Pediatric Inflammatory Bowel Disease (IBD): Management

by Brian Alverson, MD

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    00:02 If children have Crohn’s disease or ulcerative colitis, there are many treatments out there.

    00:08 And it may be confusing for you at first when you’re seeing your first patient to understand which treatment is due when.

    00:17 This is a rapidly changing field.

    00:20 Just three years prior to recording this, we would never have used Remicade early in disease and now, we’re doing that all the time.

    00:28 So keep in mind that this is changing field and look out for changes as you go forward.

    00:34 However, let’s go through the major treatment options that are available to you in terms of types of treatments.

    00:40 So medications are the mainstay of management of both of these conditions.

    00:45 We also have to think about nutritional considerations, how can we optimize nutrition because it is the bowel wall after all that‘s involved.

    00:54 And also we have to think about surgical management in these patients.

    00:58 So, medications.

    01:01 Corticosteroids, either IV or oral, it doesn’t really matter, are used in acute flairs with moderate to severe symptoms.

    01:10 These are the mainstay of therapy, but as we know, steroid use frequently can result in all kinds of problems.

    01:19 Moon facies, buffalo hump, all the findings of Cushing’s disease.

    01:23 We want to avoid them.

    01:26 Additionally, patients may be treated by 5-aminoglycosides.

    01:31 This is usually for mild or moderate ulcerative colitis.

    01:36 Patients may also get immunomodulators like azathioprine.

    01:40 Azathioprine maintains remission in about 75% of patients.

    01:45 Also, methotrexate is frequently used especially in patients who are failing azathioprine.

    01:52 Infliximab is used both for induction and maintenance of remission.

    01:57 And antibiotics such as ciprofloxacin and metronidazole are used for fistulae and pouchitis, an inflammation of the pouch left over after a surgical resection of the colon in ulcerative colitis.

    02:13 Oral rifaximin improves abdominal pain and diarrhea.

    02:18 Additionally, patients may receive probiotics, this helps maintain remission and again may treat or prevent a pouchitis.

    02:28 Nutritional considerations are important.

    02:31 Sometimes, patients require enteral feeding because they don’t have the energy to keep it up, but nutrition is so important for healing.

    02:39 We often provide supplemental vitamins especially for patients with fat malabsorption, where we would give extra of the fat-soluble vitamins, vitamins A, D, E and K.

    02:50 Parenteral nutrition isn’t uncommon especially in patients with severe small bowel disease where they have to maintain NPO status for a long period of time.

    02:59 Remember, high protein levels are needed to both reconstruct your intestinal tissue and maintain your immune system’s needs.

    03:10 Surgical intervention is necessary in many cases.

    03:15 For ulcerative colitis, colectomy with ileal pouch and an anal anastomosis is the most optimal therapy.

    03:23 And you can see here a patient who’s had the green colon removed, replaced by the purple small bowel and they’ve created an ileal pouch that’s going to act as sort of what was previously the rectal vault.

    03:37 An area to store stool until it’s time to defecate.

    03:41 This patient has an ileostomy.

    03:43 We can hope that this patient will have that ileostomy taken down, so that they can eventually live a reasonably normal life.

    03:51 In patients with Crohn’s disease, fistulae and areas of stenosis can occur that can be highly problematic and periodically, segmental bowel resection is needed.

    04:01 These patients become very friendly with their surgeons.

    04:04 They need to be followed carefully and watched for surgical issues.

    04:10 The prognosis of inflammatory bowel disease is reasonably good.

    04:14 And that these patients can live long and meaningful lives.

    04:17 However, disease relapse is common.

    04:20 And about more than half of patients will have a relapse within two years of their original diagnosis.

    04:27 The body is constantly in an inflamed state, so delayed puberty is common.

    04:32 And these patients will achieve a lower final adult height.

    04:37 Don’t forget, especially fat soluble vitamins are a problem, so these patients are at risk for vitamin D deficiency.

    04:44 That and combined with their frequent steroid use, put them at grave risk for bone mineral density problems.

    04:52 These children can get osteopenia, osteoporosis later in life and frequent fractures.

    04:58 We have to be very careful about their bone mineral density.

    05:04 Some complications can occur in these patients.

    05:08 Toxic megacolon can occur and that is a surgical emergency.

    05:12 Patients are at risk for colorectal cancer, especially in ulcerative colitis.

    05:18 Generally, after diagnosis for ulcerative colitis within eight years, a patient is going to start being screened regularly for colorectal cancer.

    05:28 There is a lifelong increased risk and frequently patients will elect to have a colectomy to avoid the cancerous consequences.

    05:37 Patients also have a risk for cholangiocarcinoma and generally, complications of the biliary tree.

    05:44 But watching for cholangiocarcinoma is especially important in patients with inflammatory bowel disease.

    05:51 So what I’ve tried to portray for you a picture here is that these patients can live long and productive lives.

    05:58 They need help from all elements and all sides of the medical team, from everywhere from the medical doctors to the surgeons to the psychologists and to the teachers and the parents.

    06:09 But together, we can make their lives come out pretty well.

    06:12 So that’s all I have for you about this subject today.

    06:16 Thanks for listening.

    About the Lecture

    The lecture Pediatric Inflammatory Bowel Disease (IBD): Management by Brian Alverson, MD is from the course Pediatric Gastroenterology.

    Included Quiz Questions

    1. Erythromycin
    2. Ciprofloxacin
    3. Steroids
    4. Azathioprine
    5. Infliximab
    1. Toxic megacolon
    2. Acute appendicitis
    3. Intestinal obstruction
    4. Acute cholecystitis
    5. Proctitis
    1. Metronidazole
    2. Penicillin
    3. Macrolides
    4. Isoniazid
    5. Rifaximin

    Author of lecture Pediatric Inflammatory Bowel Disease (IBD): Management

     Brian Alverson, MD

    Brian Alverson, MD

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