IBD

Question 1

How might a kid with IBD present?

Answer 1

With diarrhoea
Rectal bleeding
Abdo Pain
Fever
Weight loss
Growth failure
Arthritis
Mass

Question 2

Difference between UC & Crohn’s presentation?

Answer 2

UC predominantly features diarrhoea, bleeds and abdo pain
Bloody diarrhoea more than a couple weeks = think UC

Crohn’s features more systemic symptoms incl arthritis, fever, growth problems and erythema nodosum
Less diarrhoea and rectal bleeding

Question 3

What else would you want to know about a kids history if we suspect IBD?

Answer 3

FH
Growth development
Sex development
Nutritional Status
Intestinal and other symptoms
Exclude infection 

If passing more than 6-8 stools a day = think IBD rather than IBS

May have a lower bone age, smaller = CD esp delays growth and sexual development

Question 4

How do you approach a kid you suspect of IBD?

Answer 4

Exclude an inf with stool culture etc

FBC, ESR, CRP, Albumin

Stool Calprotectin

microbiology - no stool pathogens

Radiology: (esp CD)
= MRI or Barium Meal

Endoscopy & Biopsy

• colonscopy and upper GI endoscopy
• mucousal biopsy
• capsule enteroscopy
• enteroscopy

(all children get colonscopy and UGIE. Widespread biopsies on all kids. Sometimes have to consider diff ways of looking at small bowel if not finding out what the problem is - last 2 bps)

Question 5

What would blood tests show in IBD?

Answer 5

FBC - Anaemia & Thrombocytosis
ESR & CRP - raised
Albumin - Low

(low albumin esp in CD - tends to be due to a protein losing enteropathy ie leaking protein into gut and passing it out in stool rather than a nutriitional problem) - can see with US but only at severe end of spectrum in acute severe colitis or toxic megacolon - more likely to see a raised CRP and low albumin)

Question 6

When would we use a barium meal in place of an MRI?

Answer 6

MRI best way to look for small bowel disease (MRI entercolitis) but have to lie still in a noisy machine so sometimes the little ones have to do US or barium follow thro
MRI shows thickened parts of bowel, fistulas, obstructions, comps

Barium meal is good for younger kids who can’t sit through an MRI

Question 7

Which tests are definitive for IBD?

Answer 7

MRI/Barium Meal

Endoscopy & biopsy

Question 8

How do we manage IBD?

Answer 8

Triangle/Bottom up treatment:

• Anti-inflammatories e.g. 5ASA mesalazine
• Steroids (for flare ups)
• Immunosuppressants e.g. azathioprine
• Biologics e.g. Infliximab
• Surgery

Also a polymeric diet is first line for crohn’s

Nutrional supplements and immunomodulation can help

CD: (no 5-ASA eg mesalazine in CD - skip that 1st step)
- polymeric diet (excessive enteral nutrition diet) or oral prednisolone
- steroid sparing agents azathioprine/6MP or methotrexate (immunosuppressants)
-biologics - infliximab/adalibumab
-surgery
??surgery before biologicals in isolated disease esp TI
(if child has got 1 little pocket of CD not responding to the treatment = eg fall off in height velocity and not growing normally (clue they have infl there) and if have a small section of eg ileal disease not causing them a lot of symps but is affecting their growth = resecting that area works well (end-to end anastomosis, no stoma) then they catch up growth etc so occasionally do surgery before biologics but generally do biologics before surgery)

Question 9

What does stool calprotectin tell us?

Answer 9

key test
biomarker in intestinal faeces that suggests infl

(can differentiate between IBD and IBS)

Question 10

Adults vs paeds IBD?

Answer 10

UC more common in adults
CD more common in paeds

IBUD more common in kids than adults (IBD unclassified - ie have IBD but can’t decided which one)

• most typical distribution of UC in adults = proctitis (unusual in kids, more likely older children)
• L sided colitis also common in adults, not kids
• pancolitis v common in children (more severe and extensive - more biologics, colectomy and inpatient admission in children)

CD distribution:
- isolated ileal (terminal ilelitis) more common in adults
- ileocolonic = adults and kids
- upper GI/panenteric = more commonly in children - always atypical presentation, everywhere we take a biopsy we find CD
(not sure how many adults have this as do endoscopies in kids under GA so may as well do both ends but adults get it under sedation and it’s upper GI endoscopy that’s more pleasant, so don’t do lower/colonscopy unless good reason)

so both more likely to be worse in kids

Question 11

What is it if child with a lower colon that looks like UC on colonscopy but granulomas in stomach or significant infl in duodenum?

Answer 11

CD

Question 12

Describe the appearance of UC vs CD on endoscopy?

Answer 12

UC: 
- white dots (crypt abscesses)
- sloppy mucous pus contact 
- continuous 
Eg if child having a severe acute colitis = severe bloody stool 6/7 times a fay, blood in stool, sloppy stools, up during the night, abdo pain, tired, lethargic 

CD:

• sepriginous ulcers = looks like slime a snail leaves behind
• skip lesions

some could be either = IBDU

Question 13

Histopathology: CD vs US (ie from biopsy)

Answer 13

CD: granulomas, patchy infl, more destructive changes

UC: disordered, crypts, pus within cyrpts - crypt abscesses, great increase in infl cells

Question 14

What are the aims of treatment?

Answer 14

Induce and maintain remission
Correct nutritional deficiencies
Maintain normal growth and development

remember children tend to have more severe and extensive disease

Question 15

What are the methods of treatment?

Answer 15

Medical

• Anti-inflammatory
• Immuno-suppressive
• Biologicals ( Infliximab)

Nutritional
-Immune modulation
-Nutritional supplementation
eg TPN

Surgical (colectomies, pouch surgery. Never curative in CD so as limited as poss - can have comps, strictures etc)