NASPGHAN clinical report on the evaluation and treatment of pediatric patients with internal penetrating Crohn disease: intraabdominal abscess with and without fistula

Early Anti-Tumor-Necrosis-Factor Therapy for Crohn's Disease-Related Abdominal Abscesses and Phlegmon in Children

BACKGROUND

Internally penetrating Crohn's Disease complications, including abscesses and phlegmon, represent a high-risk Crohn's Disease phenotype. Anti-tumor-necrosis-factor-α (Anti-TNF) therapies are effective in treating penetrating Crohn's Disease and early initiation has shown unique benefits. However, timing of anti-TNF initiation in the setting of internally penetrating Crohn's Disease complications is typically heterogenous due to concern over precipitating serious infections. Recent studies demonstrate such an association may not exist.

AIMS

We aimed to describe the multidisciplinary management of pediatric patients with internally penetrating Crohn's Disease complications, focusing on the utilization and timing of anti-TNF therapy relative to complication resolution and adverse events.

METHODS

We performed a single-center retrospective cohort study of pediatric patients with internally penetrating Crohn's Disease complications from 2007 to 2021. The safety and effectiveness of anti-TNF therapy initiation prior to complication resolution was assessed by comparing rates of infectious and Crohn's Disease-related adverse events between those who received anti-TNF therapy prior to complication resolution, versus those who did not.

RESULTS

Twenty-one patients with internally penetrating Crohn's Disease complications were identified. 7/21 received anti-TNF therapy prior to complication resolution. Infectious adverse events within 90 days of complication occurred in 0/7 patients initiating anti-TNF therapy prior to complication resolution and 10/14 patients who did not (p = 0.004). Crohn's Disease-related surgeries and hospitalizations within 1 year of complication occurred in 12/20 patients, with similar frequency between groups.

CONCLUSIONS

Initiating anti-TNF therapy prior to internally penetrating Crohn's Disease complication resolution may be a safe and effective strategy to improve clinical outcomes.

Therapy Strategies for Children Suffering from Inflammatory Bowel Disease (IBD)-A Narrative Review

The incidence of inflammatory bowel disease (IBD) is increasing, and more children at a younger age are affected. The pathogenesis seems to be an interaction of microbial factors, a sensitivity of the immune system, and the intestinal barrier, leading to an inappropriate immune response. Not only has the role of biological agents become more important in the last decade in the treatment of children and adolescents, but also new insights into the composition of the gastrointestinal microbiome and personal diet implications have increased our understanding of the disease and opened up potential therapeutic pathways. This narrative review provides an overview of current recommendations, therapeutic options, drug monitoring, and practical guidelines for paediatricians involved with paediatric IBD patients. Furthermore, the off-label use of potential helpful drugs in the treatment of these patients is discussed.

Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary?

BACKGROUND

Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection.

METHODS

A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed.

RESULTS

Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups.

CONCLUSIONS

In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.

Predictors of surgical intervention in patients with inflammatory bowel disease (two-center study)

Background

Sixty percent of Crohn’s disease (CD) patients require intestinal resection, and 20% of ulcerative colitis (UC) patients undergo proctocolectomy for medically refractory disease. Scarcity of literature about predictors for surgical intervention in inflammatory bowel disease (IBD) encouraged the conduction of this study to assess risk factors for surgical intervention in IBD patients.

Results

This cohort study included 80 Egyptian inflammatory bowel disease patients recruited from two medical centers. Patients were classified into two groups, 40 patients each, according to their need for surgical intervention to control inflammatory bowel disease. The two groups were compared regarding age of onset, type and location of disease, smoking, extraintestinal manifestations, perianal disease, granuloma, severity scores, stool calprotectin, complete blood count, erythrocyte sedimentation rate, C-reactive protein, and serum albumin at diagnosis for Crohn’s disease patients.

Twelve ulcerative colitis and 28 Crohn’s disease patients required surgical intervention in the form of total colectomy (30%), fistulectomy (32.5%), resection anastomosis (17.5%) or abscess drainage (20%). Perianal disease, smoking, and disease severity scores showed high significant differences (P value < 0.001); disease type and presence of granuloma showed statistically significant difference (P value < 0.05) between both groups. But, patient age at onset, location of the disease or extraintestinal manifestation had no statistical significance (P value > 0.5). Surgical interventions were more likely to be needed in patients with higher stool calprotectin level, C-reactive protein, erythrocyte sedimentation rate, and lower serum albumin for Crohn’s disease patients (P value < 0.001 for each).

Conclusion

Smoking, perianal disease, higher severity scores, stool calprotectin, C-reactive protein, and erythrocyte sedimentation rate levels are predictors of surgical treatment.

Similar Long-Term Outcomes in Children Presenting With Abscess vs Phlegmon at Diagnosis of Crohn Disease

Background

Limited data are available for long-term outcomes of pediatric patients with abdominal abscess or phlegmon at diagnosis of Crohn disease.

Methods

We performed a retrospective chart review of such children over a recent 6-year period at 5 pediatric inflammatory bowel diseases.

Results

Fifty-two patients (mean age 15.9 ± 1.8 years) were reviewed. Thirty-six had an abscess and 27 (75%) required resectional therapy compared to 16 with phlegmon which 10 (63%) requiring surgery. Overall (37/52) 71% had surgery which was performed within 6 months in 32 (86%).

Conclusions

A similar high surgical rate exists whether pediatric patients with Crohn disease present with abscess or phlegmon.

Updates in diagnosis and management of inflammatory bowel disease

Worldwide incidence of inflammatory bowel disease (IBD) is stable in developed countries, but rising in developing countries. Presenting symptoms of IBD can be highly variable. New imaging modalities, a greater armamentarium of therapeutic options, and a greater understanding of complication risks have changed the diagnosis and management of pediatric inflammatory bowel diseases. Effective teamwork among those who care for pediatric patients with IBD minimizes complications and maximizes desired outcomes.

Penetrating Crohn disease: does it occur in the absence of stricturing disease?

PURPOSE

To establish the relationship between penetrating complications and bowel luminal narrowing/stricturing disease in pediatric Crohn disease (CD).

MATERIALS AND METHODS

This retrospective study was IRB-approved and HIPAA compliant with waiver of informed consent. CT and MRI examinations describing intra-abdominal penetrating complications in CD patients ≤ 18 years old between January 1, 2009 and March 31, 2016 were reviewed to document: type of complication, affected bowel segment, minimum bowel luminal diameter, maximum upstream diameter, location of penetrating complication relative to luminal narrowing, length of narrowed bowel segment, and the presence of active bowel wall inflammation. Data were summarized using descriptive statistics including means, standard deviations, as well as counts and percentages.

RESULTS

A total of 52 penetrating complications were identified in 45 patients. Mean patient age was 15.7 ± 2.2 years (range 11-18 years) with 25/45 (56%) boys. Nearly all penetrating complications (51/52, 98%) were associated with a minimum bowel luminal diameter of ≤ 2 mm, with no visible lumen in 26/52 (50%). Mean maximum upstream diameter was 2.8 ± 0.8 cm (range 1.2-5.2 cm), and 17/52 (33%) penetrating complications were associated with > 3 cm upstream diameter. The mean ratio of maximum to minimum luminal diameter was 26.2 ± 8.8 (range 3.6-52.0). Active intestinal inflammation was associated with 100% (52/52) of penetrating complications. Nearly every penetrating complication (51/52, 98%) involved the terminal or distal ileum.

CONCLUSIONS

Penetrating complications in pediatric CD nearly always occur in the setting of considerable luminal narrowing or stricture and active intestinal inflammation.

The Burden of Hospital Readmissions among Pediatric Patients with Inflammatory Bowel Disease

OBJECTIVE

To evaluate the burden and predictors of hospital readmissions among pediatric patients with inflammatory bowel disease using the Nationwide Readmissions Database.

STUDY DESIGN

We performed a retrospective cohort study using 2013 Nationwide Readmissions Database. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients <18 years with diagnoses of ulcerative colitis (UC) or Crohn's disease (CD). Demographic factors and details of hospitalizations were evaluated using survey procedures in SAS v 9.4 (SAS Institute, Cary, North Carolina). Multivariable logistic regression was used to estimate ORs and 95% CIs of readmission.

RESULTS

Among 2733 hospitalizations (63% CD, 37% UC), 611 (22%) patients were readmitted within 90 days of the index hospitalization. Readmission resulted in weighted estimates of 11 440 excess days of hospitalization and total charges of over $107 million. For CD, male sex (aOR 1.36, 95% CI 1.03-1.81) and co-existing anxiety or depression (aOR 1.89, 95% CI 1.06-3.40) were associated with increased readmissions, while patients who underwent surgery had decreased readmissions (aOR 0.40, 95% CI 0.24-0.65). In patients with UC, an index admission of >7 days was associated with increased readmissions (aOR 1.69, 95% CI 1.09-2.62).

CONCLUSIONS

Readmission occurs frequently in children with inflammatory bowel disease and is associated with significant cost and resource burdens. Among patients with CD, psychiatric comorbidities such as anxiety and depression are apparent drivers of readmission.

Outcome of medical management of intraabdominal abscesses in children with Crohn disease

INTRODUCTION

Crohn disease (CD) is a chronic inflammatory condition of the gastrointestinal tract that is complicated by fistulas, strictures, and intraabdominal abscesses (IAA) in 10%-30% of patients. To avoid surgical resection of the bowel, medical therapy with antibiotics (Ab) with or without percutaneous drainage (PD) is first undertaken. Our objectives are to examine the outcome of IAA in CD patients treated with antibiotics alone vs antibiotics and PD, and to identify risk factors for medical therapy failure.

METHODS

Charts for patient with CD who were diagnosed between 2004 and 2016 at the Women and Children's Hospital of Buffalo were retrospectively reviewed. We compared the two modalities of medical therapy (Ab + PD vs Ab alone) in terms of abscess resolution and the need for surgical intervention.

RESULTS

Twenty-nine patients, ages ranging from 12 to 18years, mean 15.5±2.5, 48% Male with IAA were identified. Overall, 69% of abscesses failed medical therapy including 87% of the drained abscesses and 50% of nondrained abscesses, p=0.04. The abscesses that failed medical therapy were more likely to have been drained (P=0.03) as they were larger in size (P = 0.03), patients were more likely to have a known CD on immunosuppression (P=0.016), and more likely to have an associated upper GI disease (P=0.002), when compared to those that were successful with medical therapy alone.

CONCLUSION

Our results show that the majority of our patients required surgical intervention for abscess treatment and resolution of associated findings despite drainage. Risk factors include big drainable abscesses, developing IAA while on immunosuppression, and a more extensive disease with associated fistulae and strictures. Small undrainable abscesses are likely to resolve with antibiotics alone, therefore early detection and treatment are essential.

TYPE OF STUDY

Level 2, retrospective study.

Surgery in Pediatric Crohn's Disease: Indications, Timing and Post-Operative Management

Pediatric onset Crohn's disease (CD) tends to have complicated behavior (stricture or penetration) than elderly onset CD at diagnosis. Considering the longer duration of the disease in pediatric patients, the accumulative chance of surgical treatment is higher than in adult onset CD patients. Possible operative indications include perianal CD, intestinal stricture or obstruction, abdominal abscess or fistula, intestinal hemorrhage, neoplastic changes and medically untreatable inflammation. Growth retardation is an operative indication only for pediatric patients. Surgery can affect a patient's clinical course, especially for pediatric CD patient who are growing physically and mentally, so the decision should be made by careful consideration of several factors. The complex and diverse clinical conditions hinder development of a systemized treatment algorithm. Therefore, timing of surgery in pediatric CD patients should be determined with individualized approach by an experienced and well organized multidisciplinary inflammatory bowel disease team. Best long-term outcomes will require proactive post-operative monitoring and therapeutic modifications according to the conditions.

Ciprofloxacin Use in Hospitalized Children: Approved or Off-label?

Objective:

Fluoroquinolones are not routinely used as the first-line antimicrobial therapy in pediatrics. The American Academy of Pediatrics (AAP) and the United States Food and Drug Administration (FDA) approved fluoroquinolones on certain indications in children. The aim of this study was to evaluate to what extent and how ciprofloxacin is used on approved indication or as off-label. Besides, dose adequacy and treatment duration were assessed.

Methods:

In a 10-month observational study, all children receiving systemic ciprofloxacin were assessed. We classified ciprofloxacin prescription to an AAP/FDA or off-label indication. The off-label prescriptions were further categorized to justified and unjustified therapy subgroups. The AAP/FDA category and the justified subgroup constituted the appropriate prescriptions.

Findings:

During the study period, 32 patients were prescribed ciprofloxacin. In general, 37% (12) of prescriptions determined to be appropriate. Of the appropriate prescriptions, 7 were AAP/FDA-approved indications. Children with Crohn's disease with abdominal abscess and children with infectious bloody diarrhea constituted the off-label; justified therapy subgroup. Unjustified prescriptions mainly occurred in the presence of a suitable alternative antibiotic for ciprofloxacin. Mean ± SD of ciprofloxacin dose (mg/kg/day) and duration (days) were 21.25 ± 6.35 and 13.56 ± 8.48, respectively. Of the appropriate prescriptions, 41% were underdosed. Underdosing was more encountered in patients with cystic fibrosis. Duration of treatment of the appropriate prescriptions was determined to be appropriate.

Conclusion:

The majority of children were receiving ciprofloxacin off-label and in an inappropriate manner. This issue emphasizes that antimicrobial stewardship program on ciprofloxacin use in pediatric hospitals should be implemented. Further studies evaluating clinical and microbiological outcomes of these programs in children are needed.

The Adjunctive Role of Nutritional Therapy in the Management of Phlegmon in Two Children with Crohn's Disease

Crohn's disease may be complicated by the development of penetrating (fistulizing) or structuring complications. The presentation of an intra-abdominal phlegmon or abscess with or without an associated fistula has traditionally required surgical intervention. This series of two cases illustrates a beneficial role of non-surgical management, with parenteral and then enteral nutrition playing central roles. This report further elaborates the potential adjunctive role of enteral nutrition in the management of this complication of CD.

Fecal calprotectin in the prediction of postoperative recurrence of Crohn's disease in children and adolescents

BACKGROUND

Fecal calprotectin (FC) correlates with endoscopic recurrence of Crohn's disease (CD) in adults but has not been studied among children postoperatively. We aimed to analyze whether FC relates with postoperative CD recurrence in children.

METHODS

Altogether 51 postoperative endoscopies and FC measurements from 22 patients having undergone surgery for CD at age ≤18years were included.

RESULTS

Ileocecal resection (n=15), small bowel resection (n=6), or left hemicolectomy (n=1) was performed at median age of 15.1 (interquartile range 14.4-17.6) years. Following surgery, FC decreased significantly (659 vs. 103μg/g, p=0.001). During median follow-up of 5.7 (4.2-7.7) years, either endoscopic or histological recurrence occurred in 17 patients (77%). FC >139μg/g at time of endoscopy or FC increase of 79μg/g compared to first postoperative value was suggestive of endoscopic recurrence (Rutgeerts score i2-i4), while FC >101μg/g or increase of 21μg/g indicated histological recurrence. Best accuracy for prediction of recurrence was obtained by combining FC at endoscopy and the postoperative increase of FC. The corresponding AUROC values were 0.74 (95% 0.58-0.89) for endoscopic recurrence whereas 0.81 (95% CI 0.67-0.95) for histological recurrence.

CONCLUSION

FC is a useful surrogate marker of postoperative recurrence also in pediatric CD patients.

Management of intra-abdominal abscesses in children with Crohn's disease: a 12-year, retrospective single-center review

BACKGROUND

Intra-abdominal abscesses (IAA) are complications of Crohn's disease, which often result in hospitalization, surgery, and increased cost. Initial management may include medical therapy, percutaneous drainage (PD), or surgery, although the optimal management of IAA in children is unclear.

METHODS

Retrospective review of all pediatric patients with Crohn's disease who developed an IAA from January 1, 2000 to April 30, 2012. Three groups, based on initial IAA treatment modality (medical, PD, and surgery), were compared.

RESULTS

Thirty cases of IAA were identified (mean age at IAA diagnosis, 15.4 ± 2.6 yr, 67% female, median Crohn's disease duration, 2.6 mo). Computed tomography was the most common initial (93%) and follow-up (47%) imaging. The average time to follow-up imaging was 8.5 days. For initial management, 18 received medical therapy, 10 PD, and 2 had surgery. The medical therapy group received more computed tomography scans for follow-up imaging than the PD group (12 [67%] versus 2 [20%], P = 0.046). There were no significant differences in abscess characteristics or management of posttreatment course between these 2 groups. Surgical resection occurred in 3 patients (17%) in the medical group and 2 (20%) in the PD group during index hospitalization. No significant differences were identified among treatment groups for readmissions, complications, or abscess recurrence. By 1 year, 12 of the 18 medically managed patients (67%) had surgery, and 6 of the 10 patients (60%) treated with initial PD ultimately had surgery.

CONCLUSIONS

The majority of patients with IAA require definitive surgical treatment, and there were no clear predictors of those who did not.

Use of the star sign to diagnose internal fistulas in pediatric patients with penetrating Crohn disease by MR enterography

Development of internal fistula due to extramural spread of inflammatory bowel disease is a characteristic feature of penetrating disease in patients with Crohn disease. The "star sign" is a radiological finding of internal fistula that has previously been described in the gastroenterology literature in adult Crohn disease patients undergoing MR enteroclysis. The goal of this paper is to review the clinical and imaging features of penetrating disease in pediatric Crohn disease patients, highlighting the star sign as a useful diagnostic tool for diagnosing internal fistula in children by MR enterography. The recognition of penetrating complications by MR imaging can have important therapeutic and prognostic implications.

Highlights in IBD Epidemiology and Its Natural History in the Paediatric Age

Background. The number of patients of all age brackets diagnosed with Inflammatory Bowel Disease (IBD) has risen dramatically worldwide over the past 50 years. IBD's changing epidemiology suggests that environmental factors play a major role in modifying disease expression. Aim. To review studies carried out worldwide analyzing IBD epidemiology. Methods. A Medline search indicating as keywords “Inflammatory Bowel Disease,” “epidemiology,” “natural history,” “Crohn's Disease,” “Ulcerative Colitis,” and “IBD Unclassified” was performed. A selection of clinical cohort and systematic review studies that were carried out between 2002 and 2013 was reviewed. Studies referring to an earlier date were also considered whenever the data were relevant to our review. Results. The current mean prevalence of IBD in the total population of Western countries is estimated at 1/1,000. The highest prevalence and incidence rates of IBD worldwide are reported from Canada. Just as urbanization and socioeconomic development, the incidence of IBD is rising in China. Conclusions. Multicenter national registers and international networks can provide information on IBD epidemiology and lead to hypotheses about its causes and possible management strategies. The rising trend in the disease's incidence in developing nations suggests that its epidemiological evolution is linked to industrialization and modern Westernized lifestyles.