Paediatric Upper & Lower GI Disorders - Crohn's, IBD, UC

Question 1

Incidence of Crohn’s Disease in Scottish Children - how is it changing?

Answer 1

increasing

Question 2

what are the Presenting Features of CD and UC and how do they differ between one another?

Answer 2

In UC, most have diarrhea, rectal bleeding and abdominal pain

Blood diarrohoea more than a couple weeks = think about UC

CD almost always shows up on blood tests whereas UC is a bit more difficult as blood tests often more normal

Question 3

how is a diagnosis of IBD made?

Answer 3

• History & Examination
• Intestinal symptoms (Not a lot of signs normally)
• Extra-intestinal manifestations
• Exclude infection
• Family History
• Growth and sexual development (particularly for CD)
• Nutritional status (take weight and height and plot on growth chart, not single one off measurement but longitudinal measurement)

Question 4

what is shown here?

Answer 4

ERYTHEMA NODOSUM:

See it commonly

More so in CD

Question 5

what can happen to the mouth in IBD?

Answer 5

Oral changes:

ulcers

rounded edge

Question 6

what Laboratory investigations can be done to make a diagnosis?

Answer 6

Full blood count & ESR (Do blood tests, particularly point you to CD):

• Anaemia
• Thrombocytosis
• Raised ESR

Biochemistry:

• Stool calprotectin (the key these days)
• Raised CRP
• Low Albumin (particularly in CD, tends to be due to leaking protein in gut and passing it out in stool, tends to be that more so than a nutritional problem)

Microbiology:

•No stool pathogens

Question 7

Differences between adult and paediatric IBD rates

Answer 7

Children’s tend to be more severe and more extensive

IBDU - know they have IBD but cant say which one it is

Question 8

Differences to adult UC:

how common in Proctitis in adults and children?

Answer 8

Paediatric:

4% < 5 years

17% 5 – 17 years

Adult = 40%

Proctitis most typical in adults

Question 9

Differences to adult UC:

how common in L sided colitis adults and children?

Answer 9

Paediatric = 14%

Adult = 40%

Question 10

Differences to adult UC:

how common in Pancolitis adults and children?

Answer 10

Paediatric = >60%

Adult = 20%

In paeds closer to 80%

Much more severe and extensive phenotype

In children use more biologics

Question 11

Differences to adult Crohn’s Disease

how common in isolated ilial in adults and children?

Answer 11

Paediatric = 6%

Adults = 36%

Question 12

Differences to adult Crohn’s Disease

how common in Ileocolonic in adults and children?

Answer 12

Paediatric = 45%

Adults = 50%

Question 13

Differences to adult Crohn’s Disease

how common in Upper GI/panenteric in adults and children?

Answer 13

Paediatric = 51%

Adults = ?%

far less frequent in adults

Question 14

what are some definitive investigaitons that could be done for IBD?

Answer 14

Radiology (especially Crohn’s disease):

• MRI
• Barium meal and follow-through (younger kids)

Endoscopy:

• Colonoscopy & Upper GI endoscopy
• Mucosal biopsy
• Capsule enteroscopy
• Enteroscopy

we struggle to get a look into the small bowel

Question 15

what is shown here?

Answer 15

Ulcerative colitis

Colonoscopy

Severe bloody stools

Abdomen pain

Sloopy muco pus, contact bleeding, white dots are crypt abscesses (on histology crypt is full of puss)

Question 16

what is shown here?

Answer 16

Crohn’s disease

Typical ulcers (looks like slime of snail)

Question 17

what is shown here?

Answer 17

Could be either ……

These are the ones we put in the IBDU category

Question 18

histopatholigy - Pathology very helpful

what is shown here?

Answer 18

2 left you can see granuloma and you know you have CD – don’t see in all children with CD

Right is UC – disordered crypts, pus in crypts, great increase in inflammatory cells

Question 19

what are the Aims of Treatment?

Answer 19

• Induce and maintain remission
• Correct nutritional deficiencies
• Maintain normal growth and development:

Growth is what makes management harder in children than adults

Inflammation and steroid use will affect growth and slow it

Try avoid steroids and get disease under control

Kids have more extensive and severe disease

Question 20

what are the methods of treatment?

Answer 20

• Medical - Anti-inflammatory, Immuno-suppressive, Biologicals ( Infliximab)
• Nutritional (Nutritional therapy particularly for CD) - Immune modulation, Nutritional supplementation
• Surgical

Sometimes have to use surgery, use it for UC if we cant bring it under control, we do colectomies, pouch surgery

In CD its never curative so do as limited surgery as we can

Question 21

what is “Bottom-up” treatment for Crohn’s disease?

Answer 21

Start with gentle treatment

2nd step is things like immunomodulation that stops the inflammation coming back again

You can do surgery before biologics sometimes