourage an integrative approach to the interpretation of clinical and imaging data for diagnosis and follow-up in daily clinical settings.

Current issues of pediatric inflammatory bowel disease in Korea

Inflammatory bowel disease (IBD) is a chronic relapsing disorder of unknown etiology, which is believed to be multifactorial. Recently, the incidence of pediatric IBD has steeply increased in Korea since 2000. Poorly controlled disease activity can result in complications such as intestinal fistulae, abscess, and stricture, as well as growth retardation and delayed puberty in children. Because of a lack of confirmative tests, various diagnostic modalities must be used to diagnose IBD. Onset age, location, behavior, and activity are important in selecting treatments. Monogenic IBD must be excluded among infantile and refractory very-early-onset IBD. Early aggressive therapy using biologics has recently been proposed for peripubertal children to prevent growth failure and malnutrition.

Acute cognitive and behavioral effects of systemic corticosteroids in children treated for inflammatory bowel disease

Systemic corticosteroids are a mainstay of treatment for many pediatric medical conditions. Although their impact on the central nervous system has been well-studied in animal models and adults, less is known about such effects in pediatric populations. The current study investigated acute effects of corticosteroids on memory, executive functions, emotion, and behavior in children and adolescents with inflammatory bowel disease (IBD). Patients 8-17 years with IBD (Crohn's disease, CD; ulcerative colitis, UC) on high-dose prednisone (n = 33) and IBD patients in remission off steroids (n = 33) completed standardized neuropsychological tests and behavior rating scales. In the IBD sample as a whole, few steroid effects were found for laboratory cognitive measures, but steroid-treated patients were rated as exhibiting more problems with emotional, and to a lesser extent with cognitive function in daily life. Steroid effects, assessed by laboratory measures and questionnaires, were more prevalent in CD than UC patients; UC patients on steroids sometimes performed better than controls. Sleep disruption also predicted some outcomes, diminishing somewhat the magnitude of the steroid effects. Corticosteroid therapy can have acute effects on cognition, emotion, and behavior in chronically ill children; the clinical and long-term significance of these effects require further investigation.

Vitamin D deficiency in children with inflammatory bowel disease

BACKGROUND

Osteopenia and osteoporosis are commonly seen in inflammatory bowel disease (IBD). Vitamin D deficiency potentially contributes to diminished bone acquisition in childhood.

OBJECTIVES

The objectives of this study were to assess vitamin D in a group of Australian children with IBD and to ascertain associations between vitamin D status and key clinical factors, for example disease location and severity.

METHODS

Data were obtained retrospectively from the records of children with IBD who had at least one measurement of serum 25-hydroxyvitamin D (25(OH)D) over a two-year period. Demographic variables, disease activity, inflammatory markers, disease location, duration, and therapy were recorded. Moderate and severe deficiency were defined as 25(OH)D <51 nmol/l and <30 nmol/l, respectively. Insufficiency was defined as 25(OH)D between 51 and 75 nmol/l.

RESULTS

Overall, the mean 25(OH)D level in 78 children (104 measurements) was 71.2 (SD ± 26.5) nmol/l. Fifteen (19%) children were vitamin D deficient and 30 (38%) children were insufficient. Levels of 25(OH)D were not associated with disease location or use of immunosuppressive drugs. Children with vitamin D deficiency had greater corticosteroid exposure than those with normal status (P = 0.001). The mean 25(OH)D of 38 children treated with nutritional therapy at diagnosis was higher than for 17 children initially treated with corticosteroids (P = 0.04).

CONCLUSIONS

A high proportion of these Australian children with IBD were vitamin D deficient. This emphasizes the importance of monitoring vitamin D status, and treating deficiency, in the management of pediatric IBD. The possible benefit of nutritional therapy in protection against vitamin D deficiency requires further prospective study.

Impact of inflammatory bowel disease and high-dose steroid exposure on pupillary responses to negative information in pediatric depression

OBJECTIVE

To better understand emotional information processing in pediatric inflammatory bowel disease (IBD) and its relationship with depression. Pediatric IBD is associated with higher rates of depression than seen in other physical diseases and in community samples. In systemic inflammation, proinflammatory cytokines have been implicated in altering activity in brain regions known to affect emotion processing and emotion regulation in depression.

METHODS

We examined differences in pupillary responses as a marker of brain function in response to negative emotional information in youths (ages, 8-17 years) with IBD both with (n = 8) and without (n = 15) comorbid depression and who were receiving high-dose steroid treatment. We compared their responses to each other and to depressed youths without IBD (n = 20) and healthy youths (n = 22).

RESULTS

Youths with IBD demonstrated greater pupillary responses to the initial presentation of negative emotional stimuli, regardless of their depression status (p = .05). In contrast, depressed youths, regardless of their IBD status, demonstrated a greater constriction of the pupil 10 seconds to 12 seconds after exposure to negative stimuli. This constriction was associated with greater depressive severity and lower albumin levels.

CONCLUSIONS

IBD may be associated with increased sensitivity to negative emotional stimuli above and beyond depression diagnosis. Depressed youths potentially demonstrate affective blunting, emotional avoidance, or a failure to regulate emotion after exposure to negative emotional information. Thus, there seem to be unique contributions of medical disease and depression to physiological indications of emotional reactivity, but these factors do not seem to interact.

Serologic investigations in children with inflammatory bowel disease and food allergy

The aim of the study was the evaluation of frequency and titre of IgA ASCA and IgG ASCA and p-ANCA, c-ANCA in children with IBD and occurrence of ASCA antibodies in relation to coexistence of FA. Patients and methods. The study comprised 95 children at the ages of 2 to 18 years. The diagnosis of IBD was established on the basis of Porto criteria. Tests of blood serum were performed in all children: IgA and IgG ASCA, p-ANCA, c-ANCA using ELISA method. Results. IgE-dependent FA was found in 32.5% children with UC and in 21% with CD. We did not observe any relation between the occurrence of FA and the frequency and ASCA titre. p-ANCA were significantly more frequent in the group of children with UC. The occurrence of ASCA antibodies was observed in 73.7% of children with CD, 17.5% with UC and almost 30% with allergic colitis. Conclusions. Patients with CD and the presence of ASCA revealed a significantly more frequent localization of lesions within the small bowel and a tendency towards older age. We observed a connection between the occurrence of antibodies and the examined mutations of gene NOD2/CARD15.

Pediatric Crohn's disease activity at diagnosis, its influence on pediatrician's prescribing behavior, and clinical outcome 5 years later

BACKGROUND

No studies have been performed in which therapeutic regimens have been compared between mild and moderate-to-severe pediatric Crohn's disease (CD) at diagnosis. The aim was to analyze pediatric CD activity at diagnosis, its influence on pediatrician's prescribing behavior, and clinical outcome 5 years later.

METHODS

In a retrospective multicenter study we divided pediatric CD patients at diagnosis into mild or moderate-severe disease. We compared initial therapies, duration of first remission, number of exacerbations, height-for-age and weight-for-height evolvement, and cumulative duration of systemic steroid use in a 5-year follow-up period.

RESULTS

Forty-three children were included (25 with mild and 18 with moderate-severe disease). Aminosalicylate monotherapy was more frequently prescribed in the mild group (40% versus 17%; P < 0.01). The median duration of systemic steroid use was 18.3 months in the mild group and 10.4 months in the moderate-severe group (P = 0.09). Duration of first remission was 15.0 months in the mild group and 23.4 months in the moderate-severe group (P = 0.16). The mean number of exacerbations was 2.2 in the mild group and 1.8 in the moderate-severe group (P = 0.28).

CONCLUSIONS

CD patients with mild disease were treated with aminosalicylate monotherapy more frequently. These patients, however, tend to have more exacerbations, shorter duration of first remission, and longer total duration of systemic steroid use. Our data support the concept that severity of disease at diagnosis does not reliably predict subsequent clinical course. This study suggests that there is no indication that children with mild CD should be treated differently compared to children with moderate-severe disease.

Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression

OBJECTIVE

To examine the feasibility and efficacy of a manual-based cognitive-behavioral therapy (CBT) in reducing depressive symptomatology in adolescents with inflammatory bowel disease (IBD). Primary and Secondary Control Enhancement Therapy-Physical Illness (PASCET-PI) modified for youths with IBD was compared to treatment as usual (TAU), plus an information sheet about depression, without therapist contact using assessable patient analysis.

METHOD

Following assessment, participants 11 to 17 years old with IBD and mild to moderate subsyndromal depression were randomly assigned to PASCET-PI (n = 22) or comparison treatment (n = 19). Primary outcome measures at baseline (T1) and 12 to 14 weeks posttreatment (T2) were Children's Depression Inventory (child/parent report), Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), Children's Global Assessment Scale, and Perceived Control Scale for Children.

RESULTS

The PASCET-PI group showed significantly greater improvement in Children's Depression Inventory (child/parent report), Children's Global Assessment Scale, and Perceived Control Scale for Children posttreatment than the comparison group.

CONCLUSIONS

Screening and treatment of depressive symptoms in pediatric settings is feasible. PASCET-PI may be an efficacious intervention for subsyndromal depression in adolescents with IBD, although comparison with a more active treatment is necessary to attribute the improvement to PASCET-PI.

CLINICAL TRIAL REGISTRATION INFORMATION

URL: http://clinicaltrials.gov. Unique identifier: NCT00446238.

Role of CARD15, DLG5 and OCTN genes polymorphisms in children with inflammatory bowel diseases

AIM: To investigate the contribution of variants of CARD15, OCTN1/2 and DLG5 genes in disease predisposition and phenotypes in a large Italian cohort of pediatric patients with inflammatory bowel diseases (IBD).

METHODS: Two hundred patients with Crohn’s disease (CD), 186 ulcerative colitis (UC) patients, 434 parents (217 trios), and 347 healthy controls (HC) were studied. Polymorphisms of the three major variants of CARD15, 1672C/T and -207G/C SNPs for OCTN genes, IGR2096a_1 and IGR2198a_1 SNPs for the IBD5 locus, and 113G/A variant of the DLG5 gene were evaluated. Potential correlations with clinical sub-phenotypes were investigated.

RESULTS: Polymorphisms of CARD15 were significantly associated with CD, and at least one variant was found in 38% of patients (15% in HC, OR = 2.7, P < 0.001). Homozygosis for both OCTN1/2 variants was more common in CD patients (1672TT 24%, -207CC 29%) than in HC (16% and 21%, respectively; P = 0.03), with an increased frequency of the TC haplotype (44.8% vs 38.3% in HC, P = 0.04). No association with the DLG5 variant was found. CD carriers of OCTN1/2 and DLG5 variants more frequently had penetrating disease (P = 0.04 and P = 0.01), while carriers of CARD15 more frequently had ileal localization (P = 0.03). No gene-gene interaction was found. In UC patients, the TC haplotype was more frequent (45.4%, P = 0.03), but no genotype/phenotype correlation was observed.

CONCLUSION: Polymorphisms of CARD15 and OCTN genes, but not DLG5 are associated with pediatric onset of CD. Polymorphisms of CARD15, OCTN, and DLG5 genes exert a weak influence on CD phenotype.

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.

Pediatric inflammatory bowel disease

Inflammatory bowel disease is an important cause of gastrointestinal pathology in children and adolescents. The incidence of pediatric inflammatory bowel disease is increasing; therefore, it is important for the clinician to be aware of the presentation of this disease in the pediatric population. Laboratory tests, radiology studies, and endoscopic procedures are helpful in diagnosing inflammatory bowel disease and differentiating between Crohn’s disease and ulcerative colitis. Once diagnosed, the goal of medical management is to induce remission of disease while minimizing the side effects of the medication. Specific attention needs to be paid to achieving normal growth in this susceptible population. Surgical management is usually indicated for failure of medical management, complication, or malignancy. Algorithms for diagnostic evaluation and treatment of pediatric inflammatory bowel disease are presented. The specific psychosocial issues facing these patients are also discussed in this review as are the future goals of research in the complex problem of pediatric inflammatory bowel disease.

Evaluation of the pediatric crohn disease activity index: a prospective multicenter experience

BACKGROUND AND OBJECTIVES

Longitudinal assessment of disease activity is necessary for studies of therapeutic intervention in children with Crohn disease. The Pediatric Crohn Disease Activity Index (PCDAI) was developed a decade ago for such a purpose, but it function has only been examined in a small number of studies with a limited number of patients. The primary objectives of the present study were to develop cut scores reflecting disease activity as determined by physician global assessment (PGA) and to evaluate the responsiveness of the PCDAI to changes in patient condition after therapeutic interventions.

METHODS

Data were derived from a prospective database of newly diagnosed children with inflammatory bowel disease established in 2002 at 18 pediatric gastroenterology centers in the United States and Canada. At diagnosis, at 30 days and 3 months after diagnosis, and quarterly thereafter, children (<16 years of age) with Crohn disease had disease assessment performed by PGA and PCDAI. Disease management was provided according to the dictates of the attending gastroenterologist and not by predetermined protocol.

RESULTS

181 patients had concomitant PGA and PCDAI performed at diagnosis, and 95 of these had similar assessment at short-term follow up. Mean +/- SD PCDAI scores for mild, moderate, and severe disease by PGA at diagnosis were 19.5 +/- 10.4, 32.2 +/- 12.7, and 47.8 +/- 14.9, respectively (P < 0.001 for all comparisons). Mean +/- SD PCDAI for inactive disease after treatment was 5.2 +/- 5.4. Receiver operating characteristic (ROC) curve analysis suggested that: 1) activity of moderate/severe disease was best reflected by a PCDAI of > or = 30 points, 2) clinical response (moderate/severe disease improving to mild/inactive) was best reflected by a decrease in PCDAI of > or = 12.5 points, and 3) a PCDAI < 10 best reflected inactive disease.

CONCLUSIONS

PCDAI scores accurately reflect disease activity as assessed by physician global assessment. A PCDAI score of > or = 30 has acceptable sensitivity and specificity to indicate disease of moderate/severe activity. A PCDAI decrease of 12.5 points or greater following therapeutic intervention accurately reflects a clinically significant response. The PCDAI is an appropriate tool for intervention trials in Crohn disease in children.