Critical Appraisal Of The Literature For Imflammatory Bowel Disease
A literature search was performed using PubMed, Ovid MEDLINE®, Google Scholar, and the Cochrane Database of Systematic Reviews with the search terms pediatric inflammatory bowel disease, epidemiology, emergency, treatment, complications, and malignancy. Over 200 articles met the selection criteria. Of those, 109 articles with full texts were reviewed, and 87 are cited in this review. Clinical cohort and systematic review studies were also analyzed. Few prospective trials have been conducted for treatment in the pediatric population. Further research is needed in the management of the child with IBD.
Introduction For Pediactric Inflammatory Bowel Disease
Inflammatory bowel disease includes both Crohn disease and ulcerative colitis. Approximately 2 million people worldwide are afflicted with IBD, and 20% to 30% of all patients with IBD are diagnosed during childhood.1,2
Childhood incidence of ulcerative colitis is estimated at 0.5-4.3/100,000 and Crohn disease at 0.2-8.5/100,000.3 The peak incidence of initial presentation for IBD occurs between the ages of 15 and 25 years, and approximately 20% of patients with ulcerative colitis and 25% to 30% of patients with Crohn disease present before the age of 20 years.4 Crohn disease and ulcerative colitis occur equally in the first 8 years of life, but Crohn disease is more common in older children.5 The incidence of ulcerative colitis has remained relatively stable, whereas the incidence of Crohn disease has increased.6-9 Utilization of colonoscopy in developed countries may have led to greater differentiation of Crohn disease from ulcerative colitis and relatively more diagnoses of Crohn disease. The number of emergency department visits per year is unknown however, the public health burden of disease is significant in patients with IBD, due to utilization of outpatient resources, ED visits, and inpatient care.10
Both medical and surgical interventions have the goal of inducing and maintaining remission in IBD. However, these treatments are not without side effects, the most significant of which are immunosuppression, infusion reaction, and postsurgical complications.
Prognosis And Outcomes Of Ibd In Children
Given diagnosis in the first decades of life, infants and children have many decades of disease in front of them. Several recent cohorts have illustrated key aspects of the natural history and outcomes of IBD in children, with emphasis of key differences from adult-onset cohorts.
Immune reactivity based upon a series of specific serological responses, has been shown to associate with disease outcome in children. In this group of 796 children with CD, an increased number of serological responses were linked with more aggressive disease pattern and earlier progression of disease. Subsequently, Siegel et al have developed a tool to outline predicted disease course in children with CD, incorporating serologic responses, along with patient and disease factors. The need for surgery has also been linked with NOD2 mutations in children with CD. Risk scores have also been considered in paediatric UC: Moore et al showed that white blood count and haematocrit values at diagnosis were associated with colectomy at 3 years in a cohort of 135 children with UC.
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Response To Corticosteroids And 5
As for any chronic condition, the optimal management for pediatric UC is to use the lowest dose of the safest therapy that is effective for maintaining full remission. For a child with UC, sustained corticosteroid-free remission on maintenance therapy with 5-ASAs is the ideal outcome. Prior studies have demonstrated that corticosteroid-free clinical remission with this strategy ranges between 38 and 40% .
Historically, 5-ASA therapy with or without corticosteroids during induction of remission was the most common first-line strategy for the majority of mildly to moderately active UC prior to resorting to alternative salvage therapy. Predictors of responses to a combination of corticosteroids and 5-ASA regimens were evaluated in a multicenter retrospective cohort study . Interestingly, corticosteroid-free clinical remission 3 months after diagnosis, as evidenced by a PUCAI < 10, was the strongest predictor for 1-year sustained corticosteroid-free clinical remission on 5-ASA. No baseline variables, including PUCAI, endoscopic evaluation, or laboratory serum markers, predicted corticosteroid-free remission or colectomy. However, baseline PUCAI did predict subsequent acute severe colitis and need for salvage therapy.
Table 2. Predicted probability of week 52 outcomes for select patient scenarios based on the PROTECT study predictive models.
How Is Ulcerative Colitis Diagnosed
There is no single test to diagnose ulcerative colitis, so your childs doctor will first rule out other likely causes of symptoms. In addition to a standard physical exam and discussion of symptoms and family history, a combination of tests and procedures will be used to confirm a diagnosis. Those may include laboratory tests of blood and stool .
Other procedures include:
- Colonoscopy:Thedoctor uses a small camera mounted to the end of a lighted tube to examine the interior of the colon. This is done when your child is asleep under general anesthesia.
- Sigmoidoscopy: This is similar to a colonoscopy, but the physician only examines the rectum and the lower colon.
- Capsule endoscopy: The patient swallows a capsule that has a camera in it. The capsule travels through the small intestine, taking pictures that are transmitted to a receiver belt. The camera is expelled through a bowel movement and does not need to be retrieved.
- Imaging: The patient drinks a contrast dye and has an X-ray, Computed Tomography Enterography , or Magnetic Resonance Imaging Enterography.
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Risk Management Pitfalls For Inflammatory Bowel Disease
What Questions Should I Ask My Doctor
If you have Crohns disease, you may want to ask your healthcare provider:
- Why did I get Crohns disease?
- What form of Crohns disease do I have?
- Whats the best treatment for this disease type?
- How can I prevent flare-ups?
- If I have a genetic form, what steps can my family members take to lower their risk of Crohns disease?
- Should I make any dietary changes?
- What medications should I avoid?
- Should I take supplements?
- Should I get tested for anemia?
- Do I need to cut out alcohol?
- Should I look out for signs of complications?
A note from Cleveland Clinic
Crohns disease flare-ups are unpredictable and can disrupt your daily life. Talk to your healthcare provider about the steps you can take to keep the disease in check. With the right treatment and lifestyle changes, you can manage symptoms, avoid complications and live an active life.
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The Nurse Is Aware That The Most Common Assessment Finding In A Child With Ulcerative Colitis Is
Medically reviewed by Mia Armstrong, MD By Rachel Nall, MSN, CRNA Updated on September 14, 2021
- When to seek help
Ulcerative colitis is a type of inflammatory bowel disease . It causes inflammation in the colon, also called the large intestine. The inflammation can cause swelling and bleeding, as well as frequent bouts of diarrhea. About 40,000 children in the United States live with ulcerative colitis. For anyone, especially a child, these symptoms can be difficult to experience.
Ulcerative colitis is a chronic condition. Theres no cure unless your child has surgery to remove all of their colon.
However, your doctor can help you and your child manage the condition in many ways. Treatments for children are often slightly different from treatments for adults.
Ulcerative colitis usually affects adults, but it can occur in children, too.
Children with ulcerative colitis can have a variety of symptoms related to inflammation. These symptoms may range from moderate to severe.
Children with ulcerative colitis often go through peaks and valleys of the disease. They may not have symptoms for some time, then they may experience a flare-up of more serious symptoms.
Symptoms may include:
These symptoms can make ulcerative colitis difficult to diagnose. The symptoms may seem like theyre due to a different underlying condition.
On top of that, children may have a hard time explaining their symptoms. Adolescents may feel too embarrassed to discuss their symptoms.
Future Applications Of Machine Learning
Machine learning has the potential to change practice in UC, a chronic disease as described above that has a variable disease course in individuals. Advances have been made in next-generation sequencing, and high-throughput omics, leading to a greater understanding of the molecular basis of pediatric UC. Innovations in the application of machine learning to derive not only automated learning of relevant features but also learning from patterns that are not obvious to human vision will advance the field further. Our reliance on multiple modalities such as endoscopy, histology, and imaging to ascertain the diagnosis and to monitor disease progression positions our field to capitalize on advances in machine learning. In leveraging computational approaches that can analyze large multimodal data, we could truly translate established and newly discovered predictive factors into the clinical setting. Incorporating a clinical decision support tool that, for example, supports patient stratification at disease onset and allocation of personalized therapies, all within the electronic health record, could provide data-driven solutions for individual patient encounters.
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Diagnosing Ulcerative Colitis In Children
At Hassenfeld Childrens Hospital at NYU Langone, doctors in the Pediatric Gastroenterology Program diagnose ulcerative colitis in children. In this form of inflammatory bowel disease, or IBD, the lining of the colon, or large intestine, becomes chronically inflamed. This condition can occur in any part of the colon.
Signs and symptoms include bloody stools, abdominal pain, ulcers in the colon, diarrhea, and weight loss. Without treatment, symptoms can worsen over time. Children with ulcerative colitis often experience flare-ups between periods of remission, which is an absence of symptoms.
The causes of ulcerative colitis in children arent fully understood, but genetics, environment, and an autoimmune response are all thought to play a role.
Ulcerative colitis is not the same as irritable bowel syndrome, or IBS. In IBS, a collection of symptoms occurs together. These may include abdominal cramping, constipation, and diarrhea. Unlike with inflammatory bowel disease, IBS does not lead to inflammation that damages the gastrointestinal tract.
Another form of IBD is Crohns disease, which mainly affects the small intestine and colon but can affect any part of the gastrointestinal tract. The symptoms of these two types of IBD can be similar. For this reason, our doctors perform a physical exam and extensive testing when diagnosing ulcerative colitis in children.
What Are The Signs & Symptoms Of Ulcerative Colitis
The most common symptoms of ulcerative colitis are cramping belly pain and diarrhea. Other symptoms include:
- blood in the toilet, on toilet paper, or in the stool
- urgent need to poop
Ulcerative colitis can cause other problems, such as rashes, eye problems, joint pain and arthritis, and liver disease. Kids with ulcerative colitis may not grow as well as other kids their age and puberty may happen later than normal.
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What Causes Ulcerative Colitis
The exact cause of ulcerative colitis is not clear. It is probably a combination of genetics, the immune system, and something in the environment that causes inflammation in the gastrointestinal tract. Diet and stress may make symptoms worse, but probably don’t cause ulcerative colitis.
Ulcerative colitis tends to run in families. But not everyone with ulcerative colitis has a family history of ulcerative colitis or IBD. Ulcerative colitis can happen at any age, but is usually diagnosed in teens and young adults.
How To Talk To Your Child About Ulcerative Colitis
Its important to help your child feel comfortable to share changes in symptoms, or when theyve missed a medication dose. Here are some ways to help them cope with symptoms and to feel confident about opening up to you:
- Ask them for updates on how they feel both mentally and physically.
- Use language they can understand. Medical terminology can be scary and confusing, so be sure to explain things at their level.
- Dont diminish the severity of their symptoms. Make sure they feel like they can keep you informed of any changes in how theyre feeling. This can be especially true for psychological symptoms like anxiety and depression.
- Make sure children know that their condition isnt their fault and that they arent alone. Online support groups, forums, and even specialized summer camps can be a good way to share other childrens stories.
- Be an advocate for your child with all medical professionals to let them know that you have their back.
- Remember to take care of yourself as a caregiver. Its easy to let your own needs slide when caring for others.
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What Is Crohns Disease
Crohns disease, also called regional enteritis or ileitis, is a lifelong form of inflammatory bowel disease . The condition inflames and irritates the digestive tract specifically the small and large intestines. Crohns disease can cause diarrhea and stomach cramps. Its common to experience periodic disease flare-ups.
Crohns disease gets its name from American gastroenterologist Dr. Burrill Crohn . He was one of the first physicians to describe the illness in 1932. Ulcerative colitis is another commonly diagnosed IBD.
Response To Other Biologic And Small
Vedolizumab , an 47 anti-integrin inhibitor, is from a second biologic class that was approved for the use of adult IBD in 2014. The first pediatric retrospective study of VDZ identified that 76% of UC patients were in remission at week 14. In a subanalysis at week 22 that included both patients with UC and CD, anti-TNF-naïve patients were more likely to be in remission than anti-TNF-exposed patients . Another retrospective pediatric study demonstrated that 59% of anti-TNF-naïve patients with UC achieved endoscopic remission, compared to 15% of anti-TNF-exposed patients. However, the authors noted that anti-TNF-naïve patients had lower partial Mayo baseline scores compared with exposed patients . The anti-TNF exposure findings were similar to the original adult GEMINI study in which anti-TNF-naïve patients had faster symptom improvement , and a subsequent network meta-analysis confirmed that more anti-TNF-naïve patients achieved remission compared with anti-TNF-exposed patients .
Even fewer pediatric-specific predictors of response are known for anti-TNF therapy beyond IFX and adalimumab such as golimumab or other biologic classes not yet approved for pediatric UC beyond anti-TNF and VDZ or biosimilars or novel small molecules such as Janus kinase inhibitors.
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How Is Crohn’s Disease Diagnosed
Most people with Crohns first see a healthcare provider because of ongoing diarrhea, belly cramping or unexplained weight loss. If you have a child who has been experiencing the symptoms of Crohns disease, reach out to your pediatrician.
To find the cause of your symptoms, your healthcare provider may order one or more of these tests:
- Blood test: A blood test checks for high numbers of white blood cells that may indicate inflammation or infection. The test also checks for low red blood cell count, or anemia. Approximately one in three people with Crohns disease have anemia.
- Stool test: This test looks at a sample of your stool to check for bacteria or parasites. It can rule out infections that cause chronic diarrhea.
- Colonoscopy: During a colonoscopy, your doctor uses an endoscope to examine the inside of your colon. Your doctor may take a tissue sample from the colon to test for signs of inflammation.
- Computed tomography scan: A CT scan creates images of the digestive tract. It tells your healthcare provider how severe the intestinal inflammation is.
- Upper gastrointestinal endoscopy: Your doctor threads a long, thin tube called an endoscope through your mouth and into your throat. An attached camera allows your doctor to see inside. During an upper endoscopy, your doctor may also take tissue samples.
- Upper gastrointestinal exam: X-ray images used during an upper GI exam allow your doctor to watch as a swallowed barium liquid moves through your digestive tract.
How Can I Help My Child Live With Ulcerative Colitis
Children with this condition need long-term care. Your child may have times when symptoms go away . This can sometimes last for months or years. But symptoms usually come back.
Your child should learn what foods trigger his or her symptoms and avoid these foods. You and your childs healthcare provider should make sure your child gets enough nutrients to grow and develop well. Support groups can help you and your child. Work with your childs healthcare provider to create a care plan for your child.
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Pediatric Uc Epidemiology And Disease Features
Worldwide, the prevalence of UC is rising, and while the incidence is stabilizing in much of the Western world, rates are increasing in newly industrialized countries, specifically in parts of South Asia . To address the increasing disease burden, there is an urgent need to develop biomarkers that predict disease severity and disease course in a wide diverse population .
Features indicative of pediatric UC are well-described in the criteria set forth by the North American and European Societies for Pediatric Gastroenterology Hepatology and Nutrition . UC typically presents with a continuous inflammation of the rectum and colon proximally and is further categorized based on disease location and severity by the Paris pediatric modification of the Montreal classification of IBD . It is well-recognized that, in children, UC can present with atypical features, including macroscopic rectal sparing , backwash ileitis in association with severe pancolitis, and limited distal disease associated with mild cecal inflammation with an otherwise normal right colon . The presentation and natural history of pediatric UC are distinct from those of adult UC in that the majority of pediatric-onset UC presents with extensive colitis affecting the entire colon . On the contrary adults predominately present with left-sided colitis , with more than half in remission or with mild disease activity after initial presentation .