INFLAMMATORY BOWEL DISEASE IN PEDIATRIC AND ADOLESCENT PATIENTS

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Once considered rare in pedatric practice, chronic inflammatory bowel disease (IBD) is now being recognized with increasing frequency in children of all ages. In fact, 25% to 30% of all patients with Crohn's disease (CD) and 20% of those with ulcerative colitis (UC) present before age 20.47 Four percent of pediatric IBD occurs before the age of 5 years, with a peak age of onset in the late adolescent years. IBD has long been known to occur in the pediatric population; the first patient Crohn described with regional enteritis was a 16-year-old boy.7 With the increasing recognition of IBD among pediatric patients, it has become one of the most significant chronic diseases affecting children and adolescents.12

In addition to the usual gastrointestinal symptoms of diarrhea, abdominal pain, weight loss, anemia, joint symptoms, and rectal bleeding, children may exhibit prominent extraintestinal manifestations, such as growth failure and delayed puberty. Other problems unique to pediatrics include the lack of controlled clinical trials and the lack of medical preparations available for and tested in children as well as the psychological issues that occur in children and adolescents with IBD. These unique problems that are encountered in the pediatric population necessitate a different medical approach than is used for adult-onset IBD.

Section snippets

EPIDEMIOLOGY

Since the 1930s, the incidence of IBD has greatly increased. In the 1950s, UC was twice as prevalent as CD, but studies in the United States show that CD has been steadily increasing.14 The age-specific incidence rates in North America for 10- to 19-year-olds are approximately 2:100,000 for UC and 3.5:100,000 for CD.6 The incidence of CD has increased in the pediatric age group with approximately 4% presenting before 5 years of age. Most studies have reported an equal incidence of CD in boys

Ulcerative Colitis

UC is a diffuse mucosal inflammation limited to the colon. It invariably affects the rectum and may extend proximally in a symmetric uninterrupted pattern to involve parts or all of the large intestine. Because UC is a mucosal disease limited to the colon, the most common presenting symptoms are rectal bleeding, diarrhea, and abdominal pain. Langholz et al37 reported that at diagnosis children with UC had more extensive disease than did adults. Abdominal pain was also more common. The

GASTROINTESTINAL COMPLICATIONS

CD and UC are both associated with significant gastrointestinal complications. The major intestinal complications of UC are massive bleeding, toxic megacolon, and carcinoma. In contrast, the major intestinal complications of CD are due to the transmural nature of the disease. This nature leads to the formation of abscesses, fistulas, strictures, and adhesions, which may also contribute to the development of obstruction or bacterial overgrowth.

The most serious acute complication of UC is toxic

EXTRAINTESTINAL MANIFESTATIONS

Twenty-five percent to 35% of patients with IBD have at least one extraintestinal manifestation. These diseases may be diagnosed before, concurrently with, or after the diagnosis of IBD is made.8 Extraintestinal manifestations can occur even after colectomy for UC. The presence of extraintestinal manifestations may carry prognostic significance. Patients with UC and extraintestinal manifestations have a significantly higher rater of pouchitis after colectomy and ileoanal anastomosis.29

Skin

GROWTH FAILURE

Growth failure and delayed sexual development are common problems in adolescents and children with CD.4 Studies have evaluated the growth of children with CD, and it is clear that impairment of linear growth is common before diagnosis as well as during subsequent years and that height at maturity is often compromised.19 Height velocity is the most sensitive parameter by which to diagnose impaired growth and to follow the effects on growth after therapy. Kanof et al34 reported a decrease in

DIAGNOSIS

The initial evaluation of suspected IBD should be performed by the primary physician. The importance of the history cannot be overemphasized. Recent antibiotic intake and family history are important and often overlooked. Abdominal examination is often nonspecific, although a fullness or mass in the right lower quadrant may indicate CD. Rectal examination is important to detect perianal disease and fecal blood. A careful assessment of growth and development is an important part of the

DIFFERENTIAL DIAGNOSIS

The diagnosis of IBD is often difficult because of the subtle manner in which it may present. Recurrent abdominal pain is a common problem in pediatrics, with 10% of all children complaining of nonspecific periumbilical pain at some time during childhood. Recurrent abdominal pain in children with IBD is generally associated with other problems, such as anorexia, growth failure, decreased appetite, diarrhea, or extraintestinal manifestations. Therefore, children with abdominal pain and any of

MANAGEMENT

The general goals of treatment for children with IBD are to

  • 1

    Achieve the best possible clinical and laboratory control of the inflammatory disease with the least possible side effects from medication

  • 2

    Promote growth through adequate nutrition

  • 3

    Permit the patient to function as normally as possible (e.g., school attendence, participation in sports)

Not all of these goals are always attainable.

The treatment of IBD has changed greatly over the past few years with the development of new agents that

SUMMARY

IBD is a chronic pediatric disease that needs to be treated by a team of experts consisting of pediatricians, pediatric gastroenterologists, psychologists, nutritionists, social workers, and nurses. A critical factor in successful management of this disease is the willingness of the patient to participate and cooperate with the team. Parents and patients must be educated and supported to treat these disorders effectively. Much further research is necessary to understand the specific causative

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