Table of Contents

1. Introduction
• Explanation of IBD, its subtypes – Crohn’s disease (CD) and ulcerative colitis (UC)
2. Pediatric Inflammatory Bowel Disease
• CD is predominant in the pediatric population
3. Symptoms of IBD:
4. Differences Between Crohn’s Disease and Ulcerative Colitis
5. Types of Crohn’s Disease
6. Other Types of Colitis
7. IBD Treatment

Crohn’s disease (CD) and ulcerative colitis (UC) represent two broadest subtypes of Inflammatory bowel disease (IBD), which encompasses a spectrum of diseases. CD is inflammation of any part of the gastrointestinal tract which causes patchy areas of inflammation in different sections. While UC typically involves some or all of the large intestine and causes continuous inflammation in one area. 1. They are a type of chronic and relapsing intestinal inflammation with some extraintestinal complications. Recently, rising incidence of IBD has been observed internationally 2. CD generally affects young adults in the third decade of life.

However, pediatric inflammatory bowel disease is often more extensive and severe than adult cases and a quarter all IBD cases are diagnosed in children <18 years 4.  Also, it is reported that patients with childhood-onset CD exhibit a more active disease and require more immunosuppressive therapy. Overall, CD is the predominant IBD subtype comprising 59–73% of pediatric IBD, while UC comprises 24–32% of pediatric IBD 5,6. Colorectal cancer (CRC) is the most frequent malignant complication in patients with IBD.

The common symptom reported by the patients are abdominal pain and diarrhea. In UC cases mostly rectal bleeding has also been observed (83–95%) compared to CD (40%). In patients with CD often weight loss and perianal disease have been observed. For the diagnosis of IBD physical examination is very fundamental. General assessment may show some evidence of growth failure or pubertal delay as well as pallor suggestive of anemia. Additionally, a careful perianal examination is also performed to examine for the perianal disease. Further investigation is done for occult or gross blood in the stool. IBD patients might also experience extraintestinal manifestations like joint disease and mucocutaneous disease. Thus, clinicians also search for tender swollen joints, apthous stomatitis, and erythema nodosum (tender red nodules typically on the extensor surface of lower extremities).

The inflammation caused by Crohn’s disease goes deeper into the intestinal wall. In Crohn’s disease patients, approximately 60% have some colon inflammation along with inflammation elsewhere in the digestive tract, while for the other half the disease is limited to the colon. In spite of differences between Crohn’s disease and ulcerative colitis, at times it can be difficult to differentiate between the two. Also often the treatment options are different depending on the diagnosis. Few other complications from Crohn’s colitis are – abscesses (pockets of pus that forms in the colon) or fistulas (abnormal connections formed between the colon and other organs) and the narrowing of the colon. Patients with Crohn’s disease of the colon are also at a higher risk of developing colorectal cancer. Chron’s disease is characterized into five types based on which parts of the digestive tract are affected. The location of inflammation affects what symptoms you have and what type of treatment is needed. (Table 1)

 

Of the above five form of Chron’s disease, Ileocolitis is the most common form. It affects about 40% of people with Crohn’s disease. It is estimated that about 50 to 200 people are living with Crohn’s disease per 100,000 people. UC also has a few types depending on the affected area. Rectum inflammation is called ulcerative proctitis and entire large intestine inflammation is pancolitis.  According to an estimate, there are 120 to 200 people living with UC/100,000 people whereas about 8 to 14 UC cases are diagnosed per 100,000 people each year.

Sometimes, when it is difficult to differentiate between Crohn’s disease and ulcerative colitis  “indeterminate colitis” term is used. When the inflammation is in the large intestine and can be seen only under a microscope Microscopic colitis term is used. There are 2 forms of microscopic colitis collagenous colitis and lymphocytic colitis.

Microscopic colitis is most common in older adults. and often overlaps with other autoimmune diseases. An inflammation in the part of the large intestine that is left after surgery to redirect waste (feces) out of the body is called as Diversion colitis. Normally, waste travels through the large intestine to the rectum. and eliminated through the anus. However, if there are problems with the intestine, waste can be eliminated through an ostomy, or surgical opening in the skin. It develops in the part of the intestine that is no longer in use. It may develop because of the bacteria in that part living on the undigested starches and fiber in normal waste. Most people who have fecal diversion surgery develop diversion colitis, but less than half of people have symptoms. Further inflammation of the blood vessels can also occur and it is termed as Behçet’s disease, a rare autoimmune disease. The most common symptoms of Behçet’s disease are mouth ulcers, genital ulcers, and eye inflammation. When the digestive tract is affected, ulcers typically appear at the end of the small intestine (ileum) and start of the large intestine (cecum). For this reason, Behçet’s disease may be confused with Crohn’s disease.

There is a range of drugs prescribed for the IBD treatment. These include steroids, 5ASAs, thiopurines, 6-mercaptopurine (6-MP), immunosuppressants such as azathioprine, methotrexate and ciclosporin, and biological drugs like infliximab and adalimumab. Other drugs used for IBD include antibiotics such as metronidazole and ciprofloxacin, and symptomatic drugs such as antidiarrheals and bulking agents. Initially, the aim of drug treatment is to reduce inflammation in the gut.  Once the condition is under control maintenance treatment is given where drugs are prescribed to maintain remission and prevent relapse 8. In some cases, if medical treatment is not effective, then surgery may be required.

IBD disease management is a complex process which includes both treatment and non-treatment decisions (such as self-management behaviors) to improve symptoms and reduce disease flares. These non-treatment methods, such as diet modification, stress management, and alternative therapies, are decisions meant to decrease symptoms and improve health-related quality of life.

References

  1. Carvalho RS, Abadom V, Dilworth HP, et al. Indeterminate colitis: a significant subgroup of pediatric IBD. Inflamm Bowel Dis. 2006;12:258–262.
  2. Kapoor A, Bhatia V, Sibal A. Pediatric inflammatory bowel disease. Indian Pediatr. 2016;53:993–1002.
  3. Pigneur B, Seksik P, Viola S, et al. Natural history of Crohn’s disease: comparison between childhood- and adult-onset disease. Inflamm Bowel Dis. 2010;16: 953–961.
  4. Abraham BP, Mehta S, El-Serag HB. Natural history of pediatric-onset inflammatory bowel disease: a systematic review. J Clin Gastroenterol. 2012;46: 581–589. \
  5. Winter DA, Karolewska-Bochenek K, Lazowska-Przeorek I, et al. Pediatric IBDunclassified is less common than previously reported: results of an 8-year audit of the EUROKIDS Registry. Inflamm Bowel Dis. 2015;21:2145–2153.
  6. Bequet E, Sarter H, Fumery M, et al. Incidence and phenotype at diagnosis of very-early-onset compared with later-onset paediatric inflammatory bowel disease: a population-based study [1988–2011]. J Crohns Colitis. 2016;11: 519–526.
  7. Mills, S., & Stamos, M.J. (2007). Colonic Crohn’s disease. Clin Colon Rectal Surg, 20, 309–313.
  8. Mottet C, Schoepfer AM, Juillerat P, et al. Experts Opinion on the Practical Use of Azathioprine and 6-Mercaptopurine in Inflammatory Bowel Disease. Inflamm Bowel Dis 2016;22(11):2733-2747