Inflammatory Bowel Disease Across the Age Continuum: Similarity and Disparity

Spectrum and trend of pediatric inflammatory bowel disease: A two-decade experience from northern India

BACKGROUND

Pediatric inflammatory bowel disease (IBD) has been known to be a disease predominant in the west. There is scarcity of data on pediatric IBD (P-IBD) from northern India. The objective of our study was to analyze the clinical spectrum of P-IBD in northern India.

METHODS

A retrospective analysis of 126 children (<18-year old) diagnosed with IBD from January 1999 to December 2019 was done on a pre-designed proforma. It was systematically entered in a MS Excel spreadsheet and analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0. The descriptive phenotypes of Ulcerative colitis (UC) and Crohn's disease (CD) were revised according to the Paris classification.

RESULTS

Of 126 children, UC was diagnosed in 76 (60.3%), CD in 44 (34.9%) and IBD-unclassified (IBD-U) in six (4.76%) patients. The mean age at diagnosis was 11.3 years; 38.8% were < 10 years with the male: female ratio of 1.6:1. Sixteen children (12.7%) had very early onset IBD (VEOBD). Overall, the median time to diagnosis in IBD was 12 months (interquartile range [IQR]: 3.25-24), which was as high as 52.5 months (IQR: 11-98) in CD. Pancolitis with bleeding per rectum and ileocolonic involvement with pain in abdomen were the commonest presentations in UC and CD, respectively. Stricturing disease was seen in 27% of CD cases. Relapses were seen in 46% (35/76) of U.C and 23% (10/44) of CD kids. Step-up treatment protocol was employed in them with the use of biologicals in 12% of cases. There was a 2.75-fold rise in the IBD cases in the last 10 years (2010-20). There was reduction in time to diagnosis (21 months vs. 90 months; p - 0.012) and empirical anti-tubercular therapy use (90% vs. 5.8%) in CD over two decades.

CONCLUSION

From our experience in a tertiary care centre in northern India, P-IBD is on the rise. UC is more common than CD. Pancolitis and ileocolonic disease are the commonest disease sites in UC and CD, respectively There is a significant delay in the time to diagnosis in CD. Stricturing disease was seen in a quarter of children with CD.

A Single-Center Study of Long-Term Effectiveness of Vedolizumab in Anti-TNF Refractory Pediatric Inflammatory Bowel Disease

Vedolizumab is an anti-α4β7 integrin antibody that has been used successfully in the treatment of adult-onset inflammatory bowel diseases (IBDs: Crohn disease [CD] and ulcerative colitis [UC]). Its off-label use in the pediatric IBD (PIBD) population is increasing, but knowledge on durability beyond 6 months of treatment is limited.

Methods

A real-life, single-center, retrospective study of PIBD patients treated with vedolizumab was performed. Data on demographics, prior and concomitant treatments, and disease activity were obtained at 14 weeks, 26 weeks, 1 year, and 2 years of therapy. Primary outcome was corticosteroid- and other biologic-free remission (based on pediatric ulcerative colitis activity index [PUCAI]).

Results

Thirty-nine patients were studied. By 1 year, 65% of CD and 68% of UC patients continued on vedolizumab therapy. Corticosteroid- and other biologic-free remission was 29% in CD and 16% in UC. By 2 years, 36% of CD and 47% of UC patients continued therapy. Corticosteroid- and other biologic-free remission was 21% in CD and 40% in UC. By 2 years, 80% of CD and 100% of UC patients were on intensified treatment regimen compared to the manufacturer guidance. Nine patients (23%) required surgical intervention within 26 months of starting vedolizumab indicating the severity of IBD in this cohort.

Conclusions

Vedolizumab is a useful therapeutic modality in PIBD patients refractory to anti-TNF therapy, although with declining effectiveness by 2 years. Intensified treatment regimens are associated with long-term durability. Larger prospective trials in children are warranted.

Very early onset inflammatory bowel disease in a South Asian country where inflammatory bowel disease is emerging: a distinct clinical phenotype from later onset disease

BACKGROUND/AIMS

Information on pediatric inflammatory bowel disease (PIBD) and very early onset IBD (VEOIBD) are sparse in India, where IBD is emerging. We aimed to evaluate characteristics of VEOIBD and later onset PIBD (LO-PIBD) in India.

METHODS

We performed retrospective analysis of a large, prospectively maintained IBD registry. PIBD was divided in to VEOIBD ( < 6 years) and LO-PIBD (6-17 years). Demographic data, disease characteristics and treatment were compared between the PIBD groups and with other Asian/Western studies as well as the adult patients of the registry.

RESULTS

Of 3,752 IBD patients, 292 (7.8%) had PIBD (0-17 years) (175 Crohn's disease [CD], 113 ulcerative colitis [UC], 4 IBD-undifferentiated; 22 VEOIBD [7.5%], and 270 LO-PIBD [92.5%]). VEOIBD patients had more severe disease compared to LO-PIBD in both UC (P= 0.003) and CD (P< 0.001). Familial IBD was more common in VEOIBD (13.6%) compared to LO-PIBD (9.2%). Ileal disease (L1) was an independent risk factor for diagnostic delay in pediatric CD. Diagnostic delay ( > 6 months) was significantly lower in VEOIBD (40.9%) than in LO-PIBD (78.8%) (P< 0.001). Compared to other Asian and Western studies, extensive UC (72.5%) and complicated CD (stricturing/penetrating: 42.7%) were relatively more common. Perianal CD was relatively less frequent (7.4%). PIBD had a significantly higher number of complicated and ileal CD and extensive UC comparison to adult cohort of the registry.

CONCLUSIONS

VEOIBD has more aggressive phenotype than LO-PIBD. Disease appears distinct from other Asian and Western studies and adult onset disease, with more complicated CD and extensive UC.

Role of a multidisciplinary team (MDT) in the diagnosis, treatment, and outcomes of inflammatory bowel disease: a single Chinese center's experience

The incidence of inflammatory bowel disease (IBD) with a poor prognosis is increasing, and a single field is not capable of fully diagnosing and comprehensively treating IBD. The purpose of the current study was to explore the role of a multidisciplinary team (MDT) in the diagnosis and treatment of IBD. Subjects were 55 patients with IBD who underwent surgery at this hospital before the establishment of a MDT (before June 2016) and 276 patients who were discussed by a MDT; 72 of the latter patients underwent surgery. The preoperative rate of diagnosis, preoperative basic nutritional status, frequency of emergency surgery, and surgical complications in the two groups were compared to determine whether the MDT significantly affected the diagnosis and treatment of IBD and to explore trends in the types of patients with IBD and treatment decision-making since the establishment of MDT. Results revealed that the MDT significantly improved preoperative diagnostic accuracy for patients with IBD who underwent surgery (p < 0.005), and the frequency of elective surgery decreased significantly (p < 0.005). There were significant differences in the rate of clinical recurrence (p < 0.005) and the rate of additional surgery (p < 0.01) between the two groups, with higher rates in the control group. In terms of preoperative nutritional status, the proportion of decreased serum albumin and hemoglobin in the experimental group was significantly lower than that in the control group (p < 0.05). MDT plays a positive role in accurate preoperative diagnosis, improvement of preoperative preparations, and a reduction in postoperative adverse events for patients with IBD undergoing surgery.

Body image, self-esteem, and quality of life in children and adolescents with inflammatory bowel disease in a tertiary hospital in South Korea

PURPOSE

This study aimed to examine body image, self-esteem, and quality of life (QOL) in children and adolescents with inflammatory bowel disease (IBD) and to analyze factors influencing QOL.

METHODS

This descriptive study involved 87 participants at a tertiary hospital aged 10 to 18 years who were diagnosed with IBD. Body image, self-esteem, and QOL were measured. Descriptive analysis, the independent t-test, the Mann-Whitney U test, analysis of variance, Pearson correlation analysis, and stepwise multiple regression were used for data analysis.

RESULTS

The average score was 16.95±3.55 for body image, 31.32±5.25 for self-esteem, and 78.64±15.98 for QOL. Height, weight, hospitalization experience, current symptoms, and consumption of oral steroids showed statistically significant effects on QOL. The most significant predictors of QOL were self-esteem (β=.31, p=.002), body image (β=.28, p=.005), number of symptoms (β=-.25, p=.004), and number of hospitalizations in the last year (β=-.24, p=.004).

CONCLUSION

To improve the QOL of children and adolescents with IBD, it is necessary to evaluate self-esteem, body image, and physical problems. In addition, various intervention strategies to improve self-esteem and body image and to reduce physical discomfort should be developed.

Crohn’s disease in low and lower-middle income countries: A scoping review

BACKGROUND

While Crohn’s disease has been studied extensively in high-income countries, its epidemiology and care in low and lower-middle income countries (LLMICs) is not well established due to a lack of disease registries and diagnostic capacity.

AIM

To describe the published burden, diagnostic/treatment capacity, service utilization, challenges/barriers to individuals with Crohn’s in LLMICs and their providers.

METHODS

We conducted a scoping review utilizing a full search strategy was developed and conducted in PubMed, Embase and World Health Organization Global Index Medicus. Two independent reviewers screened the titles and abstracts of all of the publications found in this search, reviewed selected publications, and extracted relevant data, which underwent descriptive review and was analyzed in Excel.

RESULTS

The database search yielded 4486 publications, 216 of which were determined to be relevant to the research questions. Of all 79 LLMICs, only 21 (26.6%) have publications describing individuals with Crohn’s. Overall, the highest number of studies came from India, followed by Tunisia, and Egypt. The mean number of Crohn’s patients reported per study is 57.84 and the median is 22, with a wide range from one to 980.

CONCLUSION

This scoping review has shown that, although there is a severe lack of population-based data about Crohn’s in LLMICs, there is a signal of Crohn’s in these settings around the world.

Peripheral Blood Eosinophilia and Long-term Severity in Pediatric-Onset Inflammatory Bowel Disease

BACKGROUND

Peripheral blood eosinophilia (PBE) is a biomarker of an aggressive multiyear natural history in adults with inflammatory bowel diseases (IBDs). Additionally, PBE at diagnosis is associated with higher disease activity in pediatric-onset IBD. We sought to determine if PBE can function as a biomarker of long-term disease severity in pediatric-onset IBD patients who are followed into adulthood.

METHODS

We analyzed a consented, prospective, natural history IBD registry at an adult tertiary center from 2009 to 2018. Prevalence of PBE was evaluated in both pediatric- and adult-onset IBD patients. Demographics, clinical characteristics, and health care utilization data were compared in patients with and without PBE.

RESULTS

Among 2800 adult IBD patients, 23.4% had pediatric-onset disease. PBE was found in 34% of the pediatric-onset patients compared with 26.8% of the adult-onset IBD patients (P < 0.001). In the pediatric-onset IBD cohort, PBE was associated with higher rates of allergies (P < 0.0001), but not of asthma, allergic rhinitis, or primary sclerosing cholangitis. In the adult IBD patients with pediatric-onset disease, PBE was associated with higher rates of C-reactive protein elevation (P < 0.0001), erythrocyte sedimentation rate elevation (P < 0.0001), higher health care utilization, and higher average health care charges per year (P < 0.00001).

CONCLUSIONS

Peripheral blood eosinophilia was more prevalent in adult IBD patients with pediatric-onset compared with adult-onset disease. Among all IBD patients with long-term follow-up, PBE defined a subgroup with more severe illness. These data suggest that PBE may be a biomarker for a high-risk subgroup with high cost trajectory and long-term severity in pediatric-onset IBD that persists into adulthood.

Ketorolac after colectomy for ulcerative colitis in children: An analysis of opioid utilization and postoperative complications

INTRODUCTION

Enhanced recovery protocols include multimodal perioperative pain control and frequently include use of NSAIDs. There is conflicting evidence that ketorolac use in inflammatory bowel disease (IBD) may precipitate disease flares and postoperative complications. The outcomes of children who receive ketorolac in this setting are not well known. We sought to evaluate ketorolac utilization in children following colectomy for ulcerative colitis.

METHODS

All patients undergoing colectomy for ulcerative colitis between 2007 and 2017 at a tertiary children's hospital were reviewed. We collected patient age, duration of symptoms, operative details, medication utilization, length of stay, and postoperative complications. We performed a cohort comparison of these variables across patients who did vs. did not receive postoperative ketorolac.

RESULTS

Sixty children were identified with median age at diagnosis of 12.6 years (IQR: 9.9-14.5). At colectomy, patients had a median PUCAI score of 60 (45-70), ESR 34 mm/h (15-50), hemoglobin 10.9 g/dL (9.3-12.9), and albumin 3.1 g/dL (2.4-3.8). Postoperatively, 45% (n = 27) received ketorolac. Patients in both cohorts had a similar length of stay, duration of opioid exposure, total morphine equivalents utilized, readmission rate, and unexpected return to the operating room. There were no documented cases of postoperative bleeding, acute kidney injury, or disease related flares among children receiving ketorolac.

CONCLUSIONS

Administration of ketorolac after colectomy in IBD was not associated with an increase in any postoperative complications, though the study was underpowered to detect these differences. However, ketorolac administration did not lead to a decreased utilization of opioid analgesia. Further prospective research is necessary to understand whether ketorolac in this population is safe and offers benefit.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

III.

Paediatric inflammatory bowel disease in India: a prospective multicentre study

BACKGROUND

Paediatric inflammatory bowel disease (PIBD) is increasing across the world. However, information from India is sparse. This multicentre study evaluated the demographics, clinical phenotype and outcome of PIBD from India.

METHODS

Data of children (≤18 years) with PIBD were collected using a proforma containing details of demographics, clinical profile, extraintestinal manifestations (EIM), investigations, disease extent and treatment.

RESULTS

Three hundred twenty-five children [Crohn's disease: 65.2%, ulcerative colitis: 28.0%, IBD unclassified (IBDU): 6.7%, median age at diagnosis: 11 (interquartile range 6.3) years] were enrolled. 6.9% children had family history of IBD. Pancolitis (E4) was predominant in ulcerative colitis (57.8%) and ileocolonic (L3, 55.7%) in Crohn's disease. Perianal disease was present in 10.9% and growth failure in 20.9% of Crohn's disease cases. Steroids were the initial therapy in 84.2%, 5-amino salicylic acid in 67.3% and exclusive enteral nutrition (EEN) in 1.3% cases. Overall, immunomodulators and biologics were given to 84.3 and 17.9% cases, respectively, and 2.9% cases underwent surgery. Very early onset IBD (VEOIBD) was seen in 60 (19.2%) children. IBDU was commoner in the VEOIBD than the older-PIBD (18/60 vs 4/253; P < 0.001). VEOIBD-Crohn's disease patients more often had isolated colonic disease than the older Crohn's disease (45.4% vs 11.8%; P < 0.001). Prevalence of perianal disease, EIM, therapeutic requirements and outcome were not different between VEOIBD and older-PIBD.

CONCLUSION

Disease location and phenotype of PIBD in Indian children is similar to the children from the west. However, the therapeutic options of EEN, biologics and surgery are underutilized. VEOIBD accounted for 19.2% of PIBD.