Inflammatory bowel disease in a child

Question 1

How has the incidence of IBD in children changed?

Answer 1

Increased in last 20 years - could be interplay between genetics, microbiome and mucosal immunity

Question 2

Is Crohn’s or UC more common?

Answer 2

Crohn’s more common in children (opposite in adults).

Question 3

Name 3 general effects of IBD on children.

Answer 3

• Poor general growth
• Growth restriction
• Adverse effects on psychological well-being

Question 4

What is a typical presentation of Crohn’s disease?

Answer 4

Question 5

What can Crohn’s be mistaken for in childhood?

Answer 5

• Psychological problems
• Anorexia nervosa

Question 6

What do investigations show in Crohn’s disease?

Answer 6

• Raised inflammatory markers (platelets, CRP, ESR)
• Iron deficiency anaemia
• Low serum albumin

Imaging:

• Endoscopy and biopsy - diagnostic
• CT/MRI - narrowing, fissuring and mucosal irregularities with bowel wall thickening
• Remission with nutritional therapy

Question 7

Define Crohn’s disease. Which part of bowel is usually affected?

Answer 7

A transmural, focal, subacute or chronic inflammatory disease, most commonly affecting the distal ileum and proximal colon.

Question 8

What can be a complication of acutely inflamed, thickened bowel in Crohn’s?

Answer 8

Strictures of the bowel and fistulae may develop between adjacent loops of bowel or between bowel and organs (e.g. vagina and bladder)

Question 9

What is the histological hallmark of Crohn’s disease?

Answer 9

Non-caseating epithelioid cell granulomata, although this is not identified in up to 30% at presentation.

Question 10

How is remission induced with nutritional therapy in Crohn’s disease?

Answer 10

Nutritional therapy - normal diet is replaced by whole protein modular feeds (polymeric diet) for 6-8 weeks. Effective in 75% of cases.

Systemic steroids if this is ineffective

Question 11

How is relapse managed in Crohn’s disease?

Answer 11

Immunosuppressant medication - azathioprine, mercaptopurine or methotrexate; almost always required to maintain remission

Biologics - anti-TNF (infliximab, adalimumab) when conventional treatments have failed

Question 12

How can growth failure be corrected in Crohn’s?

Answer 12

Overnight nasogastric or gastrostomy feeds

Question 13

What complications may require surgery in Crohn’s?

Answer 13

• Obstruction
• Fistulae
• Abscess formation
• Severe localised unresponsiveness to medical treatment often manifesting as growth failure

Question 14

What is the prognosis in Crohn’s disease?

Answer 14

Usually good in childhood and may lead normal lives, with occasional relapses

Question 15

Define ulcerative colitis.

Answer 15

Recurrent, inflammatory and ulcerating disease involving the mucosa of the colon

Question 16

What is a typical presentation of UC?

Answer 16

• rectal bleeding
• diarrhoea
• colicky pain
• weight loss/growth failure (less frequently than in Crohn’s)
• erythema nodosum
• arthritis

Question 17

What is shown here?

Answer 17

erythema nodosum

seen in both Crohn’s and UC

Question 18

What is the pattern of inflammation in UC?

Answer 18

Extends from the rectum proximally for a variable length - 90% of children have pancolitis (not just confined to the distal colon like in adults)

Question 19

How is diagnosis of UC made?

Answer 19

Endoscopy (upper and ileocolonoscopy) and histological features

Question 20

What is seen on histology in UC?

Answer 20

• mucosal inflammation
• crypt damage (cryptitis, architectural distortion, abscesses, crypt loss)
• ulceration

Question 21

What investigations are done for UC?

Answer 21

Bloods:

-

Imaging/invasive:

• Endoscopy and biopsy - excludes infectious causes of colitis
• Imaging - excludes extra-colonic inflammation present in Crohn’s disease

Question 22

What is used for induction and maintenance of remission in UC? What other treatments are available?

Answer 22

• Aminosalicylates e.g. mesalazine
• Immunomodulatory therapy, e.g. azathioprine alone to maintain remission or in combination with low-dose corticosteroid therapy.

Biological therapies such as infliximab or ciclosporin in patients with resistant disease

If ineffective, surgery should not be delayed.

Question 23

What is the use for steroids in UC?

Answer 23

Topical steroids - only used in disease confined to the rectum and sigmoid colon (which is rare in children)

Systemic steroids - used in aggressive/extensive disease for acute exacerbations.

Question 24

How is severe fulminating UC managed?

Answer 24

Medical emergency and requires IV fluids and steroids. If this fails, ciclosporin may be used.

Colectomy with an ileostomy or ileorectal pouch for severe fulminating disease (may be complicated by a toxic megacolon)

Question 25

The risk of which cancer is increased in UC?

Answer 25

Increased incidence of adenocarcinoma (1 in 200 risk for each year between 10-20 years from diagnosis)

Regular colonoscopic screening is done 10 years post-diagnosis .