PEDIATRIC INFLAMMATORY BOWEL DISEASE Alexis Rodriguez, MD - - PDF document

4/6/18 1

PEDIATRIC INFLAMMATORY BOWEL DISEASE

Alexis Rodriguez, MD Pediatric Gastroenterology Advocate Children’s Hospital

Disclosers

• Abbott Nutrition - Speaker

Inflammatory Bowel Disease

• Chronic inflammatory disease of the gastrointestinal tract

~ Can affect any area of GI tract

• 2 Major Types:

~ Crohn’s Disease ~ Ulcerative Colitis

• Other Types:

~ Indeterminate colitis ~ Very Early Onset (VEO-IBD)

• Has relapsing and remitting course

~ Goal is to induce and stay in remission

• Exact pathogenesis poorly understood

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4/6/18 3 Environmental Factors

• Smoking is a risk factor for CD (OR = 1.76; 95% CI:

1.40-2.22)

• Protective against UC
• Appendectomy is a risk factor for CD
• Protective against UC (OR = 0.31; 95% CI:

0.25-0.38)

• Vitamin D deficiency risk factor for aggressive CD and UC
• Western diet risk factor for both UC and CD
• High sugar
• High animal protein
• Decreased complex carbohydrates/plant fibers

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Alliment Pharm May 2015; 42(2)

4/6/18 5 How common is IBD?

• Incidence increasing among children
• Approx 1.6 million Americans with IBD
• Pediatric Incidence:

~ CD: 10.7/100,000 ~ UC: 12.2/100,000

• Pediatric Prevalence:

~ 45,000 – 100,000 children with IBD ~ 100,000 cases diagnosed annually

Age of Onset

4/6/18 6 Children Vs. Adults

• Similarities with adults:

~ Disease pathophysiology similar ~ Many of the same treatments

• Differences from adults:

~ Lack of data ~ Not as many treatment options ~ Growth and development issues

Presentation Extraintestinal Symptoms

• Arthropathies
• Optho:

~ Episcleritis ~ Uveitis

• Derm:

~ Erythema Nodosum ~ Pyoderma Gangrenosum

• Liver:

~ Primary Sclerosing Cholangitis

4/6/18 7 Initial workup

• CBC with differential

~ Anemia ~ Thrombocytosis

• CMP

~ Hypoalbuminemia

• Inflammatory markers

~ CRP, ESR ~ Stool calprotectin

• Infectious studies

~ Stool culture, O&P, C.diff

Differential Diagnosis

• Bacteria: Non Infectious:

~ C.diff ~ HSP ~ Yersinia ~ Behcet’s ~ TB ~ Celiac

• Virus: ~ Immunodeficiency

~ HIV ~ Eating disorder ~ CMV ~ Appendicitis ~ EBV ~ Functional

• Parasites:

~ Amoebiasis ~ Giardiasis

Refer to GI

4/6/18 8 Crohn’s Endoscopy

4/6/18 9 UC Endoscopy

4/6/18 10 Histology Small Bowel Imaging

• Upper GI with small bowel follow through
• MR Enterography

Small Bowel Imaging

• Capsule Endoscopy

4/6/18 11 Goals of IBD Treatment

• Improve growth and nutrition
• Improve quality of life
• Maximize therapeutic response
• Minimize toxicity
• Prevent disease complications
• Maximize adherence
• Promote psychological health

INDUCE REMISSION = CLINICAL RESPONSE

4/6/18 12 Goals of IBD Treatment

• Improve growth and nutrition
• Improve quality of life
• Maximize therapeutic response
• Minimize toxicity
• Prevent disease complications
• Maximize adherence
• Promote psychological health

INDUCE REMISSION = CLINICAL RESPONSE MUCOSAL HEALING

4/6/18 13 “Step Up” Approach Future Directions – Step Down?? Corticosteroids

• Used to induce remission only

~ Try to wean off as soon as possible

• Oral, rectal and IV forms available
• Suppresses active inflammation
• Can be used for Crohn’s and UC

~ Usually started for disease flares ~ Can serve as bridge to maintenance medication

• Problem with side effects

~ Less with budesonide (Entocort)

4/6/18 14 Aminosalicylates Aminosalicylates (5-ASA)

• Often first line treatment for mild UC

~ unclear efficacy in Crohn’s

• Oral and rectal preparations available

~ combination most effective for distal disease

• Locally reduce inflammation in the bowel wall

~ no systemic effects

• Can be used for induction and maintenance
• Generally well tolerated

~ side effects (headaches, GI symptoms) more with sulfasalazine

• Adherence can be an issue due to large number of pills

Immunomodulators

• Thiopurines (6-MP, Azathioprine), Methotrexate
• Suppress immune response that triggers intestinal

damage

• Used for moderate-severe Crohn’s and UC

~ Usually for maintenance therapy ~ Takes weeks to reach maximum efficacy levels

• Side effects:

~ Bone marrow suppression ~ Hepatitis ~ Teratogenic ~ LYMPHOMA

4/6/18 15 Biologics

• Anti TNF-α monoclonal antibodies

~ Pro-inflammatory cytokine involved in IBD ~ Neutralizes TNF-α and down-regulates other pro- inflammatory cytokines

• Anti- integrin antibodies

~ Prevents attachment of T cells to vessel walls in gut

• Anti-IL 12 and 23 cytokines

~ Disrupts cytokine signaling in inflammatory response

• Used for severe Crohn’s and UC
• Side effects include infections, infusion reactions,

lymphoma

4/6/18 16 Surgery

• Usually last resort for medically refractory disease
• Can involve limited resection, partial colectomy, total

colectomy with pouch creation

• Total colectomy curative for UC

4/6/18 17 Exclusive Enteral Nutrition

• First line for induction therapy for Crohn’s in Europe
• 100% of nutrition by formula

~ No differences in type of formula

• As effective as steroids in inducing mucosal healing
• Exact mechanism unknown

~ Possible effect through changing microbiota

• Cons:

~ Difficult to sustain ~ Cost ~ Resource demands

4/6/18 18 THANK YOU