Inflammatory bowel diseases with onset in childhood. Clinical features, morbidity, and mortality in a regional cohort

Epidemiology of inflammatory bowel disease

The incidence of IBD has either continued to increase or has stabilized at a high rate in most developed countries, whereas the incidence continues to rise in regions where IBD had been less common. The prevalence has continued to increase as a result of a combination of previously rising incidence and improved survival. Regardless of the exact prevalence, the burden of disease in North America and Europe is significant. Studying the patterns of geographic variation and age and gender distribution may yield important clues to the cause of IBD.

Colorectal cancer surveillance for patients with inflammatory bowel disease

Although the cumulative prevalence of colorectal cancer among patients with ulcerative colitis is similar to that among patients with sporadic colorectal cancer, the younger age of ulcerative colitis patients with cancer accounts for the age-specific relative risk. Approximately half of ulcerative colitis patients with colorectal cancer die from metastatic disease. Pancolitis of long duration and coexistent primary sclerosing cholangitis are strong risk factors for cancer that should prompt entry into cancer surveillance programs. When done appropriately, cancer surveillance in patients with inflammatory bowel disease can be very effective, and at a reasonable cost.

Measles-mumps-rubella vaccine and autistic spectrum disorder: report from the New Challenges in Childhood Immunizations Conference convened in Oak Brook, Illinois, June 12-13, 2000

BACKGROUND

Parents and physicians are understandably concerned about the causes and treatment of autism, a devastating disease that affects the entire family. Although much has been learned about autism, there are many gaps in our knowledge about what causes the disorder and how it can be prevented. Autistic symptoms occur along a spectrum, often referred to as autistic spectrum disorder (ASD). Concern has been raised about a possible association between measles-mumps-rubella (MMR) vaccine and inflammatory bowel disease (IBD) and ASD, especially autism with regression. Also, increased requests for educational services related to ASD have raised concerns about possible increases in the incidence of ASD.

METHODS

On June 12-13, 2000, the American Academy of Pediatrics (AAP) convened a conference titled "New Challenges in Childhood Immunizations" in Oak Brook, Illinois. At this conference, parents, practitioners, and scientists presented information and research on MMR vaccine and ASD. Attendees included representatives from select AAP committees and sections as well as federal and other organizations that address related issues. The multidisciplinary panel of experts reviewed data on what is known about the pathogenesis, epidemiology, and genetics of ASD and the available data on hypothesized associations with IBD, measles, and MMR vaccine. Supplemental information was requested from authors who have proposed the hypotheses and other experts in relevant areas.

RESULTS

Autism is a complex disorder of uncertain and probably multiple etiologies. Genetic predisposition to ASD may involve as many as 10 genes. Many experts believe that the abnormal brain development in autism occurs before 30 weeks' gestation in most instances. In utero rubella is a known cause of autism. Animal model data support the biologic plausibility that exposure to yet unrecognized infectious or other environmental agents could cause ASD. Several factors may contribute to apparent increases in incidence of ASD in recent years. Most data indicate increased recognition and reporting as primary factors, but the epidemiologic data are insufficient to determine if there has been a true increase in the incidence of ASD. Increased reporting of ASD in recent years has occurred long after the introduction of MMR vaccine in the United States in 1971 and widespread use of this vaccine in the 1970s for routine immunization of children at 12 to 15 months of age. Appropriate detailed studies are needed to define the true incidence and prevalence of ASD. Epidemiologic studies in Europe indicate no association between MMR vaccine and ASD. Some children with ASD have gastrointestinal symptoms, but an increased rate of any specific gastrointestinal disorder in children with ASD has not been established. Studies to detect evidence of measles virus in intestinal tissue specimens from patients with IBD or autism with gastrointestinal symptoms have not used uniform techniques. Several laboratories have found no evidence of measles viruses in tissue specimens from patients with IBD, but 2 groups have found evidence of measles virus using different techniques. A group that found evidence of measles virus in affected tissue specimens from patients with IBD has also reported detecting portions of measles virus in peripheral blood lymphocytes and intestinal tissue specimens from patients with autism and gastrointestinal disorders. Finding a portion of a virus using molecular techniques does not constitute evidence for a causal relationship, because some viruses persist in unaffected hosts. Additional controlled studies in several laboratories are needed to determine if portions of measles virus persist in intestinal and other tissues of people with and without gastrointestinal disease and/or ASD.

CONCLUSIONS

Although the possible association with MMR vaccine has received much public and political attention and there are many who have derived their own conclusions based on personal experiences, the available evidence does not support the hypothesis that MMR vaccine causes autism or associated disorders or IBD. Separate administration of measles, mumps, and rubella vaccines to children provides no benefit over administration of the combination MMR vaccine and would result in delayed or missed immunizations. Pediatricians need to work with families to ensure that children are protected early in the second year of life from these preventable diseases. Continued scientific efforts need to be directed to the identification of the causes of ASD.

Birth outcomes of women with ulcerative colitis: a nationwide Danish cohort study

OBJECTIVE

Our study aimed to compare the birth outcomes in offspring of women with ulcerative colitis with controls without the disease.

METHODS

A cohort study of 1531 newborns to mothers with ulcerative colitis, and 9092 controls, based on linkage between the Danish National Registry of Patients and the Danish Birth Registry from 1982 to 1992.

RESULTS

Among the births to women with ulcerative colitis, 569 took place before and 962 after the first hospitalization for ulcerative colitis. We found no increased risk of either low birth weight or intrauterine growth retardation for newborns born before or after the mothers' first hospitalization. The risk of preterm birth was increased when birth occurred after the mothers' first hospitalization (odds ratio = 1.4, 95% confidence interval = 1.1-1.9), and particularly when the first hospitalization for ulcerative colitis took place during pregnancy (odds ratio = 3.4, 95% confidence interval = 1.8-6.4).

CONCLUSIONS

In the offspring of women with ulcerative colitis, we found no increased risk of low birth weight or signs of intrauterine growth retardation. The risk of preterm birth was increased in the offspring of women with ulcerative colitis, particularly when the first hospitalization for ulcerative colitis occurred during pregnancy.

Risk of cancer in inflammatory bowel disease (IBD)

Patients with inflammmatory bowel disease (IBD) have been reported to have an increased risk of colorectal cancer. Yet, the quantitation of the risk varies widely from one study to the next. This is most likely due to biases in the assessment of cancer risk in IBD, namely, a relatively low prevalence of IBD-related cancer and the clinically heterogeneous nature of IBD in the population. Total proctocolectomy also changes the natural history of IBD-related cancer. Ulcerative colitis (UC)-related cancer is more probable in total and extensive colitis and occurs approximately a decade after diagnosis. Crohn's disease-related colorectal cancer is reported in many, but not all, studies, and the relative risk differs between hospital- and population-based studies. IBD-related cancer is relatively uncommon in childhood; however, this is also a subject of debate. There are no data on the incidence of IBD-related cancer in Europe as a whole; there are only separate studies. A reduced risk for UC-related cancer in patients treated with anti-inflammatory drugs has been reported. The two main strategies for preventing IBD-related cancer are prophylactic colectomy and colonoscopic surveillance. To date, there have virtually been no cost-effectiveness analyses and no studies regarding total disease outcome or patient's quality of life with either strategy. No controlled, prospective trials have been reported in the literature. UC patients with familiar predisposition for colorectal cancer and with concomitant primary sclerosing cholangitis are groups at high risk for IBD-related cancer. Cancer risk in IBD has to be reinvestigated and properly estimated with population-based studies in several areas with standard methods already described.

Inflammatory bowel disease in children and adolescents in Sweden, 1984-1995

BACKGROUND

A prospective study of inflammatory bowel disease (IBD) in Sweden was performed to investigate whether the incidence and morbidity have changed from 1984 through 1995.

METHODS

Children 15 years of age or less with IBD were included--i.e., those with a definite diagnosis of ulcerative colitis (UC) and Crohn's disease (CD) and those classified as having indeterminate colitis (IC) and probable Crohn's disease (PCD). The study covered 56.5% of the pediatric population of Sweden.

RESULTS

The diagnosis of IBD was made in 639 children, which corresponds to a mean annual incidence of 5.8 per 100,000. The incidence increased from 4.6 per 100,000 per year from 1984 through 1986 to 7.0 from 1993 through 1995. It reflected an increase in UC from 1.4 to 3.2 per 100,000 per year, which is a significant yearly percentage of increase (8%; confidence interval, 2-14%; P < 0.05). In contrast, no change occurred in the incidence of CD (1.2-1.3 per 100,000). The incidence of IC and PCD also remained fairly stable. The percentages of children who underwent surgery decreased from 17.3% in the first 6 years to 4.6% in the last 6 years (P < 0.001). Surgery was performed in 27.7% of CD and 5.3% of UC cases. The median age at diagnosis was 12.2 years for UC, 13.0 years for CD, 11.2 for IC, and 11.2 for PCD. At diagnosis, 48 children (7.5%) were 5 years of age or less, whereas most of the patients were 11 years of age or more (398 children, 62.3%).

CONCLUSIONS

In Sweden, the incidence of UC has increased, whereas that of CD remains the same. A significant number of children were classified with IC and PCD. In most children, IBD was diagnosed when they were 11 years old or more, but some cases were detected even in those below 6 years of age. A decrease in the frequency of surgery occurred during the study.

Predicting the need for colectomy in pediatric patients with ulcerative colitis

Total colectomy is curative for ulcerative colitis. However, many pediatric patients are medically managed and may not require surgery. There are currently no available criteria to identify children who will benefit from early colectomy. The purpose of this review was to identify criteria associated with the need for colectomy. A 15-year review of patients at a major pediatric center with biopsy-proved ulcerative colitis was conducted. Age at the time of the first symptom, diagnosis, and surgery were recorded as well as steroid dependence, site of disease, extraintestinal manifestations, and family history. Seventy-three patients ranging in age from 1 to 18 years were identified. Thirty-seven patients (50.1%) required total colectomy before the age of 18. The average patient age at the time of the first documented symptom was 11.3 +/- 0.5 years. Among patients who were steroid dependent and had pancolitis, 73% required colectomy. Patients with these factors failed medical management 77% (27 of 35) of the time, and colectomy was performed within 3 years of diagnosis. The combination of steroid dependence and pancolitis was associated with an increased need for colectomy. In pediatric patients with these factors, early colectomy may limit the need to endure prolonged courses of medications and the disability allied with this disease.

Incidence of paediatric Crohn's disease in Stockholm, Sweden

We report an increase in the incidence of Crohn's disease in northern Stockholm, Sweden.

Inflammatory bowel disease in pediatric and adolescent patients

IBD is a chronic pediatric disease that needs to be treated by a team of experts consisting of pediatricians, pediatric gastroenterologists, psychologists, nutritionists, social workers, and nurses. A critical factor in successful management of this disease is the willingness of the patient to participate and cooperate with the team. Parents and patients must be educated and supported to treat these disorders effectively. Much further research is necessary to understand the specific causative and therapeutic issues unique to young patients with IBD.

Epidemiology and the natural course of inflammatory bowel disease

Ulcerative colitis and Crohn's disease are inflammatory disorders of the gastrointestinal tract that are distributed unevenly within populations and throughout the world. Although the exact causes of inflammatory bowel disease (IBD) remain unknown, study of the epidemiology of IBD has provided insight into pathogenesis. This article examines the geographic, ethnic, and other trends of IBD; risk factors (including genetic and environmental); and the natural history of IBD.

Potential uses for quality-of-life measures in childhood inflammatory bowel disease

Health-related quality of life (HRQOL) in children with inflammatory bowel disease is clearly reduced in the physical as well as in the psychological and social functioning domains. However, very few studies of these children have been performed from a quality-of-life perspective. Multicenter studies on HRQOL are needed to answer questions about the impact of Crohn's disease and ulcerative colitis and their treatment and complications on HRQOL in children and adolescents and their association with outcome. This article describes perspectives from which quality of life studies may be performed, potential uses of HRQOL measures, and issues that should be accounted for in designing multicenter clinical studies on this topic.