If children have Crohn’s
disease or ulcerative colitis,
there are many
treatments out there.
And it may be confusing for you at first
when you’re seeing your first patient
to understand which
treatment is due when.
This is a rapidly changing field.
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.
So keep in mind that this is changing field
and look out for changes as you go forward.
However, let’s go through the
major treatment options that
are available to you in terms
of types of treatments.
So medications are the mainstay of
management of both of these conditions.
We also have to think about
how can we optimize nutrition because it is
the bowel wall after all that‘s involved.
And also we have to think about
surgical management in these patients.
Corticosteroids, either IV or
oral, it doesn’t really matter,
are used in acute flairs with
moderate to severe symptoms.
These are the mainstay of therapy,
but as we know, steroid use frequently
can result in all kinds of problems.
Moon facies, buffalo hump, all the
findings of Cushing’s disease.
We want to avoid them.
Additionally, patients may be
treated by 5-aminoglycosides.
This is usually for mild or
moderate ulcerative colitis.
Patients may also get
immunomodulators like azathioprine.
Azathioprine maintains remission
in about 75% of patients.
Also, methotrexate is frequently used
especially in patients who
are failing azathioprine.
Infliximab is used both for induction
and maintenance of remission.
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
Oral rifaximin improves
abdominal pain and diarrhea.
may receive probiotics,
this helps maintain remission and again
may treat or prevent a pouchitis.
require enteral feeding
because they don’t have
the energy to keep it up,
but nutrition is so
important for healing.
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.
Parenteral nutrition isn’t
in patients with severe
small bowel disease
where they have to maintain NPO
status for a long period of time.
Remember, high protein levels are needed
to both reconstruct your intestinal tissue
and maintain your
immune system’s needs.
Surgical intervention is
necessary in many cases.
For ulcerative colitis,
colectomy with ileal pouch and an anal
anastomosis is the most optimal therapy.
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.
An area to store stool until
it’s time to defecate.
This patient has an ileostomy.
We can hope that this patient will
have that ileostomy taken down,
so that they can eventually live a reasonably normal life.
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.
These patients become very
friendly with their surgeons.
They need to be followed carefully
and watched for surgical issues.
The prognosis of inflammatory
bowel disease is reasonably good.
And that these patients can
live long and meaningful lives.
However, disease relapse is common.
And about more than half
of patients will have a
relapse within two years of
their original diagnosis.
The body is constantly in an inflamed
state, so delayed puberty is common.
And these patients will achieve
a lower final adult height.
Don’t forget, especially fat
soluble vitamins are a problem,
so these patients are at risk
for vitamin D deficiency.
That and combined with their
frequent steroid use,
put them at grave risk for
bone mineral density problems.
These children can get osteopenia, osteoporosis
later in life and frequent fractures.
We have to be very careful about
their bone mineral density.
Some complications can
occur in these patients.
Toxic megacolon can occur and
that is a surgical emergency.
Patients are at risk for colorectal
cancer, especially in ulcerative colitis.
Generally, after diagnosis for
ulcerative colitis within eight years,
a patient is going to start being
screened regularly for colorectal cancer.
There is a lifelong increased risk
and frequently patients will
elect to have a colectomy
to avoid the cancerous
Patients also have a risk
and generally, complications
of the biliary tree.
But watching for
cholangiocarcinoma is especially
important in patients with
inflammatory bowel disease.
So what I’ve tried to portray
for you a picture here is
that these patients can live
long and productive lives.
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.
But together, we can make their
lives come out pretty well.
So that’s all I have for you
about this subject today.
Thanks for listening.