IBD

Question 1

Which inflammatory bowel condition leads to “skip” lesions, fistulas, and adhesions?

Answer 1

Crohn’s disease

Question 2

How likely is a monozygotic twin to develop Crohn’s disease, if the other twin has it?

Answer 2

50 % will also develop it

Question 3

In children, which gender suffers from Crohn’s disease more frequently?

Answer 3

Males

In adulthood, it’s equally common in males & females

Question 4

Perianal tags suggest which type of IBD may be present?

Answer 4

Crohn’s

Question 5

What proportion of Crohn’s disease patients have perianal involvement?

Answer 5

¼ to ½

Question 6

If a Crohn’s disease patient primarily has terminal ileum involvement, what vitamin deficiency may develop?

Answer 6

B12

Question 7

If a Crohn’s disease patient primarily has duodenal involvement, what deficiency may develop?

Answer 7

Iron

Question 8

What GI tumor are Crohn’s disease patients at especially high risk to develop?

Answer 8

Adenocarcinoma

Question 9

Why do Crohn’s disease patients frequently develop diarrhea?

Answer 9

Malabsorption & bacterial overgrowth

Question 10

What are the mainstays of treatment for Crohn’s disease?

3 general categories

Answer 10

1.  Immunosuppression
2.  Anti-inflammatories
3.  Antibiotics

Question 11

Which general types of anti-inflammatories are used to treat Crohn’s disease?

Answer 11

Aspirin-based preparations

  &

Steroids

(both in local and systemic forms)

Question 12

Which types of immunosuppressives are usually used to treat Crohn’s disease?

(3)

Answer 12

1.  Steroids
2.  Azathioprine
3.  Cyclosporin

Question 13

When should you consider surgery in the treatment of your Crohn’s disease patients?

(5)

Answer 13

1.  Fistula
2.  Obstruction
3.  Abscess
4.  Bleeding (not easily controlled)
5.  Growth retardation

Question 14

The most-difficult-to-manage Crohn’s disease occurs when which part of the gut is affected?

Answer 14

Colon

Question 15

Why are Crohn’s patients likely to develop renal stones?

Answer 15

•  High rate of cell turnover increases urea → uric acid stones
•  Can’t absorb & break down oxalate well → oxalate stones

Question 16

What is the epidemiology of pediatric inflammatory bowel disease (IBD)?

Answer 16

The most significant increases have occurred in younger children with increases of 5% in those

Question 17

How do ulcerative colitis and Crohn disease vary in intestinal distribution?

Answer 17

Ulcerative colitis is limited to the superficial mucosa of the colon. It always involves the rectum and extends proximally to a variable extent. Ulcerative colitis more commonly involves the entire colon in children than in adults, who more commonly will have limited left-sided disease. Regional enteritis, or Crohn disease , is characterized by transmural inflammation of the bowel that may affect the entire tract from the mouth to the anus. Because of the transmural nature of the inflammation, patients can develop fistulas and abscesses more commonly with Crohn disease. The typical cobblestone appearance of Crohn disease is produced by crisscrossing ulcerations ( Fig. 7-10 ). Crohn colitis, with no involvement of the small bowel, is more common in younger children and can be difficult to distinguish from ulcerative colitis.

Question 18

What features differentiate ulcerative colitis from Crohn disease?

Answer 18

Distribution
Clinical presentation
Bleeding
Growth failure
Obstruction
Weight loss
Perianal disease
Endoscopic findings
Histological findings

Question 19

What is the role of serologic panels in the diagnosis of IBD?

Answer 19

Certain antibodies can help distinguish between Crohn disease and ulcerative colitis in patients with indeterminate colitis. These panels are not useful in population screening as false-positive results can create unwarranted anxiety and unnecessary testing. One-third of individuals with positive serology do not have IBD. Higher antibody titers are associated with more aggressive disease. Average positivity is as follows:

• ASCA (anti- Saccharomyces cerevisiae antibody) : CD (40% to 56%), UC (0% to 7%), Controls (

Question 20

What are the extraintestinal manifestations of pediatric IBD?

Answer 20

• Growth failure
• Arthralgias/arthritis
• Bone disease including osteopenia and osteoporosis
• Oral lesions, most commonly recurrent aphthous lesions
• Skin lesions: granulomatous, reactive, and secondary to nutritional deficiencies
• Eye lesions: episcleritis and uveitis
• Liver disease: hepatitis, fatty liver, cholelithiasis, amyloidosis, and primary sclerosing cholangitis
• Rare extraintestinal manifestations (

Question 21

What pharmacologic therapies are used in the treatment of ulcerative colitis and Crohn disease?

Answer 21

Mild disease and remission: 5-Aminosalicylic acids (ASA) (mesalamine, mesalazine), oral and rectal, particularly for ulcerative colitis; antibiotics; extended-release budesonide;

Moderate disease: Metronidazole (for Crohn disease); prednisone

Severe and refractory disease: Azathioprine; 6-Mercaptopurine; intravenous steroids; methotrexate; anti-tumor necrosis factor agents (e.g., infliximab, adalimumab); cyclosporine

Question 22

How are therapies chosen for IBD?

Answer 22

Traditionally, medications have been chosen in a “step-up” approach using medications with less severe side effects such as ASA or steroids before initiation of immunomodulators or biologic therapies. This is now being challenged with a “top-down” approach using more potent medications earlier in the course of the disease to induce mucosal healing, interrupt the natural history of the disease processes, and decrease potential for long-term complications including need for surgical intervention. Overall, the age, presenting symptoms and severity, and sex of the child must be taken into consideration when starting therapy.

Question 23

Is there a potential role for thalidomide in the treatment of Crohn disease?

Answer 23

Thalidomide has properties of lowering tumor necrosis factor and inhibiting angiogenesis. Investigators in Italy found that, compared with placebo, treatment with thalidomide for children and adolescents with refractory Crohn disease resulted in improved clinical remission at 8 weeks, which was maintained in a long-term period of continued treatment.

Question 24

In a child who has been diagnosed with Crohn disease, what are potential long-term complications?

Answer 24

• Severe perianal disease can be a debilitating complication. More prevalent in patients with Crohn disease, it may range from simple skin tags to the development of perianal abscesses or fistulas.
• Enteroenteral fistulas may occur and “short circuit” the absorptive process. The thickened bowel may obstruct or perforate, thus requiring operation. The recurrence rate is high after surgery, repeated operations are often necessary, and short bowel syndrome may result. In many cases, a permanent ostomy is placed, although pouch construction and continent ileostomies have become more common.
• Growth retardation and delayed puberty are seen extensively in patients with pediatric Crohn disease. The insidious onset may result in several years of linear growth failure before the correct diagnosis is made. With epiphyseal closure, linear growth is terminated, and short adult stature will be permanent.
• Decrease in bone mineralization ( osteopenia ) is a more commonly recognized complication of Crohn disease, secondary to growth failure and malnutrition, disease activity, and toxic effect of corticosteroids. All patients should have a bone densitometry scan to assess for this complication. Treatment includes increased weight-bearing activity, correction of nutritional deficits, vitamin D and calcium supplementation, and more aggressive medical treatment of disease.
• Hepatic complications of IBD include chronic active hepatitis and sclerosing cholangitis, which may require liver transplantation.
• Nephrolithiasis may occur in patients with resections or steatorrhea as a result of the increased intestinal absorption of oxalate.
• Chronic reactive and restrictive pulmonary disease has been noted.
• Arthralgias are common, but destructive joint disease is uncommon.
KEY

Question 25

When is surgery indicated for children with Crohns?

Answer 25

Perforation with abscess formation 
Obstruction with or without stenosis 
Uncontrolled massive bleeding 
Draining fistulas and sinuses 
Toxic megacolon 
Growth failure in patients with localized areas of resectable disease

Question 26

When is surgery indicated for children with UC?

Answer 26

Urgent: 
Hemorrhage
Perforation
Toxic megacolon
Acute fulminant colitis unresponsive to maximal medical therapy

Elective:
Chronic disease with recurrent severe exacerbations
Continuous incapacitating disease despite adequate medical treatment
Growth retardation with pubertal delay
Disease of > 10 years’ duration with evidence of epithelial dysplasia