Inflammatory bowel disease is being recognized as an important cause of chronic abdominal disease in children. The two major types are Ulcerative Colitis and Crohn's Disease.
Epidemiology
1. Equal distribution between males and females
2. Whites > non-whites
3. Jews from Eastern Europe higher incidence
4. Increase incidence with + family history.
Ulcerative Colitis-there is superficial inflammation of the mucosa and disease is confined to the colon. The rectum is usually involved and 40% will have pancolitis.
a. Clinical Presentation
1. Bloody diarrhea
2. Pain with defecation
3. Nausea and vomiting
4.Growth failure
b. Diagnosis
1. Rule out infectious cause of bloody diarrhea. Infection may trigger first episode
2. CBC- anemia, usually secondary to low Iron, and increased platelets
3. Increased ESR and CRP
4. Endoscoy with biopsy
Crohn's Disease- may affect all areas of GI tract from the mouth to the anus. Inflammation may extend to the serosa layer and through the wall leading to fistula formation. Most often involves the terminal ileum.
a. Clinical Manifestations
1. Abdominal pain, usually severe, with location related to area of intestinal involvement.
2. 50% will have bloody diarrhea secondary to colon inflammation
3. Nausea, vomiting, early satiety
4. perirectal inflammation with skin tags and fissures
5. May present as fever without localization (FUO)
6. Growth failure and weight loss
7. Clubbing
b. Diagnosis-often delay in diagnosis because of vague symptoms
1. History and physical examination
2. radiograph of upper gastrointestinal tract
3. ESR and CRP,
4. Anemia, hypoalbuminemia,
5. Rule out enteric infections
Extraintestinal findings
1. Joint pains and arthritis
2. Delayed growth and sexual maturation
3. Malabsorption
4. Skin findings- erythema nodosum, vasculitis, and pyoderma gangrenosum
5. Liver and gall bladder-sclerosing cholangitis, chronic active hepatitis
6. Mouth ulcers, gingivitis
7. Eye changes including uveitis and iritis
Differential Diagnosis of IBD
1. Enteric infection
2. Anorexia nervosa and other eating disorders
3. Peptic ulcer disease
4. Appendicitis
5. HSP
6. Vasculitis
7. Celiac disease
8. Allergic enteritis
9. Neoplasm
Treatment
1. Goals
a. Control gastrointestinal symptoms
b. Improve and maintain nutritional status
c. Decrease extraintestinal symptoms
d. Improve emotional status, get child back to school and participating in normal activities
2. Aminosalicylates
3. Corticosteroids
4. Antibiotics including metronidazole
5. Immunosuppressive agents including Azathioprine, 6-MP, Cyclosporine
6. Surgery- indicated for cases that do not respond to medical management, continues to have growth failure, continues to hemorrhage, fistula formation, and cancer prophylaxis.
References
1. Hyams, Jeffrey Inflammatory Bowel Disease Pediatrics Review Sept. 2000
2. Markowitz, James Inflammatory bowel disease: The pediatrician's role Contemporary Pediatrics May 1996 pg. 25-46
3. Hanauer, S. Inflammatory Bowel Disease. NEJM Vol. 334, No. 13 March 28, 1996
4. Podolsky D.K. Inflammatory
Bowel Disease. NEJM
Vol. 347 No. 6 August 8, 2002