A28 RESPONSE RATE OF VERY EARLY ONSET INFLAMMATORY BOWEL DISEASE (VEOIBD) PATIENTS TO ANTI-TNF TREATMENT IS HIGHER THAN PREVIOUSLY REPORTED, BUT HIGHER DOSING IS REQUIRED-A LARGE TERTIARY SINGLE CENTER EXPERIENCE

Background

Very early onset inflammatory bowel disease (VEOIBD) patients are known to have special disease characteristics. Limited data is available regarding biologic use and long-term outcomes in VEOIBD patients.

Aims

We aimed to assess long-term outcomes and time to progression to biologic treatment in VEOIBD patients. Secondary aim was to determine Infliximab prescribing practice during the course of treatment.

Methods

We retrospectively reviewed IBD patients diagnosed under 6 years of age, between January 2005 and December 2019, from the British Columbia (BC) Pediatric IBD database. Demographic data, disease characteristics, symptoms at diagnosis, disease location and severity were documented. Data on biologic treatment at initiation and during follow up including type of biologic, dosing and response were collected. Kaplan Meier curves were used to assess the number of years to progression to biologic treatment and the parameters influencing commencement. Infliximab dosing and intervals were recorded for all patients treated with Infliximab during induction, after one year and at last follow up.

Results

89 patients with VEOIBD were diagnosed during the study period. Median age at diagnosis was 3.8 years (IQR 2.6–5.1), 45.3% had Crohn’s disease (CD) and 62.8% were males. Median duration of follow up was 6.39 years (IQR 3.71–10.55). Biologic treatment was started on 39.5% of patients and 7.1% underwent surgery. In patients with CD, the addition of perianal fistulizing disease or stricturing disease was associated with more rapid progression to biologic treatment (p=0.024, p=0.038, respectively). In patients with UC, disease severity (p=0.017) was associated with early initiation of a biologic. The median Infliximab dose at one year was 10 mg/kg (IQR 7.5–11) with median dose interval of 4 weeks (IQR 4–6). At the time of the last follow up, 18 patients (72%) maintained treated with Infliximab and had a median dose of 9 mg/kg per dose (IQR 8.1–10) and a median dose interval of 4.5 weeks (IQR 4–6). Clinical remission was reported in 61.8% of patients on their first biologic agent at the last follow up.

Conclusions

Factors influencing earlier progression to biologics were disease severity and disease behaviour. The response rate was higher than previously reported and might be due to higher Infliximab dosing with shorter infusion intervals than standard dosing.

Funding Agencies

None

A59 SEVERE CHEMOTHERAPY-INDUCED SECRETORY DIARRHEA

Background

Diarrhea is one of the most common side effects of chemotherapy, estimated to occur in up to 40% of all patients undergoing cancer therapy. Non-complicated chemotherapy-induced diarrhea (CID) can be managed with loperamide, whereas complicated CID should be treated with continuous infusion of octreotide. Octreotide is usually effective within 48hs of administration. Options for patients that do not respond to loperamide or octreotide include atropine, oral budesonide and cholestyramine.

Aims

To describe the case of an 18 yo girl with acute myeloid leukemia (AML) who developed severe secretory diarrhea during her treatment course.

Methods

Retrospective case report.

Results

The patient was initially treated with Cytarabine, Daunorubicin and Etoposide, and on her third cycle, Gemtuzumab was added. Four weeks later she presented with watery diarrhea up to 6 L/day. She continued with high output despite no oral intake, which was consistent with secretory diarrhea. Infectious workup was negative, and she received Loperamide. Her output decreased to 1 L for 2 days but then increased again to 6 L. She deteriorated and loperamide was switched to octreotide 0.8mcg/Kg/h. The dose was increased to 1.2mcg/Kg/h and she presented blood in the stools. Her stool output was still 4 L/day and octreotide was stopped after one week. Flex sigmoidoscopy showed proctocolitis with friability. Biopsy showed architectural distortion with loss of the superficial epithelium. She was emotionally distressed due to many days of no oral intake, hence Pediasure peptide was introduced, with no changes in the output. Rice was introduced but her diarrhea worsened, and oral intake was stopped again. Four weeks after the onset of diarrhea, her stool output was still above 2 L/day, and cholestyramine 4g once daily was started. Four days later her output decreased and diet was slowly introduced. Two weeks later she had a normal stool output. Cholestyramine was stopped and she was discharged home.

Finding the culprit for this case is a challenge, but important to avoid this drug in the future as prior history of CID is a risk factor for a new-onset. Gemtuzumab is a relatively new anti-CD33 antibody used in AML, and results from a meta-analysis showed that adding it to induction chemotherapy may increase the incidence of diarrhea. Her diarrhea started four weeks after the dose of Gemtuzumab, and we believe this new agent might have played an important role in her case. To our knowledge, there are no cases in the literature associating Gemtzumab with such prolonged and severe diarrhea.

Conclusions

This was a challenging case of CID that did not respond to Loperamide or octreotide and caused a lot of emotional distress for the patient and her providers. Since she responded well to cholestyramine, we recommend its use when the loperamide and octreotide have failed, or in addition to octreotide in severe cases.

Funding Agencies

None

A191 TEN YEARS FOLLOW UP OF EARLY ONSET INFLAMMATORY BOWEL DISEASE PATIENTS- A SINGLE CENTER RETROSPECTIVE COHORT STUDY

Background

Early onset inflammatory bowel disease (EOIBD) and Very early onset inflammatory bowel disease (VEOIBD) prevalence has been increasing over the last decades. These young patients have been known to have special disease characteristics and disease location. Although it is known that only a low percentage of these patients require biologic treatment after diagnosis, there is only scarce evidence about their long- term outcome and biologic requirements.

Aims

To assess the ten year outcome of early onset and very early onset IBD patients.

Methods

We retrospectively reviewed IBD patients diagnosed under 10 years of age, between January 2005 and December 2009, from the British Columbia (BC) Pediatric IBD database. Disease characteristics and symptoms at diagnosis were documented. The disease location and severity at diagnosis were documented according to the Paris classification. Data collected retrospectively included a ten year treatment follow up period, number of hospitalizations, corticosteroid courses and surgeries. These parameters were documented at three time points: after the first year, after five years and ten years.

Results

68 patients under the age of 10 were diagnosed with IBD during the study period. 2 patients failed to meet inclusion criteria and were excluded. Median age at diagnosis was 6.06 (IQR 4.5–8.6). 47.7% of patients had Crohn’s disease and 71.2% were males. 63 patients completed the 5 year follow up, and 52 the 10-year period due to lack of follow up or transfer to adult care. After the first year of follow up 0% patients in the VEOIBD group and 5% patients in the EOIBD group were treated with biologic treatment, whereas after the 10-year period 42.3% and 29.6% of patients were treated with biologic therapy respectively (p=0.282). Overall, 4 patients underwent colectomy and 2 a small bowel resection.

Conclusions

Although the percentage of VEIBD and EOIBD patients receiving biologic treatment after ten years is higher than after the first year, it is still lower than what is reported in the literature in older pediatric IBD patients and adults.

Funding Agencies

None

A171 MAGNETIC RESONANCE IMAGING IN CHILDREN WITH EARLY ONSET INFLAMMATORY BOWEL DISEASE- A RETROSPECTIVE COHORT STUDY

Background

Magnetic Resonance (MR) Imaging is the preferred imaging method in Inflammatory Bowel Disease (IBD) patients to investigate for small bowel disease. There are challenges in performing MR imaging in Early Onset IBD (EO-IBD) patients, and in particular in children with Very Early Onset IBD (VEO-IBD). These children often need a general anaesthetic which exposes them to adverse effects and preclude conventional luminal distention influencing the quality of the test. Therefore, the utility of MR imaging in this age group is questionable.

Aims

To assess the quality of MRI studies in VEO-IBD and EO-IBD patients and to compare the utility of this test between the two groups.

Methods

We retrospectively identified and reviewed IBD patients diagnosed under 10 years of age, between January 1999 and December 2011, from the British Columbia Children’s Hospital (BCCH) GI Division IBD database. Patients’ first diagnostic MRI results were recorded. Disease location and severity were documented according to the Paris classification.

Results

124 patients were included in the cohort, 54 VEO-IBD and 70 EO-IBD patients (See Table 1). Median age at diagnosis was 6.46 (IQR 3.94–8.71), 65.32% males and 43.54% were diagnosed with Crohn’s disease. Overall, 52 patients underwent MRI, 17 (31.48%) in the VEO-IBD group and 35 (50%) in the EO-IBD group; median time from diagnosis to MRI was 3.02 years (IQR 1.08–5.83) for VEO-IBD and 0.44 years (IQR 0.07–1.58) for EO-IBD (p<0.001). In the EO-IBD group there was a significantly higher percentage of patients with MRI findings than in the VEO-IBD group, 23 (67.31%) and 5 (29.41%) respectively (p=0.014). Only one patient in the VEO-IBD group had a disease characteristic identified by MR imaging that could not be diagnosed by endoscopy (small bowel disease).

Conclusions

The diagnostic yield of MRI in children with VEO-IBD appears to be quite limited but requires further study.

Funding Agencies

None