Extraintestinal manifestations of pediatric inflammatory bowel disease and their relation to disease type and severity

Prevalence and outcomes of arthritis in pediatric IBD: A multicenter study from the Italian Society of Pediatric Gastroenterology Hepatology and Nutrition

BACKGROUND AND AIMS

The aim of the present study was to assess prevalence and disease outcomes of arthritis in a nationwide cohort of pediatric patients with inflammatory bowel disease (IBD).

METHODS

We collected data of pediatric IBD patients experiencing arthritis from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition IBD registry. We gathered baseline and one-year follow-up data on concomitant IBD and arthritis diagnosis.

RESULTS

150 patients [(99 Crohn's Disease (CD), 51 Ulcerative Colitis (UC) and Unclassified IBD (IBDU)] with arthritis out of 3061 (1301 CD and 1760 UC) patients were identified, with an overall prevalence of 4.9 %. Arthritis was more frequent in CD than in UC (7.6 % vs 2.9 %, p < 0.01). Peripheral arthritis was more frequently diagnosed in patients with active IBD than in those with quiescent disease (94.6 % vs 67.3 %, p < 0.01). At one-year follow-up, clinically active IBD was independently associated with lower peripheral arthritis remission rates, whereas it did not impact axial arthritis remission. The presence of additional EIMs was associated with lower IBD clinical remission rates.

DISCUSSION

Clinically active IBD impacts peripheral arthritis but not axial one, whose activity appeared to be independent by intestinal disease. The presence of additional EIMs has a negative prognostic impact on IBD course.

Childhood-onset inflammatory bowel disease and chronic non-bacterial osteomyelitis: a Swedish nationwide cohort study 2002-2022

BACKGROUND AND AIMS

Nationwide, population-based studies of chronic non-bacterial osteomyelitis (CNO) in patients with childhood-onset inflammatory bowel disease (IBD) are lacking.

METHODS

We used nationwide registers to identify all children in Sweden diagnosed with IBD during 2002-2022 and the occurrence of CNO in this IBD cohort and general population non-IBD comparators. To estimate the temporal associations between IBD and CNO we used Cox regression. We compared clinical data for IBD patients with CNO (IBD+CNO) and the IBD patients without CNO.

RESULTS

We identified 8244 children with IBD and 82 400 non-IBD comparators. At IBD diagnosis, CNO had been diagnosed in 0.13% (11/8244) of the IBD cohort and 0.03% (26/82 400) of the non-IBD comparators. During follow-up, 13 additional CNO cases occurred in the IBD cohort and 22 in the non-IBD comparators (adjusted hazard ratio = 5.87 [95% CI 2.95-11.66]). The prevalence of CNO among all prevalent children with IBD and prevalent matched non-IBD comparators December 31, 2022 was 0.48% (9/1885) and 0.02% (4/18 567), respectively. Median age at IBD diagnosis was lower in IBD + CNO compared to IBD without CNO (11 vs 14 years [-3 years, 95% CI -5 to -1]). Extraintestinal manifestations (except CNO) were more frequent in IBD + CNO (62% vs 21%, P < .0001). Treatment with biologics was more common in the IBD + CNO group (78% vs 44%, P = .004), prescribed for IBD and/or CNO.

CONCLUSIONS

We found a 6-fold increased risk of CNO in childhood-onset IBD compared to non-IBD comparators. Patients with IBD + CNO are characterized by younger age at IBD onset, more frequent extraintestinal manifestations, and higher usage of biologics.

Risk of Intestinal Complications, Extraintestinal Morbidity, and Mortality in Patients with Crohn's Disease and Ocular Involvement

PURPOSE

Patients with Crohn's disease (CD) and subsequent ocular manifestations may have worse outcomes when compared to matched patients with CD without ocular disease.

METHODS

In this retrospective cohort study, an aggregated electronic health records research network, TriNetX (Cambridge, MA, USA), was used to identify patients diagnosed with CD stratified by the presence or absence of ocular involvement with at least 1 year of follow-up. Propensity score matching (PSM) was performed to control for baseline demographics and medical comorbidities.

RESULTS

Patients with CD with ocular disease showed a greater risk of undergoing bowel resections (RR: 2.06, 95% CI: 1.48-2.85, p < 0.001), developing other CD-related gastrointestinal complications (RR: 1.31, CI: 1.15-1.49, p < 0.001), or acquiring Clostridioides difficile infections (RR: 2.19, CI: 1.89-2.54, p < 0.001). Further, patients with CD with ocular sequelae had a greater risk of developing NASH (RR: 1.43, CI: 1.31-1.56, p < 0.001), CD-related nutrient deficiencies (RR: 1.38, CI: 1.29-1.49, p < 0.001), iron deficiency anemia (RR: 1.41, CI: 1.33-1.50, p < 0.001), CD-related dermatological disease (RR: 1.84, CI: 1.65-2.05, p < 0.001), osteoporosis (RR: 1.49, CI: 1.37-1.64, p < 0.001) and primary sclerosing cholangitis (RR: 1.63, CI: 1.11-2.38, p = 0.011). Among patients with CD with ocular involvement, there was an elevated risk of MI (RR: 1.36, CI: 1.14-1.63, p < 0.001), stroke (RR: 1.42, CI: 1.18-1.70, p < 0.001), VTE (RR: 1.37, CI: 1.22-1.54, p < 0.001), and sepsis (RR: 1.53, CI: 1.37-1.71, p < 0.001).

CONCLUSIONS

Patients who have CD and subsequent ocular involvement have an increased risk of local intestinal complications, extraintestinal morbidity, and cardiovascular complications when compared to patients with CD without ocular involvement.

Salivary Immunoglobulin a Alterations in Health and Disease: A Bibliometric Analysis of Diagnostic Trends from 2009 to 2024

BACKGROUND/OBJECTIVES

Salivary immunoglobulin A (IgA) is a mediator of local immunity and host defence. Altered IgA levels may predispose to bacterial invasion of the mucosa in the gastrointestinal tract, including the oral cavity. Our study aimed to present the diagnostic trends related to salivary IgA in health and disease based on a bibliometric analysis of published papers between 2009 and 2024.

METHODS

By 14 September 2024, 1247 English original articles were found in the database Web of Science. We selected 838 records considering the diagnostic usefulness of IgA in human subjects. Based on bibliographic data, we created citation and keyword co-occurrence maps using VOSviewer 1.6.20.

RESULTS

Most articles belonged to the "Sport Sciences" category (n = 169), followed by the "Immunology" category (n = 93). The Brazilian researcher Alexandre Moreira from the University of Sao Paulo had the most published and most frequently cited papers. Most of the included articles came from the USA (n = 158), England (n = 105), Brazil (n = 95), and Japan (n = 95). The most cited article described research on IgA in response to SARS-CoV-2 infection (n = 690), but the subsequent two papers considered the role of salivary IgA in the dysbiosis of the intestinal microbiota in inflammatory bowel diseases (n = 272) and the formation of systemic immune responses from the gastrointestinal tract (n = 245).

CONCLUSIONS

Salivary IgA is a widely evaluated diagnostic marker in both patients and healthy individuals. Numerous reports have identified its changes as a result of physical exertion in various groups of athletes, during infections (including SARS-CoV-2) and in the course of local diseases (e.g., periodontal disease) or systemic diseases (e.g., inflammatory bowel disease).

The association between erythema nodosum and pyoderma gangrenosum and pediatric inflammatory bowel disease

OBJECTIVES

The objectives of this study is to estimate rates and identify factors associated with erythema nodosum (EN) and pyoderma gangrenosum (PG) in pediatric patients with inflammatory bowel disease (IBD).

METHODS

This cohort study examined longitudinal visits of patients aged ≤ 21 years from the ImproveCareNow (ICN) registry. We evaluated the association of factors at the patient-level (demographics and IBD diagnosis age) and visit-level (IBD severity scores, markers and phenotypes, comorbidities, and treatment) with the presence of EN and PG, using longitudinal logistic regression models adjusted for time and within-patient clustering.

RESULTS

A total of 285,913 visits from 32,497 patients aged ≤ 21 years from the ICN registry were analyzed. The occurrence of EN was 1.57% (95% confidence interval [95% CI]: 1.43%-1.71%) and the occurrence of PG was 0.90% (95% CI: 0.80%-1.00%). Co-occurrence of EN and PG was reported in 0.30% (95% CI: 0.25%-0.37%) patients. Both EN and PG were associated (p < 0.0001) with worse intestinal disease, lower remission, higher inflammatory markers, and extraintestinal manifestations (EIMs) arthritis and uveitis.

CONCLUSIONS

EN and PG were associated with increased disease severity and other noncutaneous EIMs (arthritis and uveitis). A small subset of patients had developed both EN and PG.

Takayasu arteritis in an adolescent with untreated Crohn's disease: A case report

Extraintestinal manifestations in inflammatory bowel disease (IBD) most frequently involve the joints, skin, and organs such as the liver and pancreas. Inflammation of the aorta is less commonly described in pediatrics, although it has been described in adults. We report a case of an adolescent female with Crohn's disease who presented with worsening diarrhea, vomiting, and weight loss, found to have aortitis on imaging. We review the pathogenesis and clinical features of Takayasu arteritis, as well as some of its similarities to IBD to raise awareness, as early detection of this less-known extraintestinal manifestation has been associated with better outcomes.

Mucocutaneous manifestations of inflammatory bowel disease

Mucocutaneous manifestations can be indicative of a variety of gastrointestinal diseases, and the dermatologist needs to know how to recognize them to refer the right patients to the gastroenterologist. Conversely, the gastroenterologist is often confronted with mucocutaneous lesions that raise the question of a possible association with a known digestive disease. Among the extra-intestinal manifestations of inflammatory bowel disease (IBD), mucocutaneous manifestations are the most common. This review will provide a breakdown by classifying them into 4 groups: 1) reactive manifestations, which include neutrophilic dermatoses, aphthous stomatitis, erythema nodosum, and vasculitis; 2) Crohn's disease-specific granulomatous skin lesions, which are histologically characterized by tuberculoid granulomas similar to those found in the gastrointestinal tract; 3) nutritional deficiency manifestations secondary to anorexia, malabsorption, loss, and drug interactions; and 3) a variety of autonomous autoimmune or inflammatory skin diseases. Dermatologists may also be involved in the management of the adverse effects of IBD treatments, especially the so-called "paradoxical" psoriatic eruptions.

The Prevalence and Characteristics of Inflammatory Bowel Disease-related Ocular Involvement in Children

BACKGROUND

Ocular manifestations (OMs) in patients with inflammatory bowel disease (IBD) are uncommon, particularly in children. We aimed to explore the prevalence and characteristics of IBD-associated OM in a large cohort study.

METHODS

A cross-sectional study was performed using the Maccabi Healthcare Services (MHS) database. The eligible population included all patients diagnosed with IBD as children (<18 years) between January 2005 and July 2023.

RESULTS

Out of 2567 children with IBD (males 55%, Crohn's disease 64%), 78 (3%) were diagnosed with OM at any time during the disease course. In 54 patients (69%), the ocular disease occurred after IBD diagnosis with a median time of 2.6 (0.47-7) years between the 2 events, whereas in 24 patients (31%), ocular involvement preceded IBD diagnosis with a median time of 2.1 (0.6-5.7) years. The presence of ocular involvement was associated with increased usage of systemic corticosteroids (P < .001) and biologic agents (P = .04). There were 55 patients with ocular involvement during childhood who were ever diagnosed with IBD. In this population, ocular involvement was also associated with increased usage of systemic corticosteroids (P < .001). The prevalence of OM among patients with IBD did not change significantly over time (P = .75), with a prevalence of 2.3% at the end of the study period.

CONCLUSIONS

The prevalence of ocular involvement in children with IBD is rare and steady; it is also associated with a greater usage of systemic corticosteroids and biologic agents, potentially representing a more severe disease course.

Prevalence and clinical features of chronic uveitis in pediatric inflammatory bowel diseases: A nationwide study

Inflammatory bowel diseases (IBD) encompass a group of chronic inflammatory disorders primarily affecting the gastrointestinal tract but capable of impacting various organs, including the eye, with uveitis being the most common ocular condition. We assessed uveitis prevalence and clinical features in a nationwide cohort of pediatric IBD. Among 4229 cases, six patients (four Crohn's disease, one ulcerative colitis, and one unclassified IBD) were identified, resulting in an overall prevalence rate of 141.8 per 100,000 patients. Uveitis onset varied: two before IBD, two after, and two concomitantly. Symptomatic uveitis occurred in 2/6 patients, with anterior involvement in all cases. Median follow-up was 3 years (interquartile range 2-4.75 years). At the last follow-up, 5/6 patients exhibited quiescent IBD, while 4/6 had inactive uveitis. One patient had ocular complications. Uveitis is a rare but potentially complicating manifestation of pediatric IBD.

Diagnosis change in pediatric inflammatory bowel disease

OBJECTIVES

This study aims to characterize pediatric inflammatory bowel disease (IBD) patients who change diagnosis and describe the characteristics of that change.

METHODS

A retrospective study was conducted on pediatric IBD patients from the ImproveCareNow (ICN) multicenter international cohort from 2007 to January 2019. Primary outcome was change in diagnosis after the first four visits. Other variables included demographics, diagnostics, disease characteristics, and timing.

RESULTS

6.1% of 18,055 patients aged 1-20 years changed diagnosis. Median time between the baseline visit and first diagnosis change was 0.9 years. Change in diagnosis occurred in 257/12,178 (2.1%) patients with Crohn's disease (CD), 347/4758 (7.3%) patients with ulcerative colitis (UC), and 495/1119 (44.2%) patients with IBD-Unclassified (IBD-U). In multivariable analysis, initial diagnosis of IBD-U and longer follow-up times were associated with greater odds of a diagnosis change.

CONCLUSION

IBD-U initial diagnosis and longer follow-up were associated with increased diagnosis change risk. The most common change was reclassification to CD. Disease activity, moderate malnutrition, and presence of EIMs were not associated with change in diagnosis.

Prevalence of Hepatobiliary Manifestations in Inflammatory Bowel Disease: A GRADE Assessed Systematic Review and Meta-Analysis of more than 1.7 Million Patients

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] comprises an immune-mediated group of chronic gastrointestinal disorders. Patients with IBD may experience extraintestinal manifestations, such as hepatobiliary complications. This meta-analysis aims to assess the prevalence of different hepatic manifestations in IBD patients.

METHODS

For this systematic review and meta-analysis, PubMed, Scopus, Web of Science, and Embase were searched until July 20, 2022, by specifying keywords for IBD, hepatic manifestations, and study type. Full texts of cohort studies in English that examined the prevalence of different hepatic manifestations were included in this study. The primary outcome was the overall prevalence of hepatic manifestations in IBD patients. For the statistical analysis, a proportion by random effect model meta-analysis was performed. The registration number for the protocol of this study in PROSPERO is CRD42022369595.

RESULTS

From the 4421 articles retrieved from the primary search, 118 met the inclusion criteria and were included in the final analysis. After a pooled analysis of 1 729 128 patients, the overall prevalence of hepatic manifestations was 3.49% (95% confidence interval [CI]: 3.31-3.68%; I2: 99.55%). The pooled prevalence of non-alcoholic fatty liver disease in 228 216 patients was 26.1% [95% CI: 22.1-30.2%; I2: 99.018%]. After pooled analysis of 9642 patients, the prevalence of primary sclerosing cholangitis was 1.67% [95% CI: 1.47-1.88%; I2: 99.10%]. The pooled prevalence of biliary stones was 4.1% [95% CI: 3.6-4.7%; I2: 97.43%]. Autoimmune hepatitis (0.51% [95% CI: 0.26-0.75%]; I2: 85.36%) and portal vein thrombosis (0.21% [95% CI: 0.08-0.33%]; I2: 97.95%) are considered as rare manifestations.

CONCLUSION

This study summarizes the prevalence and importance of different hepatic manifestations in IBD patients. These findings are crucial for the management of extraintestinal manifestations, especially hepatic manifestations, in IBD patients.

Ocular extraintestinal manifestations and treatments in patients with inflammatory bowel disease

Between 3-47% of patients with inflammatory bowel disease (IBD) have extraintestinal manifestations (EIMs), and between 1.3-86.9% of patients with IBD suffer from ocular EIMs (O-EIMs) making the eye the third most common organ affected. These O-EIMs exist among a spectrum, with a variety of types and amounts of inflammation which can lead to decreased vision, and in some cases, vision loss, without treatment. We performed a literature review concerning O-EIMs in patients who had or were later found to have a diagnosis of IBD in order to identify ocular EIMs that commonly occur with IBD and to assess which patients with IBD may be at higher risk of developing O-EIMs. We were also interested in ascertaining whether O-EIMs were more common in specific populations of people or in specific subtypes of IBD. Lastly, we explored the common treatments of O-EIMs in patients with IBD. Upon review of the literature, we found that the most common O-EIMs are episcleritis and uveitis. Anterior uveitis is more commonly seen, although, inflammation may occur in the posterior segment of the eye as well and may also manifest as retinal vasculitis. While these diagnoses are sometimes known retrospectively, most patients present with nonspecific eye complaints of which decreased vision with or without pain is the most common. Visual symptoms associated with ocular EIMs may be non-specific so physicians should have a low threshold to refer to ophthalmology for visual complaints. It is important to keep in mind that ocular EIMs can cluster with skin and joint EIMs. Screening should be prioritized for female patients with Crohn's disease and concurrent arthritis. Treatments for O-EIMs are outlined and compared in this paper as well.

Legius Syndrome and Inflammatory Bowel Disease: A Pediatric Case Report

Legius syndrome (LS) is a rare and underrecognized disorder that is often misdiagnosed as neurofibromatosis type 1 (NF1). It is characterized by café-au-lait macules without the tumoral manifestations of NF1. We report the case of an 11-year-old patient with multiple café-au-lait macules and intertriginous freckling who was admitted for bloody stools, joint pain, and weight loss. His clinical and endoscopic findings were consistent with inflammatory bowel disease (IBD). He also met the clinical diagnostic criteria for NF1 but not for LS. Genetic testing played a pivotal role in the differential diagnosis and revealed a loss-of-function mutation in the SPRED1 gene, confirming the diagnosis of LS. This is the first reported case of a patient with IBD and LS. The subtle manifestations of LS make it an underdiagnosed disease, which reduces the likelihood of it being diagnosed in association with other diseases, such as IBD. There are, however, 10 published case reports linking IBD and NF1, and some pathophysiological mechanisms have been proposed. Continued reporting will help clarify the relationship between IBD and RASopathies such as NF1 and LS.

Health Care Maintenance in Pediatric Inflammatory Bowel Disease

Patients with pediatric inflammatory bowel disease (pIBD) are at an increased risk for complications and comorbidities including infection, nutritional deficiencies, growth delay, bone disease, eye disease, malignancy, and psychologic disorders. Preventative health maintenance and monitoring is an important part to caring for patients with pIBD. Although practice is variable and published study within pIBD is limited, this article summarizes the important field of health-care maintenance in pIBD. A multidisciplinary approach, including the gastroenterologist provider, primary care provider, social worker, psychologist, as well as other subspecialists is necessary.

Pancreatic Involvement in the Course of Inflammatory Bowel Disease in Children-A Multi-Center Study

The coexistence of inflammatory bowel disease (IBD) with pancreatic pathology is rare in children. A retrospective analysis of data from 1538 children diagnosed with IBD in 2014-2021 was conducted to determine the frequency and causes of pancreatitis and asymptomatic hyperlipasemia (HL) or hyperamylasemia (HA) in this group of patients. Among the 176 children (11.4%) with pancreatic involvement (PI), acute pancreatitis (AP) was diagnosed in 77 children (43.8%), and HA or HL was observed in 88 children (50.0%). Only a few patients were diagnosed with autoimmune or chronic pancreatitis (6.2%). PI was observed at the time of the IBD diagnosis in 26.1% of the cases. A total of 54.5% of the patients had moderate to severe IBD, and 96% had colonic involvement at the time of diagnosis of PI. Idiopathic PI was the most common (57%), followed by drug-induced PI (37%) and azathioprine (AZA). In patients with AZA-induced AP, the successful introduction of 6-mercaptopurine (6-MP) to therapy was noted in 62.5% of the children. Our results suggest that routine monitoring of pancreatic enzymes in patients with IBD should be performed, especially after the initiation of the AZA treatment. The presence of transient HA/HL in IBD does not necessarily indicate pancreatic pathology.

Extraintestinal manifestations in infl ammatory bowel diseases in children, a modern view of the problem

Inflammatory bowel disease (IBD) is a group of severe systemic diseases with a multiple intestinal and extraintestinal manifestations (EIM). EIM can affect any organ systems, determine the course, therapy and prognosis of the underlying disease. The frequency of EIM (6–80%) differs significantly in studies depending on the cohort of patients (number, age of patients, IBD phenotype). In 6–10% of children EIM are the first symptoms of the disease. The classification of EIM most often depends on the activity of the disease in the intestine. The most commonly affected «target organs» in children and adults are joints, skin and mucous membranes, eyes, and the hepatobiliary system. Physical development delay is specific for children IBD, not always reversible. The article highlights the incidence of ulcerative colitis and Crohn’s disease EIM in children and adults, analyzes the basics of epidemiology, pathogenesis, clinical manifestations, approaches to the diagnosis and treatment of arthritis, growth disorders, mucocutaneous, ocular and hepatobiliary EIM of IBD in children. Therapy of EIM associated with IBD activity is aimed at controlling the underlying disease and includes a wide range of drugs, ФНОα antagonists are the most effective. The treatment protocols for other EIM are not standardized in either adult or pediatric practice and are significantly less successful.

Frequent Occurrence of Perianal Disease and Granuloma Formation in Patients with Crohn's Disease and Coexistent Orofacial Granulomatosis

BACKGROUND

Orofacial granulomatosis (OFG) is an inflammatory disorder of the perioral region and oral cavity. Crohn's disease (CD) in conjunction with OFG (CD-OFG), has been suggested to constitute a phenotype of CD with distinct features at diagnosis.

AIMS

The aim of this project was to investigate whether the distinct phenotypic features of CD-OFG persist in the years following the initial diagnosis of CD.

METHODS

Clinical data were extracted from medical records covering the first 5 years post-diagnosis for a cohort of patients with CD-OFG, and were compared to those of references with CD without OFG.

RESULTS

The clinical characteristics of our cohort of patients with CD-OFG (N = 25) were evaluated in comparison to references with CD without OFG (ratio 1:2). Five years post-diagnosis, more patients with CD-OFG had a phenotype with perianal disease (cumulative incidence: 16/25, 64% vs 13/50, 26%, P = 0.002) and intestinal granulomas (cumulative incidence: 22/25, 88% vs 24/50, 48%, P = 0.0009) than patients in the CD reference group. The patients with CD-OFG were also more likely to have undergone perianal surgery (12/25, 48% vs 4/50, 8%, P = 0.0002). At the end of the observation period, more of the patients with CD-OFG were receiving combination therapy, i.e., immunomodulators and tumor necrosis factor antagonists, than those in the CD reference group (9/25, 36% vs 5/50, 10%, P = 0.01).

CONCLUSION

The results support the notion that CD in conjunction with OFG represents a specific phenotype of CD that is characterized by frequent perianal disease, pronounced intestinal granuloma formation and a need for extensive therapy.

The risk of subsequent surgery following bowel resection for Crohn's disease in a national cohort of 19 207 patients

AIM

Surgery is required for most patients with Crohn's disease (CD) and further surgery may be necessary if medical treatment fails to control disease activity. The aim of this study was to characterize the risk of, and factors associated with, further surgery following a first resection for Crohn's disease.

METHODS

Hospital Episode Statistics from England were examined to identify patients with CD and a first recorded bowel resection between 2007 and 2016. Multivariable logistic regression was used to examine risk factors for further resectional surgery within 5 years. Prevalence-adjusted surgical rates for index CD surgery over the study period were calculated.

RESULTS

In total, 19 207 patients (median age 39 years, interquartile range 27-53 years; 55% women) with CD underwent a first recorded resection during the study period. 3141 (16%) underwent a further operation during the study period. The median time to further surgery was 2.4 (interquartile range 1.2-4.6) years. 3% of CD patients had further surgery within 1 year, 14% by 5 years and 23% by 10 years. Older age (≥58), index laparoscopic surgery and index elective surgery (adjusted OR 0.65, 95% CI 0.54-0.77; 0.77, 0.67-0.88; and 0.77, 0.69-0.85; respectively) were associated with a reduced risk of further surgery by 5 years. Prior surgery for perianal disease (1.60, 1.37-1.87), an extraintestinal manifestation of CD (1.51, 1.22-1.86) and index surgery in a high-volume centre for CD surgery (1.20, 1.02-1.40) were associated with an increased risk of further surgery by 5 years. A 25% relative and 0.3% absolute reduction in prevalence-adjusted index surgery rates for CD was observed over the study period.

CONCLUSIONS

Further surgery following an index operation is common in CD. This risk was particularly seen in patients with perianal disease, extraintestinal manifestations and those who underwent index surgery in a high-volume centre.

Pathophysiological Concepts and Management of Pulmonary Manifestation of Pediatric Inflammatory Bowel Disease

Pulmonary manifestation (PM) of inflammatory bowel disease (IBD) in children is a rare condition. The exact pathogenesis is still unclear, but several explanatory concepts were postulated and several case reports in children were published. We performed a systematic Medline search between April 1976 and April 2022. Different pathophysiological concepts were identified, including the shared embryological origin, "miss-homing" of intestinal based neutrophils and T lymphocytes, inflammatory triggering via certain molecules (tripeptide proline-glycine-proline, interleukin 25), genetic factors and alterations in the microbiome. Most pediatric IBD patients with PM are asymptomatic, but can show alterations in pulmonary function tests and breathing tests. In children, the pulmonary parenchyma is more affected than the airways, leading histologically mainly to organizing pneumonia. Medication-associated lung injury has to be considered in pulmonary symptomatic pediatric IBD patients treated with certain agents (i.e., mesalamine, sulfasalazine or infliximab). Furthermore, the risk of pulmonary embolism is generally increased in pediatric IBD patients. The initial treatment of PM is based on corticosteroids, either inhaled for the larger airways or systemic for smaller airways and parenchymal disease. In summary, this review article summarizes the current knowledge about PM in pediatric IBD patients, focusing on pathophysiological and clinical aspects.

Ocular Complications of Pediatric Inflammatory Bowel Disease: A Case Series From a Pediatric Tertiary Medical Center

Background. Ocular extraintestinal manifestations (O-EIMs) are one of the most well-known EIMs in patients with inflammatory bowel disease (IBD). This study aimed to identify the frequency of O-EIMs in children with IBD, referred to Mofid Children's Hospital, Tehran, Iran, during 2014 to 2019. Methods. Children with IBD, younger than the age of 18 years, who were referred to an ophthalmologist, were included in this study. Results. Ninety-six patients with IBD were examined. Four patients had ocular manifestation of IBD. Two patients had complications due to treatment of IBD. The mean age of the patients was 11.25 ± 4.17 years (range: 5.5-17 years). The O-EIMs included 3 (50.0%) cases of anterior uveitis, 1 (16.7%) case of episcleritis, and 2 (33.3%) cases of posterior subcapsular cataract. Conclusion. O-EIMs are important in children with IBD. Therefore, it is recommended that annual screening for ocular complications be performed in all children with IBD.

Erythema Nodosum in Children: A Narrative Review and a Practical Approach

Erythema nodosum (EN) is the most frequent form of panniculitis in children. We performed a literature review analyzing studies on pediatric EN published from 1990 to February 2022. EN is rare in pediatric age. It can be primary/idiopathic in 23–55% cases, or secondary in 47–77% cases. Secondary EN is related to a wide variety of conditions including infectious diseases, autoimmune disorders, malignancy, drugs, vaccinations, and pregnancy. The diagnosis of EN is clinical, based on the acute appearance of painful and red nodules localized to lower limbs, bilaterally distributed. If EN is diagnosed, basic work-up should include inflammatory markers, serum aminotransferases, lactate dehydrogenase, creatinine, protein electrophoresis, immunoglobulins, testing for streptococcal infection, and a tuberculin skin test. Based on the medical history and associated manifestations, further laboratory and radiological exams should be performed. The prognosis of EN is excellent, with spontaneous resolution in most patients within 2–6 weeks. Treatment, if needed, is addressed to the underlying condition. Despite being a rare manifestation in children, EN can be isolated or the first manifestation of a systemic or infectious condition. EN diagnosis is clinical, and a high index of suspicion is needed to perform investigations for the underlying disorders.

Granulomas in Diagnostic Biopsies Associated With High Risk of Crohn's Complications-But May Be Preventable

BACKGROUND

Granulomatous intestinal inflammation may be associated with aggressive Crohn's disease (CD) behavior. However, this has not been confirmed, and it is unknown if associated disease complications are preventable.

METHODS

This is a retrospective cohort of patients younger than 21 years at CD diagnosis (November 1, 2005 to November 11, 2015). Clinical information was abstracted, including dates of starting medications and the timing of perianal fistula or stricture development, if any. Diagnostic pathology reports were reviewed, and a subset of biopsy slides were evaluated by a blinded pathologist. Patients were excluded if perianal fistula or stricture developed within 30 days after CD diagnosis. Medications were included in analyses only if started >90 days before development of perianal fistula or stricture.

RESULTS

In total, 198 patients were included. Half (54%) had granulomas at diagnosis. Granulomas were associated with a greater than 3-fold increased risk of perianal fistula (hazard ration [HR] = 3.24; 95% confidence interval CI], 1.40-7.48). Immunomodulator and anti-tumor necrosis factor-α (anti-TNF) therapy were associated with 90% (HR, = 0.10; 95% CI, 0.03-0.42) and 98% (HR, = 0.02; 95% CI, 0.01-0.10) reduced risk of perianal fistula, respectively. Patients with granulomatous inflammation preferentially responded to anti-TNF therapy with reduced risk of perianal fistula. The presence of granulomas was not associated with risk of stricture. Immunomodulator and anti-TNF therapy were associated with 96% (HR, = 0.04; 95% CI, 0.01-0.22) and 94% (HR, = 0.06; 95% CI, 0.02-0.20) reduced risk of stricture, respectively.

CONCLUSIONS

Granulomas are associated with increased risk of perianal fistula but not stricture. Steroid sparing therapies seem to reduce the risk of both perianal fistula and stricture. For those with granulomas, anti-TNF-α therapy greatly reduced the risk of perianal fistula development, whereas immunomodulators did not.

Sacroiliac joint involvement in children with inflammatory bowel diseases

Objective

Sacroiliitis (SI), an inflammatory arthropathy, may accompany pediatric inflammatory bowel diseases (IBDs), present with non- specific back pain, hence might be unnoticed. The aims of this study were to assess the frequency of the SI in children with IBD and determine the characteristics of the association of SI with the clinical hallmarks of the IBD.

Methods

In this prospective, cross sectional study, twenty-seven children with IBD, 7-18 years of age were evaluated. Patients with low back pain or stiffness, alternating buttock pain, or hip pain were examined for the presence of SI. The radiologic manifestations on X-ray suggesting sacroilitis were confirmed with Magnetic resonance imaging (MRI).

Results

Twenty-seven children (16 girls, female/male=1.45), with mean age of 12.55±3.6 years, of which 52% had ulcerative colitis (UC), 41% had Crohn's disease (CD), and two had indeterminate colitis (IC). The median time from IBD diagnosis was 6.0 (18.0) months for patients with SI and 12.0 (13.5) months for patients without SI. Low back pain or stiffness was observed in 13 patients (48%). SI was present in eight (30%) of the children with IBD. The patients with CD were more prone to SI (45% of CD vs. 21% of UC patients). All patients with SI were negative for HLA-B27 genotyping. The disease activity and gender were not associated with increased risk for SI. MRI was remarkable for bone marrow edema in all of the patient, followed by erosions in six of them (75%), synovial enhancement observed in five (63%), and erosion associated enthesitis of the pelvic region was observed in two (25%) of the patients.

Conclusion

SI may remain obscured in children with IBD. Children with CD are more prone to SI than those with UC. Pediatric rheumatology-pediatric gastroenterology collaboration might augment screening in at-risk patients.

Epidemiology of Musculoskeletal Manifestations in Pediatric Inflammatory Bowel Disease: A Systematic Review

OBJECTIVE

Pediatric inflammatory bowel disease (p-IBD) is a chronic relapsing gastrointestinal disorder of childhood with long-term morbidity. Several extraintestinal manifestations are described, the most common being joint pain and/or inflammation. However, patient and disease characteristics, treatments, and outcomes of p-IBD-associated musculoskeletal disease are not well established. Our study aims to summarize the recent literature on the epidemiology of musculoskeletal manifestations in p-IBD in the era of biologics.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, Web of Science Core Collection, and Cumulative Index to Nursing and Allied Health Literature databases was performed with relevant keywords. Studies in English published from January 1, 2000, to December 21, 2020, were included. In total, 3893 articles were identified and screened. Study and population characteristics and outcomes of interest were recorded. Risk of bias assessment was performed using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

Thirteen studies were included for full review, which were primarily single-center observational studies with retrospective or cross-sectional designs. The diagnostic criteria and definitions used for musculoskeletal manifestations varied. Musculoskeletal manifestation prevalence ranged from 2% to 35%. Only one study assessed the response of musculoskeletal manifestations to biologics. Risk of bias demonstrated heterogeneity in study quality.

CONCLUSION

This is the first systematic review of musculoskeletal manifestations in p-IBD. Analysis was limited because of variability in study design and data-reporting methods. Definitions varied among included studies, with a clear lack in standardization. Our study demonstrates the need for standardized assessment of musculoskeletal manifestations of p-IBD and further research to explore optimal management to advance care for this group of children.

Extraintestinal manifestation of inflammatory bowel disease and associated factors in pediatric patients

Objective

Extraintestinal manifestations in irritable bowel disease (IBD), Crohn's disease and ulcerative colitis are reported in different system of the body. We aimed to investigate the factors determining disease severity and evaluate extraintestinal manifestations in patients with irritable bowel disease based on disease activity scoring system.

Methods

This cross-sectional study was conducted on all patients with irritable bowel disease referred to clinic and gastroenterology ward of (XXX). Medical history, gastrointestinal complications and incidence of extraintestinal manifestations were recorded. Disease severity in ulcerative colitis was rated based on PUCAI (Pediatric Ulcerative Colitis Activity Index) score and in Crohn's disease was calculated based on PCDAI (Pediatric Crohn's Disease Activity Index) score.

Results

Of 73 children included in our study, 54.80% were diagnosed with ulcerative colitis and 45.20% were diagnosed with Crohn's disease. The most prevalent symptom was weight loss (81.81%), diarrhea (72.72%) and abdominal pain (69.69%) in Crohn's diseases and bloody diarrhea (80%), abdominal pain (77.5%) and weight loss (57.5%) in ulcerative colitis. The average of PCDAI score was 43.44 and PUCAI score was 35.62. The most prevalent extraintestinal manifestation of the disease was arthritis in 7 Crohn's disease patients (21.21%) and 5 patients (12.5%) with ulcerative colitis, oral plague in 5 patients (15.15%) with Crohn's disease and erythema nodosum in 2 patients (6.06%) with Crohn's disease.

Conclusion

The severity of oral plaque was positively associated with the severity of the disease. There was no significant association among other parameters. Scoring systems, to determine the extraintestinal manifestation, should be standardized based on the scoring outcomes.

•

Crohn’s disease and ulcerative colitis are the most common types of inflammatory bowel disease.

•

The severity of oral plaque was positively associated with the severity of the disease.

•

The qualitative score of the disease was significantly associated with oral plague.

Characteristics and Frequency of Pediatric Inflammatory Bowel Disease-Associated Pancreatitis: A Japanese Nationwide Survey

Acute pancreatitis (AP) develops in approximately 2% of patients with the diagnosis of inflammatory bowel disease (IBD), but the characteristics and frequency of childhood-onset IBD-associated AP in Japan have not been studied. The present study aimed to clarify the characteristics of IBD-associated AP in Japan.

Methods

A nationwide survey of pediatric patients with IBD (age, <17 years) was conducted from December 2012 to March 2013 at 683 hospitals and medical centers in Japan. A secondary survey was also sent to the centers with the target patients to evaluate their characteristics.

Results

The response rate to the first part of the survey was 61.2% (n = 418). In total, 871 patients with Crohn disease and 1671 patients with ulcerative colitis were enrolled. The second part of the survey found that 11 (1.3%) patients with Crohn disease and 23 (1.4%) patients with ulcerative colitis experienced IBD-associated AP caused by medication (n = 18, 53%), a primary disease (n = 11, 32%), autoimmune pancreatitis (n = 1, 3%), or an anatomical abnormality (n = 1, 3%). All the patients had only mild AP.

Conclusions

IBD-associated AP was not very frequent and was generally mild. The major cause of the pancreatitis was the medication used to treat the IBD.

Joint involvement, disease activity and quality of life in pediatric Crohn's disease - a cross-sectional study

BACKGROUND

Few published data describe how joint involvement, the most prevalent extraintestinal manifestation, affects quality of life (QoL) of children with Crohn's disease (CD). Arthritis and arthralgia rates in pediatric CD patients are reportedly 3-24% and 17-22%, respectively, but studies on pre-emptive and systematic screening of joint involvement with detailed musculoskeletal rheumatological exam are lacking. More detailed data collection on joint involvement improves our understanding of how arthropathy relates to disease activity and QoL measured by the Pediatric CD Activity Index (PCDAI) and IMPACT-III questionnaire. Our study aims were to assess joint involvement in pediatric CD and correlate it with the PCDAI and IMPACT-III.

METHODS

In this cross-sectional, observational study, a pediatric gastroenterologist assessed consecutively-seen pediatric CD patients at a tertiary care center. Patients were screened for prevalence of current and previous arthropathy, including arthritis, enthesitis and arthralgia. A single experienced pediatric rheumatologist evaluated detailed musculoskeletal history, joint status, and modified Juvenile Arthritis Multidimensional Assessment Reports (JAMAR). PCDAI, IMPACT-III, sacroiliac MRI, and HLA-B27 genetic testing were also completed.

RESULTS

A total of 82 (male:female, 1.2:1; age, 13.7 ± 3.2 years) patients were involved in this study. Mean disease duration at time of study was 21.6 ± 21 months; eight of the patients were newly-diagnosed. Of the 82 patients, 29 (35%) had evidence of arthritis; for 24 of those, this was revealed by physical exam during cross-sectional screening, and by prior documentation for the remaining five patients. Joint examination confirmed active arthritis in 8/24 (33%), active enthesitis in 1/24 (4%), and evidence of previous arthritis in 15/24 (62.5%) patients. Hip (41%) and knee (38%) joints were most commonly affected. Cumulative incidence of arthralgia was 48% (39/82), and 46% (18/39) of those patients had only arthralgia without arthritis, usually affecting the knee. Axial involvement was present in 10/82 (12%) patients. Joint involvement correlated with more severe CD disease activity, specifically higher PCDAI and lower IMPACT-III scores, and increased requirement for infliximab treatment. Sacroiliitis and HLA-B27 positivity were insignificant factors in this cohort.

CONCLUSIONS

When a rheumatologist performed the assessment, joint involvement in pediatric CD was more prevalent than previously reported, in this cross-sectional study. Arthritis was associated with more severe CD disease activity and lower QoL.

Liver Pathology in Children with Diagnosed Inflammatory Bowel Disease-A Single Center Experience

BACKGROUND

Inflammatory bowel disease (IBD) in children is frequently associated with liver pathology manifested as transient elevation of liver enzymes or specified liver diseases. The aim of the study was to evaluate the prevalence and the type of liver pathology in children with IBD within 2 years' follow-up after the IBD diagnosis.

METHODS

We retrospectively reviewed records of children with IBD. Liver pathology was defined as elevated activity of liver enzymes (alanine transaminase (ALT) and/or gamma-glutamyl transpeptidase (GGT)) and bilirubin concentration in serum and/or as pathological changes of the organ on imaging tests (abdominal ultrasound and/or magnetic resonance cholangiopancreatography) or on liver histology performed when indicated.

RESULTS

Liver pathology was detected in 21 from 119 children (18%), including 7 (17%) with Crohn's disease (CD) and 14 (18%) with ulcerative colitis (UC). Specified diagnosis for liver abnormality was found in 14 of 21 children (67%), including primary sclerosing cholangitis (PSC, 19%), non-alcoholic fatty liver disease (NAFLD, 19%), autoimmune sclerosing cholangitis (ASC, 5%), autoimmune hepatitis (AIH, 5%), cholelithiasis (5%), drug-induced liver disease (9%) and viral infection (herpes simplex virus, 5%). Most patients manifested mild IBD or were in clinical remission at the time of liver pathology diagnosis. 14% of patients with liver disease (including only cases with PSC) were diagnosed before IBD, 33% at the same time, and 52% in the later period. Patients with the specified diagnosis of liver pathology were younger, had higher ALT activity and more often demonstrated liver abnormalities on imaging tests. UC patients with idiopathic elevation of liver enzymes had higher pediatric ulcerative colitis activity index scores compared to children with specified liver disease.

CONCLUSIONS

Liver pathology was observed in a significant percentage of children with IBD in our study. The majority of cases of hepatobiliary abnormalities were detected after diagnosis of IBD; therefore, children with IBD should undergo routine monitoring of liver enzymes.

Severe Disease Activity Based on the Paris Classification Is Associated with the Development of Extraintestinal Manifestations in Korean Children and Adolescents with Ulcerative Colitis

BACKGROUND

There are limited data regarding the extraintestinal manifestations (EIMs) associated with pediatric inflammatory bowel disease (IBD) in Korea. We aimed to investigate the clinical features and factors associated with the development of EIMs in Korean children and adolescents with IBD.

METHODS

This multicenter, retrospective study was conducted from 2010 to 2017. Baseline clinicodemographic, laboratory findings, disease activity, disease phenotypes, and EIMs were investigated.

RESULTS

A total of 172 patients were included. One-hundred thirty-seven (79.7%) had Crohn's disease (CD), and 35 (20.3%) had ulcerative colitis (UC). EIMs occurred in 42 patients (24.4%). EIMs developed in 34/137 diagnosed with CD (24.8%), and in 8/35 diagnosed with UC (22.9%), during a median follow-up duration of 3.2 (interquartile range, 1.9-5.4) years for CD and 3.0 (1.0-4.0) years for UC, respectively. Arthritis/arthralgia was most commonly observed (n = 15, 35.7%), followed by stomatitis/oral ulcer (n = 10, 23.8%), hepatitis (n = 5, 11.9%), nephritis (n = 4, 9.5%), pancreatitis (n = 2, 4.8%), erythema nodosum (n = 2, 4.8%), pyoderma gangrenosum (n = 1, 2.4%), primary sclerosing cholangitis (n = 1, 2.4%), uveitis (n = 1, 2.4%), and ankylosing spondylitis (n = 1, 2.4%). A significant difference in disease severity based on the Paris classification (P = 0.011) and ESR at diagnosis (P = 0.043) was observed between the EIM positive and negative group in patients with UC. According to logistic regression analyses, S1 disease severity based on the Paris classification was the only factor that was significantly associated with the development of EIMs (odds ratio, 16.57; 95% confidence interval, 2.18-287.39; P = 0.017).

CONCLUSION

Severe disease activity based on the Paris classification in pediatric patients with UC was significantly associated with EIM development. As disease severity in the Paris classification is a dynamic parameter, treatment should be focused on disease control to minimize the occurrence of EIMs in Korean children and adolescents with UC.

Clinical and Laboratory Characteristics Are Associated With Biologic Therapy Use in Pediatric Inflammatory Bowel Disease: A Retrospective Cohort Study

Background

Biologic agents are a highly useful class of medications for treating inflammatory bowel disease (IBD). Limited evidence exists to guide initiation of biologic therapy, especially in pediatric patients. It is unclear if disease severity is connected to biologic response. We hypothesized that the clinical, biochemical and radiographic characteristics of pediatric IBD at diagnosis were associated with subsequent initiation of biologic therapy.

Methods

We performed a retrospective analysis of the charts of all pediatric patients diagnosed with IBD at our centre over 14 years. Kaplan–Meier curves evaluated patient characteristics at diagnosis with time to initiation of biologic therapy. A Cox proportional hazards model was used for multivariate characteristic analysis.

Results

A total of 198 patients were included, 57.6% had Crohn’s disease, 27.8% had ulcerative colitis and 14.6% had IBD type unclassified. Mean follow-up time was 47.8 months. About 55.5% of the patients received a biologic medication, the mean time to biologic initiation was 21.5 months. Earlier initiation of biologic therapy was frequently associated with older age, higher disease activity index and lower serum albumin.

Conclusions

Older pediatric patients with more severely active disease and lower serum albumin levels at the time of IBD diagnosis were more likely to initiate biologic therapy when considering biologic initiation, even many years after diagnosis. Identification of these characteristics may help inform decisions to initiate biologic therapy earlier in the IBD disease course.

Extra-Intestinal Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with extra-intestinal manifestations (EIMs) that tend to parallel intestinal activity and have a debilitating effect on the quality of life. EIMs primarily affect the joints, skin, and eyes with less frequent involvement of the liver, kidney, and pancreas. This article reviews the prevalence of musculoskeletal, dermatological, ocular, and other manifestations in IBD and their coalition with underlying intestinal inflammation. EIMs occurring independently of intestinal activity are managed by targeted therapies, categorical regimens, and specific treatments. On the other hand, EIMs paralleling the bowel activity are carefully monitored while the IBD is brought under control. Since the etiology of the disease is responsible for the development of the EIMs, the research scrutinizes the identified pathogenic mechanisms that tend to involve genetic susceptibility, aberrant self-recognition, and autoantibodies directed against organ-specific antigens shared by intestinal and extra-intestinal organs. This article also provides an overview of the epidemiology, clinical features, diagnostic modalities, and management of the EIMs associated with IBD.

Dental Caries Occurrence in Inflammatory Bowel Disease Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

The present review aimed to systematically evaluate the occurrence of caries in patients with inflammatory bowel disease (IBD), either Crohn's disease (CD) or ulcerative colitis (UC), compared to healthy controls.

MATERIALS AND METHODS

MEDLINE (PubMed), Embase, Google Scholar, LILACS, and Cochrane Library electronic databases were screened. Caries experience was measured through the Decayed, Missing, Filled Teeth (DMFT) index. The weighted mean difference (WMD) with 95% confidence interval was calculated between IBD patients and healthy controls.

RESULTS

Six studies were selected for the inclusion in the systematic review, 5 of which were also included in the quantitative synthesis of data. The WMD in the DMFT index between IBD and healthy subjects was 3.04 (1.52, 4.56) (p = 0.10). Subgroup analysis showed no difference (p = 0.31) between CD (2.52 [0.54, 4.49]) and UC (4.01 [1.52, 4.56]) subjects.

CONCLUSIONS

There is a remarkably higher past and present occurrence of dental caries in subjects with IBD than healthy controls. This result should encourage clinicians to include oral health preventive programs in the overall treatment plan of IBD patients.

Pancreatic Associated Manifestations in Pediatric Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBDs) are chronic relapsing inflammatory conditions of the gastrointestinal tract, encompassing Crohn’s disease (CD), ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBD-U). They are currently considered as systemic disorders determined by a set of genetic predispositions, individual susceptibility and environmental triggers, potentially able to involve other organs and systems than the gastrointestinal tract. A large number of patients experiences one or more extraintestinal manifestations (EIMs), whose sites affected are mostly represented by the joints, skin, bones, liver, eyes, and pancreas. Pancreatic abnormalities are not uncommon and are often underestimated, encompassing acute and chronic pancreatitis, autoimmune pancreatitis, exocrine pancreatic insufficiency and asymptomatic elevation of pancreatic enzymes. In most cases they are the result of environmental triggers. However, several genetic polymorphisms may play a role as precipitating factors or contributing to a more severe course. The aim of this paper is to provide an updated overview on the available evidence concerning the etiology, pathogenesis and clinical presentation of pancreatic diseases in IBD pediatric patients.

Infliximab Therapy for Children with Moderate to Severe Ulcerative Colitis: A Step-Up versus a Top-Down Strategy

PURPOSE

We aimed to investigate clinical outcomes between top-down (TD) and conventional step-up (SU) therapies in pediatric patients with moderate to severe ulcerative colitis (UC).

MATERIALS AND METHODS

All patients underwent clinical and endoscopic evaluation at diagnosis and 4 months and 1 year after treatment. Patients who started treatment with corticosteroid were grouped in the SU group, while those that initiated early infliximab (IFX) were grouped in the TD group. Among the SU group, patients who eventually changed to IFX treatment due to steroid resistance or dependency were included in the SU(R) group.

RESULTS

In total, 44 children with moderate to severe UC were included for analysis. Twenty-one patients were included in the SU group, 23 were included in the TD group, and 10 were enrolled in the SU(R) group. Relapse rates were 47.6% (10/21) in the SU group and 17.4% (4/23) in the TD group (p=0.033). Among relapsed patients, the durations from remission to relapse were 17.3 months (0.9-46.9) in the SU group and 24.3 months (1.8-44.9) in the TD group. There was no statistically significant difference in the sustained durations of remission after IFX administration between the SU(R) and TD groups [3.9 (1.4-6.3) and 2.3 (0.3-5.2) years, respectively (p>0.05)].

CONCLUSION

According to our study, early use of IFX without corticosteroid treatment for children with moderate to severe UC helps to lower relapse rates. We also found that IFX was a very effective treatment for pediatric UC, with a sustained duration of remission similar between TD and SU(R) groups.

Pancreatic Disorders in Children with Inflammatory Bowel Disease

Background and Objectives: Inflammatory bowel disease (IBD) is a chronic condition and mainly affects the intestines, however, the involvement of the other organs of the gastrointestinal tract (upper part, pancreas, and liver) have been observed. The coexistence of IBD with pancreatic pathology is rare, however, it has been diagnosed more frequently during recent years in the pediatric population. This article reviews the current literature on the most common pancreatic diseases associated with IBD in the pediatric population and their relationship with IBD activity and treatment. Materials and Methods: We performed a systematic review of data from published studies on pancreatic disorders, also reported as extraintestinal manifestations (EIMs), among children with IBD. We searched PubMed and Web of Science to identify eligible studies published prior to 25 April 2020. Results: Forty-four papers were chosen for analysis after a detailed inspection, which aimed to keep only the research studies (case control studies and cohort studies) or case reports on children and only those which were written in English. The manifestations of IBD-associated pancreatic disorders range from asymptomatic increase in pancreatic enzymes activity to severe disease such as acute pancreatitis. Acute pancreatitis (AP) induced by drugs, mainly thiopurine, seems to be the most- often-reported pancreatic disease associated with IBD in children. AP associated with other than drug etiologies, and chronic pancreatitis (CP), are rarely observed in the course of pediatric IBD. The pancreatic involvement can be strictly related to the activity of IBD and can also precede the diagnosis of IBD in some pediatric patients. The course of AP is mild in most cases and may occasionally lead to the development of CP, mainly in cases with a genetic predisposition. Conclusions: The involvement of the pancreas in the course of IBD may be considered as an EIM or a separate co-morbid disease, but it can also be a side effect of IBD therapy, therefore a differential diagnosis should always be performed. As the number of IBD incidences with concomitant pancreatic diseases is constantly increasing in the pediatric population, it is important to include pancreatic enzymes level measurement in the workup of IBD.

Exploitation of Marine-Derived Robust Biological Molecules to Manage Inflammatory Bowel Disease

Naturally occurring biological entities with extractable and tunable structural and functional characteristics, along with therapeutic attributes, are of supreme interest for strengthening the twenty-first-century biomedical settings. Irrespective of ongoing technological and clinical advancement, traditional medicinal practices to address and manage inflammatory bowel disease (IBD) are inefficient and the effect of the administered therapeutic cues is limited. The reasonable immune response or invasion should also be circumvented for successful clinical translation of engineered cues as highly efficient and robust bioactive entities. In this context, research is underway worldwide, and researchers have redirected or regained their interests in valorizing the naturally occurring biological entities/resources, for example, algal biome so-called "treasure of untouched or underexploited sources". Algal biome from the marine environment is an immense source of excellence that has also been demonstrated as a source of bioactive compounds with unique chemical, structural, and functional features. Moreover, the molecular modeling and synthesis of new drugs based on marine-derived therapeutic and biological cues can show greater efficacy and specificity for the therapeutics. Herein, an effort has been made to cover the existing literature gap on the exploitation of naturally occurring biological entities/resources to address and efficiently manage IBD. Following a brief background study, a focus was given to design characteristics, performance evaluation of engineered cues, and point-of-care IBD therapeutics of diverse bioactive compounds from the algal biome. Noteworthy potentialities of marine-derived biologically active compounds have also been spotlighted to underlying the impact role of bio-active elements with the related pathways. The current review is also focused on the applied standpoint and clinical translation of marine-derived bioactive compounds. Furthermore, a detailed overview of clinical applications and future perspectives are also given in this review.

IBD phenotype at diagnosis, and early disease-course in pediatric patients in Croatia: data from the Croatian national registry

BACKGROUND

Pediatric inflammatory bowel disease (IBD) presents with extensive phenotype. The aim of this study was to determine the phenotype of pediatric IBD patients in Croatia at diagnosis and follow-up.

METHODS

Children were prospectively recruited into Croatian IBD national registry. Data on diagnostic evaluation, therapy and 1-year follow-up were collected.

RESULTS

A total of 51 newly diagnosed patients were recruited (19 Crohn's disease (CD), 28 ulcerative colitis (UC) and 4 IBD-unclassified (IBD-U)). Most common location in CD was ileocolonic disease (52.6%), and pancolitis in UC (53.6%). The recommended complete diagnostic algorithm was performed only in 29.4% of patients. First-line therapy used in CD was exclusive enteral nutrition for remission induction (84.2%) and azathioprine for maintenance (73.7%). In patients with UC, aminosalicylates were the most common drug used (89.3%). By the end of the first year 41.2% of CD and 53.9% of UC patients had one or more relapses and required treatment escalation.

CONCLUSION

Our data confirm extensive intestinal involvement in pediatric IBD and relatively high relapse rate during the first year of follow-up. More effort should be invested on the national level to implement more stringent adherence to the current European guidelines.

IMPACT

The key message of our article is that pediatric IBD in Croatia shows extensive intestinal involvement with high relapse rates in first year of follow-up. It is the first cohort study reporting on the phenotype of pediatric IBD in Croatia, but also investigates adherence to diagnostic and therapeutic European guidelines which is not commonly reported. The study is national based, thus having the greatest impact on Croatian health care,stressing out that more effort should be invested on the national level to implement more stringent adherence to the current European guidelines.

Chronic Ulcers and Malnutrition in an African Patient

An 11-year-old girl with a congenitally malformed left hand, sickle cell trait, asthma, and history of appendicitis was transferred from Zambia for evaluation and treatment of widespread suppurative and ulcerative skin lesions that typically appeared after trauma to her skin. The ulcers first presented 3 years earlier but had markedly worsened in the 9 months before transfer, spreading circumferentially on her extremities and abdomen at the site of an appendectomy. They were painful and did not resolve with multiple courses of intravenous antibiotics and close management by a pediatric infectious disease specialist working for a nongovernmental organization (NGO) in her home country. Per NGO records, she had previously been  average weight-for-age. On presentation after international transfer, she was severely malnourished, with lesions covering ∼35% of her body. In initial workup, leukocytosis of 21 × 103 cells per μL (79% neutrophils), hemoglobin of 6.1 g/dL, and mean corpuscular volume of 66 fL were found. Iron studies revealed an iron level of 18 μg/dL, ferritin level of 55 ng/mL, total iron binding capacity of 222 μg/dL, and transferrin saturation of 8%. Inflammatory markers were elevated, C-reactive protein was 20.1 mg/dL, and the erythrocyte sedimentation rate was 131 mm/h. A chest computed tomography scan revealed bilateral pulmonary nodules, the largest in her left upper lobe measuring 2.4 × 2.0 × 1.9 cm. Our panel of experts reviews the evaluation and treatment of this patient with extensive suppurative and ulcerative skin lesions and the factors considered in offering charity care to international patients.

Dermatological Manifestations in Pediatric Inflammatory Bowel Disease

Background and Objectives: Over the last years, inflammatory bowel disease (IBD) has been reported on a high incidence in pediatric populations and has been associated with numerous extraintestinal manifestations, making its management a real challenge for the pediatric gastroenterologist. Dermatological manifestations in IBD are either specific, related to the disease activity or treatment-associated, or non-specific. This literature review aims to identify and report the dermatological manifestations of IBD in children, the correlation between their appearance and the demographical characteristics, the relationship between these lesions and disease activity, and to highlight the impact of dermatological manifestations on an IBD treatment regime. Materials and Methods: A systemic literature review was performed, investigating articles and case reports on dermatological manifestations in children with IBD starting from 2005. A total of 159 potentially suitable articles were identified and after the exclusion process, 75 articles were selected. Results: The most common dermatological manifestations reported in pediatric IBD are erythema nodosum and pyoderma gangrenosum. More rare cases of metastatic Crohn’s disease, epidermolysis bullosa acquisita, small-vessel vasculitis, necrotizing vasculitis, leukocytoclastic vasculitis, cutaneous polyarteritis nodosa, and Sweet’s syndrome have been reported. Oral manifestations of IBD are divided into specific (tag-like lesions, mucogingivitis, lip swelling with vertical fissures, aphthous stomatitis, and pyostomatitis vegetans) and non-specific. IBD treatment may present with side effects involving the skin and mucosa. Anti-tumor necrosis factor agents have been linked to opportunistic skin infections, psoriasiform lesions, and a potentially increased risk for skin cancer. Cutaneous manifestations such as acrodermatitis enteropathica, purpuric lesions, and angular cheilitis may appear secondary to malnutrition and/or malabsorption. Conclusions: The correct diagnosis of dermatological manifestations in pediatric IBD is of paramount importance because of their impact on disease activity, treatment options, and a patient’s psychological status.

Salivary changes in oxidative stress related to inflammation in oral and gastrointestinal diseases

OBJECTIVES

The early diagnosis and monitoring of Crohn's disease (CD) and orofacial granulomatosis (OFG) might be facilitated by assaying potential disease biomarkers in saliva. Markers of oxidative stress and inflammation were assayed in salivas from patients with CD, OFG and concurrent OFG and CD (OFG + CD).

SUBJECTS

Unstimulated whole mouth saliva was collected from 93 subjects, and immunoglobulin A (IgA), lactoferrin (LF) and myeloperoxidase (MPO) were determined by ELISA. Markers of oxidative stress and antioxidant status were assayed spectrophotometrically.

RESULTS

Immunoglobulin A was significantly (p < .03) higher in experimental groups vs the control group. LF was significantly (p < .01) higher in OFG + CD compared to CTRL and CD. Ferric reducing antioxidant power was lower (p ≤ .009) in all experimental groups, and advanced glycation end products were higher (p ≤ .01) in CD and OFG + CD patients.

CONCLUSION

Oxidative stress is increased in saliva in CD and OFG. Although MPO, a product of inflammatory cells, was not significantly increased, the other innate immune markers, IgA and LF, which are also secreted by salivary glands, were increased. This study suggests that saliva might be utilized in monitoring CD and OFG but further longitudinal studies focused on analysing a panel of salivary markers are needed.

Extraintestinal Manifestations Are Associated With Disease Severity in Pediatric Onset Inflammatory Bowel Disease

OBJECTIVES

The aim of this study was to investigate a possible association between extraintestinal manifestations (EIM) and a more severe disease course in pediatric onset inflammatory bowel disease (pIBD).

METHODS

This study compares the disease course of pIBD patients (IBD diagnosis <15 years of age) with and without EIM in a population-based cohort from Denmark. Patients diagnosed with pIBD between 1998 and 2008 were included in the study and followed until December 31, 2014. Data on phenotype, treatment, relapses, and the temporal relationship between IBD relapses and activity of EIM were collected at end of follow-up by manual revision of patient charts.

RESULTS

Of 333 pIBD patients, 14 (4.2%) had EIM at time of diagnosis and 47 (14.1%) developed EIM during follow-up. Median follow-up time was 9.6 years for patients with EIM and 8.8 years for patients without. In ulcerative colitis, EIM were associated with an increased risk of biological treatment and surgery (hazard ratio: 2.6; 95% confidence interval [CI]: 1.3-5.5, P = 0.008 and 2.9 [95% CI: 1.1-7.7, P = 0.03], respectively). In Crohn disease, EIM were associated with an increased relapse rate (1.3 [95% CI: 1.1-1.5], P = 0.001). Lastly, we found a positive temporal relationship between relapse of IBD and EIM activity.

CONCLUSION

The presence of EIM is associated with a more severe disease course in pIBD. This should be considered when deciding treatment options, as a more aggressive treatment approach could be warranted in patients with EIM. However, prospective studies are needed to fully evaluate this.

Pulmonary Manifestations in Adolescents With Inflammatory Bowel Disease

Objectives. The available literature on pulmonary disease in pediatric inflammatory bowel disease is limited. We evaluated the prevalence of pulmonary manifestations in pediatric inflammatory bowel disease and their association with disease severity. Methods. Patients completed the St. George's Respiratory Questionnaire (SGRQ), a self-reported measure of quality of life in patients with pulmonary disease. Chart review provided demographic information and Pediatric Crohn's Disease Activity Index (PCDAI) and Pediatric Ulcerative Colitis Activity Index scores. Regression models were utilized to evaluate associations between SGRQ score and clinical risk factors. Results. The prevalence of pulmonary manifestations was 9.62% (95% confidence interval = 5.48% to -15.36%). PCDAI scores in Crohn's disease patients with pulmonary symptoms were significantly higher (SGRQ mean = 10.71 ± 10.94) than in patients without such symptoms. SGRQ score was also higher in patients with indeterminate colitis (8.64, 95% confidence interval = 0.72-16.57, P = .03), when compared with Crohn's disease. Conclusions. Additional investigations including pulmonary function tests and imaging could provide further insight into this issue.