Surgery for Crohn's disease in childhood: influence of site of disease and operative procedure on outcome

Colectomy in refractory Crohn's colitis improves nutrition and reduces steroid use

BACKGROUND

Pediatric patients with severe refractory Crohn's colitis (CC) may require total colectomy (TC) or diverting loop ileostomy (DLI). Our understanding of outcomes (postoperative complications, nutrition and restoration of intestinal continuity) is currently limited.

METHODS

Pediatric patients with severe CC who underwent TC or DLI were identified. Demographics, pre and postoperative anthropometric and biochemical data, surgical complications and medication requirements were recorded.

RESULTS

Twenty-seven patients (TC=22, DLI=5) with a median age of 15.0years (range 3-18) were identified, 64% male with a median follow-up of 45months (range 3-120). Mean weight and BMI improved for TC patients by 1year postoperatively - weight z-score from -1.08 to -0.54 (p=0.02), BMI z-score from -0.83 to -0.38 (p=0.04), with a non-significant height change from - 0.79 to -0.65 (p=0.07). Mean hemoglobin and albumin both also improved - 9.88g/dl to 11.76g/dl (p=0.003) and 3.44g/dl to 4.03g/dl (p=0.004) respectively. These measures did not significantly improve after DLI. Most TC patients (59%) had attempted restoration of intestinal continuity with 45% in continuity at end of follow-up. One DLI patient underwent ileostomy takedown but subsequently needed re-diversion.

CONCLUSIONS

In severe CC, TC offers an opportunity to improve nutrition and growth, with a reasonable likelihood of restoring intestinal continuity.

LEVEL OF EVIDENCE

Level IV - Case series.

Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN

The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.

Nutrition Issues in Pediatric Crohn's Disease

Twenty-five percent of inflammatory bowel disease (IBD) diagnoses present in childhood, with Crohn's disease (CD) being the most common type. Many children have poor nutrition status at presentation of the disease, which may worsen during the clinical course, with a significant number of children having impaired linear growth. The cause of this poor nutrition status is complex, and contributing factors include inadequate intake, malabsorption, altered energy demands, and losses through stool, particularly in colitis. The principal aim of medical management is to induce disease remission, with minimal side effects, thereby enabling normal growth and development. This must include active consideration of the nutrition needs of such children and how they may be best met. However, our understanding of the manner in which the disease process affects the energy demands of children with CD or how poor nutrition, in turn, may affect the disease course is limited. This may constrain the efficacy and effectiveness of standard therapeutic approaches to care. This review explores the many factors of relevance in the delivery of nutrition support to children with inflammatory bowel disease, and explores the role of exclusive enteral nutrition as a corticosteroid-sparing strategy to induce remission in children with active Crohn's disease.

Enteral Nutrition as Primary Therapy in Childhood Crohn's Disease: Control of Intestinal Inflammation and Anabolic Response

Crohn's disease in childhood is a chronic relapsing and remitting condition that can significantly impact normal growth and development. This influences choice of both initial and ongoing management. The goal of therapy is to induce and maintain remission with minimal side effects. Enteral nutrition is effective in active disease and will induce disease remission in most cases avoiding corticosteroid use. The high frequency of relapse means additional immunosuppressive therapies are usually required but nutrition remains a key priority as part of the subsequent management strategy.

Surgery in Pediatric Crohn Disease: Case Series from a Single Tertiary Referral Center

Introduction

There is a recognized increase of lifelong surgery risk in Crohn disease (CD). Outcome data concerning surgery in children, particularly in the biological era, are limited.

Aim

To characterize the clinical profile and the clinical outcome in children and adolescents with CD who underwent surgical intervention, in a single tertiary referral center.

Methods

Retrospective, cross-sectional study, including pediatric patients with CD undergoing intra-abdominal surgery in the last 11 years.

Results

Included eight of 50 CD total patients (16%); six female; median age at CD diagnosis of 12.0 years; Paris classification: (a) location: ileocolonic (5), colonic (1), upper disease (1), ileocolonic/upper disease (1); (b) behavior: stricturing (4), nonstricturing nonpenetrating (2), penetrating (1), both penetrating and stricturing disease (1); growth delay (2). Six children received thiopurines, five mesalazine, three corticosteroids and four anti-TNF therapy, preoperatively. Surgery followed diagnosis by a median of 2.9 years. Median PCDAI at the time of surgery was 35.0. Elective surgery was performed in six patients and emergency surgery in two, without major complications. Five children received anti-TNF and three thiopurines post-operatively. Within the follow-up period (median 1.7 years), relapse occurred in one child (3.2 years after intervention); the remaining seven patients persist in clinical remission. Median PCDAI in the last evaluation was 6.3. Weight and height recovery was observed in seven patients, at last follow-up.

Conclusion

Surgical treatment of CD is a valid alternative in selected cases, contributing to the resolution of acute complications and maintenance of remission, allowing disease-free interval and nutritional recovery.

Colonic disease site and perioperative complications predict need for later intestinal interventions following intestinal resection in pediatric Crohn's disease

INTRODUCTION

We studied variables associated with outcomes following intestinal resection for Crohn's disease.

METHODS

A retrospective review of a prospectively maintained single surgeon database was performed. Outcomes evaluated included disease recurrence, need for further resection/dilatation, and complications. Explanatory variables included: anatomical region of resection, open or laparoscopic approach, surgical procedure, technique of anastomosis, number of anastomoses, use of biological therapy, resection margin disease, age at resection, and period (quartile) in series.

RESULTS

81 children had 100 resections at a median age 14.5years with a median follow-up of 7.7years. Overall complication rate was 22%. Of the 77 children with no prior resection, 40 (52%) had disease recurrence, and 24 (31%) underwent further resection or dilatation. None of the explanatory variables predicted complications. Disease recurrence was significantly associated with younger age at first resection but not duration of follow-up. The probability of further intestinal intervention was strongly associated with disease site and complications. Odds ratio for further surgery for colonic disease site compared to ileocecal disease site was 7 (95% CI 1.8-26; P=0.004). Odds ratio for further intestinal resection following surgery where a complication had occurred compared to no complication was 3.4 (95% CI 1.1-10.3; P=0.02. Both disease site and complication status also significantly affected the interval to further surgery.

CONCLUSIONS

The probability of requiring a second intestinal intervention for pediatric Crohn's disease is related to the disease site and the complication status.

Surgery for children with Crohn's disease: indications, complications and outcome

BACKGROUND

Outcome data for surgery in paediatric Crohn's disease are limited. We report 10 years' experience at a regional paediatric gastroenterology centre.

METHODS

Children undergoing surgery for Crohn's disease (January 2002-December 2012) were identified from an onsite patient register. Patients were followed until transition to adult services. Data were obtained from medical records and are expressed as median (range).

RESULTS

Sixty-nine children, aged 13.8 years (6.3-17.0) at diagnosis, were included. 42 were male (61%). Follow-up was 1.8 years (27 days-6 years). Surgery followed diagnosis by 9 months (0 days-7 years). 52 children (75%) received thiopurines and 5 (7%) anti-TNF (tumour necrosis factor) therapy preoperatively. 58 (84%) underwent intra-abdominal surgery (40 right hemicolectomy, 8 stoma formation, 2 subtotal colectomy, 2 small bowel resection, 6 other) and 10 (14%) underwent surgery for perianal disease. The commonest indications for intra-abdominal surgery were stricturing disease 35 (60%) and unresponsive luminal disease 13 (22%). There were 13 (22%) early, and 5 (8.6%) late, complications following intra-abdominal surgery. Nine children had disease relapse, five required further surgery. Height SD scores (SDS) did not increase between diagnosis; -0.5 (-3.4-2.1) and most recent follow up; -0.4 (-3.0-1.1). Body Mass Index (BMI) SDS increased from -1.0 (-6.3-1.5) to -0.3 (-3.3-2.0) (p<0.05).

CONCLUSIONS

Surgery was associated with a 22% early complication rate and a 15% risk of relapse. 21% of patients required a second unplanned intra-abdominal procedure. Surgical intervention was associated with an increase in BMI SDS, but not in height SDS.

Surgery in children with Crohn disease refractory to medical therapy

OBJECTIVE

The aim of this study was to evaluate the results of surgery in children with Crohn disease (CD) not responding to medical therapy and establish whether surgery improves growth and nutrition.

PATIENTS AND METHODS

Children with CD diagnosed between 1998 and 2008 were reviewed. Relapse was defined by Harvey-Bradshaw index >5. Data, reported as median (range), were compared by Fisher exact test and repeated-measures ANOVA.

RESULTS

One hundred forty-one children, ages 12.7 years (3.5-16.8), were identified; 27 (19%) required surgery 14.5 months (1.1-61.8) after diagnosis. Twenty-one had elective surgery (19 isolated ileocaecal disease and stricture, 2 diffuse disease of ileum); 6 had emergency surgery (3 peritonitis, 2 haemorrhage, 1 perforation). Surgery included 18 ileocaecal resection and end-to-end anastomosis, 5 stoma formation, 2 left hemicolectomy and end-to-end anastomosis, and 2 stricturoplasty. Follow-up was 2.5 years (1-9.4). Growth and nutrition improved by 6 and 12 months after surgery, with a significant increase in weight z score (P < 0.0001), height z score (P < 0.0001), albumin (30 [13-36] vs 39 [30-46] vs 40 [33-45], P < 0.0001), and haemoglobin [10 (6.8-13.2) vs 11.7 (8.2-13.7) vs 12.0 (9.3-14.7), P < 0.0001]. All patients of the received azathioprine (2-2.5 mg · kg⁻¹ · day⁻¹) after surgery. Fifteen patients (55%) relapsed with a modified Harvey-Bradshaw index of 8 (6-11) within 11.5 months (4.2-33.4). Of these, 5 patients (18%) relapsed within 1 year. Five patients (18%) had further surgery (2 anastomotic strictures, 2 diseased stoma, and 1 enterocutaneous fistula).

CONCLUSIONS

Growth and nutrition following surgery for CD improve, but there is a high relapse rate. Despite this, the improved growth and nutrition before relapse may be beneficial during puberty and justify surgery in children not responding to medications.

Mechanisms of growth impairment in pediatric Crohn's disease

Crohn's disease manifests during childhood or adolescence in up to 25% of patients. The potential for linear growth impairment as a complication of chronic intestinal inflammation is unique to pediatric patient populations. Insulin-like growth factor I (IGF-I), produced by the liver in response to growth hormone (GH) stimulation, is the key mediator of GH effects at the growth plate of bones. An association between impaired growth in children with Crohn's disease and low IGF-I levels is well recognized. Early studies emphasized the role of malnutrition in suppression of IGF-I production. However, a simple nutritional hypothesis fails to explain all the observations related to growth in children with Crohn's disease. The direct, growth-inhibitory effects of proinflammatory cytokines are increasingly recognized and explored. The potential role of noncytokine factors, such as lipopolysaccharides, and their potential to negatively influence the growth axis have recently been investigated with intriguing results. There is now reason for optimism that the modern anticytokine therapeutic agents available for treating children and adolescents with Crohn's disease will reduce the prevalence of this otherwise common complication. As our understanding of the mechanisms that underlie growth impairment advance, so too should the opportunity for developing further novel and targeted therapies.

Guidelines for the management of growth failure in childhood inflammatory bowel disease

Around 1 in 4 patients with inflammatory bowel disease (IBD) present in childhood, the majority around the time of their pubertal growth spurt. This presents challenges over and above those of managing IBD in adults as this period is a time of dramatic psychological and physical transition for a child. Growth and nutrition are key priorities in the management of adolescents and young adults with IBD. Growth failure in IBD is characterized by delayed skeletal maturation and a delayed onset of puberty, and is best described in terms of height-for-age standard deviation score (Z score) or by variations in growth velocity over a period of 3-4 months. Growth failure is common at presentation in Crohn's disease (CD), but less common in ulcerative colitis (UC). The etiology of growth failure is multifactorial. Principal determinants, however, include the inflammatory process per se, with proinflammatory cytokines (e.g., IL-1beta, IL-6) being directly implicated. Furthermore, poor nutrition and the consequences of prolonged corticosteroid use also contribute to the significant reduction in final adult height of almost 1 in 5 children. Initially a prompt, where possible steroid-free, induction of remission is indicated. The ideal is then to sustain a relapse-free remission until growth is complete, which is often not until early adulthood. These goals can often be achieved with a combination of exclusive enteral nutrition (EEN) and early use of immunosuppressants. The advent of potent and efficacious biological agents considerably improves the range of growth-sparing interventions available to children around puberty, although well-timed surgery remains another highly effective means of achieving remission and significant catch-up growth. We carried out a systematic review of publications to identify the best available evidence for managing growth failure in children with IBD. Despite the paucity of high-quality publications, sufficient data were available in the literature to allow practical, evidence-based where possible, management guidelines to be formulated. Although there is clear evidence that exclusive enteral nutrition achieves mucosal healing, its effect on growth has only been assessed at 6 months. In contrast to corticosteroids, EEN has no negative effect on growth. Corticosteroids remain the key therapy responsible for medication-induced growth impairment, although the use of budesonide in selected patients may minimize the steroid effect on dividing growth plates. Immunosuppressants have become a mainstay of treatment in children with IBD, and are being used earlier in the disease course than ever before. However, there are currently no long-term data reporting better growth outcome if these agents are introduced very soon after diagnosis. In comparison, recent data from a large prospective trial of infliximab in children with moderate to severe CD suggested significant catch-up growth during the first year of regular infusions. The only other intervention that has documented clear catch-up growth has been surgical resection. Resection of localized CD, in otherwise treatment-resistant children, early in the disease process achieves clear catch-up growth within the next 6 months. There are no data available that growth hormone improves final adult height in children with CD. In conjunction with expert endocrinological support, pubertal delay, more common in boys, may be treated with parenteral testosterone if causing significant psychological problems. The optimal management of children and adolescents requires a multidisciplinary approach frequently available within the pediatric healthcare setting. Dedicated dietetic support, along with nurse-specialist, child psychologist, and with closely linked medical and surgical care will likely achieve the best possible start for children facing a lifetime of chronic gut disease.

Surgical management of Crohn's colitis

Crohn's disease in childhood is changing. The incidence is increasing, colonic disease is becoming more prevalent in younger children, and colon reconstruction is more acceptable. Genetic phenotypes are influencing decisions for surgery, and targeted immunotherapy has renewed hope for more durable remissions following less extensive resections. The tasks facing the surgeon evaluating a child with Crohn's colitis include confirming the specific diagnostic subtype and selecting the correct procedure. This chapter will review the unique aspects of pediatric Crohn's colitis and the increased complexity of surgical choice for this most challenging presentation. Recent success with less extensive surgery offers renewed hope for children with intractable colonic disease.

Protein and energy metabolism response to the initial dose of infliximab in children with Crohn's disease

BACKGROUND

Tumor necrosis factor-alpha (TNF-alpha) may contribute to the alterations in protein and energy metabolism present in children with Crohn's disease (CD), who frequently suffer from growth disturbance. We hypothesized that anti-TNF-alpha therapy would reduce protein losses, due to decreased proteolysis and increased protein synthesis, and that anti-TNF-alpha therapy would decrease resting energy expenditure.

METHODS

Children with active CD underwent metabolic assessment immediately before and 2 weeks following initial infliximab infusion. Using the stable isotopes [d5] phenylalanine and [1-13C] leucine, 2 independent measures of protein metabolism were determined during fasting and in response to parenteral nutrition. Energy expenditure, determined by indirect calorimetry, was measured in fasting and parenterally fed states.

RESULTS

Fifteen children completed the study. Following infliximab therapy, significant reductions in proteolysis (P < 0.05) were noted in the fasting state (8%-11%) and during parenteral nutrition infusion (10%-12%). Phenylalanine utilization for protein synthesis decreased significantly (8%-13%) following infliximab (P < 0.05). Protein balance was not significantly altered. No significant changes in energy expenditure were observed following infliximab in fasting or parenterally fed states. Supplementation with parenteral nutrition resulted in significantly decreased proteolysis (8%-21%; P < 0.05), increased protein synthesis (37%-45%; P < 0.01), and improved protein balance (P < 0.01) compared to the fasting state.

CONCLUSIONS

Following the initial infliximab infusion in children with CD, proteolysis and protein synthesis were significantly reduced in the fasting and parenterally fed states. Supplementation with parenteral nutrition resulted in significant improvements in protein metabolism compared to the fasting state both before and after infliximab therapy.

Surgical management of inflammatory bowel disease

AIM

To evaluate the outcome and morbidity after major surgical interventions for inflammatory bowel disease (IBD).

METHODS

Retrospective case note analysis of 227 children referred to a tertiary referral centre between 1994 and 2002 for treatment of IBD.

RESULTS

26 of 125 children with Crohn's disease (21%) required surgical management. 13 with disease proximal to the left colon underwent limited segmental resections and primary anastomosis, without significant morbidity. Primary surgery for 13 children with disease distal to the transverse colon included 6 subtotal-colectomies or panprocto-colectomies. All seven children undergoing conservative segmental resections (three with primary anastomosis, four with stoma formation), required further colonic resection or defunctioning stoma formation. All three children undergoing primary anastomosis developed a leak or fistula formation. 22 of 102 children with ulcerative colitis (22%) required surgery. Definitive procedures (n = 17) included J-pouch ileoanal anastomosis (n = 11), ileorectal anastomosis (n = 2), straight ileoanal anastomosis (n = 3), and proctectomy/ileostomy (n = 1). Five children await restorative surgery after subtotal colectomy. Median daily stool frequency after J-pouch surgery was 5 (range 3-15), and 10 of 11 children reported full daytime continence. All three children with straight ileoanal anastomosis had unacceptable stool frequency and remain diverted.

CONCLUSION

The complication rate after resectional surgery for IBD was 57% for Crohn's disease, and 31% for ulcerative colitis. In children with Crohn's disease, limited resection with primary anastomosis is safe proximal to the left colon. Where surgery is indicated for disease distal to the transverse colon, subtotal or panproctocolectomy is indicated, and an anastomosis should be avoided. Children with ulcerative colitis had a good functional outcome after J-pouch reconstruction. However, the overall failure rate of attempted reconstructive surgery was 24%, largely owing to the poor results of straight ileoanal anastomosis.

BAPS UK inflammatory bowel disease surgical practice survey

AIMS

A recent survey of children with inflammatory bowel disease (IBD) identified wide regional variations of care within the UK. The present study was designed to analyse paediatric surgical provision for children with ulcerative colitis and Crohn's disease.

METHODS

All UK paediatric surgical centres were contacted to identify surgeons with a subspecialist interest in IBD. A questionnaire was designed to probe specific areas including team working, caseload, and transitional care. Annual consultant caseload was requested for colonoscopy, J-pouch ileoanal anastomosis (IPAA) for ulcerative colitis, and strictureplasty (Crohn's disease). The questionnaire and the accompanying letter were approved by the BAPS Research and Clinical Effectiveness Committee.

RESULTS

The response rate from individual centres was 86% (25/29). In 11% of centres, care was shared between 2 consultants. A transitional care clinic was provided by 77% of centres. The median experience with IPAA was 0.9 cases per year of consultant practice (range, 0-3.7), and 12.5% of surgeons had limited experience of revision pouch surgery. The majority have arrangements for joint operating with adult surgeons for IPAA. Forty percent of surgeons reported experience with strictureplasty. Surgical preference for recalcitrant left-side Crohn's colitis favoured segmental resection (60%), compared to subtotal/panproctocolectomy.

CONCLUSIONS

Paediatric surgeons use a diversity of surgical management options in IBD. Experience with IPAA is limited for most surgeons. Whether children should undergo elective IPAA independent of experienced adult practitioners, who naturally assume responsibility after transition, requires careful debate.

Distinct phenotype of early childhood inflammatory bowel disease

GOALS

Our goals were to answer 2 questions: (1) Is the presentation of early-onset inflammatory bowel disease (IBD) similar to typical adolescent-onset IBD? (2) Is there variability in familial aggregation in childhood IBD?

BACKGROUND

The phenotype of IBD in children under 5 years of age (early-onset) is poorly defined. Clinical and genetic studies of IBD, however, generally assume the phenotype to be homogenous throughout childhood.

STUDY

We analyzed data from 413 consecutive pediatric IBD outpatients attending our center between 1995 and 2000. Disease type, anatomic distribution, and family history were compared between children presenting before (early-onset) and after the age of five (5 to 15 y).

RESULTS

Disease presentation was predominantly colonic in early-onset IBD, most patients presenting with ulcerative colitis (UC). Isolated colonic disease was most frequent in early-onset Crohn disease (colonic 76.5%, ileocolic 24%) compared with ileocolic disease (ileocolic 45.5%, colonic 26%, ileal 19.4%, proximal 6.3%) in the older age group. First-degree family history was highest in early-onset UC 26% versus 11% in the older UC group.

CONCLUSIONS

We describe a distinct phenotype of early childhood onset IBD, with a strikingly high familial aggregation in UC and greater tendency to present with colonic disease. As more genetic heterogeneity is identified in IBD, careful definition of phenotype is required to identify further susceptibility genes. The early-onset form of UC presents an ideal group for further genetic analysis. These phenotype differences also suggest that treatment and outcome may vary in early-onset childhood IBD; prospective studies are required to confirm this.

Interventions for growth failure in childhood Crohn's disease

BACKGROUND

Crohn's disease in childhood is a chronic relapsing condition. Fifteen to forty per cent of children with Crohn's disease have growth retardation (Griffiths 1993a). Some treatment modalities including corticosteroids have been implicated in growth failure but it is thought mainly to be secondary to uncontrolled disease activity (Motil 1993; Markowitz 1993). Growth is fundamental to the practice of pediatrics, so by taking growth as the primary outcome measure we address issues important to both patients, their families and pediatricians.

OBJECTIVES

To evaluate the effectiveness of the different modalities available for the treatment of childhood Crohn's disease with regard to the reversal of growth failure and the promotion of normal growth.

SEARCH STRATEGY

Searches were made of the following databases using the Collaborative Review Group Search Strategy: EMBASE (1984-2004), MEDLINE (1966-2004), The Cochrane Central Register of Controlled Trials, The Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group Specialized Trials Register and the Science Citation Index. Abstracts from the major gastrointestinal research meetings and references from published articles were also reviewed.

SELECTION CRITERIA

Randomized controlled trials pertaining to children less than 18 years of age with Crohn's disease were selected. Those with growth as an outcome measure were included in the review.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of the methodological quality of each trial was independently reviewed by two reviewers. Only one good quality randomized controlled trial was included in the review and therefore no statistical analysis was possible.

MAIN RESULTS

Three randomized controlled trials were identified. One was of good methodological quality (Markowitz 2000). This study looked at the use of 6-mercaptopurine (6-MP) as a steroid sparing agent. No difference in linear growth was observed between the intervention and placebo groups, although the total steroid dose received over the 18 month follow up period was reduced in the group receiving 6-MP. The two remaining randomized controlled trials (Sanderson 1987; Thomas 1993a) consider the use of enteral feeding versus corticosteroids for induction of remission, with height velocity standard deviation score at 6 months as an outcome measure. Although of less rigorous methodological quality, the results of these studies are discussed in detail in the review. In both studies height velocity standard deviation scores were significantly increased in the enteral feeding group compared with the corticosteroid group.

AUTHORS' CONCLUSIONS

In addition to these randomized controlled trials, a body of lower quality evidence does exist relevant to two other important interventions; the use of supplemental enteral nutrition (Morin 1980; Belli 1988; Israel 1995) and the judicious use of surgical interventions in pre-pubertal children with refractory disease (Alperstein 1985; Lipson 1990; McLain 1990). Newer treatments, such as infliximab, are now becoming more widely used and may offer advantages in promoting growth. These effects are as yet unstudied. This review highlights the need for large, multi centre studies of the different treatment options in paediatric Crohn's disease and the importance of standardised measurements of growth, such as height velocity standard deviation scores and height standard deviation scores as outcome measures.

Inflammatory bowel disease in children 5 years of age and younger

OBJECTIVES

Clinicians are becoming increasingly aware that inflammatory bowel disease (IBD) can affect all age groups, although it has not been well described in infants and young children. Our aim was to evaluate early onset IBD in patients 5 yr of age and younger.

METHODS

Medical records of patients diagnosed with early onset IBD at The Children's Hospital of Philadelphia between 1977 and 2000 were reviewed. Patients were divided into three categories: those with Crohn's disease (CD), those with ulcerative colitis (UC), and those with indeterminant colitis (IC).

RESULTS

A total of 82 patients fulfilled the criteria. In 12 patients (15%), the IBD diagnosis was changed during the course of illness. At the end of the follow-up period, linear growth failure was present in 10 of 35 (29%) children with CD, one of 30 (3%) with UC, and three of 17 (18%) with IC. Failure to thrive was a frequent presenting symptom in children with CD (44%) and IC (39%), whereas in all four patients with UC and failure to thrive the diagnosis was subsequently changed to CD or IC. A high proportion of patients with CD had large bowel (89%), and perianal (34%) disease. None of the tested patients were positive for anti-Saccharomyces cerevisiae antibody (ASCA), and 10 tested positive for perinuclear antineutrophil cytoplasmic antibody (three of five patients with CD, five of seven with UC, and two of three with IC).

CONCLUSIONS

Failure to thrive, at the time of presentation, is indicative of a final diagnosis of CD or IC, not UC. Linear growth failure is a common finding in patients with early onset CD. A high proportion of patients with CD have failure to thrive, colonic, and perianal disease. The IBD serology panel is of limited clinical relevance in providing definitive diagnostic information in this pediatric population.

Inflammatory Bowel Disease in Children

Crohn's disease and ulcerative colitis remain medically incurable conditions with potentially significant morbidity. The treatment of children with these conditions therefore should seek to reduce or eliminate symptoms, optimize nutritional status, promote normal growth and development, prevent complications, and minimize the potential psychologic effects of chronic illness. Treatment strategies must seek to both induce and maintain clinical remission. For all but the most mildly affected children with Crohn's disease, a combination of nutritional and pharmacologic approaches is optimal. For those with ulcerative colitis, anti-inflammatory medication is necessary. Moderate to severe Crohn's disease acutely responds best to potent immunomodulatory therapy, eg, corticosteroids and infliximab. Either agent must be coupled with 6-mercaptopurine or azathioprine to maintain long-term remission and to minimize toxicity. Particular attention must be paid to limit the growth suppression and other toxic effects of corticosteroids. Elemental or semielemental enteral nutrition also can induce remission effectively, but relapse is common after primary nutritional therapy is discontinued, mandating concomitant pharmacologic therapy with either 6-mercaptopurine or azathioprine. The availability of 6-mercaptopurine/azathioprine metabolite testing allows optimization of immunomodulatory therapy, detection of noncompliance, and avoidance of potentially dangerous toxicity. Mild ulcerative colitis acutely responds to treatment with a 5-aminosalicylate medication. Long-term remission frequently can be maintained with the same medication. Moderate to severe disease activity requires potent immunomodulatory therapy if colectomy is to be avoided. Surgery is a potential cure for patients with ulcerative colitis, although the development of pouchitis after ileal pouch anal anastomosis is common and frequently requires long-term medical management. Surgery provides only palliative relief of complications in those with Crohn's disease. Emerging therapies, especially evolving biologic and probiotic agents, offer hope for better treatments in the years ahead.

Pediatric Crohn's disease: risk factors for postoperative recurrence

OBJECTIVE

Postoperative recurrence of Crohn's disease in adults has been extensively studied; however, the course of Crohn's disease after surgery in children has not been well defined. The aim of this study was to examine the postoperative course of pediatric Crohn's disease and the factors that may predict early postoperative recurrence.

METHODS

We identified 100 resective surgeries in 79 children with Crohn's disease seen at the Children's Hospital of Philadelphia between 1978 and 1996. A retrospective, multivariable analysis of factors potentially influencing postoperative clinical recurrence was performed. Preoperative and postoperative height measurements were compared, and z scores were computed for height-for-age. Two-tailed t test was used for the analysis.

RESULTS

Clinical recurrence rates were 17% at 1 yr, 38% at 3 yr, and 60% at 5 yr. Patients with colonic Crohn's disease had a significantly shorter postoperative recurrence-free interval (median 1.2 yr) than patients with ileocecal (median 4.4 yr) or diffuse disease (median 3.0 yr) (p = 0.01). On multivariable analysis, a high Pediatric Crohn's Disease Activity Index at the time of surgery (p = 0.01) and preoperative use of 6-mercaptopurine (6-MP) (p < 0.005) were also independently associated with higher postoperative recurrence rates. There was a significant improvement in z scores for height (p = 0.04) after surgery.

CONCLUSIONS

In children undergoing resective surgery for Crohn's disease, high rates of postoperative Crohn's disease recurrence are associated with severe disease at the time of surgery, colonic Crohn's disease, and the preoperative use of 6-MP. Patients who require preoperative use of 6-MP are likely to suffer from a more aggressive disease and would benefit from postoperative 6-MP prophylaxis. Height growth was improved after intestinal resection for Crohn's disease.

Therapy of Crohn's disease in childhood

Crohn's disease in childhood is a chronic relapsing condition with a high morbidity. Growth failure is common. The aim of therapy is to induce and then maintain disease remission and thereby promote well-being and normal growth and development. Enteral nutrition (either polymeric or elemental) is effective and used as initial therapy. This is employed as sole therapy over a 6- to 8-week period followed by a period of controlled food reintroduction. The relapse rate is high and further courses of enteral nutrition or alternative therapies are frequently required. Corticosteroids are also effective as initial therapy and are required in difficult cases but there are problems with their long term use, particularly their adverse effects on growth. Many patients develop either corticosteroid-dependent or corticosteroid-resistant disease. In this instance, additional immunosuppression, such as azathioprine, can be used. Surgery is required for those patients with disease resistant to medical therapy and this will result in remission; however, the relapse rate with surgery is high. There are many areas for future research. Very little is known about why enteral nutrition works, how long it should be given or its role as maintenance therapy. Newer immunosuppressive strategies based on cytokine modulation may be helpful in children once more experience is gained from their use in adults.

Nutrition in inflammatory bowel disease

Nutrition is clearly disturbed by active intestinal inflammation. Appetite is reduced, yet energy substrates are diverted into the inflammatory process, and thus weight loss is characteristic. The nutritional disturbance represents part of a profound defect of somatic function. Linear growth and pubertal development in children are notably retarded, body composition is altered, and there may be significant psychosocial disturbance. Macrophage products such as tumour necrosis factor-alpha and interleukins-1 and 6 may be the central molecules that link the inflammatory process to this derangement of homeostasis. Intriguingly, there is also increasing evidence that an aggressive nutritional programme may in itself be sufficient to reduce the mucosal inflammatory response. Recent evidence suggests that enteral nutrition alone may reduce many pro-inflammatory cytokines to normal and allow mucosal healing. In addition, specific nutritional components, such as n-3 polyunsaturated fatty acids, may have an anti-inflammatory effect as they may alter the pattern of leukotrienes generated during the immune response. The recent discovery of the specific molecular mediators of appetite and body composition, such as leptin and myostatin, may allow increased therapeutic specificity and further improvement in the nutritional treatment of the inflammatory bowel diseases.

Responsiveness of IGF-I and IGFBP-3 to therapeutic intervention in children and adolescents with Crohn's disease

OBJECTIVE

Abnormal linear growth is common in childhood and adolescent Crohn's disease. We have studied the concentrations of the inflammatory marker CRP and of serum IGF-I and IGFBP-3 in patients with active Crohn's disease and have assessed the changes in these parameters during therapeutic intervention with enteral nutrition or intestinal resection.

DESIGN

Children and adolescents attending the inflammatory bowel disease clinic at our hospital underwent treatment either with enteral nutrition (Study A) or intestinal resection (Study B). These are two separate studies and the results cannot be compared. Serum concentrations of CRP, IGF-I and IGFBP-3 were determined at 0, 2, 8 and 16 weeks after start of enteral nutrition and in addition to height velocity, at 0 and 6 months after intestinal resection.

SUBJECTS

Study A: 14 patients, 9 male, 5 female, median age 12.5 years (range 7.0-17.2), puberty stage 1 (n = 13), stage 3 (n = 1). All had active Crohn's disease. Study B: 9 patients, 7 male, 2 female, median age 13.5 years (range 7.8-16.5), puberty stage 1 (n = 5), stages 2-4 (n = 4). All had Crohn's disease resistant to medical therapy.

METHODS

Crohn's disease was confirmed radiologically, endoscopically and histologically. Disease activity was scored using the Lloyd Still index (LSI). Study A: nutritional support was with a polymeric, casein-based formula feed AL 110. Study B: surgical procedures were small bowel resection (n = 2), right hemicolectomy (n = 5), subtotal colectomy (n = 2).

MEASUREMENTS

Study A: weight SDS, CRP, IGF-1 and IGFBP-3 were measured at 0, 2, 8, 16 weeks after start of enteral feeding. Study B: height velocity, CRP, IGF-I and IGFBP-3 were measured 0, 6 months after intestinal resection.

STATISTICAL ANALYSIS

Medians and ranges were used. Significance of changes was calculated using the Wilcoxon rank test for the analysis of paired data.

RESULTS

Study A: median LSI before treatment was 39 and increased after 8 weeks of enteral nutrition to 60 (P < 0.05). Weight SDS increased at 8 and 16 weeks (P < 0.05) compared to pretreatment. CRP was elevated at 0 weeks, falling during treatment. Median (range) values (normal < 5 mg/l) at 0 at 2, 8, 16 weeks were 53 mg/l (15-150), 8 mg/l (5-25), 7 mg/l (5-83) and 14 mg/l (5-39), all P < 0.001 compared with pretreatment. Median IGF-I-values increased during treatment. Median (range) values at 0, 2, 8, 16 weeks (all P < 0.005) compared to pretreatment, median (range) values at 0, 2, 8, 16 weeks were 78 micrograms/l (50-204), 131 micrograms/l (73-251), 119 micrograms/l (77-291) and 133 micrograms/l (67-497), all P < 0.005 compared to pre-treatment. IGFBP-3 levels increased during treatment. Median (range) values at 0, 2, 8, 16 weeks were 2.4 mg/l (1.4-3.1), 2.9 mg/l (1.8-4.6), 3.0 mg/l, 3.2 mg/l (1.8-4.5), all P < 0.01 compared to pretreatment. Study B: height velocity increased during 6 months after surgery. Median (range) values; 3.3 cm/year (0-8.3) before surgery, 8.4 cm/year (2-12.6) 6 months post-surgery, P < 0.01. Median (range) CRP values fell from 45 mg/l (5-150) to 8 mg/l (5-31) and IGF-I-values increased from 163 micrograms/l (64-286) to 226 micrograms/l (71-391). These changes were not statistically significant. IGFBP-3 values did not change.

CONCLUSION

The IGF system, as shown by serum IGF-I and IGFBP-3, is responsive to therapeutic intervention in active Crohn's disease. It is likely that a combination of decreased inflammatory activity and improved nutrition contributes to these changes.

Crohn's disease in adolescents

The clinical features of Crohn's disease manifest during adolescence are varied as in adults. The potential complication of growth impairment and concomitant delay in pubertal development is unique to this population. Cytokines released from the inflamed bowel and chronic nutritional insufficiency are the major factors in the pathophysiology of growth inhibition. Hence reduction of intestinal inflammation and consistent provision of adequate nutrition are of paramount importance in management. Drug treatment mirrors that of adults; few specifically paediatric clinical trials have been conducted. Enteral nutrition is an important therapeutic alternative for young patients. There is evidence that it constitutes both a primary therapy of inflammation and a means of providing the calories needed for growth. In the setting of extensive disease, dependency on corticosteroids should be minimized through judicious administration of immunosuppressive drugs. For an adolescent with localized stenotic disease, optimal management includes a timely referral for intestinal resection as a means of providing an asymptomatic interval during which growth and pubertal development can normalize.

Therapy of Crohn's disease in childhood

The aim of therapy in Crohn's disease in childhood is to induce and to maintain a remission of disease activity so that normal growth and development of the child may occur. Enteral nutrition may now be recommended as the first-line treatment for most children with Crohn's disease. However, the evidence for remission is better for children with Crohn's disease of the small intestine rather than of the large intestine. There is evidence that amino acid feeds (elemental), whole protein (polymeric) and protein hydrolysate feeds (semi-elemental) may all be successful. Such a therapeutic approach can lead to healing of the mucosa and down-regulation of inflammation. However, in some cases surgery is required, particularly in children with growth failure and delayed puberty. Drug therapy also continues to have a role in therapy especially with severe colonic disease.

Surgery for Crohn's disease in infants and children

The course of Crohn's disease is quite variable in children. To assess the frequency and indications for surgery with current medical therapy, the authors reviewed the cases of 204 children (ages, 0.2 to 18.8 years at diagnosis, median, 12.8 years) who had Crohn's disease treated at a single institution from December 1968 to January 1994, with a median of 3.8 years of follow-up (range, 0.0 to 22.2 years). Ninety-four children (46%) required surgical resection for the following indications: (1) failure of medical therapy with persistent symptoms or growth retardation (n = 44, 47%), (2) intraabdominal abscess or perforation (n = 15, 16%), (3) fistula formation (n = 13, 14%), (4) obstruction (n = 15, 16%), (5) hemorrhage (n = 4, 4%), and (6) appendectomy at exploration for diagnosis (n = 3, 3%). The probability for surgery 3 years after diagnosis is 28.8% and by 5 years is 47.2%. Resections included ileocolectomy (71 children), colectomy (n = 16), small bowel resection (n = 4), and appendectomy (n = 3). Fourteen fistulas in 13 children required surgical intervention (7 enteroenteral, 3 enterovesical, 2 enterovaginal, and 2 enterocutaneous). The median duration from diagnosis to surgery for the fistulas was 2.6 years (range 0.1 to 9.8 years). Forty patients experienced recurring disease after resection during follow-up with a median of 1.8 years (range 0.4 to 18.1 years). The authors found that the course of the disease was unpredictable, with some children requiring early surgical intervention and others continuing with medical therapy for years.

Crohn's disease in children

Crohn's disease is a chronic inflammatory condition that may affect any part of the gastrointestinal system and multiple extraintestinal organs. Although its exact pathogenesis remains unknown, increasing evidence suggests an abnormality in the control of "physiologic" inflammation caused by bacterial and other antigens. Diagnosis starts with a careful history and physical examination, and confirmation rests with radiologic and histologic studies. Newer treatments are more specifically targeting the cascade of cytokine-mediated events that perpetuate inflammation.

Lipocortin-1 autoantibody concentration in children with inflammatory bowel disease

BACKGROUND

Corticosteroids are widely used to treat children with inflammatory bowel disease although the response is variable, side-effects are common, and many patients develop a partial or complete steroid resistance. The mechanism underlying these phenomena are unclear. Corticosteroids mediate some of their actions through lipocortin-1, and the induction of autoantibodies to lipocortin has been proposed as a possible mechanism by which steroid efficacy is suboptimal in vivo.

PATIENTS AND METHODS

We have measured serum lipocortin-1 antibody concentration by ELISA in 38 children with Crohn's disease, 12 with ulcerative colitis and in 15 controls.

RESULTS

IgG and IgA anti-lipocortin-1 antibody levels were higher in the Crohn's group than in the ulcerative colitis or control groups. Elevated concentrations did not relate to disease activity, history of steroid therapy or steroid-responsiveness. Lipocortin IgM antibody status was similar in all three groups.

CONCLUSION

It is therefore unlikely that serum antibodies to lipocortin-1 have a role in the development of steroid-resistance in children with inflammatory bowel disease.

Polymeric nutrition as the primary therapy in children with small bowel Crohn's disease

BACKGROUND

Recent studies in adults have shown that polymeric (whole protein) diets are as effective as semi-elemental and elemental formulae for the induction of remission in small bowel Crohn's disease. Whole protein diets are more palatable and cheaper. There have been no studies confirming efficacy in children.

PATIENTS AND METHODS

We report our experience with seven children with active small bowel Crohn's disease given a casein-based, polymeric feed rich in TGF-beta 2 (Specific Polymeric Diet; Nestle-Clintec; Vevey, Switzerland) as complete nutrition for 8 weeks.

RESULTS

Initial and follow-up assessments were performed. All children showed a significant improvement in disease activity, with C-reactive protein returning to normal, an increase in serum albumin and a good weight gain. Initial and follow-up ileal biopsies were assessed and showed reduced mucosal inflammation in six of seven children, with complete healing in two.

CONCLUSION

In an uncontrolled descriptive study we have shown that a polymeric (whole protein) diet is a therapeutic option for small bowel Crohn's disease in children. By comprehensive follow-up we have demonstrated clinical and biochemical remission, with an improved endoscopic appearance and a reduction of mucosal inflammation in the terminal ileum.

Medical management of chronic inflammatory bowel disease

In the absence of a definitive cure for Crohn's disease and ulcerative colitis, the aim of therapy must be to induce and maintain clinical remission at acceptable cost to the patient in terms of adverse effects. Despite the differences in their pathogenesis, the first-line treatments for Crohn's disease and ulcerative colitis are still based upon combinations of amino-salicylic acid derivatives and corticosteroids, although the use of enteral nutrition regimes is becoming increasingly widespread in Crohn's disease. In this chapter we attempt to provide reasonably didactic guidance for the management of most cases of chronic inflammatory bowel disease. However, we have tried to go beyond this brief, motivated by the recent explosion in knowledge of inflammatory mechanisms, to suggest a rational approach to the choice of newer and less well tested therapeutic approaches in the affected child who is not responding effectively. The relative failure of cyclosporine therapy in Crohn's disease has been particularly disappointing in view of its ideal theoretical suitability. However, the encouraging early reports of treatment with anti-CD4 and anti-TNF alpha monoclonals suggest that the shift from broad spectrum immunomodulation to the targeting of critical components of the inflammatory cascade may yet field important dividends.

Surgical therapy of chronic inflammatory bowel disease in childhood

The overall impression gained from the experience of the Departments of Paediatric Gastroenterology and Surgery attached to St Bartholomew's Hospital are the enormous benefits that surgery has to confer on the large percentage of children with both Crohn's disease and idiopathic proctocolitis who require it. The surgical procedures described in this chapter have been accompanied by a remarkably low complication rate, dispelling the impression that morbidity in such cases would be high. This must in large measure be due to the fact that the children who come to surgery are in as good a state of nutrition as can be achieved by means of the various forms of enteral and parenteral feeding now available. Anxiety about healing of anastomoses and the development of fistulas after surgery for example, has not been a feature of the surgical care of these patients. The principal benefit of surgery has been a clear demonstration of an improvement in growth velocity in both Crohn's disease and idiopathic proctocolitis patients provided always that surgery is correctly timed. It is the author's experience that maximum benefit is achieved if the bulk of the diseased bowel can be removed. Plainly relief of symptoms such as abdominal pain and diarrhoea has also been rewarding. In many instances second procedures such as restorative proctectomy in idiopathic proctocolitis can be timed to fit in with educational commitments. In Crohn's disease the likelihood of recurrence in adult life is high but these patients are in a fit state to cope with further therapy including surgery should the need arise. From the management point of view the close cooperation between physicians and surgeons at all stages has been crucial, firstly to achieve smooth preparation prior to surgery and satisfactory after care. But of even more importance in the assessment of Crohn's disease is the presence of all clinicians involved in the case in the operating theatre so that the surgical options are fully assessed. This united approach avoids any unnecessary anxiety when, as inevitably happens, recurrence of symptoms due to relapse occurs. The involvement of patients of whatever age, and parents in all the decision making processes from the time of diagnosis has been vital. Early discussion about stomas involving members of the Stomatherapy Department has been invaluable. One final important aspect of the management of these patients is the seamless hand-over of care to an adult combined medical and surgical clinic at an appropriate time, usually at the age of 17 years.(ABSTRACT TRUNCATED AT 400 WORDS)

Growth and puberty in chronic inflammatory bowel disease

The consequences of IBD during childhood and adolescence may be devastating in terms of loss of growth potential, particularly if there has been a clinical course of frequent relapses resulting in inadequate nutrition and associated with repeated courses of steroid treatment. There is to date, however, a paucity of data recording final adult heights in such patients. The anticipation of relapse should become easier with increasing awareness of the importance of parameters of growth and pubertal development. Early and intensive nutritional support, and the use of steroid-sparing agents should help reduce the frequency and severity of any height deficit. The performance and timing of surgery must take into account the child's status in terms of height velocity and pubertal development. The importance of inducing the remission before the onset of puberty is stressed and this remission should be sustained at all costs during the pubertal years so that valuable height is not lost as a consequence of a missed pubertal growth spurt. Thus, increasing awareness of the issues of growth and development in these patients should improve the accuracy of initial diagnosis and early recognition of relapse, such that these children are ensured the best possible provision for achieving their full height potential.

Inflammatory bowel disease

Inflammatory bowel disease in children encompasses at least two forms of intestinal inflammation: ulcerative colitis and Crohn's disease. These two disease processes are differentiated based on clinical presentation, radiologic findings, endoscopic findings, histologic evaluation, and exclusion of alternative causes. The treatment and operative interventions are reviewed.

Surgical treatment of Crohn disease in children and adolescents; how conservative can the paediatrician be?

Thirty-eight children (21 male, 17 female, age 3-18 years), treated for Crohn disease in two Dutch university centres, were retrospectively studied in order to evaluate the results of conservative treatment and to find out in what way surgical treatment in this age group may have differed from treating adults with this disease. Both groups had an equal distribution of age and sex. Diarrhoea with discharge of blood and mucus, abdominal pain, nausea/vomiting, weight loss, fever and general discomfort were the most frequent presenting symptoms. Twenty-three children (60%) showed signs of malabsorption; 4 children (10%) had growth retardation. In 27 children (70%), 63 surgical procedures were performed (2.4 operations per child). There was no surgical mortality. Most operations were performed for ileocolitis and colon-only localizations needed most re-operations. Of the surgical procedures performed, 55% were excisional procedures. Already 3 years after the onset of symptoms, 50% of all children had had their first resection, whereas in adults, 50% of the patients undergo surgery 8 years after disease onset. Eight children were treated with split ileostomy. In only one of these children, operated for non-toxic colitis and severe steroid-dependent growth retardation, could the colon eventually be saved. The time between the onset of symptoms and the first operation seems to be shorter in children compared to adults. Severe malabsorption and growth retardation are additional specific indications for surgery for Crohn disease in childhood. The latter combined with non-toxic colitis, may perhaps be the only indication left for performing split ileostomy in Crohn disease.

Current management of inflammatory bowel disease

The aetiology of ulcerative colitis and Crohn's disease remains unknown. While this remains so, treatment must be directed towards pathogenetic mechanisms. Corticosteroids, sulphasalazine and the new salicylates, the immunosuppressants azathioprine, 6-MP and, more recently, cyclosporin and metronidazole have become the accepted and standard forms of treatment. The importance of maintaining nutritional status is often overlooked but must be considered in every patient. Recognition of the occurrence of disease in all age groups, and in particular in children and adolescents, is also important, as is an appreciation of the special problems involved. The possibility of surgery at some stage of the disease should be raised with the patient. As the pathogenetic mechanisms of inflammatory bowel disease are further elucidated, new forms of treatment will be developed. This is already happening, with studies looking at such agents as immunoglobulin G, eicosapentaenoic acid and a new specific inhibitor of 5-lipoxygenase. These offer hope of more potent drugs with low side-effect profiles that may complement or replace the currently available agents used in the management of inflammatory bowel disease.

Serum concentrations of tumour necrosis factor alpha in childhood chronic inflammatory bowel disease

Serum tumour necrosis factor alpha (TNF alpha) concentrations were measured by enzyme linked immunoadsorbent assay in 31 normal children and during 65 episodes of clinical remission and 54 episodes of relapse in 92 children with chronic inflammatory bowel disease. An appreciable rise in TNF alpha was found only in children in relapse of ulcerative colitis and colonic Crohn's disease. The group of children with small bowel Crohn's disease in relapse did not show increases of TNF alpha above control concentrations, despite an equivalent rise in disease indices. Height velocity was depressed in children with relapse of large bowel Crohn's disease and ulcerative colitis compared with the equivalent condition in remission. The impairment of growth velocity was significantly greater in relapse of large bowel Crohn's disease and ulcerative colitis than in small bowel Crohn's disease alone, although for the subgroups in stage 1 puberty (prepubertal) the differences were not significant. Inadequate growth in chronic inflammatory bowel disease is currently ascribed to inadequate nutrition and TNF alpha may contribute to this through its cachexia inducing effects. It may, in addition, diminish pituitary growth hormone release. These results suggest that production of TNF alpha may be associated with growth failure in relapse of colonic inflammatory bowel disease.

The nutritional consequences of gastrointestinal disease in adolescence

The growth spurt of adolescence, during which body weight nearly doubles and height increases by 16%, demands an increased delivery of nutrients by the gastrointestinal tract. Chronic disorders of digestion and absorption at this age, therefore have a potentially profound effect upon growth, skeletal maturation and sexual development. Moreover, the emotional climate of adolescence, which requires affiliation with peer groups, and a distancing from authority figures such as doctors and parents, is often associated with a deterioration in drug and dietary compliance and with erratic clinic attendance. Nutritional problems in adolescent patients with Crohn's disease, cystic fibrosis and coeliac disease are the most common. About one third of adolescents with Crohn's disease experience growth failure and delayed sexual development, probably as a consequence of long-term undernutrition. There is a strong argument for the care of these patients being in the hands of paediatric gastroenterologists. Enteral nutrition, often administered overnight, is successful in inducing catch-up growth, and reducing steroid dosage, although resection of diseased gut is often followed by good growth, and surgery should not be overlooked. Cystic fibrosis in adolescence is commonly complicated by protein-energy malnutrition. Pathogenesis includes anorexia, maldigestion and an increase in resting energy expenditure. Malnutrition has been treated by a number of enteral regimens. In general, there is no place for repeated, short-term interventions of less than 6 months. Long-term studies have all shown good nutritional repletion and growth, but results with respect to improved respiratory function are conflicting. More prospective control trials are needed before the precise indications for enteral nutrition in cystic fibrosis can be accurately defined. Once started it is difficult to stop, although preoperative treatment of patients awaiting heart-lung transplantation seems entirely appropriate. The major problem in the management of coeliac disease in adolescence is dietary compliance. Even those patients who claim to have good dietary compliance often have jejunal biopsy evidence of gluten ingestion and tend to be underweight. This is particularly worrying, as after 5 years adherence to a gluten free diet, the increased risk of gastrointestinal malignancy appears to return to normal.