Upper gastrointestinal mucosal disease in pediatric Crohn disease and ulcerative colitis: a blinded, controlled study

BACKGROUND: Upper gastrointestinal endoscopic biopsies often show histologic abnormalities in Crohn disease. Consequently, it has been proposed that routine endoscopy could help to distinguish Crohn disease from ulcerative colitis. Surprisingly, however, recent case reports and an uncontrolled study suggested that similar abnormalities may occur in ulcerative colitis. Therefore, a blinded, controlled study was performed. METHODS: Esophageal, gastric antral, and duodenal biopsies from children with Crohn disease (n = 28) and ulcerative colitis (n = 14) were compared with those from controls undergoing endoscopy for suspected reflux esophagitis (n = 22). Two pathologists, unaware of patient identity and diagnosis, agreed on a consensus report. Severity of inflammation was scored semiquantitatively. Helicobacter pylori colonization was an exclusion criterion. RESULTS: Inflammation was reported as follows: esophagitis: controls 91%; Crohn disease: 72%; ulcerative colitis: 50%; gastritis: controls: 27%; Crohn disease: 92% (P < 0.001); ulcerative colitis: 69%; duodenitis: controls: 9%; Crohn disease: 33%; ulcerative colitis: 23%. In Crohn disease, granulomas were noted in 40% of patients (P = 0.001). Duodenal cryptitis was noted in 26% of patients with Crohn disease but not ulcerative colitis. In one patient with ulcerative colitis, neutrophilic infiltration of gastric glands was seen. Abnormalities seen in Crohn disease and ulcerative colitis included gastroduodenal ulceration (Crohn disease, 7%; ulcerative colitis, 8%), villus atrophy (Crohn disease, 11%; ulcerative colitis, 15%), and increased intraepithelial lymphocytes (Crohn disease, 15%; ulcerative colitis, 31% [P < 0.05]). None of these abnormalities was noted in the controls. CONCLUSION: Although the presence of granulomas can support a diagnosis of Crohn disease, severe inflammation and other abnormalities occur in the proximal gastrointestinal tract in Crohn disease and ulcerative colitis.     

Azathioprine in the treatment of children with inflammatory bowel disease

During a 6-year period, we treated 21 patients with azathioprine, 2 mg/kg/day, as an adjunct to their customary regimen. Nine patients had ulcerative colitis and 12 patients had Crohn disease; the patients' ages ranged from 3 to 17 years. The median duration of disease before the start of azathioprine therapy was 2 years, and median follow-up was 2 years. Sixteen patients seemed to respond to azathioprine therapy: six patients in each disease group had complete responses and four patients (one with ulcerative colitis and three with Crohn disease) had partial responses. Two patients with ulcerative colitis and three patients with Crohn disease did not respond. The median time until patients responded was less than 3 months for patients with ulcerative colitis and 4 months for those with Crohn disease. Reduction of corticosteroid dose was possible for all patients who responded to azathioprine therapy. Only minimal side effects were attributable to the drug. We conclude that azathioprine is an effective adjunctive agent for the treatment of inflammatory bowel disease in childhood, but because questions remain regarding its long-term safety, its use should be reserved for children with refractory disease or severe and unacceptable side effects of corticosteroids.     

Elevated serum hepatocyte growth factor in children and young adults with inflammatory bowel disease.

BACKGROUND: Elevated serum levels of several potent angiogenesis factors, including vascular endothelial growth factor and basic fibroblast growth factor have been described in children with active inflammatory bowel disease. Angiogenesis-promoting cytokines may promote inflammation by increasing vascular permeability but also mediate tissue repair by activating fibroblasts. Hepatocyte growth factor (HGF) is another angiogenesis-promoting cytokine that is increased in colon cancer tissues. We therefore evaluated serum HGF levels in individuals with Crohn disease and ulcerative colitis. METHODS: Serum samples were obtained from 60 patients with Crohn disease, 31 with ulcerative colitis, and 38 controls with functional abdominal pain and other gastrointestinal illnesses. Disease activity for Crohn disease patients was determined using the pediatric Crohn disease activity index, and for ulcerative colitis patients using the Kozarek score. The HGF levels were measured by enzyme-linked immunosorbent assay. RESULTS: Serum HGF levels were significantly ( P < 0.001) higher for Crohn disease patients (1439 +/- 84 pg/mL) and ulcerative colitis patients (1384 +/- 107 pg/mL) than for control patients (807 +/- 50 pg/mL). Serum HGF levels also rose with increasing disease activity in individuals with both Crohn disease and ulcerative colitis. CONCLUSION: Serum HGF is elevated in children and young adults who have Crohn disease or ulcerative colitis. Levels of serum HGF correlate directly with disease activity. The raised serum HGF suggests that HGF may mediate angiogenesis and vascular permeability in the mucosa of children with inflammatory bowel disease. Alternatively, the raised serum HGF may be an epiphenomenon of inflammation.     

Incidence, clinical presentation and location at diagnosis of pediatric inflammatory bowel disease: a prospective population-based study in northern France (1988-1999)

OBJECTIVE: To assess the incidence and location at diagnosis of inflammatory bowel disease in children and adolescents in northern France between 1988 and 1999. METHODS: A 12-year prospective population-based study was conducted by gastroenterologists and pediatric gastroenterologists of northern France (1,312,141 children <17 years of age). RESULTS: From 1988 to 1999, 509 cases of childhood inflammatory bowel disease were recorded (7.2% of all inflammatory bowel disease cases in Northern France): 367 Crohn disease, 122 ulcerative colitis and 20 indeterminate colitis. The mean standardized incidence was 3.1/10(5) for inflammatory bowel disease as a whole (2.3 for Crohn disease, 0.8 for ulcerative colitis and 0.12 for indeterminate colitis). Crohn disease location at diagnosis was: small bowel and colon (71%), colon only (10%) and small bowel only (19%). Location of initial ulcerative colitis was: proctitis (11%), left colitis (57%) and pancolitis (32%). Although ulcerative colitis incidence remained stable (0.8), Crohn disease incidence increased from 2.1 in 1988 to 1990 to 2.6 in 1997 to 1999 (P = 0.2). CONCLUSIONS: The incidence of Crohn disease in the children of northern France showed an increasing trend (20%; not significant) during the 12-year period while the incidence of ulcerative colitis remained stable. In the entire population(children and adults)the incidence of Crohn disease increased significantly (+23%; P < 0.001), while the incidence of ulcerative colitis decreased (-17%; P < 0.0001).     

In vitro release of eosinophil cationic protein from peripheral eosinophils reflects disease activity in childhood Crohn disease and ulcerative colitis

The aim of this study was to compare in vitro release of eosinophil cationic protein (ECP) from peripheral blood eosinophils during active phases of childhood Crohn disease (CD) and ulcerative colitis with phases of remission. Ten children with CD and nine children with ulcerative colitis were investigated during 55 and 56 clinical visits, respectively. Each patient was investigated during at least one phase of clinically active disease and one phase of remission. Disease activity was assessed by means of the Paediatric Crohn Disease Activity Index (PCDAI) in Crohn disease and according to the clinical activity index of Rachmilewitz in ulcerative colitis. On an intra-individual basis, in vitro ECP release was significantly higher (P < 0.001) during active phases of CD and ulcerative colitis than in phases of remission (CD:median: 24.5 μg/l, range 16.0–61.2 versus median: 5.7 μg/l, range 2.0–16.7; ulcerative colitis: 14.8 μg/l, 8.3–39.8 versus 4.9 μg/l, 2.0–9.9). On an inter-individual basis, in CD and ulcerative colitis a strong and highly significant correlation was observed between disease activity indices and in vitro release of ECP from peripheral eosinophils (r = 0.89, P < 0.0001 and r = 0.82, P < 0.0001, respectively). Conclusion These results show that in vitro ECP release from peripheral eosinophils reflects disease activity in both CD and ulcerative colitis and therefore can be used as a new appropriate laboratory parameter for assessment of disease activity in chronic inflammatory bowel disease. Received: 26 October 1996 and in revised form: 8 April 1997 / Accepted: 15 April 1997     

Current diagnosis, management and morbidity in paediatric inflammatory bowel disease

In the 1970s several reports highlighted the long delay in diagnosis often experienced by children with Crohn's disease. In recent years this disorder has attracted much publicity, and many believe that the incidence has increased substantially. The aim of this investigation was to determine whether heightened awareness had shortened the interval to diagnosis, improved clinical management and reduced morbidity. A retrospective study was therefore carried out on 112 children with inflammatory bowel disease (64 Crohn's disease, 41 ulcerative colitis, 7 indeterminate colitis) referred to a paediatric gastroenterology department in the UK between 1994 and 1998. In Crohn's disease the median interval to diagnosis was 47 wk (maximum 7 y). In those without diarrhoea this was longer (66 vs 28 wk; p = 0.005). In ulcerative colitis the median interval was 20 wk (maximum 3 y). Even in severe colitis the median interval was 5.5 wk (range 3-9 wk) and 4 required urgent colectomy soon after referral. Many with unrecognized Crohn's disease had undergone inappropriate treatments, such as growth hormone or psychiatric therapy. Nineteen (17%) had undergone endoscopic investigations in adult units prior to referral. Malnutrition was equally common in Crohn's disease and ulcerative colitis (11%). Short stature was present in 19% with Crohn's disease, and 5% with ulcerative colitis, and was severe in 8% with Crohn's disease. There was a significant correlation between symptom duration and the degree of growth impairment present (r(s) = -0.4; p = 0.004). Conclusion: This study suggests that late diagnosis and inappropriate investigation and management are still significant problems.     

The role of esophagogastroduodenoscopy in the initial evaluation of childhood inflammatory bowel disease: a 7-year study

OBJECTIVES: To assess the role of esophagogastroduodenoscopy in the evaluation of children with suspected inflammatory bowel disease. METHODS: All children with inflammatory bowel disease who underwent esophagogastroduodenoscopy during their initial evaluation at our institution during a 7-year period (December 1993 to November 2000) were included in the study. RESULTS: The study included 115 patients: 81 with Crohn disease (mean age, 11.34 years; 42 males) and 34 with ulcerative colitis (mean age, 11.79 years; 20 males). Abnormal findings on esophagogastroduodenoscopy were noted in 64% of patients with Crohn disease and 50% of children with ulcerative colitis; histologic abnormalities were found in 81.6% and 70.6% of the patients, respectively. Granulomas were found in the upper gastrointestinal tracts of 23 of 81 patients (28.4%), with the most common site being the gastric mucosa. Nine of these 23 patients had granulomas solely in the upper gastrointestinal tract. Additional unsuspected pathology noted included: candidiasis, hiatal hernia, Helicobacter pylori infection, and giardiasis. CONCLUSIONS: Endoscopic and histologic abnormalities were found in the upper gastrointestinal tracts of a significant number of children with inflammatory bowel disease. While the mechanism(s) underlying these abnormalities in patients with ulcerative colitis is unclear, the pathology can contribute to the patient's clinical condition. Pathology in the upper gastrointestinal tract should not exclude a diagnosis of ulcerative colitis. Granulomas, confirming the diagnosis of Crohn disease, were found in the upper gastrointestinal tracts of 28% of our patients with Crohn disease. In some cases, granulomas were found solely in the upper gastrointestinal tracts. Based on our data, esophagogastroduodenoscopy with biopsy should be performed in all pediatric patients with suspected inflammatory bowel disease.     

Serum macromolecular creatine kinase type 1 as a diagnostic clue in inflammatory bowel disease?

In adults, macromolecular creatine kinase (CK) type 1 has been linked to ulcerative colitis (UC), but not to Crohn’s disease (CD). We present two patients with pediatric inflammatory bowel disease (IBD) in which macrocreatine kinase (macro-CK) type 1 led to the final diagnosis of UC. A 13 year old with bloody diarrhea and weight loss was diagnosed with CD. CK elevation was interpreted as perimyocarditis attributed to CD. CK elevation persisted; however, cardiac evaluation remained unremarkable. CK gel electrophoresis revealed macro-CK type 1. During a disease flare-up and reevaluation (endoscopy and histology), the diagnosis was changed to UC. A 12-year-old girl with bloody diarrhea, weight loss, and anemia was diagnosed with CD (patchy distal colitis and aphtoid lesions). Repeated CK elevation was observed. Gel electrophoresis confirmed macro-CK type 1. After reevaluation during a flare-up (endoscopy and histology), the diagnosis was changed to UC. Conclusion CK elevation in pediatric IBD could suggest macro-CK type 1 formation, which is possibly linked to UC. In a subset of IBD patients, macro-CK type 1 could help differentiate UC from CD.     

Chronisch entzündliche Darmerkrankungen bei Kindern und Jugendlichen

The register of inflammatory bowel disease (IBD) in children and adolescents in Saxony/Germany was established to record the presenting symptoms, the diagnostic procedures used, and the initial therapy applied in paediatric patients suffering from IBD in this region. In this paper, we report on 122 patients who were initially diagnosed with IBD between January 2000 and March 2003 and who were younger then 16 years at the time of diagnosis. The mean age was 12.8 years (median 13.5 years), and the youngest patient was 2.2 years of age. The aignosis most frequently made was Crohn’s disease (52.5%, or 64/122 patients), followed by ulcerative colitis (37.7%; 46/122 patients). Unexplained colitis was diagnosed in 9.8% (12/122) of patients. There were no sex-related differences in the pattern of conditions diagnosed. Intermittent abdominal pain was the most common initial symptom in these patients (89/122 patients; 73%). Blood in the stool was most frequent in patients with ulcerative colitis (38/46 patients; 83%), whereas weight loss (37/64 patients; 58%) and anaemia (25/64 patients; 39%) were more common in patients with Crohn’s disease. In 111 (91%) of the 122 patients diagnostic endoscopy with histopathological assessment was performed. The most common localization of Crohn’s disease was the terminal ileum , where it was found in 47 (73.4%) of the 64 patients affected. Ulcerative colitis was found most frequently (in 41/46 patients, 89%) in the descending colon and sigmoid. The initial drug therapy most commonly used was medication with ASA derivates, which were administered to 84.2% of these patients. Topical medication (ASA derivatives, corticosteroids, budesonide) were used rather rarely. Nutritional therapy was prescribed in 23.8% (29/122) of cases. Our results show that consistent records of patients with IBD can lead to new uniform guidelines for therapy, disease management, and quality control. We therefore support the intention of establishing a national German register of pediatric patients with IBD.     

Chemokine production by buccal epithelium as a distinctive feature of pediatric Crohn disease

OBJECTIVES: Inflammatory bowel diseases (IBD) represent an aberrant immune response by the mucosal immune system to luminal bacteria. Because the oral mucosa harbors the first epithelial cells that interact with microorganisms, we assessed the immunologic activity of buccal epithelium in children with IBD and adults with Crohn disease. METHODS: Buccal epithelial cells were obtained from 17 children and 14 adults with Crohn disease, 18 children with ulcerative colitis, and 40 controls. Cells were cultured with and without microbial stimulation. Chemokine levels were determined in culture supernatants by cytometric bead array and enzyme-linked immunoabsorbent assay. CXCL-8 production was studied by immunohistochemical analysis of these cells. CXCL-8 production by lipopolysaccharide stimulated monocyte-derived dendritic cells from these patients was determined. RESULTS: Compared with controls, pediatric ulcerative colitis patients, and adult Crohn disease patients, only in children with Crohn disease did buccal epithelial cells exhibit enhanced production of CXCL-8, CXCL-9, and CXCL-10. In vitro stimulation with lipopolysaccharide or zymosan resulted in a further increase of chemokine levels only in cells from pediatric Crohn disease patients. CXCL-8 production by stimulated monocyte-derived dendritic cells from children with Crohn disease was equal to that of children with ulcerative colitis. CONCLUSIONS: Buccal epithelium of children with Crohn disease is immunologically active, even in the absence of oral lesions. The enhanced chemokine production is associated with pediatric Crohn disease and appears restricted to cells derived from the epithelial barrier. Assessment of chemokine production by buccal epithelial cells may become a new, rapid, noninvasive test for screening and classification of IBD in children.     

Increased rectal nitric oxide in children with active inflammatory bowel disease

BACKGROUND: Luminal nitric oxide increases in ulcerative colitis and Crohn disease. The authors have previously used a minimally invasive method to demonstrate increased luminal nitric oxide in ulcerative colitis and Crohn disease of the colon. The aim of the current study was to determine whether this method could be applied to identify inflammatory activity in ulcerative colitis and Crohn disease in children. METHODS: Thirty-six children (18 of whom had active disease) with inflammatory bowel disease localized to the colon were studied. The control group comprised 12 healthy children. To measure nitric oxide, a silicon catheter with an inflatable balloon was inserted into the rectum and inflated with 10 mL of nitric oxide-free air. After a 10-minute incubation time, the air was withdrawn and nitric oxide concentrations were immediately analyzed using a chemiluminescence technique. RESULTS: Children with active ulcerative colitis and Crohn disease of the colon had greatly increased luminal nitric oxide concentrations in the rectum (8,840 +/- 5,120 and 15,170 +/- 4,757 parts per billion [ppb], respectively) compared with controls (77 +/- 17 ppb) (P < 0.001). Children with nonactive ulcerative colitis or Crohn disease displayed low concentrations of rectal nitric oxide (356 +/- 110 and 188 +/- 55 ppb, respectively), which was not different from that of healthy controls. CONCLUSION: Rectal nitric oxide measurement is a feasible and useful method for monitoring disease activity in inflammatory bowel disease, especially in children.     

The potential of digital X-ray radiogrammetry (DXR) in the assessment of osteopenia in children with chronic inflammatory bowel disease

Background Loss of bone mass is a known complication of chronic inflammatory bowel disease (IBD) in children. The gold standard in the evaluation of bone mineral density (BMD) is dual energy X-ray absorptiometry (DXA). Objective In this preliminary study we evaluated digital X-ray radiogrammetry (DXR) which estimates BMD (DXR-BMD) from hand radiographs in children with IBD. Materials and methods A total of 26 children with IBD (10 girls, 16 boys; age range 10–18 years) underwent DXR for the calculation of DXR-BMD and metacarpal index (DXR-MCI) using the Pronosco X-posure system. The results were compared with a local reference database and correlated with the results of DXA. Results DXR-BMD was 0.36–0.56 g/cm² (median 0.46 g/cm²) in Crohn disease patients and 0.38–0.63 g/cm² (median 0.48 g/cm²) in ulcerative colitis patients. DXR-MCI was 0.29–0.49 in Crohn disease patients and 0.28–0.53 in ulcerative colitis patients. The Z-scores were reduced to <−1 SD in five Crohn disease patients and in six ulcerative colitis patients. The coefficients (r) for the correlations between DXR-BMD and DXA-BMD were 0.78 for the lumbar spine and 0.61 for the proximal femur (P<0.01), and between DXR-MCI and DXA-BMD were 0.78 for the lumbar spine and 0.51 for the proximal femur (P<0.01). Conclusions DXR seems to be able to estimate cortical osteopenia in children with chronic IBD. The DXR results showed a positive correlation with DXA results.     

Fecal calprotectin: validation as a noninvasive measure of bowel inflammation in childhood inflammatory bowel disease

BACKGROUND: Calprotectin is an abundant neutrophil protein, which is extremely stable in feces. This study aimed to validate fecal calprotectin as a marker of bowel inflammation against invasive measures in children with inflammatory bowel disease (IBD), including colitis and small bowel Crohn disease. METHODS: Fecal calprotectin was measured using a simple enzyme-linked immunosorbent assay in 36 spot stool samples from 22 children before colonoscopy and from 14 children before technetium-99 (99Tc) scanning. Using standard scoring systems, the severity of inflammation was assessed macroscopically and histologically at six standard sites in those who underwent colonoscopy and also at six standard sites in those who underwent 99Tc scanning. The subscores from each site were summated to give combined severity and extent scores for macroscopic and for histologic inflammation in the group undergoing colonoscopy and total inflammation in the group undergoing 99Tc scanning. RESULTS: In the 22 children who underwent colonoscopy, median fecal calprotectin was 4.9 mg/L (0.1-272.5 mg/L) (range). Disease groups included six normal cases, nine ulcerative colitis cases, two isolated Crohn colitis cases, two indeterminate colitis cases, and three allergic colitis cases. Fecal calprotectin correlated closely with colonic macroscopic inflammation (r = 0.75, P < 0.001) and histologic inflammation (r = 0.85, P < 0.001). Of the 14 children undergoing 99Tc scanning, 10 had Crohn disease, 3 had ulcerative colitis, and 1 had allergic colitis. Median fecal calprotectin was 9.1 mg/L (0.3-141.7 mg/L), and this correlated closely with the 99Tc scanning score (r = 0.80, P = 0.001). CONCLUSION: Fecal calprotectin correlates closely with the best invasive measures of colonic and small bowel inflammation in childhood inflammatory bowel disease. As a sensitive objective measure of bowel inflammation that is risk-free and noninvasive, fecal calprotectin lends itself particularly to the monitoring of and assessment of therapeutic interventions in children with inflammatory bowel disease.     

Incidence of Crohn disease in the Czech Republic in the years 1990 to 2001 and assessment of pediatric population with inflammatory bowel disease

BACKGROUND: The aim of this study was to assess the pediatric population that suffered from inflammatory bowel disease (IBD) in the Czech Republic and to determine the incidence of Crohn disease (CD) in children up to 15 years age between 1990 and 2001. METHODS: Diagnostic criteria for CD, ulcerative colitis (UC), and indeterminate colitis (IC) were defined. Medical records provided a source of basic information about the children. A standardized protocol was filled out and sent to the coordinator of the study. All protocols were checked to see whether the data corresponded to the defined criteria and then were processed further. The study was retrospective in character for the years 1990 to 1999 and prospective for the years 2000 and 2001. RESULTS: Diagnostic criteria were met in 470 patients with IBD; 201 of them turned 18 years old during the study period. CD was diagnosed in 223 patients. The incidence of CD in children up to 15 years of age increased from 0.25/100,000 in 1990 to 1.25/100,000 in 2001. Eighty-two percent of children with CD were treated with aminosalicylates in combination with corticosteroids; 29% of patients received azathioprine. Severe growth retardation was recorded in 6.4% of adolescents with CD at the age of 18. UC was diagnosed in 202 patients. Therapy with aminosalicylates only was sufficient for control of the disease in 23% patients; 68% children were treated with corticosteroids, 15 of them (23% of the whole group) received additional azathioprine. Criteria for IC were met in 9.8% of all patients with IBD. CONCLUSION: This study confirmed an increase in incidence of CD in children younger than 15 years in the Czech Republic.     

High incidence of upper gastrointestinal tract involvement in children with Crohn disease

This retrospective study of Crohn disease in 230 children and adolescents with a mean age of 12.5 years at the time of diagnosis and an average follow-up of 6.6 years showed that 30% had lesions of the esophagus, stomach, and duodenum. Three patients had Crohn disease isolated to the upper gastrointestinal tract. The 169 patients with both small and large bowel disease were at greater risk (33%, P less than .05) of having upper gastrointestinal lesions than the 37 with isolated small bowel disease and the 21 with disease limited to the colon and/or rectum. An aggregate of symptoms and signs more likely present in those with upper gastrointestinal involvement included: dysphagia, pain when eating, nausea and/or vomiting, and aphthous lesions of the mouth. Furthermore, weight loss was more severe and hypoalbuminemia more frequent. Because upper gastrointestinal series x-ray studies failed to detect upper gastrointestinal lesions in 13 patients of 69 of those with upper gastrointestinal disease, endoscopy should be considered in all children and adolescents in whom a diagnosis of Crohn disease is entertained. Endoscopy and biopsy of the upper gastrointestinal tract should be done in any patient with symptoms suggestive of proximal involvement. Finally, in view of the fact that endoscopy established the diagnosis of Crohn disease in five patients previously thought to have chronic ulcerative colitis, the procedure should routinely be performed in all patients with chronic ulcerative colitis or indeterminate colitis before surgery is performed.     

Long-term outcome of inflammatory bowel disease—Unclassified in children

Objectives

To document the frequency at diagnosis and evolution over time of inflammatory bowel disease-unclassified in children.

Methods

Analysis of case records (2004–2011) of patients diagnosed with inflammatory bowel disease-unclassified following uppergastrointestinal endoscopy, ileocolonoscopy and small bowel imaging. Any subsequent diagnostic reclassification by 2016 was recorded.

Results

344 children diagnosed as inflammatory bowel disease: 58% Crohn’s disease, 34.5% ulcerative colitis, and 7.5% (n=26) inflammatory bowel disease-unclassified. 25/26 inflammatory bowel disease-unclassified patients were followed for 4.5–11.5 years. 17 of these patients needed endoscopic reevaluation leading to changed diagnosis in ten (Crohn’s disease 7, ulcerative colitis 3).

Conclusion

7.5% (25/344) of inflammatory bowel disease children had inflammatory bowel disease-unclassified at diagnosis; 10 (40%) evolved into Crohn’s disease or ulcerative colitis.

     

Accuracy of abdominal ultrasound and MRI for detection of Crohn disease and ulcerative colitis in children

Background

Endoscopy is currently the primary diagnostic technique for inflammatory bowel disease (IBD) in children.

Objective

To assess the accuracy of US and dynamic contrast-enhanced MRI for diagnosing inflammatory bowel disease and for distinguishing Crohn disease and ulcerative colitis in comparison to a reference standard.

Materials and methods

Consecutive children with suspected IBD underwent diagnostic workup including ileocolonoscopy and upper gastrointestinal endoscopy as the reference standard, abdominal US, and MR enterography and colonography at 3 T. The protocol included a dynamic contrast-enhanced 3-D sequence. Sensitivity, specificity and kappa values were calculated for one ultrasonographer and two MRI observers.

Results

We included 28 children (15 boys) with mean age 14 years (range 10–17 years). The diagnosis was IBD in 23 children (72%), including 12 with Crohn disease, 10 with ulcerative colitis and 1 with indeterminate colitis. For the diagnosis of inflammatory bowel disease the sensitivity was 55% for US and 57% (both observers) for MR entero- and colonography, and the specificity was 100% for US and 100% (observer 1) and 75% (observer 2) for MR entero- and colonography. Combined MRI and US had sensitivity and specificity of 70% and 100% (observer 1) and 74% and 80% (observer 2), respectively. With the addition of a dynamic contrast-enhanced MR sequence, the sensitivity increased to 83% and 87%. US and MRI could only distinguish between Crohn disease and ulcerative colitis when terminal ileum lesions were present.

Conclusion

US and MR entero- and colonography have a high accuracy for diagnosing inflammatory bowel disease in children but cannot be used to distinguish Crohn disease and ulcerative colitis.     

Inflammatory bowel disease in children and adolescents: recommendations for diagnosis--the Porto criteria

Ulcerative colitis and Crohn disease may present before the age of 20 years in 25% to 30% of all patients with inflammatory bowel disease. Reported incidence figures vary considerably depending on the collection of data. Multicenter, multinational collaboration is needed when studying pediatric inflammatory bowel disease. The essential first step is uniformity in the work-up and criteria used for diagnosis. The Porto diagnostic criteria presented here provide the tool that is needed. These criteria are the result of consensus reached by the ESPGHAN inflammatory bowel disease working group. Diagnosis of Crohn disease, ulcerative colitis and indeterminate colitis is based on clinical signs and symptoms, endoscopy and histology and radiology. Every child suspected of inflammatory bowel disease should undergo a complete diagnostic program consisting of colonoscopy with ileal intubation, upper gastrointestinal endoscopy and (in all cases except in definite ulcerative colitis) radiologic contrast imaging of the small bowel. Multiple biopsies from all segments of the gastrointestinal tract are needed for a complete histologic evaluation. A diagnosis of indeterminate colitis cannot be made unless a full diagnostic program has been performed.