Ulcerative colitis (UC) and
Crohn disease (CD) are chronic intestinal inflammatory diseases that can present as bloody
diarrhea,
abdominal pain, and
malnutrition. Collectively, these disorders are referred to as
inflammatory bowel disease (IBD). All patients with IBD share a common pathophysiology. However, there are a number of developmental, psychosocial, and physiologic issues that are unique to the approximate, equals 20% of patients that present during childhood or adolescence. These include the possibility of disease-induced delays in linear growth or physical development, differences in
drug dosing, and the changes in social and cognitive development that occur as children move from school-age years into adolescence and early adulthood. Gastroenterologists caring for these children must therefore develop an optimal regimen of pharmacologic
therapies, nutritional management, psychologic support, and properly timed surgery (when necessary) that will maintain disease remission, minimize disease and
drug-induced adverse effects, and optimize growth and development. This article reviews current approaches to the management of patients with UC and CD and highlights issues specific to the treatment of children with IBD. The principal medical
therapies used to induce disease remission in patients with UC are aminosalicylates (for mild disease),
corticosteroids (for moderate disease), and
cyclosporine (
ciclosporin) (for severe disease). If a patient responds to the induction regimen, maintenance
therapies that are used to prevent disease relapse include aminosalicylates,
mercaptopurine, and
azathioprine.
Colectomy with creation of an
ileal pouch anal anastomosis (
J pouch) has become the standard of care for patients with severe or refractory
colitis and results in an improved quality of life in most patients. Therefore, the risks associated with using increasingly potent
immunosuppressant agents must be balanced in each case against a patient's desire to retain their colon and avoid a temporary or potentially permanent
ileostomy. Decisions about
drug therapy in the management of patients with CD are more complex and depend on both the location (e.g. gastroduodenal vs small intestinal vs colonic), as well as the behavior of the disease (inflammatory/mucosal vs stricturing vs perforating) in a given patient. Induction
therapies for CD typically include aminosalicylates and
antibiotics (for mild mucosal disease), nutritional
therapy (including elemental or polymeric formulas),
corticosteroids (for moderate disease), and
infliximab (for
corticosteroid-resistant or fistulizing disease). Aminosalicylates,
mercaptopurine,
azathioprine,
methotrexate, and
infliximab can be used as maintenance
therapies. Because surgical treatment of CD is not curative, it is typically reserved for those patients either with persistent symptoms and disease limited to a small section of the intestine (e.g. the terminal ileum and cecum) or for the management of complications of the disease including
stricture or
abdominal abscess. When surgery is necessary, maintenance medications administered postoperatively will postpone recurrence. Patients with UC and CD are at risk for the development of
micronutrient deficiencies (including
folate,
iron, and
vitamin D deficiencies) and require close nutritional monitoring. In addition, patients with UC and CD involving the colon are at increased risk of developing
colon cancer, and should be enrolled into a colonoscopy surveillance program after 8-10 years of disease duration.