Inflammatory bowel disease in a child Flashcards
How has the incidence of IBD in children changed?
Increased in last 20 years - could be interplay between genetics, microbiome and mucosal immunity
Is Crohn’s or UC more common?
Crohn’s more common in children (opposite in adults).
Name 3 general effects of IBD on children.
- Poor general growth
- Growth restriction
- Adverse effects on psychological well-being
What is a typical presentation of Crohn’s disease?
What can Crohn’s be mistaken for in childhood?
- Psychological problems
- Anorexia nervosa
What do investigations show in Crohn’s disease?
- 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
Define Crohn’s disease. Which part of bowel is usually affected?
A transmural, focal, subacute or chronic inflammatory disease, most commonly affecting the distal ileum and proximal colon.
What can be a complication of acutely inflamed, thickened bowel in Crohn’s?
Strictures of the bowel and fistulae may develop between adjacent loops of bowel or between bowel and organs (e.g. vagina and bladder)
What is the histological hallmark of Crohn’s disease?
Non-caseating epithelioid cell granulomata, although this is not identified in up to 30% at presentation.
How is remission induced with nutritional therapy in Crohn’s disease?
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
How is relapse managed in Crohn’s disease?
Immunosuppressant medication - azathioprine, mercaptopurine or methotrexate; almost always required to maintain remission
Biologics - anti-TNF (infliximab, adalimumab) when conventional treatments have failed
How can growth failure be corrected in Crohn’s?
Overnight nasogastric or gastrostomy feeds
What complications may require surgery in Crohn’s?
- Obstruction
- Fistulae
- Abscess formation
- Severe localised unresponsiveness to medical treatment often manifesting as growth failure
What is the prognosis in Crohn’s disease?
Usually good in childhood and may lead normal lives, with occasional relapses
Define ulcerative colitis.
Recurrent, inflammatory and ulcerating disease involving the mucosa of the colon
What is a typical presentation of UC?
- rectal bleeding
- diarrhoea
- colicky pain
- weight loss/growth failure (less frequently than in Crohn’s)
- erythema nodosum
- arthritis
What is shown here?
erythema nodosum
seen in both Crohn’s and UC
What is the pattern of inflammation in UC?
Extends from the rectum proximally for a variable length - 90% of children have pancolitis (not just confined to the distal colon like in adults)
How is diagnosis of UC made?
Endoscopy (upper and ileocolonoscopy) and histological features
What is seen on histology in UC?
- mucosal inflammation
- crypt damage (cryptitis, architectural distortion, abscesses, crypt loss)
- ulceration
What investigations are done for UC?
Bloods:
-
Imaging/invasive:
- Endoscopy and biopsy - excludes infectious causes of colitis
- Imaging - excludes extra-colonic inflammation present in Crohn’s disease
What is used for induction and maintenance of remission in UC? What other treatments are available?
- 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.
What is the use for steroids in UC?
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.
How is severe fulminating UC managed?
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)
The risk of which cancer is increased in UC?
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 .
