Pediatric Inflammatory Bowel Disease (IBD): Management

00:01 If children have Crohn's disease or ulcerative colitis, there are many treatments out there.

00:07 And it may be confusing for you at first when you're seeing your first patient to understand which treatment is due when.

00:16 This is a rapidly changing field. Just three years prior to recording this we would never have used Remicade early in disease and now we're doing that all the time.

00:27 So keep in mind that this is a changing field and lookout for changes as you go forward.

00:34 However, let's go through the major treatment options that are available to you in terms of types of treatments.

00:40 So, medications are the mainstay of management of both of these conditions.

00:44 We also have to think about nutritional considerations, how can we optimize nutrition because it is the bowel wall after all that's involved.

00:53 And also we have to think about surgical management in these patients.

00:58 So, medications. Corticosteroids, either IV or oral, it doesn't really matter are used in acute flares with moderate to severe symptoms.

01:10 These are the mainstay of therapy.

01:12 But as we know, steroid use frequently can result in all kinds of problems.

01:18 Moon faces, buffalo hump, all the findings of Cushing's disease.

01:23 We want to avoid them.

01:24 Additionally, patients may be treated by 5-amino salicylic acid.

01:30 This is usually for mild or moderate ulcerative colitis.

01:35 Patients may also get immunomodulators like azathioprine.

01:39 Azathioprine maintains remission in about 75% of patients.

01:43 Also in methotrexate is frequently used especially in patients who are failing azathioprine.

01:50 Infliximab is used both for induction and maintenance of remission.

01:56 And antibiotics such as ciprofloxacin and metronidazole are used for fistulae and pouchitis, an inflammation of the pouch left over after a surgical resection of the colon in ulcerative colitis.

02:12 Oral rifaximin improves abdominal pain and diarrhea.

02:16 Additionally, patients may receive probiotics.

02:20 This helps maintain remission and again may treat or prevent a pouchitis.

02:25 Nutritional considerations are important.

02:29 Sometimes patients require enteral feeding because they don't have the energy to keep it up.

02:34 But nutrition is so important for healing.

02:37 We often provide supplemental vitamins especially for patients with fat malabsorption where we'll give extra of the fat-soluble vitamins.

02:47 Vitamin A, D, E, and K.

02:49 Parenteral nutrition isn't uncommon especially in patients with severe small bowel disease where they have to maintain NPO status for a long period of time.

02:58 Remember, high protein levels are needed to both reconstruct your intestinal tissue and maintain your immune system's needs.

03:08 Surgical intervention is necessary in many cases.

03:13 For ulcerative colitis, colectomy with an ileal pouch and an anal anastomosis is the most optimal therapy.

03:23 And you can see here a patient who's had the green colon removed replaced by the purple small bowel.

03:30 And they've created an ileal pouch that's gonna act as sort of what was previous to the rectal vault, an area to store stool until it's time to defecate.

03:40 This patient has an ileostomy.

03:42 We can hope that this patient will have that ileostomy taken down so that he can eventually live a reasonably normal life.

03:49 In patients with Crohn's disease, fistulae and areas of stenosis can occur that can be highly problematic and periodically segmental bowel resection is needed.

04:00 These patients become very friendly with their surgeons.

04:03 They need to be followed carefully and watched for surgical issues.

04:07 The prognosis of inflammatory bowel disease is reasonably good and that these patients can live long and meaningful lives.

04:16 However, disease relapse is common.

04:19 And about more than half of patients will have a relapse within two years of their original diagnosis.

04:26 The body is constantly in an inflamed state.

04:29 So delayed puberty is common and these patients will achieve a lower final adult height.

04:35 Don't forget, especially fat soluble vitamins are a problem so these patients are at risk for vitamin D deficiency.

04:43 That and combined with their frequent steroid use put them at grave risk for bone mineral density problems.

04:51 These children can get osteopenia/osteoporosis later in life and frequent fractures.

04:57 We have to be very careful about their bone mineral density.

05:02 Some complications can occur in these patients.

05:06 Toxic megacolon can occur and that is surgical emergency.

05:11 Patients are at risk for colorectal cancer especially in ulcerative colitis.

05:17 Generally, after diagnosis for ulcerative colitis, within eight years, a patient is gonna start being screened regularly for colorectal cancer.

05:27 There is a lifelong increased risk and frequently patients will elect to have a colectomy to avoid the cancerous consequences.

05:36 Patients also have a risk for cholangiocarcinoma and generally complications of the biliary tree and -- but watching for cholangiocarcinoma is especially important in patients with inflammatory bowel disease.

05:50 So what I've tried to portray for you a picture here is that these patients can live long and productive lives.

05:57 They need help from all ailments and all sides of the medical team.

06:02 From everywhere from the medical doctors, to the surgeons, to the psychologists and to the teachers and the parents.

06:08 But together we can make their lives come out pretty well.

06:11 So, that's all I have for you about this subject today. Thanks for listening.