Treating children with inflammatory bowel disease: Current and new perspectives.

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gut characterised by alternating periods of remission and relapse. Whilst the mechanism underlying this disease is yet to be fully understood, old and newer generation treatments can only target selected pathways of this complex inflammatory process. This narrative review aims to provide an update on the most recent advances in treatment of paediatric IBD. A MEDLINE search was conducted using "paediatric inflammatory bowel disease", "paediatric Crohn's disease", "paediatric ulcerative colitis", "treatment", "therapy", "immunosuppressant", "biologic", "monitoring" and "biomarkers" as key words. Clinical trials, systematic reviews, and meta-analyses published between 2014 and 2016 were selected. Studies referring to earlier periods were also considered in case the data was relevant to our scope. Major advances have been achieved in monitoring the individual metabolism, toxicity and response to relevant medications in IBD including thiopurines and biologics. New biologics acting on novel mechanisms such as selective interference with lymphocyte trafficking are emerging treatment options. Current research is investing in the development of reliable prognostic biomarkers, aiming to move towards personalised treatments targeted to individual patients

Highlights in IBD Epidemiology and Its Natural History in the Paediatric Age.

Background. The number of patients of all age brackets diagnosed with Inflammatory Bowel Disease (IBD) has risen dramatically worldwide over the past 50 years. IBD's changing epidemiology suggests that environmental factors play a major role in modifying disease expression. Aim. To review studies carried out worldwide analyzing IBD epidemiology. Methods. A Medline search indicating as keywords "Inflammatory Bowel Disease," "epidemiology," "natural history," "Crohn's Disease," "Ulcerative Colitis," and "IBD Unclassified" was performed. A selection of clinical cohort and systematic review studies that were carried out between 2002 and 2013 was reviewed. Studies referring to an earlier date were also considered whenever the data were relevant to our review. Results. The current mean prevalence of IBD in the total population of Western countries is estimated at 1/1,000. The highest prevalence and incidence rates of IBD worldwide are reported from Canada. Just as urbanization and socioeconomic development, the incidence of IBD is rising in China. Conclusions. Multicenter national registers and international networks can provide information on IBD epidemiology and lead to hypotheses about its causes and possible management strategies. The rising trend in the disease's incidence in developing nations suggests that its epidemiological evolution is linked to industrialization and modern Westernized lifestyles

Peculiarities of Paediatric Digestive Endoscopy

1. Introduction 1.1. What is the role of paediatric endoscopy nowadays? Which are the main indications and contra-indications? An increased knowledge of normal and pathologic endoscopic patterns in paediatric patients has been increasing in the last decades. Besides, the availability of flexible instruments with narrow diameter and elevate qualitative resolution allows Paediatric Gastroenterologists to investigate small infants too. An adequate setting including endoscopic equipment, endoscopic room, support area and dedicated caregivers is fundamental to perform appropriate procedures. Diagnostic endoscopy comprehends fiber-endoscopy, capsule endoscopy, confocal microendoscopy and echo-endoscopy. Roles of Digestive Endoscopy \u2022 Visualisation of the mucosa; \u2022 Evaluation of architecture and vascularisation; \u2022 Evaluation of mucosal secretions; \u2022 Availability to take biopsy samples for histological examination with optic microscopy, ultra-structural examination with electronic microscopy, cultures, CRP methods, dissecting microscopy, chromo-endoscopy, vital staining, enzymatic studies, brushing; \u2022 Endoscopic treatments. Functions of Digestive Endoscopy \ua9 2013 Gasparetto and Guariso; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. \u2022 Morphologic diagnosis of structural congenital and acquired alterations (optic microscopy, immune-histochemistry, electronic microscopy, confocal microendoscopy, brushing); \u2022 Identification of infective processes (CRP techniques of molecular biology) and cultural examination; \u2022 Morphological, chemical and microbiological evaluation of endoluminal secretions; \u2022 Endoscopic treatment in case of gastrointestinal bleeding, varices, polyps, stenoses, tumors. Appropriateness. Indications and contraindications to endoscopic examinations [1-2] An endoscopic exam is indicated when the expected benefits (longer life survival, pain contention, reduction of anxiety, increase in functional capacity) exceed the potential negative consequences (mortality, morbidity, anxiety, pain, disability). An endoscopic exam is necessary when it is unavoidable and mandatory for the care of the patient. Signs and Symptoms of Indication for Upper Gastrointestinal (GI) Endoscopy \u2022 GI bleeding; \u2022 Disphagia, odinophagia, persistent feeding refusal, persistent chest pain; \u2022 Upper abdominal pain with signs and symptoms suggesting organic diseases (red flags); \u2022 Suspect of peptic disease; \u2022 Persistent vomit; \u2022 Suspected alterations at upper GI imaging; \u2022 Suspected caustic ingestion; \u2022 Iron deficiency anaemia. Pathologic Conditions for which Diagnostic Upper GI Endoscopy is indicated: \u2022 Peptic esophagitis, hemorrhagic gastritis, peptic ulcers in stomach, bulbus and duodenum; \u2022 Gastrointestinal opportunistic infections i.e. Cytomegalovirus, Fungi; \u2022 Eosinophilic esophagitis; \u2022 Caustic ingestion; \u2022 Atrophic gastritis; \u2022 Helicobacter pylori (HP) gastritis; \u2022 Coeliac disease; \u2022 Inflammatory bowel disease (IBD) with localisation at the upper GI tract; 268 Endoscopy of GI Tract \u2022 Patients with liver cirrhosis, disphagia, malnutrition, oesophageal varices; \u2022 Congestive gastropathy; \u2022 Chronic diarrhoea of unknown nature; \u2022 Structural alteration of the mucosa (Microvillus Inclusion Disease, Tufting Enteropathy); \u2022 Benign or malignant lesions in common bile duct or duodenum; \u2022 Graft Versus Host Disease (GVHD) after bone marrow transplantation; \u2022 Lymphoproliferation after organ transplantation i.e. EBV-related gastric lymphoma after liver transplantation. Pathologic Conditions for which Therapeutic Upper GI Endoscopy is indicated: \u2022 Polypectomy; \u2022 Treatment of oesophageal varices; \u2022 Placement of ostomies; \u2022 Treatment of GI bleeding (i.e. bleeding ulcers) non responsive to medical therapy; \u2022 Removal of foreign bodies; \u2022 Oesophageal stricture. Absolute Contraindication to Upper GI Endoscopy \u2022 Suspect of Gastrointestinal Perforation. Relative Contraindications to Upper GI Endoscopy \u2022 Non complicated gastro-oesophageal reflux; \u2022 Functional uncomplicated abdominal pain; \u2022 Congenital hypertrophic stenosis of the pylorus; \u2022 Isolated spasm of the pylorus; \u2022 Follow-up controls for ulcers, mucosal abnormalities, Barrett oesophagus; \u2022 Surveillance of benign healed lesions. Upper GI endoscopy is not appropriate for all children with dyspeptic symptoms, but only for cases [3]: \u2022 With a family history of peptic ulcer and/or HP infection; \u2022 Over 10 years of age; \u2022 With symptoms persisting for more than 6 months; \u2022 With symptoms severe enough to affect activities of daily living; Peculiarities of Paediatric Digestive Endoscopy http://dx.doi.org/10.5772/52523 269 Pathologic Conditions for which Diagnostic Lower GI Endoscopy is indicated: \u2022 Inflammatory bowel disease (IBD); \u2022 Infective colitis; \u2022 Allergic colitis; \u2022 Neutrophil disfunction associated colitis i.e. Glycogenosis; \u2022 Immune mediated diseases; \u2022 Vascular abnormalities (venous ectasia secondary to portal hypertension, angiodysplasia, haemangiomas, vasculitis); \u2022 Polyps and polyposes (juvenile polyps, adenomatous polyps, hyperplastic polyps, hamartomatous polyps, hereditary polyposic syndromes as Peutz-Jeghers Syndrome, Cowden Syndrome); \u2022 Pseudopolyps of the colon; \u2022 Neoplastic lesions i.e. leiomyosarcoma, lymphoma, carcinoma; \u2022 Screening of displasia; \u2022 Surveillance after bowel transplantation (rejection, complications); \u2022 Obscure iron deficient anaemia; \u2022 Structural alteration of the mucosa (Microvillus inclusion disease, Tufting enteropathy); \u2022 Chronic diarrhoea of unknown nature; \u2022 Suspect of filling defects or stenoses at radiographic-ultrasonographic images; \u2022 Rectal trauma; \u2022 Necessity of ileal or colonic bioptic samples. Pathologic Conditions for which Therapeutic Lower GI Endoscopy is indicated: \u2022 Polypectomy; \u2022 Post-polypectomy complications; \u2022 Mucosal resections; \u2022 Ablation of vascular malformations (i.e. Dieulafoy Lesion); \u2022 GI bleeding (i.e. Bleeding ulcers); \u2022 Placement of percutaneous ostomies; \u2022 Dilatations of colonic stenoses; \u2022 Removal of foreign bodies; Absolute Contraindications to Lower GI Endoscopy 270 Endoscopy of GI Tract \u2022 Suspected intestinal perforation; \u2022 Severe acute colitis with toxic megacolon; Relative Contraindications to Lower GI Endoscopy \u2022 Acute self-limiting diarrhoea; \u2022 Gastrointestinal bleeding with demonstrated origin at the upper GI tract; \u2022 Recent intestinal resection; \u2022 Irritable bowel syndrome; \u2022 Chronic abdominal pain without significant morbidity; \u2022 Simple constipation and encopresis

The multidisciplinary health care team in the management of stenosis in Crohn's disease.

BACKGROUND: Stricture formation is a common complication of Crohn's disease (CD), occurring in approximately one-third of all patients with this condition. Our aim was to summarize the available epidemiology data on strictures in patients with CD, to outline the principal evidence on diagnostic imaging, and to provide an overview of the current knowledge on treatment strategies, including surgical and endoscopic options. Overall, the unifying theme of this narrative review is the multidisciplinary approach in the clinical management of patients with stricturing CD. METHODS: A Medline search was performed, using "Inflammatory Bowel Disease", "stricture", "Crohn's Disease", "Ulcerative Colitis", "endoscopic balloon dilatation" and "strictureplasty" as keywords. A selection of clinical cohort studies and systematic reviews were reviewed. RESULTS: Strictures in CD are described as either inflammatory or fibrotic. They can occur de novo, at sites of bowel anastomosis or in the ileal pouch. CD-related strictures generally show a poor response to medical therapies, and surgical bowel resection or surgical strictureplasty are often required. Over the last three decades, the potential role of endoscopic balloon dilatation has grown in importance, and nowadays this technique is a valid option, complementary to surgery. CONCLUSION: Patients with stricturing CD require complex clinical management, which benefits from a multidisciplinary approach: gastroenterologists, pediatricians, radiologists, surgeons, specialist nurses, and dieticians are among the health care providers involved in supporting these patients throughout diagnosis, prevention of complications, and treatment

Conservative treatment for cystic duct stenosis in a child.

Introduction. Few cases of common bile duct stenosis have been reported in the literature, and observations of strictures in the cystic duct are even more rare. Surgical cholecystectomy is the treatment needed in most cases of gallbladder hydrops. This paper describes the diagnosis and successful medical treatment of a rare pediatric case of cystic duct stenosis and gallbladder hydrops. Case Report. A formerly healthy one-year-old girl was admitted with colicky abdominal pain. Blood tests were normal, except for an increase in transaminases. Abdominal ultrasound excluded intestinal intussusception and identified a distended gallbladder with biliary sludge. MR cholangiography revealed a dilated gallbladder containing bile sediment and no detectable cystic duct, while the rest of the intra- and extrahepatic biliary tree and hepatic parenchyma were normal. This evidence was consistent with gallbladder hydrops associated with cystic duct stenosis. The baby was treated with i.v. hydration, corticosteroids, antibiotics, and ursodeoxycholic acid. Her general condition rapidly improved, with no further episodes of abdominal pain and normalization of liver enzymes. This allowed to avoid cholecystectomy, and the child is well 1.5 years after diagnosis. Conclusions. Although cholecystectomy is usually necessary in case of gallbladder hydrops, our experience suggests that surgical procedures can be avoided when the distension is caused by a cystic duct stenosis

Clinical course and outcomes of diagnosing Inflammatory Bowel Disease in children 10 years and under: retrospective cohort study from two tertiary centres in the United Kingdom and in Italy.

BACKGROUND: Most children with Inflammatory Bowel Disease (IBD) are diagnosed between 11 and 16 years of age, commonly presenting with features of typical IBD. Children with onset of gut inflammation under 5 years of age often have a different underlying pathophysiology, one that is genetically and phenotypically distinct from other children with IBD. We therefore set out to assess whether children diagnosed after the age of 5 years, but before the age of 11, have a different clinical presentation and outcome when compared to those presenting later. METHODS: Retrospective cohort study conducted at two European Paediatric Gastroenterology Units. Two cohorts of children with IBD (total number = 160) were compared: 80 children diagnosed between 5 and 10 years (Group A), versus 80 children diagnosed between 11 and 16 (Group B). Statistical analysis included multiple logistic regression. RESULTS: Group A presented with a greater disease activity (p = 0.05 for Crohn's disease (CD), p = 0.03 for Ulcerative Colitis (UC); Odds Ratio 1.09, 95 % Confidence Interval: 1.02-1.1), and disease extent (L2 location more frequent amongst Group A children with CD (p = 0.05)). No significant differences were observed between age groups in terms of gastro-intestinal and extra-intestinal signs and symptoms at disease presentation, nor was there a difference in the number of hospitalisations due to relapsing IBD during follow-up. However, children in Group A were treated earlier with immunosuppressants and had more frequent endoscopic assessments. CONCLUSION: While clinicians feel children between 5 and 10 years of age have a more severe disease course than adolescents, our analysis also suggests a greater disease burden in this age group. Nevertheless, randomized trials to document longer-term clinical outcomes are urgently needed, in order to address the question whether a younger age at disease onset should prompt per se a more "aggressive" treatment. We speculate that non-clinical factors (e.g. genetics, epigenetics) may have more potential to predict longer term outcome than simple clinical measures such as age at diagnosis

Colonic perforation in a child with Crohn's disease: successful medical treatment rescues from colectomy.

Background. The challenging treatment of penetrating paediatric Crohn's disease (CD) involves pharmacological and surgical approaches. Despite a proved efficacy of anti-TNF agents for treatment of complex fistula, a large number of patients cannot achieve a complete healing and relapse during the followup. Aim. We report a paediatric case with CD and colonic perforation who was successfully treated with medical therapy only, including anti-TNFα. Case Presentation. During a colonoscopy performed on a 9-year-old girl with CD, a perforation occurred in correspondence of a fistula at the colonic splenic flexure. The formation of a collection was then detected (US, enteric-CT), as well as a fistula connecting the colon to the collection. The girl was kept fasting and treated with total parenteral nutrition and antibiotic therapy. Treatment with Infliximab was also started, and after the third dose a US control showed disappearance of the collection and healing of the enteric fistula. Parenteral nutrition was progressively substituted with enteral feeding, and no surgical treatments were needed. Discussion. In pubertal children with penetrating CD, the option of an efficacious medical treatment to avoid a major surgical approach on the bowel is to be aimed for growth improvement. This approach requires a strictly monitored long-term followup