Julie A. Bass

Occurrence of Crohn’s Disease in Children After Total Colectomy for Ulcerative Colitis

BACKGROUND Colectomy is the definitive treatment for ulcerative colitis (UC) to remove the inflammatory burden. Crohns disease, however, can affect any portion of the bowel with a propensity to involve the terminal ileum. In some patients with fulminant colitis, distinction between the two is imperfect. Manifestations of Crohns after colectomy can be devastating because the ileum is needed for restoration of continuity. There is currently little information in the pediatric literature addressing this concern. Therefore, we reviewed all of our patients who underwent colectomy for inflammatory bowel disease to evaluate the risk of subsequent Crohns manifestations and to document the outcomes. METHODS A two-center retrospective review of children who underwent colectomy for IBD from January 2000 to July 2010 was performed. Demographic, diagnostic, management, and outcome variables were recorded. RESULTS We identified 70 patients who underwent colectomy for UC. The mean age at diagnosis was 12 y ± 7 y, and 59% were female. Clinical diagnosis prior to colectomy was UC in 90%, and indeterminate colitis in 10%. There was discordance between clinical and pathologic diagnosis in five patients, two patients were clinically diagnosed with UC but had an indeterminate biopsy, and three patients were clinically diagnosed as indeterminate colitis with a biopsy confirming UC. Indications for colectomy were refractory bleeding in 63%, failure of medical treatment in 28%, toxic megacolon in 6%, and perforation in 3%. A restorative pouch was created after colectomy in 46% using a two-stage approach while, 53% were managed with an initial colectomy and three-stage approach. In one patient, Crohns was intraoperatively diagnosed from the operative colectomy specimen. This patient had a clinical diagnosis of UC with concordant biopsy prior to surgery. After total abdominal colectomy, 68 patients went on to ileal pouch anal anastomosis by either a two-stage or three-stage approach. In these patients, nine (13%) had a change in their diagnosis to Crohns after reconstruction. Crohns complications requiring an operation consisted of two patients with anastomotic dilations, four patients with fistulotomies, and one patient with perianal abscess drainage procedures. CONCLUSIONS In the children studied, 13% had a diagnostic change to Crohns disease, and 13% were diagnosed with Crohns after ileal pouch-anal anastomosis (IPAA). In patients with IPAA and Crohns, there were more operative interventions for perianal disease.

Pediatric Crohn Disease Presenting as Appendicitis: Differentiating Features from Typical Appendicitis

BACKGROUND The initial presentation of Crohn disease (CD) may mimic acute appendicitis, and preoperative clues may aid in recognizing patients at risk for CD. METHODS A retrospective case control study of patients presenting over 10 years compared control patients with appendicitis versus patients presenting with appendicitis who ultimately developed CD. We matched 10 patients of the same age, gender, and perforated versus nonperforated appendicitis status for each of the CD patients. Demographic, laboratory, and clinical data were compared. Additionally, appendectomy specimens of CD patients were genotyped for common NOD2 (nucleotide-binding oligomerization domain-containing protein 2) mutations. RESULTS Of 2718 patients treated for appendicitis, 8 subsequently developed CD. Compared to the matched controls, CD patients were found to have lower hemoglobin (10.4 + 1.0 vs. 13.3 + 0.2, p < 0.0001) and mean corpuscular volume (MCV) (72.5 + 3.4 vs. 84.1 + 0.5, p < 0.0001) values, and higher platelets values (444.8 + 42.2 vs. 275.6 + 8.0, p < 0.0001) at initial presentation. Anthropometric z-scores, length of stay, and antibiotic therapy duration did not significantly differ between groups. The NOD2 mutation frequency (25%) was consistent with the currently described CD population. CONCLUSIONS Preoperative findings of a low hemoglobin level and MCV count, and a high platelet count in a child presenting with appendicitis warrant further evaluation for CD, as prompt diagnosis allows for optimal treatment and quality of life for these patients.

Practice survey: adherence monitoring and intervention in pediatric gastroenterology and hepatology

Purpose Despite significant medication nonadherence rates among youth with pediatric gastroenterology and hepatology disorders, little is known about current adherence practices in pediatric gastroenterology care. This study summarizes current practices surrounding adherence monitoring and intervention in pediatric gastrointestinal (GI) and hepatologic care in the USA. Participants and methods One hundred and fifty-four pediatric GI providers completed an online survey designed to examine current practices surrounding adherence monitoring and intervention, specific strategies used to monitor and treat poor adherence, and the barriers currently experienced in relation to adherence monitoring and intervention. Results Practices varied greatly in terms of when and how patient adherence is monitored and by whom; however, physicians and nursing professionals take primary responsibility for adherence monitoring. Approximately 25% utilize screeners to assess adherence, and most participants use patient and caregiver reports as a primary measure of adherence. Most participants rated their level of adherence monitoring and intervention as fair to poor. While most participants perceive adherence monitoring to be very important in clinical practice, only 20.8% perceive being able to significantly modify patient adherence. Conclusion There exists great variability in adherence monitoring and intervention practices across pediatric GI providers. Greater understanding of current adherence practices can inform future clinical efforts.