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Greene AC, Mankarious MM, Finkelstein A, El-Mallah JC, Kulaylat AS, Kulaylat AN. Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis. J Surg Res 2024; 295:399-406. [PMID: 38070253 DOI: 10.1016/j.jss.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/21/2023] [Accepted: 11/08/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes. METHODS Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay. RESULTS The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference. CONCLUSIONS There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Adam Finkelstein
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Jessica C El-Mallah
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Audrey S Kulaylat
- Division of Colon and Rectal Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania.
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Martinelli M, Fedele F, Romano C, Aloi M, Lionetti P, Alvisi P, Arrigo S, Bosa L, Bramuzzo M, D'Arcangelo G, Dipasquale V, Felici E, Fuoti M, Gatti S, Graziano F, Illiceto MT, Labriola F, Norsa L, Pastore M, Scarallo L, Strisciuglio C, Zuin G, Miele E, Staiano A. Disease course of ulcerative proctitis in children: A population-based study on behalf of the SIGENP IBD Group. Dig Liver Dis 2024; 56:70-76. [PMID: 37481430 DOI: 10.1016/j.dld.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/19/2023] [Accepted: 07/10/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND The natural history of ulcerative proctitis (UP) has been poorly investigated in children. AIMS We aimed to compare the disease course of children with UP at diagnosis to the other locations and to identify extension predictors. METHODS This was a multicenter, observational study carried out from data prospectively entered in the SIGENP-IBD-Registry. Children with ulcerative colitis (UC) diagnosis and at least 1-year follow-up were included. On the basis of Paris classification UP patients were identified and compared with the other locations. RESULTS 872 children were enrolled (median age at diagnosis: 11.2 years; M/F: 426/446), of whom 78 (9%) with UP. Kaplan-Meier analysis demonstrated increased cumulative probabilities of disease extension in the E1 group [1 year: 20.3%; 5 years: 52.7%; 10 years: 72.4%] compared to E3 group [1 year: 8.5%; 5 years: 24.9% and 10 years: 60.1%, p=0.001]. No differences were observed comparing E1 and E2 groups [p=0.4]. Cumulative probabilities of surgery at 1, 5 and 10 years were 1.3, 2.8 and 2.8% in the E1 group and 2.5, 8 and 12.8% in the E2-E3-E4 group, respectively (p=0.1). Cox regression analysis demonstrated that PUCAI>35 at diagnosis was associated with endoscopic extension (HR=4.9; CI 95% 1.5-15.2, p=0.006). CONCLUSIONS UP is associated with similar short and long-term outcomes compared to other locations.
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Affiliation(s)
- Massimo Martinelli
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Via S. Pansini, 5, Naples 80131, Italy
| | - Flora Fedele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Via S. Pansini, 5, Naples 80131, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Marina Aloi
- Women's and Children's Health Department, Pediatric Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | | | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Unit, Institute 'Giannina Gaslini', Genoa, Italy
| | - Luca Bosa
- Department of Women's and Children's Health, Unit of Pediatric Gastroenterology Digestive Endoscopy, Hepatology and Care of the Child With Liver Transplantation, Padua, Italy
| | - Matteo Bramuzzo
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Giulia D'Arcangelo
- Women's and Children's Health Department, Pediatric Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Enrico Felici
- Pediatric and Pediatric Emergency Unit, "Umberto Bosio" Center for Digestive Diseases, The Children Hospital, AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Maurizio Fuoti
- Pediatric Gastroenterology and GI Endoscopy, University Department of Pediatrics, Children's Hospital, Spedali Civili, Brescia, Italy
| | - Simona Gatti
- Department of Pediatrics, Università Politecnica delle Marche, Ancona, Italy
| | | | - Maria Teresa Illiceto
- Santo Spirito Hospital, Pediatric Gastroenterology and Endoscopic Unit- Department of Pediatrics, Pescara, Italy
| | - Flavio Labriola
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Lorenzo Norsa
- Paediatric Hepatology Gastroenterology and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Maria Pastore
- Fondazione IRCCS Casa Sollievo della Sofferenza, Division of Pediatrics, San Giovanni Rotondo, Italy
| | - Luca Scarallo
- University of Florence-Meyer Hospital, Florence, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanna Zuin
- Department of Pediatrics, University of Milano-Bicocca, Foundation MBBM/San Gerardo Hospital, Monza, Italy
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Via S. Pansini, 5, Naples 80131, Italy.
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Via S. Pansini, 5, Naples 80131, Italy
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Dolinger MT. The Role of Noninvasive Surrogates of Inflammation in Monitoring Pediatric Inflammatory Bowel Diseases: The Old and the New. Gastroenterol Clin North Am 2023; 52:497-515. [PMID: 37543396 DOI: 10.1016/j.gtc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
Effectiveness of limited available therapies for pediatric inflammatory bowel disease has reached stagnation. Previous non-invasive monitoring strategies have relied upon cumbersome tools to evaluate clinical symptoms and biochemical markers that do not reflect endoscopic activity or respond quickly to treatments. Novel, patient-centric, and highly accurate, monitoring strategies with a focus on intestinal ultrasound for a direct, precise monitoring of activity to achieve disease modification are now possible. Ultimately, research on the optimal tight control monitoring strategies, individualized to each pediatric inflammatory bowel disease patient, are in development and offer a hope to potential therapeutic ceiling breakthrough on the horizon.
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Affiliation(s)
- Michael Todd Dolinger
- Division of Pediatric Gastroenterology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Mansuri I, Wang S, Rufo PA, Liu E, Chan C, Bousvaros A. Efficacy and Safety of Sulfasalazine Suspension in Children With Ulcerative Colitis. J Pediatr Gastroenterol Nutr 2023; 76:460-467. [PMID: 36576855 DOI: 10.1097/mpg.0000000000003698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sulfasalazine (SZ) is commonly used to treat pediatric ulcerative colitis (UC). SZ can be compounded into a suspension form which is beneficial for children with difficulty swallowing a pill. Despite being utilized for over 40 years, there is a lack of published data on the efficacy and safety of SZ suspension in children with UC. Recently, third-party payors have begun refusing to pay for SZ suspension due to lack of data. METHODS In this retrospective study, we reviewed the electronic medical records of patients ages <18 years diagnosed with UC from June 1999 to December 2019 at Boston Children's Hospital and treated with SZ suspension as a first-line agent. We obtained demographics, clinical, and endoscopic data to measure outcomes at 1 year and long term. RESULTS Of 57 patients treated with SZ suspension, 52 (91%) had a follow-up and 26 of 52 (50%) remained in steroid-free remission at 1 year. Two patients were switched to SZ tablets due to nonmedical reasons and 11 (21%) required rescue treatment (2 infliximab, 1 tacrolimus, 8 6-mercaptopurine/azathioprine) within a year. Three required colectomy within a year and 5 in long term. Four (8%) developed nonserious adverse reactions and switched to 5-aminosalicylates (5-ASA) by 1 year. The median duration of long-term follow-up was 36 months (range, 2-205 months) with 28 requiring treatment escalation in long term. CONCLUSIONS SZ suspension is a safe and effective treatment for UC in children with difficulty swallowing a pill. The 1-year remission rate on this treatment is comparable to 5-ASA utilized in children.
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Affiliation(s)
- Ishrat Mansuri
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Sophia Wang
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Paul A Rufo
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Enju Liu
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Christina Chan
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Athos Bousvaros
- From the Division of Gastroenterology, Boston Children's Hospital, Boston, MA
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Rahmani P, Rasti G, Gorgi M, Motamed F, Sharifi P. Extraintestinal manifestation of inflammatory bowel disease and associated factors in pediatric patients. Ann Med Surg (Lond) 2022; 75:103363. [PMID: 35242319 PMCID: PMC8857438 DOI: 10.1016/j.amsu.2022.103363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 02/01/2022] [Accepted: 02/10/2022] [Indexed: 11/21/2022] Open
Abstract
Objective Extraintestinal manifestations in irritable bowel disease (IBD), Crohn's disease and ulcerative colitis are reported in different system of the body. We aimed to investigate the factors determining disease severity and evaluate extraintestinal manifestations in patients with irritable bowel disease based on disease activity scoring system. Methods This cross-sectional study was conducted on all patients with irritable bowel disease referred to clinic and gastroenterology ward of (XXX). Medical history, gastrointestinal complications and incidence of extraintestinal manifestations were recorded. Disease severity in ulcerative colitis was rated based on PUCAI (Pediatric Ulcerative Colitis Activity Index) score and in Crohn's disease was calculated based on PCDAI (Pediatric Crohn's Disease Activity Index) score. Results Of 73 children included in our study, 54.80% were diagnosed with ulcerative colitis and 45.20% were diagnosed with Crohn's disease. The most prevalent symptom was weight loss (81.81%), diarrhea (72.72%) and abdominal pain (69.69%) in Crohn's diseases and bloody diarrhea (80%), abdominal pain (77.5%) and weight loss (57.5%) in ulcerative colitis. The average of PCDAI score was 43.44 and PUCAI score was 35.62. The most prevalent extraintestinal manifestation of the disease was arthritis in 7 Crohn's disease patients (21.21%) and 5 patients (12.5%) with ulcerative colitis, oral plague in 5 patients (15.15%) with Crohn's disease and erythema nodosum in 2 patients (6.06%) with Crohn's disease. Conclusion The severity of oral plaque was positively associated with the severity of the disease. There was no significant association among other parameters. Scoring systems, to determine the extraintestinal manifestation, should be standardized based on the scoring outcomes. Crohn’s disease and ulcerative colitis are the most common types of inflammatory bowel disease. The severity of oral plaque was positively associated with the severity of the disease. The qualitative score of the disease was significantly associated with oral plague.
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Affiliation(s)
- Parisa Rahmani
- Pediatric Gastroenterology and Hepatology Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghazaleh Rasti
- Pediatric Gastroenterology and Hepatology Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Gorgi
- Department of Pediatrics, School of Medicine, Childrens Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Motamed
- Pediatric Gastroenterology and Hepatology Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Parastoo Sharifi
- Pediatric Gastroenterology and Hepatology Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author. Tehran University of Medical Sciences, Tehran, Iran.
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Contemporary Risk of Surgery in Patients With Ulcerative Colitis and Crohn's Disease: A Meta-Analysis of Population-Based Cohorts. Clin Gastroenterol Hepatol 2021; 19:2031-2045.e11. [PMID: 33127595 PMCID: PMC8934200 DOI: 10.1016/j.cgh.2020.10.039] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We conducted a systematic review with meta-analysis to estimate rates and trends of colectomy in patients with ulcerative colitis (UC), and of primary and re-resection in patients with Crohn's disease (CD), focusing on contemporary risks. METHODS Through a systematic review until September 3, 2019, we identified population-based cohort studies that reported patient-level cumulative risk of surgery in patients with UC and CD. We evaluated overall and contemporary risk (after 2000) of surgery and analyzed time trends through mixed-effects meta-regression. RESULTS In patients with UC (26 studies), the overall 1-, 5-, and 10-year risks of colectomy was 4.0% (95% CI, 3.3-5.0), 8.8% (95% CI, 7.7-10.0), and 13.3% (95% CI, 11.3-15.5), respectively, with a decrease in risk over time (P < .001). Corresponding contemporary risks were 2.8% (95% CI, 2.0-3.9), 7.0% (95% CI, 5.7-8.6), and 9.6% (95% CI, 6.3-14.2), respectively. In patients with CD (22 studies), the overall 1-, 5-, and 10-year risk of surgery was 18.7% (95% CI, 15.0-23.0), 28.0% (95% CI, 24.0-32.4), and 39.5% (95% CI, 33.3-46.2), respectively, with a decrease in risk over time (P < .001). Corresponding contemporary risks were 12.3% (95% CI, 10.8-14.0), 18.0% (95% CI, 15.4-21.0), and 26.2% (95% CI, 23.4-29.4), respectively. In a meta-analysis of 8 studies in patients with CD with prior resection, the cumulative risk of a second resection at 5 and 10 years after the first resection was 17.7% (95% CI, 13.5-22.9) and 31.3% (95% CI, 24.1-39.6), respectively. CONCLUSIONS Patient-level risks of surgery have decreased significantly over time, with a 5-year cumulative risk of surgery of 7.0% in UC and 18.0% in CD in contemporary cohorts. This decrease may be related to early detection and/or better treatment.
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7
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Aloi M, Bramuzzo M, Norsa L, Arrigo S, Distante M, Miele E, Romano C, Giobbi C, Panceri R, Cucchiara S, Alvisi P. Disease Activity Patterns in the First 5 Years After Diagnosis in Children With Ulcerative Colitis: A Population-Based Study. J Crohns Colitis 2021; 15:367-374. [PMID: 33022055 DOI: 10.1093/ecco-jcc/jjaa203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to define clusters of activity in a population-based cohort during the first 5 years after diagnosis in children with ulcerative colitis [UC] and to identify early prognostic risk factors. METHODS All UC patients from the SIGENP IBD registry with a complete follow-up of at least 5 years were included. Active disease was defined every 6 months in the presence of at least one of the following: clinical activity [Paediatric Ulcerative Colitis Activity Index ≥ 35]; endoscopic activity [Mayo score ≥ 1]; faecal calprotectin > 250 µg/g; hospitalization; surgery; or treatment escalation. Formula-based clusters were generated based on four published questionnaire-based activity patterns in adults, plus one additional cluster. RESULTS In total, 226 patients were identified. Forty-two [19%] had moderate-severe chronically active disease, 31 [14%] chronic-intermittent, 75 [33%] quiescent, 54 [24%] active disease in the first 2 years after the diagnosis, then sustained remission, and 24 [11%] a remission in the first 2 years then an active disease. Mild disease onset along with a lower clinical severity not requiring the use of corticosteroids at 6 months were related to a quiescent disease course at the next follow-up (logistic model area under the curve 0.86 [95% confidence interval 0.78-0.94]; positive predictive value 67%; negative predictive value 70%). Eight per cent of patients needed surgery, none in the quiescent group [p = 0.04]. CONCLUSIONS More than one-third of children with UC present with a chronically active or intermittent course during the first 5 years of follow-up. A significant group of patients has active disease in the first 2 years and then sustained remission. Interestingly, after initial treatment, one-third of patients have well-controlled disease throughout.
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Affiliation(s)
- M Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - M Bramuzzo
- Institute for Maternal and Child Health IRCCS 'Burlo Garofalo', Trieste, Italy
| | - L Norsa
- Pediatric Hepatology Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - S Arrigo
- Pediatric Gastroenterology Unit, Institute 'Giannina Gaslini', Genoa, Italy
| | - M Distante
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - E Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - C Romano
- Pediatric Gastroenterology and Endoscopy, University of Messina, Messina, Italy
| | - C Giobbi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - R Panceri
- Department of Pediatrics, University of Milano-Bicocca Fond., MBBM/Hosp., San Gerardo Monza, Italy
| | - S Cucchiara
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - P Alvisi
- Pediatric Department, Maggiore Hospital, Bologna, Italy
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Orlanski-Meyer E, Aardoom M, Ricciuto A, Navon D, Carman N, Aloi M, Bronsky J, Däbritz J, Dubinsky M, Hussey S, Lewindon P, Martin De Carpi J, Navas-López VM, Orsi M, Ruemmele FM, Russell RK, Veres G, Walters TD, Wilson DC, Kaiser T, de Ridder L, Griffiths A, Turner D. Predicting Outcomes in Pediatric Ulcerative Colitis for Management Optimization: Systematic Review and Consensus Statements From the Pediatric Inflammatory Bowel Disease-Ahead Program. Gastroenterology 2021; 160:378-402.e22. [PMID: 32976826 DOI: 10.1053/j.gastro.2020.07.066] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS A better understanding of prognostic factors in ulcerative colitis (UC) could improve patient management and reduce complications. We aimed to identify evidence-based predictors for outcomes in pediatric UC, which may be used to optimize treatment algorithms. METHODS Potential outcomes worthy of prediction in UC were determined by surveying 202 experts in pediatric UC. A systematic review of the literature, with selected meta-analysis, was performed to identify studies that investigated predictors for these outcomes. Multiple national and international meetings were held to reach consensus on evidence-based statements. RESULTS Consensus was reached on 31 statements regarding predictors of colectomy, acute severe colitis (ASC), chronically active pediatric UC, cancer and mortality. At diagnosis, disease extent (6 studies, N = 627; P = .035), Pediatric Ulcerative Colitis Activity Index score (4 studies, n = 318; P < .001), hemoglobin, hematocrit, and albumin may predict colectomy. In addition, family history of UC (2 studies, n = 557; P = .0004), extraintestinal manifestations (4 studies, n = 526; P = .048), and disease extension over time may predict colectomy, whereas primary sclerosing cholangitis (PSC) may be protective. Acute severe colitis may be predicted by disease severity at onset and hypoalbuminemia. Higher Pediatric Ulcerative Colitis Activity Index score and C-reactive protein on days 3 and 5 of hospital admission predict failure of intravenous steroids. Risk factors for malignancy included concomitant diagnosis of primary sclerosing cholangitis, longstanding colitis (>10 years), male sex, and younger age at diagnosis. CONCLUSIONS These evidence-based consensus statements offer predictions to be considered for a personalized medicine approach in treating pediatric UC.
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Affiliation(s)
- Esther Orlanski-Meyer
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Martine Aardoom
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - Dan Navon
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Nicholas Carman
- Children's Hospital of Eastern Ontario, IBD Centre, University of Ottawa, Ottawa, Canada
| | - Marina Aloi
- Pediatric Gastroenterology Unit, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Jiri Bronsky
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Jan Däbritz
- University Medical Center Rostock, Department of Pediatrics, Rostock, Germany; Queen Mary University of London, The Barts and the London School of Medicine and Dentistry, Blizard Institute, Center for Immunobiology, London, United Kingdom
| | - Marla Dubinsky
- Pediatric Gastroenterology and Nutrition, Mount Sinai Kravis Children's Hospital; Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine, Mount Sinai, New York
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Javier Martin De Carpi
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Marina Orsi
- Pediatric Gastroenterology, Hepatology and Transplant Unit, Hospital Italiano de Buenos Aires, Argentina
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité; Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Service de Gastroentérologie Pédiatrique; Institute IMAGINE Inserm U1163, Paris, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Gabor Veres
- Pediatric Institute-Clinic, University of Debrecen, Hungary
| | - Thomas D Walters
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Thomas Kaiser
- Department of General Pediatrics, University Hospital Münster, Germany
| | - Lissy de Ridder
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Anne Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - Dan Turner
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel.
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A baseline assessment of enhanced recovery protocol implementation at pediatric surgery practices performing inflammatory bowel disease operations. J Pediatr Surg 2020; 55:1996-2006. [PMID: 32713714 PMCID: PMC7606356 DOI: 10.1016/j.jpedsurg.2020.06.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/17/2020] [Accepted: 06/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Enhanced recovery protocols (ERPs) have been used to improve patient outcomes and resource utilization after surgery. These evidence-based interventions include patient education, standardized anesthesia protocols, and limited fasting, but their use among pediatric populations is lagging. We aimed to determine baseline recovery practices within pediatric surgery departments participating in an ERP implementation trial for elective inflammatory bowel disease (IBD) operations. METHODS To measure baseline ERP adherence, we administered a survey to a staff surgeon in each of the 18 participating sites. The survey assessed demographics of each department and utilization of 21 recovery elements during patient encounter phases. Mixed-methods analysis was used to evaluate predictors and barriers to ERP element implementation. RESULTS The assessment revealed an average of 6.3 ERP elements being practiced at each site. The most commonly practiced elements were using minimally invasive techniques (100%), avoiding intraabdominal drains (89%), and ileus prophylaxis (72%). The preoperative phase had the most elements with no adherence including patient education, optimizing medical comorbidities, and avoiding prolonged fasting. There was no association with number of elements utilized and total number of surgeons in the department, annual IBD surgery volume, and hospital size. Lack of buy-in from colleagues, electronic medical record adaptation, and resources for data collection and analysis were identified barriers. CONCLUSIONS Higher intervention utilization for IBD surgery was associated with elements surgeons directly control such as use of laparoscopy and avoiding drains. Elements requiring system-level changes had lower use. The study characterizes the scope of ERP utilization and the need for effective tools to improve adoption. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Mixed-methods survey.
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Ihekweazu FD, Fofanova T, Palacios R, Ajjarapu A, Karam L, Vogel AM, Rodriguez JR, Kellermayer R. Progression to colectomy in the era of biologics: A single center experience with pediatric ulcerative colitis. J Pediatr Surg 2020; 55:1815-1823. [PMID: 32087936 PMCID: PMC7396289 DOI: 10.1016/j.jpedsurg.2020.01.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/13/2020] [Accepted: 01/29/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Clinical outcomes in pediatric ulcerative colitis (UC) in the era of biologic agents are poorly defined. We aimed to describe risk factors for colectomy in pediatric UC in the era of infliximab therapy. METHODS We reviewed 217 pediatric patients at Texas Children's Hospital with newly diagnosed UC between 2003 and 2015; 117 had a minimum of 5 years of follow-up. Extent of disease at diagnosis, medication exposure, the presence of extraintestinal manifestations (EIMs), and need for surgery were noted. RESULTS Average length of follow up was 5.02 ± 2.27 years. Forty-two percent presented with pancolitis. Infliximab was used in 39%, immunomodulators in 65%, and steroids in 89% of patients. EIMs occurred in 24.9% of patients. The cumulative rate of colectomy was 12.9% at 5 years. Children presenting as E2 (Paris Classification) and children prescribed oral steroid monotherapy at diagnosis progressed to surgery faster than any other group. Of the children who received infliximab, females and children less than 5 years old were less likely to respond to therapy. CONCLUSIONS The natural course of pediatric UC remains aggressive despite the addition of infliximab to the standard of care and suggests a need for early aggressive clinical intervention. LEVEL-OF-EVIDENCE RATING Level IV.
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Affiliation(s)
- Faith D. Ihekweazu
- Department of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin St, MW1010, Houston, TX, 77030,Corresponding author at: Section of Pediatric Gastroenterology, Hepatology & Nutrition, Baylor College of Medicine, 1102 Bates St, FT 860.28, Houston, TX 77030-2399. Tel.: +1 832 824 3754 (Voice); fax: +1 832 825 3633, (F.D. Ihekweazu)
| | - Tatiana Fofanova
- Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, One Baylor Plaza, MS BCM385, Houston, TX 77030,Program in Translational Biology and Molecular Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030
| | - Ryan Palacios
- Department of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin St, MW1010, Houston, TX, 77030
| | - Avanthi Ajjarapu
- Department of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin St, MW1010, Houston, TX, 77030
| | - Lina Karam
- Department of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin St, MW1010, Houston, TX, 77030
| | - Adam M. Vogel
- Department of Pediatric Surgery, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin St, Houston, TX 77030
| | - J R Rodriguez
- Department of Pediatric Surgery, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin St, Houston, TX 77030
| | - Richard Kellermayer
- Department of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin St, MW1010, Houston, TX, 77030,USDA/ARS Children’s Nutrition Research Center, 1100 Bates Ave, Houston, TX, 77030
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11
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Outcomes Following Pouch Formation in Paediatric Ulcerative Colitis: A Study From the Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2020; 71:346-353. [PMID: 32541197 DOI: 10.1097/mpg.0000000000002805] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Contemporary pediatric data on pouch outcomes are sparse, especially in the era of laparoscopic surgeries. We aimed to assess outcomes and predictors in children with ulcerative colitis/inflammatory bowel disease (IBD)-unclassified who underwent colectomy and ileal pouch-anal anastomosis. METHODS This was a multicenter retrospective cohort study from 17 IBD centers affiliated with the pediatric IBD Porto group of ESPGHAN. An electronic REDcap system was used to collate baseline characteristics, demographic, clinical, management and surgical data, short- and long-term outcomes, and to identify potential predictors of pouch outcome. RESULTS Of the 129 patients included, 86 (67%) developed pouchitis during follow-up of median 40 months (interquartile range 26-72), of whom 33 (26%) with chronic pouchitis. Patients operated on by surgeons performing <10 pouch surgeries/year had a higher rate of chronic pouchitis (11/27 [41%] vs 8/54 [15%], P = 0.013) on both univariable and multivariable analyses and also associated with time to pouchitis (P = 0.018) and chronic pouchitis (P = 0.020). At last follow-up, overall pouch performance was rated good/excellent in 86 (74%) patients. Time from colectomy to pouch formation was not associated with pouch outcomes. Despite higher rate of nonsevere surgical complications among children undergoing colectomy at <10 years of age (7/16 [44%] vs 10/92 [11%], P = 0.003), functional outcome and pouchitis rate did not differ. CONCLUSIONS Pouchitis rate in children with ulcerative colitis/IBD unclassified is high. Surgeon experience is the major modifiable risk factor for pouch outcome. Our analyses suggest that pouch surgery can also be performed successfully in young children.
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12
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Extraintestinal Manifestations Are Associated With Disease Severity in Pediatric Onset Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2020; 71:40-45. [PMID: 32187141 DOI: 10.1097/mpg.0000000000002707] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The aim of this study was to investigate a possible association between extraintestinal manifestations (EIM) and a more severe disease course in pediatric onset inflammatory bowel disease (pIBD). METHODS This study compares the disease course of pIBD patients (IBD diagnosis <15 years of age) with and without EIM in a population-based cohort from Denmark. Patients diagnosed with pIBD between 1998 and 2008 were included in the study and followed until December 31, 2014. Data on phenotype, treatment, relapses, and the temporal relationship between IBD relapses and activity of EIM were collected at end of follow-up by manual revision of patient charts. RESULTS Of 333 pIBD patients, 14 (4.2%) had EIM at time of diagnosis and 47 (14.1%) developed EIM during follow-up. Median follow-up time was 9.6 years for patients with EIM and 8.8 years for patients without. In ulcerative colitis, EIM were associated with an increased risk of biological treatment and surgery (hazard ratio: 2.6; 95% confidence interval [CI]: 1.3-5.5, P = 0.008 and 2.9 [95% CI: 1.1-7.7, P = 0.03], respectively). In Crohn disease, EIM were associated with an increased relapse rate (1.3 [95% CI: 1.1-1.5], P = 0.001). Lastly, we found a positive temporal relationship between relapse of IBD and EIM activity. CONCLUSION The presence of EIM is associated with a more severe disease course in pIBD. This should be considered when deciding treatment options, as a more aggressive treatment approach could be warranted in patients with EIM. However, prospective studies are needed to fully evaluate this.
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13
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Lund K, Larsen MD, Knudsen T, Kjeldsen J, Nielsen RG, Nørgård BM. The impact of anti-TNFα therapy on colectomy rates and corticosteroid treatment among 3001 paediatric and adolescent patients with ulcerative colitis-a nationwide study from 1995 to 2015. Aliment Pharmacol Ther 2019; 50:1077-1085. [PMID: 31579961 DOI: 10.1111/apt.15510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/07/2019] [Accepted: 08/29/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The long-term effects of anti-TNFα therapy in ulcerative colitis are debatable. AIM To examine whether anti-TNFα therapy changed the colectomy proportion and reduced the use of corticosteroids. METHODS A nationwide cohort study among patients (age 0-20) diagnosed with ulcerative colitis through 1995-2015 from Danish health registries. We calculated the cumulative 5-year risk of colectomy after diagnosis and used a Cox regression model for comparison between a historical pre-anti-TNFα cohort 1 (1995-2003) and a cohort 2 for the era of anti-TNFα (2004-2015). Based on anti-TNFα users, defined as patients who had at least four anti-TNFα treatments within 4 months, we examined the subsequent need for corticosteroids. RESULTS We identified 3001 patients from 1995 to 2015. The 5-year cumulative proportion of colectomy in cohort 2 was 9.7% (95% confidence interval [CI] 8.4-11.1) and 12.3% (95% CI 10.4-14.6) in cohort 1. The adjusted 5-year hazard ratio (HR) was 0.76 (95% CI 0.60-0.96) for colectomy in cohort 2 compared to cohort 1. A total of 334 patients received anti-TNFα treatments, and 16.8% (56/334) were prescribed corticosteroids in the subsequent 3-month period. Corticosteroid treatment declined with follow-up after 6 and 12 months, 5.4% and 1.2%, respectively. CONCLUSION In patient's ≤20 years, the HR for colectomy within a period of 5 years from the time of diagnosis was reduced in the era of anti-TNFα compared to a historical cohort. In patients treated with anti-TNFα, prescriptions of corticosteroids were virtually ceased after 12 months.
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Affiliation(s)
- Ken Lund
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark.,Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael Due Larsen
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark.,Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Torben Knudsen
- Department of Medicine, Hospital of Southwest Jutland, Esbjerg, Denmark.,Institute for Regional Health Science, Center Southwest Jutland, University of Southern Denmark, Esbjerg, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark.,Research Unit of Medical Gastroenterology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rasmus Gaardskjaer Nielsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Research Unit of Pediatric, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark.,Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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14
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Fragaki M, Demetriou G, Koutroubakis IE. Risk Factors of Colectomy in Patients With Refractory Ulcerative Colitis Under Calcineurin Inhibitors Combined With Vedolizumab. Clin Gastroenterol Hepatol 2019; 17:1213-1214. [PMID: 31003696 DOI: 10.1016/j.cgh.2018.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Maria Fragaki
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - George Demetriou
- Department of Gastroenterology, University Hospital Heraklion, Crete, Greece
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15
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Duricova D, Sarter H, Savoye G, Leroyer A, Pariente B, Armengol-Debeir L, Bouguen G, Ley D, Turck D, Templier C, Buche S, Peyrin-Biroulet L, Gower-Rousseau C, Fumery M. Impact of Extra-Intestinal Manifestations at Diagnosis on Disease Outcome in Pediatric- and Elderly-Onset Crohn's Disease: A French Population-Based Study. Inflamm Bowel Dis 2019; 25:394-402. [PMID: 30085159 DOI: 10.1093/ibd/izy254] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Extraintestinal manifestations (EIM) have been associated with more severe course of inflammatory bowel disease. The aim was to study the frequency of EIM in pediatric- and elderly-onset Crohn's disease (CD) and the factors associated with EIM and their impact on long-term disease outcome. METHODS Pediatric- (age at diagnosis younger than 17 years) and elderly-onset CD patients (age at diagnosis 60 years or older) from a prospective population-based registry (EPIMAD) were recruited. Data on EIM and clinical factors at diagnosis and at maximal follow-up were collected. RESULTS We included 535 pediatric- and 370 elderly-onset patients (median age 14.5 and 69.9 years; median follow-up 11.1 and 5.9 years). Extraintestinal manifestations presented in 23.5% of childhood-onset and 4.9% of elderly-onset individuals at diagnosis, while in 29.8% and 5.9% of patients, EIM developed newly during the follow-up (hazard ration [HR] 4.4, 95% CI, 2.7-7.0, P < 0.001). The most frequently involved organ in both age cohorts, either at diagnosis or during disease course, were joints (pediatric: 11.2% and 22.6%; elderly: 3.2% and 3.5%, respectively) followed by skin (pediatric: 15.9% and 13.6%; elderly: 2.7% and 2.7%, respectively). Extraintestinal manifestations at diagnosis were associated with increased risk for corticosteroids (HR 1.42, 95% CI, 1.14-1.78 and HR 3.38, 95% CI, 1.88-6.08) and immunosuppressive therapy (HR 1.30, 95% CI, 1.02-1.65 and HR 4.24, 95% CI, 1.91-9.42), in both age populations. CONCLUSIONS Extraintestinal manifestations occurred at lower frequency in elderly-onset compared with pediatric-onset patients. In both age populations, presence of EIM at diagnosis independently increased the need for corticosteroid and immunosuppressive treatment.
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Affiliation(s)
- Dana Duricova
- Public Health, Epidemiology and Economic Health, Register Epimad, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France.,IBD clinical and research centre, ISCARE, Prague, Czech Republic
| | - Hélène Sarter
- Public Health, Epidemiology and Economic Health, Register Epimad, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France.,Lille Inflammation Research International Centre LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - Guillaume Savoye
- Gastroenterology Unit, Epimad Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
| | - Ariane Leroyer
- Public Health, Epidemiology and Economic Health, Register Epimad, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France
| | - Benjamin Pariente
- Gastroenterology Unit, Hôpital Huriez, Lille University Hospital, Lille, France
| | - Laura Armengol-Debeir
- Gastroenterology Unit, Epimad Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
| | | | - Delphine Ley
- Lille Inflammation Research International Centre LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Lille University Jeanne de Flandre Children's Hospital, University of Lille, Lille, France
| | - Dominique Turck
- Lille Inflammation Research International Centre LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Lille University Jeanne de Flandre Children's Hospital, University of Lille, Lille, France
| | - Carole Templier
- Dermatology Unit, Hôpital Huriez, Lille University Hospital, Lille, France
| | - Sebastien Buche
- Dermatology Unit, Hôpital Huriez, Lille University Hospital, Lille, France
| | | | - Corinne Gower-Rousseau
- Public Health, Epidemiology and Economic Health, Register Epimad, Maison Régionale de la Recherche Clinique, Lille University and Hospital, Lille, France.,Lille Inflammation Research International Centre LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France
| | - Mathurin Fumery
- Lille Inflammation Research International Centre LIRIC - UMR 995 Inserm Lille 2 University, CHRU de Lille, Lille, France.,Gastroenterology Unit, Epimad Registry, CHU Amiens Sud, l, Amiens University Hospital, Amiens, France
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16
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Abstract
OBJECTIVES The aims of this retrospective study were to describe ulcerative colitis (UC) phenotype at diagnosis and follow-up and to identify possible predictors of severe disease course. METHODS This was a retrospective, single-center study. We reviewed the charts of patients with UC diagnosed between 2 and 18 years at our referral center from January 2007 to January 2016. Laboratory and clinical features at diagnosis, such as disease extent, atypical phenotypes, extraintestinal manifestations, and therapies, and pattern changes during the follow-up, including relapse rate, disease extension, and the cumulative risk for colectomy were collected. RESULTS One hundred eleven patients were enrolled. Atypical phenotypes were identified at diagnosis in 55 out of 111 patients (49.5%). Extraintestinal manifestations were detected in 16 out of 111 (14.4%) at the diagnosis. During the follow-up 60 out of 111 (54%) patients needed to start azathioprine, 9 out of 111 (8.1%) patients started biologic therapy and 10 out of 111 (patients underwent surgery, resulting in a cumulative risk of 8% at 5 years and 16% at 10 years. Steroid refractoriness (hazard ratio: 13.9) and starting of biologic therapy (hazard ratio: 25.3) represented the best predictors for surgery. The cumulative probability of first relapse was 47% at 6 months and 63% at 1 year. Disease extension was reported in 21 out of 70 patients (30%). CONCLUSION Pediatric UC is associated with a severe phenotype and a high percentage of atypical features. Surgery rate seems to be decreased from early reports.
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17
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Alreheili KM, Alsaleem KA, Almehaidib AI. Natural history and outcome of inflammatory bowel diseases in children in Saudi Arabia: A single-center experience. Saudi J Gastroenterol 2018; 24:171-176. [PMID: 29676289 PMCID: PMC5985636 DOI: 10.4103/sjg.sjg_490_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background/Aim Inflammatory bowel disease (IBD) is a chronic gastrointestinal disorder which includes ulcerative colitis (UC), Crohn's disease (CD), and indeterminate colitis (IC). The natural history of pediatric IBDs is poorly understood and generally unpredictable. We aim to study the natural history of IBD in Saudi children including the extraintestinal manifestations, changes in diagnosis, disease behavior, medical management, and surgical outcome. Patients and Methods A retrospective review of all the charts of children less than 14 years of age who were diagnosed as IBD and followed up in King Faisal Specialist Hospital and Research Center (KFSH and RC) from January 2001 to December 2011 was performed. Results Sixty-six children were diagnosed with IBD, 36 patients (54.5%) had CD, 27 patients (41%) had UC, and 3 patients (4.5%) had IC. Change in the diagnosis from UC to CD was made in 5 patients (7.6%). Extraintestinal manifestations were documented in 32% of all patients, and the most common was bone involvement (osteopenia/osteoporosis) in 16.7% of the patients. Arthritis (13.6%) was the second most common manifestation. Sclerosing cholangitis was reported in 2.8% in CD compared to 14.8% in UC. At the time of data collection, 8 patients (12%) were off therapy, 38 patients (57.6) were on 5-ASA, 31 patients (47%) were on azathioprine, and 12 patients (18.2%) were receiving anti-TNF. Of the children with CD, 10 patients (27.8%) underwent 1 or more major operations. Of the children with UC, 18.5% underwent 1 or more major intraabdominal procedures. Conclusions Many issues in pediatric IBD can predict the natural history of the disease including growth failure, complications, need for more aggressive medical treatment, and/or surgery. More studies are needed from the region focusing on factors that may affect the natural history and disease progression.
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Affiliation(s)
- Khalid M. Alreheili
- Department of Pediatrics, Division of Gastroenterology, Maternity and Children's Hospital, Madinah, Saudi Arabia
| | - Khalid A. Alsaleem
- Department of Pediatrics, Division of Gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ali I. Almehaidib
- Department of Pediatrics, Division of Gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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18
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Queliza K, Ihekweazu FD, Schady D, Jensen C, Kellermayer R. Granulomatous Upper Gastrointestinal Inflammation in Pediatric Ulcerative Colitis. J Pediatr Gastroenterol Nutr 2018; 66:620-623. [PMID: 28991840 PMCID: PMC5866164 DOI: 10.1097/mpg.0000000000001771] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Differentiating ulcerative colitis (UC) and Crohn disease (CD) can be clinically challenging, especially in children. Granulomatous inflammation has traditionally been attributed to CD. Crypt-associated giant cells and granulomas, however, have been observed in colonic biopsies of patients with UC. This phenomenon has not been described in the upper gastrointestinal (UGI) tract with UC. METHODS Seven pediatric patients with UC with granulomatous UGI (gUGI) lesions were identified. Diagnosis of UC was based on symptoms, clinical course, laboratory results, imaging, and endoscopy. We compared the gUGI patients to a large cohort of pediatric patients with UC (n = 149). RESULTS All fully evaluated cases were associated with bloody diarrhea and moderate to severe pancolitis. Gastric and/or duodenal biopsies demonstrated giant cells or granulomas near gland destruction. Small bowel imaging did not reveal any involvement. The majority of cases responded to standard medical therapies, except for 2 patients (28.6%) who required total colectomy. Acute severe, refractory colitis (ie, colectomy within 1 month of presentation) was significantly more common in the gUGI group than the large pediatric UC group (28.6% vs 1.3%, Fisher exact P = 0.01). CONCLUSIONS This is the first report of pediatric UC-associated granulomatous inflammation in the UGI tract. We speculate that these lesions represent extracolonic manifestations of intense colonic disease. These atypical findings expand the diagnostic considerations that should be incorporated during the differentiation between UC and CD in the pediatric age group.
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Affiliation(s)
- Karen Queliza
- Department of Pediatric Gastroenterology, Hepatology and Nutrition
| | | | - Deborah Schady
- Department of Pediatric Pathology, Baylor College of Medicine-Texas Children's Hospital
| | - Craig Jensen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition
| | - Richard Kellermayer
- Department of Pediatric Gastroenterology, Hepatology and Nutrition
- Children's Nutrition and Research Center, Houston, TX
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19
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Venkateswaran S, Prince J, Cutler DJ, Marigorta UM, Okou DT, Prahalad S, Mack D, Boyle B, Walters T, Griffiths A, Sauer CG, LeLeiko N, Keljo D, Markowitz J, Baker SS, Rosh J, Pfefferkorn M, Heyman MB, Patel A, Otley A, Baldassano R, Noe J, Rufo P, Oliva-Hemker M, Davis S, Zwick ME, Gibson G, Denson LA, Hyams J, Kugathasan S. Enhanced Contribution of HLA in Pediatric Onset Ulcerative Colitis. Inflamm Bowel Dis 2018; 24:829-838. [PMID: 29562276 PMCID: PMC6350448 DOI: 10.1093/ibd/izx084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The genetic contributions to pediatric onset ulcerative colitis (UC), characterized by severe disease and extensive colonic involvement, are largely unknown. In adult onset UC, Genome Wide Association Study (GWAS) has identified numerous loci, most of which have a modest susceptibility risk (OR 0.84-1.14), with the exception of the human leukocyte antigen (HLA) region on Chromosome 6 (OR 3.59). METHOD To study the genetic contribution to exclusive pediatric onset UC, a GWAS was performed on 466 cases with 2099 healthy controls using UK Biobank array. SNP2HLA was used to impute classical HLA alleles and their corresponding amino acids, and the results are compared with adult onset UC. RESULTS HLA explained the almost entire association signal, dominated with 191 single nucleotide polymorphisms (SNPs) (p = 5 x 10-8 to 5 x 10-10). Although very small effects, established SNPs in adult onset UC loci had similar direction and magnitude in pediatric onset UC. SNP2HLA imputation identified HLA-DRB1*0103 (odds ratio [OR] = 6.941, p = 1.92*10-13) as the most significant association for pediatric UC compared with adult onset UC (OR = 3.59). Further conditioning showed independent effects for HLA-DRB1*1301 (OR = 2.25, p = 7.92*10-9) and another SNP rs17188113 (OR = 0.48, p = 7.56*10-9). Two HLA-DRB1 causal alleles are shared with adult onset UC, while at least 2 signals are unique to pediatric UC. Subsequent stratified analyses indicated that HLA-DRB1*0103 has stronger association for extensive disease (E4: OR = 8.28, p = 4.66x10-10) and female gender (OR = 8.85, p = 4.82x10-13). CONCLUSION In pediatric onset UC, the HLA explains almost the entire genetic associations. In addition, the HLA association is approximately twice as strong in pediatric UC compared with adults, due to a combination of novel and shared effects. We speculate the paramount importance of antigenic stimulation either by infectious or noninfectious stimuli as a causal event in pediatric UC onset.
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Affiliation(s)
- Suresh Venkateswaran
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - Jarod Prince
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - David J Cutler
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA
| | - Urko M Marigorta
- Center for Integrative Genomics, Georgia Institute of Technology, Atlanta, GA
| | - David T Okou
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - Sampath Prahalad
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - David Mack
- Department of Pediatrics, Children’s Hospital of Eastern Ontario IBD Centre and University of Ottawa, Ontario, Canada
| | - Brendan Boyle
- Department of Gastroenterology, Nationwide Children’s Hospital Columbus, OH
| | - Thomas Walters
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Anne Griffiths
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Cary G Sauer
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - Neal LeLeiko
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Hasbro Children’s Hospital, Providence, RI
| | - David Keljo
- Gastroenterology, Hepatology and Nutrition Department, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - James Markowitz
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cohen Children’s Medical Center of NY, New Hyde Park, NY
| | - Susan S Baker
- Department of Digestive Diseases and Nutrition Center, University at Buffalo, Buffalo, NY
| | - Joel Rosh
- Department of Pediatrics, Goryeb Children’s Hospital, Morristown, NJ
| | - Marian Pfefferkorn
- Bronson Pediatric Gastroenterology, Bronson Children’s Hospital, Kalamazoo, MI
| | - Melvin B Heyman
- Department of Pediatrics, University of California at San Francisco, San Francisco, CA
| | - Ashish Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anthony Otley
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robert Baldassano
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Joshua Noe
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Paul Rufo
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Maria Oliva-Hemker
- Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, MD
| | - Sonia Davis
- Collaborative Studies Coordinating Center Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Michael E Zwick
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA
| | - Greg Gibson
- Center for Integrative Genomics, Georgia Institute of Technology, Atlanta, GA
| | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jeffrey Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children’s Medical Center, Hartford, CT
| | - Subra Kugathasan
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA,Address correspondence to: Subra Kugathasan, MD, Division of Pediatric Gastroenterology, Emory University School of Medicine, 1760 Haygood Drive, W427, Atlanta, GA 30322. E-mail: Tel: 404 727 4542; Fax: 404 727 4069
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Hochart A, Gower-Rousseau C, Sarter H, Fumery M, Ley D, Spyckerelle C, Peyrin-Biroulet L, Laberenne JE, Vasseur F, Savoye G, Turck D. Ulcerative proctitis is a frequent location of paediatric-onset UC and not a minor disease: a population-based study. Gut 2017; 66:1912-1917. [PMID: 27489240 DOI: 10.1136/gutjnl-2016-311970] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/29/2016] [Accepted: 07/14/2016] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Natural history of paediatric-onset ulcerative proctitis (UP) is poorly described. Our aim was to describe the phenotype and disease course of incident UP in a population-based study of paediatric-onset UC. PATIENTS AND METHODS All patients with UC diagnosed <17 years from 1988 to 2004, and followed during >2 years have been extracted from a population-based registry. UC location was defined according to the Paris classification. Cumulative risks for use of immunosuppressants (IS), anti-tumour necrosis factor alpha (TNF-α) therapy, colonic extension and colectomy were described using Kaplan-Meier method. Risk factors for colonic extension were assessed using Cox proportional hazards models. RESULTS 158 patients with paediatric-onset UC (91 females) with a median age at diagnosis of 14.5 years (Q1: 11.4-Q3: 16.1) have been identified and followed during a median of 11.4 years (8.2-15.8). Among them, 25% had UP (E1) at diagnosis and 49% of them presented a colonic extension at maximal follow-up. In these children, the cumulative risk for colonic extension was 10% at 1 year, 45% at 5 years and 52% at 10 years. No parameter at diagnosis was associated with colonic extension in the UP (E1 group). IS use was significantly lower in patients with UP than in those with E2, E3 or E4 location (p=0.049). For the UP cohort, the cumulative risk for colectomy was 3% at 1 year, 10% at 5 years, 13% at 10 years and 13% at 15 years. Risks for colonic extension, treatment with anti-TNF-α and colectomy did not differ between the E1 group and the E2-E3-E4 group. CONCLUSIONS UP is frequent in paediatric-onset UC and should not be considered as a minor disease. Compared with more extensive UC locations, risks for colonic extension, anti-TNF-α therapy and colectomy were similar in UP, whereas the risk for use of IM was lower.
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Affiliation(s)
- A Hochart
- Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Lille University and Hospital, France et Univ. Lille CHU Lille, Lille, France
| | - C Gower-Rousseau
- Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France.,Public Health, Epidemiology and Economic Health, Registre Epimad, Maison Régionale de la Recherche Clinique, Centre Hospitalier Universitaire Régional, Lille, Cedex, France
| | - H Sarter
- Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France.,Public Health, Epidemiology and Economic Health, Registre Epimad, Maison Régionale de la Recherche Clinique, Centre Hospitalier Universitaire Régional, Lille, Cedex, France
| | - M Fumery
- Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France.,Gastroenterology Unit, Epimad Registry, CHU Amiens Sud, Avenue Laennec-Salouel, Amiens University Hospital, France
| | - D Ley
- Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Lille University and Hospital, France et Univ. Lille CHU Lille, Lille, France.,Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France
| | - C Spyckerelle
- Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Saint Vincent de Paul Hospital and Lille Catholic University, Lille, France
| | - L Peyrin-Biroulet
- Hepato-Gastroenterology Unit, Inserm, U954, Nancy University Hospital, France
| | - J-E Laberenne
- Hepato-Gastroenterology Unit, Epimad Registry, General Hospital, Seclin, France
| | - F Vasseur
- Department of Biostatistics, EA 2694, Lille University Hospital, France
| | - G Savoye
- Gastroenterology Unit, Epimad Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
| | - D Turck
- Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Lille University and Hospital, France et Univ. Lille CHU Lille, Lille, France.,Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France
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21
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Duricova D, Leroyer A, Savoye G, Sarter H, Pariente B, Aoucheta D, Armengol-Debeir L, Ley D, Turck D, Peyrin-Biroulet L, Gower-Rousseau C, Fumery M, Antonietti M, Aouakli A, Armand A, Aroichane I, Assi F, Aubet JP, Auxenfants E, Ayafi-Ramelot F, Bankovski D, Barbry B, Bardoux N, Baron P, Baudet A, Bazin B, Bebahani A, Becqwort JP, Benet V, Benali H, Benguigui C, Ben Soussan E, Bental A, Berkelmans I, Bernet J, Bernou K, Bernou-Dron C, Bertot P, Bertiaux-Vandaële N, Bertrand V, Billoud E, Biron N, Bismuth B, Bleuet M, Blondel F, Blondin V, Bohon P, Boniface E, Bonnière P, Bonvarlet E, Bonvarlet P, Boruchowicz A, Bostvironnois R, Boualit M, Bouche B, Boudaillez C, Bourgeaux C, Bourgeois M, Bourguet A, Bourienne A, Branche J, Bray G, Brazier F, Breban P, Brihier H, Brung-Lefebvre V, Bulois P, Burgiere P, Butel J, Canva JY, Canva-Delcambre V, Capron JP, Cardot F, Carpentier P, Cartier E, Cassar JF, Cassagnou M, Castex JF, Catala P, Cattan S, Catteau S, Caujolle B, Cayron G, Chandelier C, Chantre M, Charles J, Charneau T, Chavance-Thelu M, Chirita D, Choteau A, Claerbout JF, Clergue PY, Coevoet H, Cohen G, Collet R, Colombel JF, Coopman S, Corvisart J, Cortot A, Couttenier F, Crinquette JF, Crombe V, Dadamessi I, Dapvril V, Davion T, Dautreme S, Debas J, Degrave N, Dehont F, Delatre C, Delcenserie R, Delette O, Delgrange T, Delhoustal L, Delmotte JS, Demmane S, Deregnaucourt G, Descombes P, Desechalliers JP, Desmet P, Desreumaux P, Desseaux G, Desurmont P, Devienne A, Devouge E, Devred M, Devroux A, Dewailly A, Dharancy S, Di Fiore A, Djeddi D, Djedir R, Dreher-Duwat ML, Dubois R, Dubuque C, Ducatillon P, Duclay J, Ducrocq B, Ducrot F, Ducrotté P, Dufilho A, Duhamel C, Dujardin D, Dumant-Forest C, Dupas JL, Dupont F, Duranton Y, Duriez A, El Achkar K, El Farisi M, Elie C, Elie-Legrand MC, Elkhaki A, Eoche M, Evrard D, Evrard JP, Fatome A, Filoche B, Finet L, Flahaut M, Flamme C, Foissey D, Fournier P, Foutrein-Comes MC, Foutrein P, Fremond D, Frere T, Fumery M, Gallet P, Gamblin C, Ganga-Zandzou S, Gerard R, Geslin G, Gheyssens Y, Ghossini N, Ghrib S, Gilbert T, Gillet B, Godard D, Godard P, Godchaux JM, Godchaux R, Goegebeur G, Goria O, Gottrand F, Gower P, Grandmaison B, Groux M, Guedon C, Guillard JF, Guillem L, Guillemot F, Guimber D, Haddouche B, Hakim S, Hanon D, Hautefeuille V, Heckestweiller P, Hecquet G, Hedde JP, Hellal H, Henneresse PE, Heyman B, Heraud M, Herve S, Hochain P, Houssin-Bailly L, Houcke P, Huguenin B, Iobagiu S, Ivanovic A, Iwanicki-Caron I, Janicki E, Jarry M, Jeu J, Joly JP, Jonas C, Katherin F, Kerleveo A, Khachfe A, Kiriakos A, Kiriakos J, Klein O, Kohut M, Kornhauser R, Koutsomanis D, Laberenne JE, Laffineur G, Lagarde M, Lannoy P, Lapchin J, Lapprand M, Laude D, Leblanc R, Lecieux P, Leclerc N, Le Couteulx C, Ledent J, Lefebvre J, Lefiliatre P, Legrand C, Le Grix A, Lelong P, Leluyer B, Lenaerts C, Lepileur L, Leplat A, Lepoutre-Dujardin E, Leroi H, Leroy MY, Lesage JP, Lesage X, Lesage J, Lescanne-Darchis I, Lescut J, Lescut D, Leurent B, Levy P, Lhermie M, Lion A, Lisambert B, Loire F, Louf S, Louvet A, Luciani M, Lucidarme D, Lugand J, Macaigne O, Maetz D, Maillard D, Mancheron H, Manolache O, Marks-Brunel AB, Marti R, Martin F, Martin G, Marzloff E, Mathurin P, Mauillon J, Maunoury V, Maupas JL, Mesnard B, Metayer P, Methari L, Meurisse B, Meurisse F, Michaud L, Mirmaran X, Modaine P, Monthe A, Morel L, Mortier PE, Moulin E, Mouterde O, Mudry J, Nachury M, N’Guyen Khac E, Notteghem B, Ollevier V, Ostyn A, Ouraghi A, Ouvry D, Paillot B, Panien-Claudot N, Paoletti C, Papazian A, Parent B, Pariente B, Paris JC, Patrier P, Paupart L, Pauwels B, Pauwels M, Petit R, Piat M, Piotte S, Plane C, Plouvier B, Pollet E, Pommelet P, Pop D, Pordes C, Pouchain G, Prades P, Prevost A, Prevost JC, Quesnel B, Queuniet AM, Quinton JF, Rabache A, Rabelle P, Raclot G, Ratajczyk S, Rault D, Razemon V, Reix N, Revillon M, Richez C, Robinson P, Rodriguez J, Roger J, Roux JM, Rudelli A, Saber A, Savoye G, Schlosseberg P, Segrestin M, Seguy D, Serin M, Seryer A, Sevenet F, Shekh N, Silvie J, Simon V, Spyckerelle C, Talbodec N, Techy A, Thelu JL, Thevenin A, Thiebault H, Thomas J, Thorel JM, Tielman G, Tode M, Toisin J, Tonnel J, Touchais JY, Touze Y, Tranvouez JL, Triplet C, Turck D, Uhlen S, Vaillant E, Valmage C, Vanco D, Vandamme H, Vanderbecq E, Vander Eecken E, Vandermolen P, Vandevenne P, Vandeville L, Vandewalle A, Vandewalle C, Vaneslander P, Vanhoove JP, Vanrenterghem A, Varlet P, Vasies I, Verbiese G, Vernier-Massouille G, Vermelle P, Verne C, Vezilier-Cocq P, Vigneron B, Vincendet M, Viot J, Voiment YM, Wacrenier A, Waeghemaecker L, Wallez JY, Wantiez M, Wartel F, Weber J, Willocquet JL, Wizla N, Wolschies E, Zalar A, Zaouri B, Zellweger A, Ziade C. Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study. J Crohns Colitis 2017; 11:1326-1334. [PMID: 28981648 DOI: 10.1093/ecco-jcc/jjx092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/05/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome. METHODS Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected. RESULTS In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups. CONCLUSIONS Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.
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Affiliation(s)
- Dana Duricova
- Public Health, Epidemiology and Economic Health, Registre EPIMAD, Lille University and Hospital, Lille, France
| | - Ariane Leroyer
- Public Health, Epidemiology and Economic Health, Registre EPIMAD, Lille University and Hospital, Lille, France
| | - Guillaume Savoye
- Gastroenterology Unit, EPIMAD Registry, Rouen University Hospital, Rouen, France
| | - Hélène Sarter
- Public Health, Epidemiology and Economic Health, Registre EPIMAD, Lille University and Hospital, Lille, France.,Lille Inflammation Research International Center LIRIC-UMR 995 Inserm Lille 2 University, Lille, France
| | - Benjamin Pariente
- Gastroenterology Unit, Hôpital Huriez, Lille University Hospital, Lille, France
| | - Djamila Aoucheta
- Associated Medical Director, Immunology, MSD France, Courbevoie cedex, France
| | | | - Delphine Ley
- Lille Inflammation Research International Center LIRIC-UMR 995 Inserm Lille 2 University, Lille, France.,Division of Gastroenterology, Hepatology and Nutrition, Lille University Jeanne de Flandre Children's Hospital, University of Lille, Lille, France
| | - Dominique Turck
- Lille Inflammation Research International Center LIRIC-UMR 995 Inserm Lille 2 University, Lille, France.,Division of Gastroenterology, Hepatology and Nutrition, Lille University Jeanne de Flandre Children's Hospital, University of Lille, Lille, France
| | | | - Corinne Gower-Rousseau
- Public Health, Epidemiology and Economic Health, Registre EPIMAD, Lille University and Hospital, Lille, France.,Lille Inflammation Research International Center LIRIC-UMR 995 Inserm Lille 2 University, Lille, France
| | - Mathurin Fumery
- Lille Inflammation Research International Center LIRIC-UMR 995 Inserm Lille 2 University, Lille, France.,Gastroenterology Unit, EPIMAD Registry, Amiens University Hospital, Amiens, France
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Cardile S, Alterio T, Candusso M, Pietrobattista A, Liccardo D, Basso MS, Papadatou B, Bracci F, Knafelz D, Torre G. Autoimmune liver diseases and inflammatory bowel diseases in children: current issues and future perspectives. Scand J Gastroenterol 2017; 52:662-667. [PMID: 28281846 DOI: 10.1080/00365521.2017.1298833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Inflammatory bowel diseases (IBDs) represent a group of intestinal disorders with a chronic and relapsing inflammation of the gut, and with a potential risk of systemic involvement of other organs and systems. Over the pediatric age, an incidence higher than 20% of developing extraintestinal manifestation during follow-up has been reported. The liver and the biliary system are frequently involved, and primary sclerosing cholangitis (PSC) is the most predominant entity with an incidence rate of 6.4-7.8% in children. PSC recognizes a multifactorial pathogenesis, and so far a not fully known mechanism for this association. The peculiar phenotype and the distinct clinical course of patients with IBD and PSC-associated make this 'linkage' an attractive study model to better understand mechanisms underlying these diseases. Approaching to these patients is complex and multidisciplinary, and a unique therapeutic strategy has not been standardized yet. New medications are being studied; however, further studies are needed to fully understand the pathogenesis and to improve the care of these patients. The aim of this paper is to review the recent literature regarding hepatobiliary involvement in IBD patients, with particular attention to PSC, and to provide the latest information for a correct diagnosis and appropriate management.
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Affiliation(s)
- Sabrina Cardile
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
| | - Tommaso Alterio
- b Department of Pediatrics , University of Messina , Messina , Italy
| | - Manila Candusso
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
| | - Andrea Pietrobattista
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
| | - Daniela Liccardo
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
| | - Maria Sole Basso
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
| | - Bronislava Papadatou
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
| | - Fiammetta Bracci
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
| | - Daniela Knafelz
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
| | - Giuliano Torre
- a Hepatology, Gastroenterology and Nutrition Unit , Bambino Gesù Children's Hospital , Rome , Italy
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Unique Inflammatory Bowel Disease Phenotype of Pediatric Primary Sclerosing Cholangitis: A Single-Center Study. J Pediatr Gastroenterol Nutr 2017; 65:404-409. [PMID: 28141677 PMCID: PMC5533626 DOI: 10.1097/mpg.0000000000001531] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES In adults, primary sclerosing cholangitis (PSC), a cholestatic liver disease characterized by inflammation/fibrosis of intra/extrahepatic bile ducts, associates with a milder form of inflammatory bowel disease (IBD), particularly ulcerative colitis (UC). The pediatric PSC-IBD phenotype is less well characterized. METHODS We performed a retrospective, single-center study examining patients with PSC-IBD at Texas Children's Hospital between 2000 and 2015. IBD-phenotype (Modified Montreal Classification), medications, laboratory values, endoscopic records, and IBD-based hospital admissions were collected. PSC-UC phenotype was compared to UC, non-PSC patients (n = 95) from Texas Children's Hospital. Elevated gamma-glutamyl transpeptidase levels were compared to calprotectin levels and IBD-flare activity, that is, gastrointestinal symptoms resulting in office/emergency department visits or hospital admission. RESULTS Of 39 patients with PSC-IBD, 34 (87.2%) had UC (PSC-UC) and 5 (12.8%) had Crohn disease. Pancolitis was more common in PSC-UC than UC, non-PSC (96.3%, 64%, P = 0.0009). Patients with PSC-UC required less treatment with steroids (76.5%, 91.6%, P = 0.0326) or infliximab (8.8%, 37.9%, P = 0.0011), and fewer had at least 1 IBD-related hospital admission (32.4%, 63.2%, P = 0.0025) than UC, non-PSC. Progression to colectomy was significantly less (5.8%, 24.2%, P = 0.0223) in PSC-UC. Median diagnosis-to-colectomy time tended to be longer in PSC-UC (6.37, 2.5 years, P = 0.0792). In 2 smaller subsets, gamma-glutamyl transpeptidase did not correlate with calprotectin in PSC-UC (n = 11, P = 0.7922) and less strongly associated with IBD-flares in PSC-UC than UC, non-PSC (n = 33, n = 67; 15.2%, 41.8%, P = 0.0120). CONCLUSIONS Pediatric PSC appears to associate with milder pancolitic-UC. PSC and IBD activity do not appear to correlate. Our findings may provide useful information toward etiology and management of pediatric PSC-IBD.
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Abstract
OBJECTIVES Data describing the incidence and risk factors for colectomy in pediatric ulcerative colitis (UC) is inconsistent. Our aim was to describe the colectomy rate and to identify risk factors associated with colectomy in a large cohort of children with UC with long-term follow-up. MATERIALS AND METHODS We performed a retrospective chart review of pediatric UC cases that were diagnosed at Schneider Children's Medical Center of Israel between 1981 and 2013. Potential predictors for colectomy including age at diagnosis, sex, disease extent, severity indices, and different therapeutic regimens during disease course were assessed. RESULTS Of 188 patients with pediatric onset UC, 34 (18%) underwent colectomy. Median follow-up was 6.9 years (range, 1-30). Kaplan-Meier survival estimates of the cumulative probability for colectomy were 4% at 1 year and 17% at 10 years from diagnosis. Multivariate Cox models showed that male sex (hazard ratio 4.2, P = 0.001) and severe disease at diagnosis reflected by Pediatric Ulcerative Colitis Activity Index score ≥65 (hazard ratio 8.9, P < 0.001) were associated with increased risk for colectomy. Age, disease extent, ethnicity, family history of inflammatory bowel disease, early introduction of immunomodulators, or treatment with antitumor necrosis factor α agent did not affect the risk of colectomy. CONCLUSIONS Male sex and higher Pediatric Ulcerative Colitis Activity Index score at diagnosis are independent risk factors for colectomy.
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Roda G, Narula N, Pinotti R, Skamnelos A, Katsanos KH, Ungaro R, Burisch J, Torres J, Colombel JF. Systematic review with meta-analysis: proximal disease extension in limited ulcerative colitis. Aliment Pharmacol Ther 2017; 45:1481-1492. [PMID: 28449361 PMCID: PMC6350510 DOI: 10.1111/apt.14063] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 12/22/2016] [Accepted: 03/06/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Disease extent in ulcerative colitis is one of the major factors determining prognosis over the long-term. Disease extent is dynamic and a proportion of patients presenting with limited disease progress to more extensive forms of disease over time. AIM To perform a systematic review and meta-analysis of epidemiological studies reporting on extension of ulcerative colitis to determine frequency of disease extension in patients with limited ulcerative colitis at diagnosis. METHODS We performed a systematic literature search to identify studies on disease extension of ulcerative colitis (UC) and predictors of disease progression. RESULTS Overall, 41 studies were eligible for systematic review but only 30 for meta-analysis. The overall pooled frequency of UC extension was 22.8% with colonic extension being 17.8% at 5 years and 31% at 10 years. Extension was 17.8% (95% CI 11.2-27.3) from E1 to E3, 27.5% (95% CI 7.6-45.6) from E2 to E3 and 20.8% (95% CI 11.4-26.8) from E1 to E2. Rate of extension was significantly higher in patients younger than 18 years (29.2% (CI 6.4-71.3) compared to older patients (20.2% (CI 13.0-30.1) (P<.0001). Risk of extension was significantly higher in patients from North America (37.8%) than from Europe (19.6%) (P<.0001). CONCLUSIONS In this meta-analysis, approximately one quarter of patients with limited UC extend over time with most extension occurring during the first 10 years. Rate of extension depends on age at diagnosis and geographic origin. Predicting those at high risk of disease extension from diagnosis could lead to personalised therapeutic strategies.
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Affiliation(s)
- G Roda
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - N Narula
- Division of Gastroenterology, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - R Pinotti
- Gustave L. and Janet W. Levy Library, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Skamnelos
- Division of Gastroenterology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - K H Katsanos
- Division of Gastroenterology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - R Ungaro
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Burisch
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Torres
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J-F Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Clinical Features and Risk Factors of Autoimmune Liver Involvement in Pediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2016; 63:259-64. [PMID: 26756875 DOI: 10.1097/mpg.0000000000001078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Autoimmune liver disease is reported in up to 7.8% of children with inflammatory bowel disease. A distinct inflammatory bowel disease phenotype has been suggested in adults and in small pediatric cohorts. The aim of the study was to evaluate the features of inflammatory bowel disease associated with autoimmune liver diseases and to analyze the characteristics of the liver disease. METHODS Information on patients was obtained from the Italian Pediatric Inflammatory Bowel Disease Registry. Data of patients with and without autoimmune liver disease were compared. RESULTS Autoimmune liver disease was detected in 6.8% of the 677 patients enrolled and was significantly associated with the diagnosis of ulcerative colitis (83%), with pancolonic involvement (84%), and with perinuclear antineutrophil cytoplasmic antibody positivity (41%) (all Ps < 0.05). Autoimmune liver disease was defined as sclerosing cholangitis in 61% of the patients and as an overlap syndrome in 33%. Concomitant intra- and extrahepatic biliary involvement was reported in 61% of cases, whereas exclusive extrahepatic lesions were reported in 21%. Hepatobiliary complications were observed in 9% of the patients during follow-up. CONCLUSIONS Autoimmune liver disease, especially sclerosing cholangitis, was significantly more common in patients with extensive ulcerative colitis. Although complications are relatively rare in the pediatric age, monitoring is recommended.
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Hirata A, Uchino M, Bando T, Hirose K, Chohno T, Sasaki H, Horio Y, Nakamura S, Hida N, Hori K, Tomita N, Takahashi Y, Takesue Y, Ikeuchi H. Long-term outcomes and sex differences after restorative proctocolectomy in pediatric patients with ulcerative colitis. J Pediatr Surg 2016; 51:454-60. [PMID: 26561247 DOI: 10.1016/j.jpedsurg.2015.10.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/01/2015] [Accepted: 10/11/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Restorative proctocolectomy (RPC) for ulcerative colitis (UC) could result in a higher patient quality of life, avoiding frequent disease flares; however, pouch failures and pouch-related complications (PRCs) can develop. PURPOSE No cohort studies have examined pouch failure and the differences between adult and pediatric patients or the sex differences in pediatric UC. Therefore, the pouch failure rates were compared between adults and pediatric patients, and pouch failure and PRCs in pediatric UC were evaluated. METHODS UC patients who underwent RPC between January 1987 and June 2014 at Hyogo College of Medicine were included. Patient background characteristics, PRCs, and pouch failure were reviewed. RESULTS A total of 1347 adult UC patients and 90 (51 boys, 39 girls) pediatric UC patients were included in the study. The cumulative rate of pouch failure at 10years after RPC was significantly higher in pediatric UC (9.5%) than in adult UC (2.1%; p<0.01). In pediatric UC, the independent risk factors for pouch failure were pouchitis (hazard ratio (HR) 19.3) and anal fistula (HR 5.5). Although a sex difference was not seen in pouch failure, an independent risk factor for PRCs was being a girl (HR 2.5). CONCLUSIONS Pouch failure was more common in pediatric than in adult UC. PRCs after RPC were more common in girls in pediatric UC.
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Affiliation(s)
- Akihiro Hirata
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Motoi Uchino
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Toshihiro Bando
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kei Hirose
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Teruhiro Chohno
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hirofumi Sasaki
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yuki Horio
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shiro Nakamura
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Nobuyui Hida
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kazutoshi Hori
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Naohiro Tomita
- Department of Lower Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshiko Takahashi
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshio Takesue
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroki Ikeuchi
- Department of inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Fumery M, Duricova D, Gower-Rousseau C, Annese V, Peyrin-Biroulet L, Lakatos PL. Review article: the natural history of paediatric-onset ulcerative colitis in population-based studies. Aliment Pharmacol Ther 2016; 43:346-55. [PMID: 26582737 DOI: 10.1111/apt.13478] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/18/2015] [Accepted: 10/27/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND A better knowledge of the natural history of disabling chronic diseases is essential to improve patient management, evaluate the impact of treatment strategies and provide predictors for disabling disease and comprehensive information for patients. AIM To summarise our current knowledge issued from population-based studies of the natural history of ulcerative colitis (UC) in children. METHODS We searched MEDLINE (source PubMed) and international conference abstracts, and included all population-based studies that evaluated long-term outcome of paediatric-onset (<17 years at diagnosis) UC. RESULTS A total of 26 population-based studies were considered in this review from the total of 61 articles or abstracts screened. Most patients presented disease extension and about two-thirds of patients had pancolitis at the end of follow-up. One-half of patients experienced extra-intestinal manifestations and primary sclerosing cholangitis was observed in 5-10% of patients. Overall, patients did not appear to have any significant growth retardation or delayed puberty. About two-thirds of patients required corticosteroid therapy and up to 25% were steroid dependent. An increased use of thiopurines was observed and the most recent data indicate that up to one-half of patients were exposed to thiopurines and 10-30% were exposed to anti-tumour necrosis factor. One-half of patients required hospitalisations and 20% of patients required colectomy after a follow-up of 10 years. CONCLUSIONS Paediatric-onset UC is characterised by a high rate of disease extension. About 20% of patients had been operated at 10-year follow-up. New population-based studies are needed to evaluate the impact of new treatment strategies comprising immunosuppressants and biologics.
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Affiliation(s)
- M Fumery
- Gastroenterology Unit, Epimad Registry, Amiens University Hospital, Université de Picardie Jules Verne, Amiens, France
| | - D Duricova
- Department of Gastroenterology, Univerzity Karlovy, Prague, Czech Republic.,EPICOM, European Crohn & Colitis Organization, Vienna, Austria
| | - C Gower-Rousseau
- EPICOM, European Crohn & Colitis Organization, Vienna, Austria.,Public Health, Epidemiology and Economic Health, Epimad Registry, Maison Régionale de la Recherche Clinique, Centre Hospitalier Universitaire Régional, 59037, Lille Cedex, France.,Lille Inflammation Research International Center LIRIC - UMR 995 Inserm/Université Lille 2/CHRU de Lille, Equipe IBD and Environmental Factors: Epidemiology and Functional Analyses, Lille University, Lille, France
| | - V Annese
- EPICOM, European Crohn & Colitis Organization, Vienna, Austria.,Division of Gastroenterology, AOU Careggi Hospital, Florence, Italy
| | - L Peyrin-Biroulet
- Gastroenterology, Inserm U954, University Hospital of Nancy-Brabois, Université Henri Poincaré, Vandoeuvre-lès-Nancy, France
| | - P L Lakatos
- EPICOM, European Crohn & Colitis Organization, Vienna, Austria.,1st Department of Medicine, Semmelweis University, Budapest, Hungary
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Chhaya V, Pollok RCG, Cecil E, Subramanian V, Curcin V, Majeed A, Saxena S. Impact of early thiopurines on surgery in 2770 children and young people diagnosed with inflammatory bowel disease: a national population-based study. Aliment Pharmacol Ther 2015; 42:990-9. [PMID: 26271196 DOI: 10.1111/apt.13361] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 05/12/2015] [Accepted: 07/22/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND The role of early thiopurine treatment in inflammatory bowel disease (IBD) is unproven. AIM To quantify the impact of timing and duration of thiopurines on the risk of first surgery in children and young people with IBD using a population-based cohort. METHODS We constructed an incident cohort of children and young people aged <25 years, diagnosed with Crohn's disease (CD) or ulcerative colitis (UC) from 1990 to 2009. We used Cox proportional hazards modelling to determine the impact of early thiopurine use, commenced within a year of diagnosis on risk of first surgery. RESULTS We identified 1595 and 1175 incident cases of CD and UC respectively with a mean length of follow-up of 4.3 years/person. There were 216 (13.5%) and 73 (6.2%) surgeries for CD and UC patients between 1990 and 2009 respectively. In CD among thiopurine users, the absolute risk of surgery at 5 years for early thiopurine use vs. late was 15.3% (95% CI: 10.5-22.1) vs. 22.1% (95% CI: 18.1-26.9) respectively. After adjustment, the early use of thiopurines was associated with a reduction in risk of first surgery of 39% (HR 0.61, 95% CI: 0.41-0.91) over the 20-year study period. In UC, early thiopurine use offered no additional benefit. CONCLUSIONS In Crohn's disease, early treatment with thiopurines in children and young people is associated with an appreciable reduction in the risk of surgery, but early treatment does not reduce surgical risk in UC.
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Affiliation(s)
- V Chhaya
- Department of Gastroenterology, St George's University Hospital, London, UK
| | - R C G Pollok
- Department of Gastroenterology, St George's University Hospital, London, UK
| | - E Cecil
- Department of Primary Care and Public Health, Imperial College, London, UK
| | - V Subramanian
- Department of Gastroenterology, St James University Hospital, Leeds, UK
| | - V Curcin
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - A Majeed
- Department of Primary Care and Public Health, Imperial College, London, UK
| | - S Saxena
- Department of Primary Care and Public Health, Imperial College, London, UK
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30
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Baillie CT, Smith JA. Surgical strategies in paediatric inflammatory bowel disease. World J Gastroenterol 2015; 21:6101-16. [PMID: 26034347 PMCID: PMC4445089 DOI: 10.3748/wjg.v21.i20.6101] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/30/2015] [Accepted: 04/09/2015] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) comprises two distinct but related chronic relapsing inflammatory conditions affecting different parts of the gastrointestinal tract. Crohn's disease is characterised by a patchy transmural inflammation affecting both small and large bowel segments with several distinct phenotypic presentations. Ulcerative colitis classically presents as mucosal inflammation of the rectosigmoid (distal colitis), variably extending in a contiguous manner more proximally through the colon but not beyond the caecum (pancolitis). This article highlights aspects of the presentation, diagnosis, and management of IBD that have relevance for paediatric practice with particular emphasis on surgical considerations. Since 25% of IBD cases present in childhood or teenage years, the unique considerations and challenges of paediatric management should be widely appreciated. Conversely, we argue that the organizational separation of the paediatric and adult healthcare worlds has often resulted in late adoption of new approaches particularly in paediatric surgical practice.
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31
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Lovasz BD, Lakatos L, Horvath A, Pandur T, Erdelyi Z, Balogh M, Szipocs I, Vegh Z, Veres G, Müller KE, Golovics PA, Kiss LS, Mandel MD, Lakatos PL. Incidence rates and disease course of paediatric inflammatory bowel diseases in Western Hungary between 1977 and 2011. Dig Liver Dis 2014; 46:405-11. [PMID: 24495511 DOI: 10.1016/j.dld.2013.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 12/03/2013] [Accepted: 12/14/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Limited data are available on paediatric inflammatory bowel diseases in Eastern Europe. Our aim was to analyse disease characteristics in the population-based Veszprem province database between 1977 and 2011. METHODS 187 (10.5%, ulcerative colitis/Crohn's disease/undetermined colitis: 88/95/4) out of 1565 incident patients were diagnosed with a paediatric onset in this population-based prospective inception cohort. RESULTS The incidence of Crohn's disease and ulcerative colitis increased from 0 and 0.7 in 1977-1981 to 7.2 and 5.2 in 2007-2011 per 100,000 person years. Ileocolonic location (45%) and inflammatory disease behaviour (61%) were most frequent in Crohn's disease, while azathioprine use was frequent (66%) and surgical resection rates were high (33% at 5 years) in cases with paediatric onset. In ulcerative colitis, 34% of patients were diagnosed with extensive disease, with high rates of disease extension (26% and 41% at 5 and 10 years), fulminant episodes (19.3%) and systemic steroid use (52.3%). The cumulative rate of colectomy was low (6.9%). CONCLUSIONS The incidence of paediatric inflammatory bowel diseases has rapidly increased in the last three decades in Western Hungary. Ileocolonic disease and a need for azathioprine were characteristic in paediatric Crohn's disease, while paediatric onset ulcerative colitis was characterised by extensive disease and disease extension, while the need for colectomy was low.
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Affiliation(s)
- Barbara D Lovasz
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Laszlo Lakatos
- Department of Medicine, Csolnoky F. Province Hospital, Veszprem, Hungary
| | - Agnes Horvath
- Department of Pediatrics, Csolnoky F. Province Hospital, Veszprem, Hungary
| | - Tunde Pandur
- Department of Medicine, Csolnoky F. Province Hospital, Veszprem, Hungary
| | - Zsuzsanna Erdelyi
- Department of Medicine, Csolnoky F. Province Hospital, Veszprem, Hungary
| | - Mihaly Balogh
- Department of Medicine, Grof Eszterhazy Hospital, Papa, Hungary
| | - Istvan Szipocs
- Department of Medicine, Municipal Hospital, Tapolca, Hungary
| | - Zsuzsanna Vegh
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary; Department of Medicine, Csolnoky F. Province Hospital, Veszprem, Hungary
| | - Gabor Veres
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Katalin E Müller
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Petra A Golovics
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Lajos S Kiss
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Michael D Mandel
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Peter L Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary.
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Abstract
IBD is a chronic disorder with disease onset ranging from early childhood to beyond the sixth decade of life. The factors that determine the age of onset currently remain unexplained. Is timing of occurrence a random event or is it indicative of different pathophysiological pathways leading to different phenotypes across the age spectrum? Over the past decade, several studies have suggested that the characteristics and natural history of IBD seem to be different according to age of onset. This heterogeneity suggests that the respective contributions of genetics, host immune system and environment to the aetiology and phenotype of Crohn's disease and ulcerative colitis are different across ages. Critical reviews that focus on differences characterizing IBD between age groups are scarce. Therefore, this Review updates the knowledge of the differences in epidemiology, clinical characteristics, and natural history of paediatric, adult and elderly-onset IBD. In addition, potential differences in host-gene-microbial interactions according to age are highlighted.
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