RESUMO
The diagnosis of inflammatory bowel disease (IBD) in children and the need to distinguish between subtypes (Crohn's disease (CD) and ulcerative colitis (UC)) requires lengthy investigative and invasive procedures. Non-invasive, rapid, and cost-effective tests to support these diagnoses are needed. Faecal volatile organic compounds (VOCs) are distinctive in IBD. VOC profiles can be rapidly determined using a gas chromatography-sensor device (OdoReader©). In an inception-cohort of children presenting with suspected IBD, we directly compared the diagnostic fidelity of faecal calprotectin (FCP, a non-specific protein marker of intestinal inflammation) with OdoReader© VOC profiles of children subsequently diagnosed with IBD with matched controls diagnosed with other gastrointestinal conditions. The OdoReader© was 82% (95% confidence interval 75-89%) sensitive and 71% (61-80%) specific but did not outperform FCP (sensitivity 93% (77-99%) and specificity 86% (67-96%); 250 µg/g FCP cut off) in the diagnosis of IBD from other gastrointestinal conditions when validated in a separate sample from the same cohort. However, unlike FCP and better than other similar technologies, the OdoReader© could distinguish paediatric CD from UC (up to 88% (82-93%) sensitivity and 80% (71-89%) specificity in the validation set) and justifies further validation in larger studies. A non-invasive test based on VOCs could help streamline and limit invasive investigations in children.
Assuntos
Colite Ulcerativa , Doença de Crohn , Fezes , Compostos Orgânicos Voláteis , Humanos , Colite Ulcerativa/diagnóstico , Criança , Doença de Crohn/diagnóstico , Compostos Orgânicos Voláteis/análise , Masculino , Feminino , Fezes/química , Adolescente , Cromatografia Gasosa/métodos , Pré-Escolar , Doenças Inflamatórias Intestinais/diagnóstico , Diagnóstico Diferencial , Complexo Antígeno L1 Leucocitário/análise , Biomarcadores/análise , Técnicas Biossensoriais/métodos , Técnicas Biossensoriais/instrumentaçãoRESUMO
OBJECTIVE: Paediatric acute severe colitis (ASC) management during the novel SARS-CoV-2/COVID-19 pandemic is challenging due to reliance on immunosuppression and the potential for surgery. We aimed to provide COVID-19-specific guidance using the European Crohn's and Colitis Organisation/European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for comparison. DESIGN: We convened a RAND appropriateness panel comprising 14 paediatric gastroenterologists and paediatric experts in surgery, rheumatology, respiratory and infectious diseases. Panellists rated the appropriateness of interventions for ASC in the context of the COVID-19 pandemic. Results were discussed at a moderated meeting prior to a second survey. RESULTS: Panellists recommended patients with ASC have a SARS-CoV-2 swab and expedited biological screening on admission and should be isolated. A positive swab should trigger discussion with a COVID-19 specialist. Sigmoidoscopy was recommended prior to escalation to second-line therapy or colectomy. Methylprednisolone was considered appropriate first-line management in all, including those with symptomatic COVID-19. Thromboprophylaxis was also recommended in all. In patients requiring second-line therapy, infliximab was considered appropriate irrespective of SARS-CoV-2 status. Delaying colectomy due to SARS-CoV-2 infection was considered inappropriate. Corticosteroid tapering over 8-10 weeks was deemed appropriate for all. After successful corticosteroid rescue, thiopurine maintenance was rated appropriate in patients with negative SARS-CoV-2 swab and asymptomatic patients with positive swab but uncertain in symptomatic COVID-19. CONCLUSION: Our COVID-19-specific adaptations to paediatric ASC guidelines using a RAND panel generally support existing recommendations, particularly the use of corticosteroids and escalation to infliximab, irrespective of SARS-CoV-2 status. Consideration of routine prophylactic anticoagulation was recommended.
Assuntos
Anticoagulantes/uso terapêutico , COVID-19 , Colectomia/métodos , Colite Ulcerativa , Doença de Crohn , Infliximab/uso terapêutico , Metilprednisolona/uso terapêutico , Adolescente , COVID-19/epidemiologia , COVID-19/terapia , Criança , Colite Ulcerativa/epidemiologia , Colite Ulcerativa/terapia , Doença de Crohn/epidemiologia , Doença de Crohn/terapia , Humanos , Imunossupressores/classificação , Imunossupressores/uso terapêutico , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Administração dos Cuidados ao Paciente/tendências , Guias de Prática Clínica como Assunto , Risco Ajustado/métodos , SARS-CoV-2/isolamento & purificação , Índice de Gravidade de Doença , Sigmoidoscopia/métodos , Reino UnidoRESUMO
OBJECTIVES: The aim of the study was to characterize epidemiology, phenotype, and clinical outcome of Inflammatory Bowel Disease (IBD) diagnosed ages 2 to 9âyears, and compare age groups 2 to 5 and 6 to 9 years. METHODS: A population-based retrospective cohort study of all <10-year-olds diagnosed with IBD between 2004 and 2017 in Southwest England was performed. Patients were divided into age groups at diagnosis. Demographics, investigations, and phenotype at diagnosis were collected. Treatments and outcomes were analysed at 1, 2, 5, and 10âyears follow-up. Poisson regression was used for IBD incidence rate ratios; Wald test for variation by age group; parametric/nonparametric tests for phenotype. RESULTS: There were 666 new paediatric IBD (pIBD) patients ages ≤16 years, from which 136 were 2 to 9 (2-5âyears: 32; 6-9âyears: 104). Incidence of pIBD increased from 4 to 6 cases per 100,000 whereas in A1a group was stable around 2 cases per 100,000. Crohn Disease (CD) children were majority boys, 2- to 5-year-olds were more likely to have ileal sparing than 6 to 9-year group but had similar rates of surgery and anti-TNF therapy. Two- to 5-year-olds with ulcerative colitis were more likely to have surgery but rates for anti-TNF therapy were similar. Sixteen percent of 2- to 5-year-olds and 10% of 6- to 9-year-olds had IBD-unclassified. No significant differences in symptoms or time to diagnosis were found. CONCLUSIONS: Twenty percent of pIBD in Southwest England are 2 to 9âyears old. pIBD incidence has increased but is stable in that group. In terms of phenotypic differences, ileal sparing in CD and pancolitis and surgery in UC, are more likely in 2- to 5-year-olds.
Assuntos
Colite Ulcerativa , Doenças Inflamatórias Intestinais , Adolescente , Criança , Pré-Escolar , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/epidemiologia , Colite Ulcerativa/terapia , Inglaterra/epidemiologia , Humanos , Incidência , Doenças Inflamatórias Intestinais/epidemiologia , Masculino , Estudos Retrospectivos , Inibidores do Fator de Necrose TumoralRESUMO
OBJECTIVES: Patients with paediatric inflammatory bowel disease (IBD) constitute one of the largest cohorts requiring transition from paediatric to adult services. Standardised transition care improves short and long-term patient outcomes. This study aimed to detail the current state of transition services for IBD in the United Kingdom (UK). METHODS: We performed a nationwide study to ascertain current practice, facilities and resources for children and young people with IBD. Specialist paediatric IBD centres were invited to contribute data on: timing of transition/transfer of care; transition resources available including clinics, staff and patient information; planning for future improvement. RESULTS: Twenty of 21 (95%) of invited centres responded. Over 90% of centres began the transition process below 16âyears of age and all had completed transfer to adult care at 18âyears of age. The proportion of patients in the transition process at individual centres varied from 10% to 50%.Joint clinics were held in every centre, with a mean of 12.9 clinics per year. Adult and paediatric gastroenterologists attended at all sites. Availability of additional team members was patchy across the UK, with dietetic, psychological and surgical attendance available in <50% centres. A structured transition tool was used in 75% of centres. Sexual health, contraception and pregnancy were discussed by <60% of teams. CONCLUSIONS: This study provides real-world clinical data on UK-wide transition services. These data can be used to develop a national strategy to complement current transition guidelines, focused on standardising services whilst allowing for local implementation.
Assuntos
Colite , Doenças Inflamatórias Intestinais , Cuidado Transicional , Adolescente , Adulto , Criança , Feminino , Humanos , Doenças Inflamatórias Intestinais/terapia , Gravidez , Reino UnidoRESUMO
OBJECTIVES: We reviewed all children who have undergone a colectomy for ulcerative colitis (UC) in our tertiary referral centre in a 12-year period to assess the rate of reclassification as Crohn disease (CD). In contrast to CD, a colectomy is considered to be definitive treatment for patients with UC. Distinguishing between the 2 can be challenging when disease is manifest only within the colon-even histological examination of a colectomy specimen may be inconclusive. Historically, the recognised "rediagnosis" rate (post-colectomy) was reported at approximately 3% to 7%. A recent study suggested that a higher rate of 13% should be expected in children. This has implications in terms of pre-operative counselling and surgical decision making. METHODS: A retrospective case-note review of all patients who underwent a colectomy for UC between 2003 and 2014 in a single paediatric tertiary referral centre was performed. RESULTS: Of the 570 children diagnosed with inflammatory bowel disease in this period, 190 were diagnosed as UC. Of these 190 cases, 29 underwent a colectomy. None of these was re-classified following histological examination of the colectomy sample. Seven out of the 29 patients (24%) were subsequently diagnosed with CD (median follow-up 7.6 years). This is significantly higher than previously reported rates (Pâ=â0.003). CONCLUSIONS: Our data suggest that later manifestation of CD is more common than previously thought (24%). Therefore, a diagnosis of UC in children should be regarded as provisional and a potential later diagnosis of CD taken into account when considering colectomy and J-pouch formation.
Assuntos
Colectomia , Colite Ulcerativa/diagnóstico , Doença de Crohn/diagnóstico , Adolescente , Criança , Pré-Escolar , Colite Ulcerativa/patologia , Colite Ulcerativa/cirurgia , Doença de Crohn/patologia , Doença de Crohn/cirurgia , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Centros de Atenção TerciáriaRESUMO
OBJECTIVE: The European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines for diagnosing celiac disease (CD) in children were modified in 2012. They recommend that in symptomatic children with anti-tissue transglutaminase antibody (anti-tTG) titer of >10 times upper limit of normal (>10× ULN) and who have positive anti-endomysial antibody and HLA-DQ2/DQ8 haplotype, the diagnosis of CD can be based on serology. The aim of this study is to establish whether serology-based pathway of the ESPGHAN guidelines could also be reliably applied to asymptomatic children from high-risk groups. METHODS: From March 2007 to February 2017, prospective data on anti-tTG titer, age, sex, and reason for screening were collected at diagnostic endoscopy on all asymptomatic children being diagnosed as having CD. The relationship between modified Marsh-Oberhuber classification histological grading and contemporaneous anti-tTG titers was analyzed. RESULTS: A total of 157 asymptomatic children were diagnosed as having CD. Eighty-four of 157 (53.5%) had antitTG >10× ULN (normal <10âIU/mL) and 75 of 84 were from high-risk groups. All 75 had definitive histological evidence (Marsh-Oberhuber 3a-3c) of small bowel enteropathy. Fifty-three of 84 children had anti-tTG >200âIU/mL and total villous atrophy was present in 29 of 53 (55%). Main reasons for serological screening were: type-1 diabetes mellitus (nâ=â36) and first-degree relatives with CD (nâ=â24). Mean age at diagnosis was 8.8 years. Serology-based diagnosis is cost-beneficial by around £1275 per child in the United Kingdom. CONCLUSIONS: All 75 asymptomatic children from high-risk groups with anti-tTG >10× ULN had histology-proven CD. This study provides further evidence that the guidelines for diagnosing CD by the serology-based pathway should be extended to these children.
Assuntos
Autoanticorpos/sangue , Doença Celíaca/diagnóstico , Programas de Rastreamento/métodos , Adolescente , Doença Celíaca/sangue , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Intestino Delgado/patologia , Masculino , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Fatores de RiscoRESUMO
The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.
Assuntos
Colectomia , Doença de Crohn/cirurgia , Intestino Delgado/cirurgia , Assistência Perioperatória/métodos , Anastomose Cirúrgica , Anti-Inflamatórios/uso terapêutico , Terapia Biológica , Quimioterapia Adjuvante , Criança , Colectomia/métodos , Doença de Crohn/tratamento farmacológico , Procedimentos Cirúrgicos Eletivos , Humanos , Imunossupressores/uso terapêutico , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Recidiva , Prevenção Secundária/métodosRESUMO
Chronic recurrent multifocal osteomyelitis (CRMO) has been reported in association with inflammatory bowel disease (IBD), mostly in children. We describe the UK paediatric experience of CRMO and IBD and review the global literature. Three cases of CRMO and IBD were identified in UK children during the last 10 years. This adds to the previously published 24 cases worldwide (15 children). We provide further evidence for the true association of CRMO and IBD, and a greater understanding of disease course. CRMO may be considered a rare extraintestinal complication of IBD.
Assuntos
Doenças Inflamatórias Intestinais/complicações , Osteomielite/complicações , Corticosteroides/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Criança , Pré-Escolar , Feminino , Humanos , Doenças Inflamatórias Intestinais/tratamento farmacológico , MasculinoRESUMO
BACKGROUND: Faecal volatile organic compounds (VOCs) differ with disease sub-type and activity in adults with established inflammatory bowel disease (IBD) taking therapy. OBJECTIVE: To describe patterns of faecal VOCs in children newly presented with IBD according to disease sub-type, severity, and response to treatment. METHODS: Children presenting with suspected IBD were recruited from three UK hospitals. Children in whom IBD was diagnosed were matched with a non-IBD child for age, sex, and recruitment site. Faecal VOCs were characterised by gas chromatography-mass spectrometry at presentation and 3 months later in children with IBD. RESULTS: In 132 case/control pairs, median (inter-quartile range) age in IBD was 13.3 years (10.2-14.7) and 38.6% were female. Compared with controls, the mean abundance of 27/62 (43.6%) faecal VOCs was statistically significantly decreased in Crohn's disease (CD), ulcerative colitis (UC) or both especially amongst ketones/diketones, fatty acids, and alcohols (p < 0.05). Short-chain, medium chain, and branched chain fatty acids were markedly reduced in severe colitis (p < 0.05). Despite clinical improvement in many children with IBD, the number and abundance of almost all VOCs did not increase following treatment, suggesting persistent dysbiosis. Oct-1-en-3-ol was increased in CD (p = 0.001) and UC (p = 0.012) compared with controls and decreased following treatment in UC (p = 0.01). In CD, propan-1-ol was significantly greater than controls (p < 0.001) and extensive colitis (p = 0.001) and fell with treatment (p = 0.05). Phenol was significantly greater in CD (p < 0.001) and fell with treatment in both CD (p = 0.02) and UC (p = 0.01). CONCLUSION: Characterisation of faecal VOCs in an inception cohort of children with IBD reveals patterns associated with diagnosis, disease activity, and extent. Further work should investigate the relationship between VOCs and the microbiome in IBD and their role in diagnosis and disease monitoring.
Assuntos
Colite Ulcerativa , Doença de Crohn , Fezes , Índice de Gravidade de Doença , Compostos Orgânicos Voláteis , Humanos , Compostos Orgânicos Voláteis/análise , Feminino , Fezes/química , Fezes/microbiologia , Masculino , Criança , Estudos de Casos e Controles , Adolescente , Colite Ulcerativa/tratamento farmacológico , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/terapia , Doença de Crohn/diagnóstico , Doença de Crohn/tratamento farmacológico , Doença de Crohn/terapia , Cromatografia Gasosa-Espectrometria de Massas , Resultado do Tratamento , Reino Unido , Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/tratamento farmacológicoRESUMO
BACKGROUND: Pediatric inflammatory bowel disease (pIBD) incidence has increased over the last 25 years. We aim to report contemporaneous trends across the South West United Kingdom. METHODS: Data were provided from centers covering the South West United Kingdom (Bristol, Oxford, Cardiff, Exeter, and Southampton), with a total area at-risk population (<18 years of age) of 2 947 534. Cases were retrieved from 2013 to 2022. Incident rates were reported per 100 000 at-risk population, with temporal trends analyzed through correlation. Subgroup analysis was undertaken for age groups (0-6, 6-11, and 12-17 years of age), sex, and disease subtype. Choropleth maps were created for local districts. RESULTS: In total, 2497 pIBD cases were diagnosed between 2013 and 2022, with a mean age of 12.6 years (38.7% female). Diagnosis numbers increased from 187 to 376, with corresponding incidence rates of 6.0 per 100 000 population per year (2013) to 12.4 per 100 000 population per year (2022) (bâ =â 0.918, P < .01). Female rates increased from 5.1 per 100 000 population per year in 2013 to 11.0 per 100 000 population per year in 2022 (bâ =â 0.865, P = .01). Male rates increased from 5.7 per 100 000 population per year to 14.4 per 100 000 population per year (bâ =â 0.832, P = .03). Crohn's disease incidence increased from 3.1 per 100 000 population per year to 6.3 per 100 000 population per year (bâ =â 0.897, P < .01). Ulcerative colitis increased from 2.3 per 100 000 population per year to 4.3 per 100 000 population per year (bâ =â 0.813, P = .04). Inflammatory bowel disease unclassified also increased, from 0.6 per 100 000 population per year to 1.8 per 100 000 population per year (bâ =â 0.851, P = .02). Statistically significant increases were seen in those ≥12 to 17 years of age, from 11.2 per 100 000 population per year to 24.6 per 100 000 population per year (bâ =â 0.912, P < .01), and the 7- to 11-year-old age group, with incidence rising from 4.4 per 100 000 population per year to 7.6 per 100 000 population per year (bâ =â 0.878, P = .01). There was no statistically significant increase in very early onset inflammatory bowel disease (≤6 years of age) (bâ =â 0.417, P = .231). CONCLUSIONS: We demonstrate significant increases in pIBD incidence across a large geographical area including multiple referral centers. Increasing incidence has implications for service provision for services managing pIBD.
Incidence of inflammatory bowel disease continues to increase in childhood, particularly in older children. This is demonstrated in a contemporary dataset collected over a 10-year period, and covering an at-risk population of nearly 3 000 000. These data have significant implications for service provision.
RESUMO
OBJECTIVE: European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines on coeliac disease (CD) recommend that children who have IgA-based antitissue transglutaminase (TGA-IgA) titre ≥10× upper limit of normal (ULN) and positive antiendomysial antibody, can be reliably diagnosed with CD via the no-biopsy pathway. The aim of this study was to examine the relationship between TGA-IgA ≥5×ULN and histologically confirmed diagnosis of CD. METHODS: Data including TGA-IgA levels at upper gastrointestinal endoscopy and histological findings from children diagnosed with CD following endoscopy from 2006 to 2021 were analysed. CD was confirmed by Marsh-Oberhuber histological grading 2 to 3 c. Statistical analysis was performed using χ² analysis (p<0.05= significant). RESULTS: 722 of 758 children had histological confirmation of CD. 457 children had TGA-IgA ≥5×ULN and 455 (99.5%) of these had histological confirmation for CD; the two that did not had eventual diagnosis of CD based on clinicopathological features. 114 of 457 had between TGA-IgA ≥5×ULN and <10×ULN, all had confirmed CD. The likelihood of a positive biopsy with TGA-IgA ≥5×ULN (455/457) compared with TGA-IgA <5×ULN (267/301) has strong statistical significance (p<0.00001). The optimal TGA-IgA cut-off from receiver operating characteristic curve analysis was determined to be below 5×ULN for the two assays used. CONCLUSION: 99.5% of children with TGA-IgA ≥5×ULN had histological confirmation of CD, suggesting that CD diagnosis can be made securely in children with TGA-IgA ≥5×ULN. If other studies confirm this finding, there is a case to be made to modify the ESPGHAN guidelines to a lower threshold of TGA-IgA for serological diagnosis of CD.
Assuntos
Doença Celíaca , Transglutaminases , Autoanticorpos , Biópsia , Doença Celíaca/diagnóstico , Criança , Humanos , Imunoglobulina A , Transglutaminases/sangueRESUMO
BACKGROUND: COVID-19 has impacted on healthcare provision. Anecdotally, investigations for children with inflammatory bowel disease (IBD) have been restricted, resulting in diagnosis with no histological confirmation and potential secondary morbidity. In this study, we detail practice across the UK to assess impact on services and document the impact of the pandemic. METHODS: For the month of April 2020, 20 tertiary paediatric IBD centres were invited to contribute data detailing: (1) diagnosis/management of suspected new patients with IBD; (2) facilities available; (3) ongoing management of IBD; and (4) direct impact of COVID-19 on patients with IBD. RESULTS: All centres contributed. Two centres retained routine endoscopy, with three unable to perform even urgent IBD endoscopy. 122 patients were diagnosed with IBD, and 53.3% (n=65) were presumed diagnoses and had not undergone endoscopy with histological confirmation. The most common induction was exclusive enteral nutrition (44.6%). No patients with a presumed rather than confirmed diagnosis were started on anti-tumour necrosis factor (TNF) therapy.Most IBD follow-up appointments were able to occur using phone/webcam or face to face. No biologics/immunomodulators were stopped. All centres were able to continue IBD surgery if required, with 14 procedures occurring across seven centres. CONCLUSIONS: Diagnostic IBD practice has been hugely impacted by COVID-19, with >50% of new diagnoses not having endoscopy. To date, therapy and review of known paediatric patients with IBD has continued. Planning and resourcing for recovery is crucial to minimise continued secondary morbidity.
Assuntos
COVID-19 , Serviços de Saúde da Criança , Endoscopia Gastrointestinal , Acessibilidade aos Serviços de Saúde , Doenças Inflamatórias Intestinais , Inibidores do Fator de Necrose Tumoral/uso terapêutico , Adolescente , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Instituições de Assistência Ambulatorial/provisão & distribuição , COVID-19/epidemiologia , COVID-19/prevenção & controle , Criança , Serviços de Saúde da Criança/estatística & dados numéricos , Serviços de Saúde da Criança/provisão & distribuição , Controle de Doenças Transmissíveis/métodos , Endoscopia Gastrointestinal/métodos , Endoscopia Gastrointestinal/estatística & dados numéricos , Nutrição Enteral/métodos , Nutrição Enteral/estatística & dados numéricos , Feminino , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/normas , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/epidemiologia , Doenças Inflamatórias Intestinais/terapia , Masculino , SARS-CoV-2 , Reino Unido/epidemiologiaRESUMO
OBJECTIVES: Peutz-Jeghers syndrome (PJS) in children may present with anaemia, intussusception, or obstruction from an early age and surgery is common. Prophylactic polypectomy may reduce subsequent complications. Traditional barium enterography (BE) has poor sensitivity and requires significant radiation. We compared the performance of capsule endoscopy (CE) with BE in children with PJS. MATERIALS AND METHODS: Children with PJS (ages 6.0-16.5 years) were prospectively recruited and underwent BE followed by CE, each reported by expert reviewers blinded to the alternate modality. Number of "significant" (>10 mm) and total number of polyps were recorded. Child preference was assessed using a visual analogue questionnaire. Definitive findings were assessed at laparotomy or enteroscopy, when performed. RESULTS: There was no significant difference for >10 mm polyp detection. Six polyps were found in 3 children by both modalities: 3 polyps in 2 children at CE, 3 polyps in 1 child at BE (P=0.50). Re-review of 1 CE identified 3 polyps that were missed in 1 child at initial reading. Significantly more <10 mm polyps were identified by CE than BE: 61 vs 6 (P=0.02). CE was significantly more comfortable than BE (median score CE 76 [interquartile range 69-87] vs BE 37 [interquartile range 31-68], P=0.03) and was the preferred investigation in 90% (P=0.02). CONCLUSIONS: CE is a feasible, safe, and sensitive test for small bowel polyp surveillance in children with PJS. It is significantly more comfortable than BE and is the preferred test of most children for future surveillance. There is a learning curve for reporting CE studies in PJS and appropriate training is essential.
Assuntos
Endoscopia por Cápsula/métodos , Pólipos Intestinais/patologia , Intestino Delgado/patologia , Síndrome de Peutz-Jeghers/patologia , Radiografia Abdominal/métodos , Adolescente , Bário , Criança , Feminino , Fluoroscopia/métodos , Humanos , Pólipos Intestinais/diagnóstico por imagem , Intestino Delgado/diagnóstico por imagem , Masculino , Satisfação do Paciente , Síndrome de Peutz-Jeghers/diagnóstico por imagem , Sensibilidade e Especificidade , Método Simples-CegoRESUMO
Background: Pediatric ulcerative colitis (UC) presents at an earlier age and increasing prevalence. Our aim was to examine morbidity, steroid sparing strategies, and surgical outcome in children with active UC. Methods: A national prospective audit was conducted for the inpatient period of all children with UC for medical or surgical treatment in the United Kingdom (UK) over 1 year. Thirty-two participating centers recruited 224 children in 298 admissions, comparisons over 6 years were made with previous audits. Results: Over 6 years, recording of Paediatric Ulcerative Colitis Activity Index (PUCAI) score (median 65)(23% to 55%, P < 0.001), guidelines for acute severe colitis (43% to 77%, P < 0.04), and ileal pouch surgery registration (4% to 56%, P < 0.001) have increased. Corticosteroids were given in 183/298 episodes (61%) with 61/183 (33%) not responding and requiring second line therapy or surgery. Of those treated with anti-TNFalpha (16/61, 26%), 3/16 (18.8%) failed to respond and required colectomy. Prescription of rescue therapy (26% to 49%, P = 0.04) and proportion of anti-TNFalpha (20% to 53%, P = 0.03) had increased, colectomy rate (23.7% to 15%) was not significantly reduced (P = 0.5). Subtotal colectomy was the most common surgery performed (n = 40), and surgical complications from all procedures occurred in 33%. In 215/224 (96%) iron deficiency anemia was detected and in 51% treated, orally (50.2%) or intravenously (49.8%). Conclusions: A third of children were not responsive to steroids, and a quarter of these were treated with anti-TNFalpha. Colectomy was required in 41/298 (13.7%) of all admissions. Our national audit program indicates effectiveness of actions taken to reduce steroid dependency, surgery, and iron deficiency. 10.1093/ibd/izy042_video1izy042.video15769503407001.
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Colectomia/estatística & dados numéricos , Colite Ulcerativa/terapia , Imunossupressores/uso terapêutico , Esteroides/uso terapêutico , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adolescente , Criança , Pré-Escolar , Colectomia/efeitos adversos , Colite Ulcerativa/epidemiologia , Feminino , Humanos , Masculino , Estudos Prospectivos , Resultado do Tratamento , Reino Unido/epidemiologiaRESUMO
BACKGROUND: The majority of children with Crohn disease (CD) are likely to need some form of immunomodulatory therapy to maintain remission and to avoid long-term corticosteroid usage. Although thiopurine agents are commonly used, some children are unresponsive or intolerant to these drugs. Biological agents like infliximab are being increasingly used in these circumstances, but long-term safety has yet to be established. Methotrexate has been shown to induce and maintain remission in CD in many adult studies, but pediatric data are limited. The present report describes our experience of using methotrexate in CD in children. PATIENTS AND METHODS: All children with CD treated with methotrexate were identified by the departmental database. Case records were reviewed for site of disease, Pediatric Crohn Disease Activity Index, medications, time to achieve remission, duration of remission, and complications. RESULTS: A total of 10 children received methotrexate, 7 of whom were female and 3 of whom were male. All of the children had colonic involvement and had active disease despite previous standard medical treatments. Seven children exhibited remission with methotrexate treatment. Median time to achieve remission was 12 weeks and median duration of remission was 21 months to the point of assessment. One child had transient increase of alanine aminotransferase levels and another developed neutropenia, which remitted with dose reduction. None needed discontinuation of methotrexate treatment. CONCLUSIONS: Methotrexate is effective and well tolerated in children with CD. It should be considered in those patients who do not experience a remission with standard medications because it may avoid the use of biological agents and their potential uncertain long-term side effects.
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Doença de Crohn/tratamento farmacológico , Imunossupressores/uso terapêutico , Metotrexato/uso terapêutico , Adolescente , Criança , Feminino , Humanos , MasculinoRESUMO
INTRODUCTION: No study to date has evaluated perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) in pediatric inflammatory bowel disease-unclassified (IBDU) as compared with Crohn's colitis (CC) and ulcerative colitis (UC), which represent the diagnostic challenge. We aimed to explore the diagnostic utility of serology and to assess whether serology can predict disease severity in these subgroups. METHODS: This was a multicenter retrospective longitudinal study including 406 children with inflammatory bowel diseases (IBD) from 23 centers affiliated with the Porto group of European Society of Pediatric Gastroenterology, Hepatology and Nutrition (mean age 10.5 ± 3.9, 54% males); 117 (29%) with CC, 143 (35%) with UC, and 146 (36%) with IBDU. Median follow-up period was 2.8 years (interquartile range, 1.6-4.2). RESULTS: The most prevalent serologic profile in IBDU was pANCA-/ASCA- (41%), followed by pANCA+/ASCA- (34%) and pANCA-/ASCA+ (17%). pANCA-/ASCA+ differentiated well between CC versus IBDU (83% specificity, 96% positive predictive value [PPV]) and UC (97% specificity, 90% PPV) patients, albeit with a low negative predictive value (13% and 40%, respectively). pANCA+/ASCA- did not differentiate as well between IBD subgroups, but UC children with pANCA+/ASCA- had more often severe disease at diagnosis (36 [62%] versus 22 [38%], P = 0.033) and needed more often calcineurin inhibitors, biologics, or colectomy (25 [80%] versus 6 [20%], P = 0.026). In CC, double positivity for ASCA and not pANCA-/ASCA+ profile was associated with disease severity. CONCLUSIONS: Serology may have some role in predicting disease course and outcomes in colonic IBD, but its routine use needs to be supported by more studies. Serology cannot routinely be recommended for differentiating between IBDU versus CC or UC as a sole diagnostic criterion given its low diagnostic utility.
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Anticorpos Anticitoplasma de Neutrófilos/sangue , Anticorpos Antibacterianos/sangue , Colite Ulcerativa/diagnóstico , Doença de Crohn/diagnóstico , Saccharomyces cerevisiae/imunologia , Adolescente , Produtos Biológicos/uso terapêutico , Inibidores de Calcineurina/uso terapêutico , Criança , Pré-Escolar , Colite Ulcerativa/sangue , Colite Ulcerativa/tratamento farmacológico , Doença de Crohn/sangue , Doença de Crohn/tratamento farmacológico , Diagnóstico Diferencial , Feminino , Humanos , Doenças Inflamatórias Intestinais/sangue , Doenças Inflamatórias Intestinais/diagnóstico , Estudos Longitudinais , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
BACKGROUND AND AIMS: Long-term effects of using enteral feed therapy to induce remission in paediatric Crohn's disease are poorly documented. The aim of this study is to examine the short and long-term impact of enteral nutrition as primary therapy for children with newly diagnosed Crohn's disease. METHODS: Since 1994, a data base was set up in Bristol for all children with inflammatory bowel diseases. The data of newly diagnosed patients with Crohn's disease in whom enteral nutrition was used as the primary therapy (44 children) was analysed, with particular reference to time to remission, to first and subsequent relapse, and to first steroid usage. RESULTS: Forty out of 44 patients (90%) responded to enteral nutrition, with a median time to remission of 6 weeks. 25 of these 40 (62%) relapsed, with a median duration of remission of 54.5 weeks (range 4-312). 15 (38%) have not relapsed. 21 of the 44 (47%) have not received steroids. In those who eventually required steroids, their use was postponed for a median 68 weeks (range 6-190). Site of disease activity had no impact on response to enteral nutrition, but there was a trend towards earlier relapse in those with isolated colonic involvement. CONCLUSIONS: This data suggests that there are long-term benefits to the use of enteral nutrition to induce remission in children with Crohn's disease Steroids may be avoided in nearly half the cases and, in others, their use postponed by 68 weeks.
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Doença de Crohn/terapia , Nutrição Enteral/métodos , Crescimento , Esteroides/uso terapêutico , Adolescente , Criança , Doença de Crohn/tratamento farmacológico , Feminino , Humanos , Estudos Longitudinais , Masculino , Recidiva , Indução de Remissão , Fatores de Tempo , Resultado do TratamentoRESUMO
Coeliac Disease (CD) is an immune-mediated systemic disorder elicited by the ingestion of gluten. Small-bowel biopsies and histology has been the gold standard for diagnosing CD. The modified ESPGHAN guidelines recommend that in symptomatic children with anti-tissue-Transglutaminase (tTG) titre of > 10 times Upper-Limit-of-Normal (ULN), diagnosis of CD can be made without small-bowel biopsies. However, positive HLA-DQ2/DQ8 serotype and anti-Endomysial Antibodies (EMA) are necessary. Studies from resource-limited countries have demonstrated applicability of the ESPGHAN guidelines for serological diagnosis of CD. CD should not be diagnosed on the basis of a single high tTG-titre. Small-bowel biopsies are necessary for diagnosing CD in asymptomatic children and those with tTG-titre < 10 x ULN. Management of CD needs lifelong gluten free diet.