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Kulungowski AM, Acker SN, Hoffenberg EJ, Neigut D, Partrick DA. Initial operative treatment of isolated ileal Crohn's disease in adolescents. Am J Surg 2014; 210:141-5. [PMID: 25457242 DOI: 10.1016/j.amjsurg.2014.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/20/2014] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We hypothesize that in children with Crohn's disease (CD) isolated to a single site, resection leads to clinical improvement, decreased medication requirements, and improved growth. METHODS A retrospective review was conducted of children with CD isolated to the terminal ileum undergoing operative intervention at Children's Hospital Colorado between 2002 and 2013. RESULTS Twenty-six patients underwent ileocecetomy (mean age at diagnosis 14.1 ± 2.6 years; mean age at resection 15.7 ± 2.5 years; median follow-up 2 ± 1.5 years). Twenty-two (84.6%) patients reported clinical improvement and 17 (65.4%) were able to decrease the number or dosage of medications. Average weight increased from the 29th to the 45th percentile (P = .09) at 1 year and to the 56th percentile (P = .02) at 3 years post resection. Average body mass index increased from the 30th to the 48th and 49th percentile at 1 and 3 years (P < .05 for both), respectively. Height increased from the 39th percentile at the time of resection to the 51st percentile at 3 years (P = nonsignificant). CONCLUSION Surgical resection of an isolated ileal segment in adolescents with CD allows for catch-up growth and reduction in medication requirements.
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Affiliation(s)
- Ann M Kulungowski
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA.
| | - Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - Edward J Hoffenberg
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - Deborah Neigut
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA
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Abstract
BACKGROUND/AIMS There has been no systematic review of natural history studies of pediatric-onset inflammatory bowel disease (IBD). We conducted a systematic review focused on understanding the long-term risks of growth failure, disease reclassification and extension, hospitalizations, cancer and death among patients with childhood IBD. METHODS PubMed searches and subsequent data abstraction were performed by 2 independent investigators. Studies published full in english with a 5-year minimum average follow-up in at least 30 patients with IBD onset before age 18 years. RESULTS We evaluated 41 total studies (only 2 population-based studies) with 3505 Crohn's disease (CD) patients, 2071 ulcerative colitis (UC) patients, and 461 indeterminate colitis (IC). Growth failure was reported in CD (10% and 56%) more often than UC (0% to 10%) or non-IBD controls. Improvements in growth occurred after surgical resection in patients with CD. There was an increase in disease reclassification over time from UC and indeterminate colitis diagnosis to CD diagnosis. Patients with CD had higher number of hospitalizations and hospital days per year in comparison with UC patients in most studies. The reported surgery rates in CD ranged between 10% and 72%; the colectomy rates in UC ranged between 0% and 50%. Cancers were reported in 6 CD patients during a total 18,270 patient-years (PY) follow-up, and 8 UC patients in 18,115 PY. Deaths directly related to IBD were 63 during 39,719 PY. CONCLUSIONS Childhood-onset IBD patients had growth failure reported in patients with CD more often than those with UC, had a reclassification of disease type to CD over time. Higher rates of surgery and hospitalizations were found with CD than with UC. The risk of cancer and death is low in this population.
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3
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Strictureplasty and intestinal resection: different options in complicated pediatric-onset Crohn disease. J Pediatr Surg 2012; 47:944-8. [PMID: 22595578 DOI: 10.1016/j.jpedsurg.2012.01.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 01/26/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND/PURPOSE Surgical resection or strictureplasty (SP) are different options for intestinal Crohn disease (CD) strictures. The aim of this article is evaluation of long-term outcome of SP and resection. METHODS From 1996 to 2011, 39 patients (23 male, 16 female) with symptomatic ileal and ileocolonic CD strictures resistant to medical/nutritional therapy and treated with surgery in 2 different surgical units were reviewed. The mean age at diagnosis was 11.82 years (range, 4-17 years). Mean age at surgery was 15.94 years (range, 4-24 years). Mean follow-up was 6.88 years (range, 0.5-15 years). Patients underwent resection (group A) or different SP techniques (group B). RESULTS Twenty patients underwent intestinal resection (ileal or ileocolonic resection), and 19 patients underwent SP (jejunal, ileal, or ileocolic). Early postsurgical complications were observed in 2 patients of group A. Follow-up of group A patients revealed that 1 patient needed emergency treatment after 8 months surgery because of adhesions and 1 patient developed recurrence treated with medical therapy. In the follow-up group B, 3 patients experienced disease recurrence, 2 of them at the site of previous surgery. CONCLUSIONS At long-term follow-up, no significant difference in relapsing rate was observed between the 2 groups. Strictureplasty and resection represent an effective treatment of pediatric CD strictures. Strictureplasty could represent the first option for intestinal preservation.
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Tigas S, Tsatsoulis A. Endocrine and metabolic manifestations in inflammatory bowel disease. Ann Gastroenterol 2012; 25:37-44. [PMID: 24714153 PMCID: PMC3959350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 12/05/2011] [Indexed: 11/23/2022] Open
Abstract
Extraintestinal manifestations from nearly every organ system are common in inflammatory bowel disease (IBD). This review article describes the epidemiology, pathogenesis, diagnosis and management of the main endocrine and metabolic manifestations in IBD, including metabolic bone disease, growth retardation, hypogonadism, pubertal delay, lipid abnormalities and insulin resistance. These clinical problems are commonly interrelated and they share a common basis, influenced by disease-related inflammation and nutritional status. In addition to nutritional support, every effort should be made to achieve and maintain disease remission, thus correcting the underlying chronic inflammation. The criteria for screening and diagnosing osteoporosis are described and treatment options are discussed (lifestyle advice, vitamin D and calcium supplementation, use of bisphosphonates or other specific antiosteoporotic agents, correction of hypogonadism). Chronic glucocorticoid therapy may affect growth as well as predispose to osteoporosis. The diagnosis and management of growth failure, pubertal delay and hypogonadism in IBD are discussed.
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Affiliation(s)
- Stelios Tigas
- Department of Endocrinology, University of Ioannina, Greece
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5
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Lee JJ, Escher JC, Shuman MJ, Forbes PW, Delemarre LC, Harr BW, Kruijer M, Moret M, Allende-Richter S, Grand RJ. Final adult height of children with inflammatory bowel disease is predicted by parental height and patient minimum height Z-score. Inflamm Bowel Dis 2010; 16:1669-77. [PMID: 20127995 PMCID: PMC3005189 DOI: 10.1002/ibd.21214] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND This study was designed to elucidate the contribution of parental height to the stature of children with inflammatory bowel disease (IBD), who often exhibit growth impairment. Accordingly, we compared patients' final adult heights and target heights based on measured parental heights and examined predictors of final adult height in pediatric IBD patients. METHODS We prospectively analyzed the growth of 295 patients diagnosed between ages 1 and 18 (211 Crohn's disease [CD], 84 ulcerative colitis [UC]) and their family members (283 mothers, 231 fathers, 55 siblings). RESULTS Twenty-two percent had growth impairment (height for age Z-score <-1.64, equivalent to <5th percentile on growth curve) in more than 1 measurement since diagnosis; most growth-impaired patients had CD (88% CD versus 12% UC). Parents of the growth-impaired group had lower mean height Z-scores compared to parents of nongrowth-impaired patients (-0.67 versus 0.02 for mothers [P < 0.001]; -0.31 versus 0.22 for fathers [P = 0.002]). For 108 patients who reached adult heights and had available parental heights, the growth-impaired group continued to demonstrate lower adult height Z-scores (-1.38 versus 0.07; P < 0.001). Adult heights were within 1 SD of target heights even for the growth-impaired group. Only 11.3% remained persistently growth-impaired in adulthood. Multivariate regression analysis demonstrated lower parental height and minimum patient height Z-score as significant predictors of lower final adult height in IBD. CONCLUSIONS Parental height is a powerful determinant of linear growth even in the presence of chronic inflammation, and should be an integral part of the evaluation of growth in IBD children.
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Affiliation(s)
- Jessica J Lee
- Division of Gastroenterology and Nutrition, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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6
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Ernährung und Chirurgie als Säulen der CED-Behandlung. Monatsschr Kinderheilkd 2010. [DOI: 10.1007/s00112-010-2197-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hartman C, Eliakim R, Shamir R. Nutritional status and nutritional therapy in inflammatory bowel diseases. World J Gastroenterol 2009; 15:2570-8. [PMID: 19496185 PMCID: PMC2691486 DOI: 10.3748/wjg.15.2570] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Underweight and specific nutrient deficiencies are frequent in adult patients with inflammatory bowel disease (IBD). In addition, a significant number of children with IBD, especially Crohn’s disease (CD) have impaired linear growth. Nutrition has an important role in the management of IBD. In adults with CD, enteral nutrition (EN) is effective in inducing clinical remission of IBD, although it is less efficient than corticosteroids. Exclusive EN is an established primary therapy for pediatric CD. Limited data suggests that EN is as efficient as corticosteroids for induction of remission. Additional advantages of nutritional therapy are control of inflammation, mucosal healing, positive benefits to growth and overall nutritional status with minimal adverse effects. The available evidence suggests that supplementary EN may be effective also for maintenance of remission in CD. More studies are needed to confirm these findings. However, EN supplementation could be considered as an alternative or as an adjunct to maintenance drug therapy in CD. EN does not have a primary therapeutic role in ulcerative colitis. Specific compositions of enteral diets-elemental diets or diets containing specific components-were not shown to have any advantage over standard polymeric diets and their place in the treatment of CD or UC need further evaluation. Recent theories suggest that diet may be implicated in the etiology of IBD, however there are no proven dietary approaches to reduce the risk of developing IBD.
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8
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Ahmed SF, Wong JSC, McGrogan P. Improving growth in children with inflammatory bowel disease. HORMONE RESEARCH 2007; 68 Suppl 5:117-21. [PMID: 18174726 DOI: 10.1159/000110604] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Growth in children with inflammatory bowel disease (IBD) is affected through a number of mechanisms; controlling disease activity and supporting poor nutritional status are paramount in these patients. Further understanding of the basic mechanisms by which cytokines influence growth will facilitate the development of therapeutic modalities to improve growth. CONCLUSIONS Clinical management that addresses growth and puberty in children with IBD should be a partnership between paediatric gastroenterologists and endocrinologists. Well-designed studies of growth-promoting hormonal treatment may answer questions regarding the efficacy and safety of treating growth retardation in the subgroup of patients who continue to fail to grow despite optimal management of their IBD.
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Affiliation(s)
- S Faisal Ahmed
- Bone & Endocrine Research Group, University of Glasgow, Glasgow, UK.
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9
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Shamir R, Phillip M, Levine A. Growth retardation in pediatric Crohn's disease: pathogenesis and interventions. Inflamm Bowel Dis 2007; 13:620-8. [PMID: 17262806 DOI: 10.1002/ibd.20115] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Growth retardation (GR) may pose a significant challenge to the quality of life and the proper management of children and adolescents with Crohn's disease (CD). It can occur in a significant proportion of patients, and may precede clinical evidence of bowel disease. Current evidence suggests that GR is a complex interaction between nutritional status, inflammation, disease severity, and genotype, which causes resistance to the effects of growth hormone. Recent research has identified a key role for the inflammatory cytokines TNF alpha, IL-6, and IL1 beta. This review summarizes current knowledge as well as gaps in our understanding of the mechanisms involved and the usefulness of the different treatment modalities in promoting growth in CD patients.
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Affiliation(s)
- Raanan Shamir
- Pediatric Gastroenterology Division of the Meyer Children's Hospital, Haifa
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Wong SC, Macrae VE, McGrogan P, Ahmed SF. The role of pro-inflammatory cytokines in inflammatory bowel disease growth retardation. J Pediatr Gastroenterol Nutr 2006; 43:144-55. [PMID: 16877976 DOI: 10.1097/01.mpg.0000226374.18494.14] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Childhood inflammatory bowel disease (IBD) especially those with Crohn disease is commonly complicated by faltering growth and pubertal delay. Pro-inflammatory cytokines are often elevated in IBD and may affect linear growth and puberty either systemically or at the level of the growth plate. Further study of the underlying mechanisms of the deleterious effects of cytokines on the growth plate may improve management of faltering growth in childhood IBD. Well-controlled clinical studies of the respective effect of nutritional support, immunomodulatory therapy, biological agents and growth and puberty promoting agents on managing faltering growth also require further attention.
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Affiliation(s)
- S C Wong
- Bone and Endocrine Research Group, Royal Hospital for Sick Children, Glasgow, UK
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11
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Singh Ranger G, Lamparelli MJ, Aldridge A, Chong SK, Mitton SG, Albanese A, Kumar D. Surgery results in significant improvement in growth in children with Crohn's disease refractory to medical therapy. Pediatr Surg Int 2006; 22:347-52. [PMID: 16518590 DOI: 10.1007/s00383-006-1664-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2006] [Indexed: 01/06/2023]
Abstract
Inflammatory bowel disease (IBD) in children can cause significant impairment in linear growth, and delay in pubertal onset. The aim of this study was to assess the impact of surgery on linear growth in children with Crohn's disease (CD) who were resistant to medical therapy, and had documented evidence of growth impairment. We performed a retrospective study on eight consecutive patients with refractory disease who had attended the paediatric IBD clinic. All patients underwent surgery as part of their treatment. Height and weight were recorded at least 6 months prior to surgery, at the time of surgery, and 6 months post surgery. Growth velocities and height Z-scores were calculated. All patients had evidence of sustained growth suppression prior to surgery. Three patients had evidence of growth failure. There was a significant increase in height velocity from 0.15 cm/month before surgery to 0.54 cm/month after surgery (P = 0.006). There was also a significant decrease in the modified Harvey-Bradshaw index (HBI) of disease activity from 2.00 before surgery, to 0.84 after surgery (P = 0.003). Improvements in height Z-score and weight velocity after surgery were not significant on statistical analysis. Our study demonstrates that before surgery, children with CD refractory to therapy have sustained growth suppression, and in some cases may even have growth failure. Surgical intervention before puberty appears to result in a significant improvement in height velocity and disease activity. These findings need to be further investigated with carefully designed prospective studies.
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Affiliation(s)
- Gurpreet Singh Ranger
- Academic Department of Colorectal Surgery, St. George's Hospital Medical School, Blackshaw Road, Tooting, SW17 0QT, London, UK.
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12
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Newby EA, Sawczenko A, Thomas AG, Wilson D. Interventions for growth failure in childhood Crohn's disease. Cochrane Database Syst Rev 2005; 2005:CD003873. [PMID: 16034910 PMCID: PMC8746189 DOI: 10.1002/14651858.cd003873.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Crohn's disease in childhood is a chronic relapsing condition. Fifteen to forty per cent of children with Crohn's disease have growth retardation (Griffiths 1993a). Some treatment modalities including corticosteroids have been implicated in growth failure but it is thought mainly to be secondary to uncontrolled disease activity (Motil 1993; Markowitz 1993). Growth is fundamental to the practice of pediatrics, so by taking growth as the primary outcome measure we address issues important to both patients, their families and pediatricians. OBJECTIVES To evaluate the effectiveness of the different modalities available for the treatment of childhood Crohn's disease with regard to the reversal of growth failure and the promotion of normal growth. SEARCH STRATEGY Searches were made of the following databases using the Collaborative Review Group Search Strategy: EMBASE (1984-2004), MEDLINE (1966-2004), The Cochrane Central Register of Controlled Trials, The Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group Specialized Trials Register and the Science Citation Index. Abstracts from the major gastrointestinal research meetings and references from published articles were also reviewed. SELECTION CRITERIA Randomized controlled trials pertaining to children less than 18 years of age with Crohn's disease were selected. Those with growth as an outcome measure were included in the review. DATA COLLECTION AND ANALYSIS Data extraction and assessment of the methodological quality of each trial was independently reviewed by two reviewers. Only one good quality randomized controlled trial was included in the review and therefore no statistical analysis was possible. MAIN RESULTS Three randomized controlled trials were identified. One was of good methodological quality (Markowitz 2000). This study looked at the use of 6-mercaptopurine (6-MP) as a steroid sparing agent. No difference in linear growth was observed between the intervention and placebo groups, although the total steroid dose received over the 18 month follow up period was reduced in the group receiving 6-MP. The two remaining randomized controlled trials (Sanderson 1987; Thomas 1993a) consider the use of enteral feeding versus corticosteroids for induction of remission, with height velocity standard deviation score at 6 months as an outcome measure. Although of less rigorous methodological quality, the results of these studies are discussed in detail in the review. In both studies height velocity standard deviation scores were significantly increased in the enteral feeding group compared with the corticosteroid group. AUTHORS' CONCLUSIONS In addition to these randomized controlled trials, a body of lower quality evidence does exist relevant to two other important interventions; the use of supplemental enteral nutrition (Morin 1980; Belli 1988; Israel 1995) and the judicious use of surgical interventions in pre-pubertal children with refractory disease (Alperstein 1985; Lipson 1990; McLain 1990). Newer treatments, such as infliximab, are now becoming more widely used and may offer advantages in promoting growth. These effects are as yet unstudied. This review highlights the need for large, multi centre studies of the different treatment options in paediatric Crohn's disease and the importance of standardised measurements of growth, such as height velocity standard deviation scores and height standard deviation scores as outcome measures.
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13
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Abstract
Crohn's disease in childhood is a chronic relapsing and remitting condition that can significantly impact on normal growth and development. This influences the choice of both initial and ongoing management. The goal of therapy is to induce and maintain remission with minimal side effects. Enteral nutrition as the sole therapy for active disease is effective in some children, thus avoiding the use of corticosteroids. In disease that is resistant to conventional treatment, immunosuppression or anti-tumour necrosis factor therapy is indicated. We review the use of these treatments and discuss the new therapies being developed, including antibodies, cytokines and probiotics.
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Affiliation(s)
- A Ronald F Bremner
- Division of Infection Inflammation & Repair, School of Medicine, University of Southampton, Southampton, UK.
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14
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Baldassano RN, Han PD, Jeshion WC, Berlin JA, Piccoli DA, Lautenbach E, Mick R, Lichtenstein GR. Pediatric Crohn's disease: risk factors for postoperative recurrence. Am J Gastroenterol 2001; 96:2169-76. [PMID: 11467649 DOI: 10.1111/j.1572-0241.2001.03876.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Postoperative recurrence of Crohn's disease in adults has been extensively studied; however, the course of Crohn's disease after surgery in children has not been well defined. The aim of this study was to examine the postoperative course of pediatric Crohn's disease and the factors that may predict early postoperative recurrence. METHODS We identified 100 resective surgeries in 79 children with Crohn's disease seen at the Children's Hospital of Philadelphia between 1978 and 1996. A retrospective, multivariable analysis of factors potentially influencing postoperative clinical recurrence was performed. Preoperative and postoperative height measurements were compared, and z scores were computed for height-for-age. Two-tailed t test was used for the analysis. RESULTS Clinical recurrence rates were 17% at 1 yr, 38% at 3 yr, and 60% at 5 yr. Patients with colonic Crohn's disease had a significantly shorter postoperative recurrence-free interval (median 1.2 yr) than patients with ileocecal (median 4.4 yr) or diffuse disease (median 3.0 yr) (p = 0.01). On multivariable analysis, a high Pediatric Crohn's Disease Activity Index at the time of surgery (p = 0.01) and preoperative use of 6-mercaptopurine (6-MP) (p < 0.005) were also independently associated with higher postoperative recurrence rates. There was a significant improvement in z scores for height (p = 0.04) after surgery. CONCLUSIONS In children undergoing resective surgery for Crohn's disease, high rates of postoperative Crohn's disease recurrence are associated with severe disease at the time of surgery, colonic Crohn's disease, and the preoperative use of 6-MP. Patients who require preoperative use of 6-MP are likely to suffer from a more aggressive disease and would benefit from postoperative 6-MP prophylaxis. Height growth was improved after intestinal resection for Crohn's disease.
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Affiliation(s)
- R N Baldassano
- Children's Hospital of Philadelphia, Department of Pediatrics, Pennsylvania 19104-4283, USA
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15
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Abstract
The combination of an unprecedented number of new therapeutic options (Fig. 1), along with new insights in how to optimize currently available therapies and advances in our understanding of disease pathogenesis, present many exciting new aspects to the management of patients with inflammatory bowel disease (IBD). Clinical management paradigms must evolve in parallel to keep pace with these advances. Traditional pediatric IBD regimens have underutilized combination therapies (Fig. 2) and immunomodulatory agents. Increased appreciation for steroid side effects is leading to a shift away from their inclusion in maintenance regimens. Immunomodulators are being introduced earlier in the course of disease for maintenance of remission and growth promotion. Recognition that the sole signs of active disease in children and adolescents may be growth and maturational delay, despite a relative lack of gastrointestinal symptoms, should prompt earlier, more aggressive interventions. When more potent, rapidly acting interventions such as infliximab, cyclosporine (CSA), or tacrolimus are considered, they should generally be co-administered with agents such as 6-mercaptopurine (6-MP) or azathioprine (AZA) for longer-term disease suppression.
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16
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Abstract
Crohn's disease in childhood is a chronic relapsing condition with a high morbidity. Growth failure is common. The aim of therapy is to induce and then maintain disease remission and thereby promote well-being and normal growth and development. Enteral nutrition (either polymeric or elemental) is effective and used as initial therapy. This is employed as sole therapy over a 6- to 8-week period followed by a period of controlled food reintroduction. The relapse rate is high and further courses of enteral nutrition or alternative therapies are frequently required. Corticosteroids are also effective as initial therapy and are required in difficult cases but there are problems with their long term use, particularly their adverse effects on growth. Many patients develop either corticosteroid-dependent or corticosteroid-resistant disease. In this instance, additional immunosuppression, such as azathioprine, can be used. Surgery is required for those patients with disease resistant to medical therapy and this will result in remission; however, the relapse rate with surgery is high. There are many areas for future research. Very little is known about why enteral nutrition works, how long it should be given or its role as maintenance therapy. Newer immunosuppressive strategies based on cytokine modulation may be helpful in children once more experience is gained from their use in adults.
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Affiliation(s)
- R M Beattie
- Paediatric Medical Unit, Southampton General Hospital, England.
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17
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Abstract
The development of reliable techniques to measure bone densitometry and evolving effective drug treatment have kindled great interest in the diagnosis and treatment of osteoporosis in adults with inflammatory bowel disease. A number of studies have examined the prevalence of abnormal bone mineral metabolism in children and adolescents. Studies, conducted over the past decade, indicate a greater likelihood of clinically significant problems in Crohn's disease than in ulcerative colitis. Corticosteroids have been proven to impair bone mineral status. It is increasingly clear that inflammation and other factors play a bigger role than malabsorbtion of minerals or vitamin D in most patients. As the use of the bisphonate class of drugs is limited in pediatric patients, there is a need to emphasize the role of diet and exercise in children and teenagers, particularly in those affected by inflammatory bowel disease.
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Affiliation(s)
- R M Issenman
- Children's Hospital, Hamilton Health Sciences Corporation, McMaster University Medical Centre, Ontario, Canada
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18
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Patel HI, Leichtner AM, Colodny AH, Shamberger RC. Surgery for Crohn's disease in infants and children. J Pediatr Surg 1997; 32:1063-7; discussion 1067-8. [PMID: 9247235 DOI: 10.1016/s0022-3468(97)90400-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The course of Crohn's disease is quite variable in children. To assess the frequency and indications for surgery with current medical therapy, the authors reviewed the cases of 204 children (ages, 0.2 to 18.8 years at diagnosis, median, 12.8 years) who had Crohn's disease treated at a single institution from December 1968 to January 1994, with a median of 3.8 years of follow-up (range, 0.0 to 22.2 years). Ninety-four children (46%) required surgical resection for the following indications: (1) failure of medical therapy with persistent symptoms or growth retardation (n = 44, 47%), (2) intraabdominal abscess or perforation (n = 15, 16%), (3) fistula formation (n = 13, 14%), (4) obstruction (n = 15, 16%), (5) hemorrhage (n = 4, 4%), and (6) appendectomy at exploration for diagnosis (n = 3, 3%). The probability for surgery 3 years after diagnosis is 28.8% and by 5 years is 47.2%. Resections included ileocolectomy (71 children), colectomy (n = 16), small bowel resection (n = 4), and appendectomy (n = 3). Fourteen fistulas in 13 children required surgical intervention (7 enteroenteral, 3 enterovesical, 2 enterovaginal, and 2 enterocutaneous). The median duration from diagnosis to surgery for the fistulas was 2.6 years (range 0.1 to 9.8 years). Forty patients experienced recurring disease after resection during follow-up with a median of 1.8 years (range 0.4 to 18.1 years). The authors found that the course of the disease was unpredictable, with some children requiring early surgical intervention and others continuing with medical therapy for years.
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Affiliation(s)
- H I Patel
- Department of Surgery, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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19
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Abstract
IBD is one of the most significant chronic diseases afflicting children and adolescents. As in adults, UC and CD constitute the two major disease entities, with many of the characteristics of these two diseases being similar in adults and children. With technical advances, a complete endoscopic examination of the colon and terminal ileum can be performed in most children without difficulty. There are, however, a number of aspects of the presentation, course, and management of these diseases that are unique to the pediatric population. Because the impact of inadequate nutrition is much greater in the growing child than in adults, growth failure is a common, serious complication of malnutrition in this population. The psychological impact of a chronic illness on both the developing child and the family can also be significant. The management of this population is further complicated by the lack of adequate studies that assess not only the effect of a medical or surgical therapy on disease activity, but also address the issues of growth and pubertal development. It has been a challenge to extrapolate data from adult studies to the pediatric population. The management of children and adolescents requires a critical understanding of the differences between pediatric and adult patients to maximize growth potential and minimize longterm sequelae of treatment. After a long period of limited controlled studies, however, collaborative efforts are underway to investigate most aspects of pediatric IBD, and we look forward to exciting advances toward the optimal management of children and adolescents with IBD.
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Affiliation(s)
- P M Hofley
- Section of Gastroenterology and Hepatology, Children's Hospital of Philadelphia, Pennsylvania
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Ferguson A, Sedgwick DM. Juvenile onset inflammatory bowel disease: height and body mass index in adult life. BMJ (CLINICAL RESEARCH ED.) 1994; 308:1259-63. [PMID: 8205017 PMCID: PMC2540211 DOI: 10.1136/bmj.308.6939.1259] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To establish the frequency of permanent growth failure in juvenile onset inflammatory bowel disease. DESIGN Measurement of height and weight in a geographically based cohort at a mean of 14 (range 5.2-29.5) years after diagnosis. Comparison with data from surveys of British adults in 1980 and 1987. SETTING NHS hospitals throughout Scotland. SUBJECTS 105 Children admitted to hospital during 1968-83 who fulfilled diagnostic criteria for Crohn's disease or ulcerative colitis and lived in specified regions. 87 were aged over 18 and living in Britain at follow up. MAIN OUTCOME MEASURES Height, weight, body mass index, and sexual maturity. RESULTS All patients were sexually mature. 67 of the 70 patients examined were of normal height, and three women with Crohn's disease were abnormally short. Weight and body mass index were normal in all patients with ulcerative colitis. Patients with Crohn's disease had significantly lower weight than those with ulcerative colitis (men 66.8 (9.5) kg v 78.4 (13.8) kg, P = 0.04; women 51.5 (8.2) kg v 63.0 (12.1) kg, P < 0.02) irrespective of disease activity. Body mass index was also significantly lower than the normal distribution (P < 0.01). Growth retardation was not mentioned as a problem for any of the 17 patients interviewed only by telephone. CONCLUSIONS Despite growth retardation in the teenage years most young people with inflammatory bowel disease will eventually achieve normal height. Reasons for lower weight in patients with Crohn's disease remain to be established.
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Affiliation(s)
- A Ferguson
- Department of Medicine, Western General Hospital, Edinburgh
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Abstract
Growth impairment is a common complication of childhood Crohn's disease, but longitudinal data and follow up studies into adulthood are sparse. This study reviewed the records of 100 Tanner stages 1 and 2 children (66 males, 34 females) consecutively diagnosed with Crohn's disease at this hospital between January 1980 and June 1988. The influence of sex, anatomical location of disease, severity of symptoms, corticosteroids, and surgical intervention on growth were analysed by univariate and multivariate regression analysis. At diagnosis mean standard deviation score (SDS) for height was -1.11 (1.28) (males -1.14 (1.26), females -1.05 (1.33)). Twenty one children were below the third centile for height. During years one and two height velocity (cm/y) was 4.4 (2.3) and 5.1 (2.7), but 40% of children in year one and 33% of children in year two grew less than expected (< 4 cm). Forty nine children grew < 4 cm/y during two or more of the 4.9 (1.8) years of follow up. Severity of gastrointestinal symptoms was the major factor influencing linear growth velocity (p < 0.01 for years one and two). Despite the high prevalence of growth impairment, the subset of children who had reached maturity by the time of the study (n = 67) nevertheless maintained their height centile. The SDS for height at ultimate follow up was -0.82 (1.1). Compared with diagnosis, change in SDS was +0.35 (1.08). Growth increments were comparable for surgically treated patients v patients only treated medically and among patients stratified by location of disease. Females (n = 25) achieved greater catch up growth than males (n = 42). Ultimate SDS for height for females was -0.48 (0.91) v -1.02 (1.19) for males. Change in SDS for height was +0.66 (1.27) for females v +0.16 (0.90) for males (p=0.02). These data confirm the frequency of growth impairment in childhood Crohn's disease. After diagnosis, however, the prognosis for ultimate linear growth is good.
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Affiliation(s)
- A M Griffiths
- Division of Gastroenterology, Hospital for Sick Children, Toronto, Ontario, Canada
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Mayer E, Stern M. Growth failure in gastrointestinal diseases. BAILLIERE'S CLINICAL ENDOCRINOLOGY AND METABOLISM 1992; 6:645-63. [PMID: 1524557 DOI: 10.1016/s0950-351x(05)80117-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Murch SH, Lamkin VA, Savage MO, Walker-Smith JA, MacDonald TT. Serum concentrations of tumour necrosis factor alpha in childhood chronic inflammatory bowel disease. Gut 1991; 32:913-7. [PMID: 1885073 PMCID: PMC1378961 DOI: 10.1136/gut.32.8.913] [Citation(s) in RCA: 363] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Serum tumour necrosis factor alpha (TNF alpha) concentrations were measured by enzyme linked immunoadsorbent assay in 31 normal children and during 65 episodes of clinical remission and 54 episodes of relapse in 92 children with chronic inflammatory bowel disease. An appreciable rise in TNF alpha was found only in children in relapse of ulcerative colitis and colonic Crohn's disease. The group of children with small bowel Crohn's disease in relapse did not show increases of TNF alpha above control concentrations, despite an equivalent rise in disease indices. Height velocity was depressed in children with relapse of large bowel Crohn's disease and ulcerative colitis compared with the equivalent condition in remission. The impairment of growth velocity was significantly greater in relapse of large bowel Crohn's disease and ulcerative colitis than in small bowel Crohn's disease alone, although for the subgroups in stage 1 puberty (prepubertal) the differences were not significant. Inadequate growth in chronic inflammatory bowel disease is currently ascribed to inadequate nutrition and TNF alpha may contribute to this through its cachexia inducing effects. It may, in addition, diminish pituitary growth hormone release. These results suggest that production of TNF alpha may be associated with growth failure in relapse of colonic inflammatory bowel disease.
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Affiliation(s)
- S H Murch
- Department of Paediatric Gastroenterology, St Bartholomew's Hospital, West Smithfield, London
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Affiliation(s)
- I W Booth
- Institute of Child Health, University of Birmingham
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Booth IW. The nutritional consequences of gastrointestinal disease in adolescence. ACTA PAEDIATRICA SCANDINAVICA. SUPPLEMENT 1991; 373:91-102. [PMID: 1927534 DOI: 10.1111/j.1651-2227.1991.tb18156.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The growth spurt of adolescence, during which body weight nearly doubles and height increases by 16%, demands an increased delivery of nutrients by the gastrointestinal tract. Chronic disorders of digestion and absorption at this age, therefore have a potentially profound effect upon growth, skeletal maturation and sexual development. Moreover, the emotional climate of adolescence, which requires affiliation with peer groups, and a distancing from authority figures such as doctors and parents, is often associated with a deterioration in drug and dietary compliance and with erratic clinic attendance. Nutritional problems in adolescent patients with Crohn's disease, cystic fibrosis and coeliac disease are the most common. About one third of adolescents with Crohn's disease experience growth failure and delayed sexual development, probably as a consequence of long-term undernutrition. There is a strong argument for the care of these patients being in the hands of paediatric gastroenterologists. Enteral nutrition, often administered overnight, is successful in inducing catch-up growth, and reducing steroid dosage, although resection of diseased gut is often followed by good growth, and surgery should not be overlooked. Cystic fibrosis in adolescence is commonly complicated by protein-energy malnutrition. Pathogenesis includes anorexia, maldigestion and an increase in resting energy expenditure. Malnutrition has been treated by a number of enteral regimens. In general, there is no place for repeated, short-term interventions of less than 6 months. Long-term studies have all shown good nutritional repletion and growth, but results with respect to improved respiratory function are conflicting. More prospective control trials are needed before the precise indications for enteral nutrition in cystic fibrosis can be accurately defined. Once started it is difficult to stop, although preoperative treatment of patients awaiting heart-lung transplantation seems entirely appropriate. The major problem in the management of coeliac disease in adolescence is dietary compliance. Even those patients who claim to have good dietary compliance often have jejunal biopsy evidence of gluten ingestion and tend to be underweight. This is particularly worrying, as after 5 years adherence to a gluten free diet, the increased risk of gastrointestinal malignancy appears to return to normal.
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Affiliation(s)
- I W Booth
- University of Birmingham, Institute of Child Health, UK
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Carré IJ. Reflux vomiting. Arch Dis Child 1991; 66:369-70. [PMID: 2025023 PMCID: PMC1792865 DOI: 10.1136/adc.66.3.369-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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