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Pediatric Update


Pediatric Update

Spring 2006

Avoid Delays When Diagnosing Inflammatory Bowel Disease

Paying careful attention to subtle or atypical symptoms of inflammatory bowel disease (IBD) can help physicians avoid delaying the diagnosis of these chronic conditions, including ulcerative colitis and Crohn’s disease, which are characterized by inflammation of the gastrointestinal tract.

Ulcerative colitis causes inflammation and micro-ulcers in the lining of the large intestine; the inflammation usually occurs in the rectum and lower part of the colon, but it may affect the entire colon. Crohn’s disease usually causes inflammation in the small intestine; the inflammation usually occurs in the ileum, which is in the lowest part of the small intestine, but can affect any part of the digestive tract.

According to Marvin Ament, M.D., chief of the Division of Pediatric Gastroenterology at Mattel Children’s Hospital at UCLA, children who experience unexplained episodes of diarrhea three or four times a year should be evaluated for IBD even if their symptoms do not seem severe. “Outside of infancy, it is not typical to have multiple episodes of diarrhea each year,” he states.

Patients with Crohn’s disease often display no obvious symptoms other than the failure to gain weight and grow. “If a child doesn’t gain weight and grow for six months, something is amiss,” asserts Dr. Ament. “It doesn’t mean they have inflammtory bowel disease—they may have some other disorder—but physicians must try to find an explanation and Crohn’s should be considered as a possible diagnosis.” Among children with Crohn’s disease, 30 percent to 40 percent present with growth failure as the primary symptom of their condition. Along with failure to gain weight and grow, some Crohn’s disease patients experience extra-intestinal symptoms of the disease, including unexplained arthralgia (pain in joints) or joint tenderness for months or years before the gastrointestinal symptoms become apparent.

Symptoms of ulcerative colitis, including abdominal pain, diarrhea and rectal bleeding, can begin to manifest in the first three months of life, especially when there is a family history of colitis. Dr. Ament observes that infants who have ulcerative colitis tend to have a much more severe course of the disease; they tend to be more symptomatic and more difficult to treat.

Testing for IBD

Stool and blood tests help distinguish IBD from irritable bowel syndrome, an uncomfortable but less serious colon condition than IBD. Dr. Ament suggests ordering fecal leukocytes, fecal alpha-1 antitrypsin (to check for protein leakage across the intestinal mucosa), sedimentation rates, and C-reactive protein tests. If these tests are negative for IBD, chances are high—95 percent—that the patient does not have IBD. “If these screening tests are negative and you’re still suspicious, then a colonoscopy and biopsy should be ordered as the ultimate test,” Dr. Ament says. “This will be necessary in less than one in 20 patients who have negative stool test results.”

Serological marker tests (an IBD screening panel) can help differentiate between Crohn’s disease and ulcerative colitis, but usually do not provide a definitive diagnosis. “Some serological marker patterns indicate that a patient is more likely to have ulcerative colitis, some are more consistent with Crohn’s disease,” notes Dr. Ament. “But for many patients the serological markers don’t make a strong case in either direction. For these, you just have to use other information to make the diagnosis.”

Advances in IBD Treatment

Corticosteroids and isomers of mesalamine have been the traditional medical treatments for IBD. Current IBD drug therapies for both ulcerative colitis and Crohn’s disease—including 6-mercaptopurine (Purinethol®), a chemotherapy agent; infliximab (Remicade®), a monoclonal antibody; and tacrolimus (Prograf®), an immunosuppressant—control inflammation and can help patients avoid taking steroids.

Some patients lack the enzyme necessary to metabolize 6-m ercaptopurine. A new test can determine which patients lack this enzyme, and thereby avoid waiting four to six weeks to learn that their bodies don’t produce the metabolites necessary to treat their condition. It can also help predict cases when the patient’s body will produce metabolites that may lead to hepatitis or bone marrow suppression.

Surgical procedures to remove part of the intestine in Crohn’s disease have declined due to improved medical options for the condition. “We used to say that the average patient with Crohn’s disease would have surgery two or three times in their lifetime; I don’t know that we can say that they will have to have surgery even once in their lifetime anymore,” Dr. Ament notes.

Surgical management of ulcerative colitis has improved. Patients who don’t respond to or have adverse reactions to medical therapies may be good candidates for an ileoanal pull-through procedure in which 90 percent to 95 percent of the colon is removed, and the rectal wall preserved and given a lining made from the ileum. This preserves the sphincter muscles and nerves, sparing continence and ejaculatory function. Dr. Ament explains, “You have to tell patients that every time they eat they’re probably going to have to go to the bathroom. However, they’re continent, don’t have a permanent ileostomy, and they can participate in sports and other activities so they can have a more normal life than they otherwise would have.”

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