Remission following an elemental diet or prednisolone in Crohn's disease

The short- and long-term effects of an elemental diet in children with acute Crohn's disease were compared with those of prednisolone in historical controls. Clinical remission was induced in 25 of 30 and in 18 of 28 episodes treated for six weeks with an elemental diet and prednisolone. Patients with proximal disease had longer remission after treatment with an elemental diet (p < 0.05) than did patients with colonic disease after treatment with prednisolone (p < 0.01). Disease activity index score improved in both groups compared with the pretreatment scores (p < 0.05). However, the improvement in the elemental diet group was significantly better than in the prednisolone group (p < 0.001). Changes in linear growth were better after treatment with an elemental diet compared with steroids (p < 0.001). Serum albumin and haematocrit concentrations all improved significantly in the children treated with an elemental diet (p < 0.001) but not in those treated with steroids. Thus an elemental diet was better than prednisolone in proximal disease and confirmed improved growth and nutritional status.     

Basic diet in Crohn's disease

26 children with acute symptoms of Crohn's disease were treated with steroids and sulfasalazine (group A, 9 patients), with an elementary diet and sulfasalazine (group B, 10 patients), or with an elementary diet together with steroids and sulfasalazine (group C, 7 patients). Mean ages in each group were very similar, and treatment periods lasted 41.3 +/- 23.5, 37.4 +/- 12.7, and 36.9 +/- 9.1 days in group A, B and C, respectively. During treatment the sedimentation rate and the frequency of defecation decreased significantly in each group. Leucocytes in plasma fell to normal levels in group B but increased slightly in group A and C. Total proteins in plasma rose in group B and C but declined in group A. The body weight increased in each group but differences before and after treatment were significant only in group B and C. The findings suggest that children with active Crohn's disease may benefit from treatment with an elementary diet. Patients with an elementary diet showed significantly more weight gain than patients on steroid treatment. Besides nutritional effects a lower activity of inflammation was also noted.     

Membranous glomerulonephritis in a patient with Crohn's disease of the small bowel

A 12-year-old girl presented with concurrent onset of membranous glomerulonephritis and Crohn's disease of the small intestine. Subsequent investigations failed to implicate any other systemic disease as a cause of the glomerulonephritis. Membranous glomerulonephritis is an immune complex--mediated glomerulopathy frequently associated with underlying systemic disease. The association of immune complex phenomenon with Crohn's disease and the variation of renal abnormalities in parallel with activity of bowel disease in this patient suggest that the glomerulonephritis may be due to the underlying Crohn's disease.     

Elemental diet in acute Crohn's disease

Fifteen patients with acute Crohn''s disease aged between 6 and 20 years were given an elemental diet. One patient received it by nasogastric tube and another would not tolerate it. All 14 patients have been reviewed for periods of between 1 and 3 years. An elemental diet appears to be a safe and effective method of inducing a remission in acute Crohn''s disease.     

Gastric and small bowel Crohn's disease assessed with leukocytes-Tc99m scintigraphy

We reviewed 312 ^99mTc leukocyte ^99mTc-WBC studies to evaluate the sensitivity and specificity of ^99mTc-WBC for identifying small-bowel and gastric inflammation in children with Crohn's disease. The ^99mTc-WBC scans were interpreted blindly and compared to the results of colonoscopy with biopsies and surgical specimens. In 46 children, total colonoscopy was done within a few days of a ^99mTc- WBC scan and in 13 others surgical specimens were available. Of the 37 children in whom the terminal ileum was visualized endoscopically (24) or surgically (13), the WBC-Tc^99m scan showed a similar degree of inflammation in 33. The sensitivity of ^99mTc-WBC scanning was 91% and the specificity 96%. The scans allowed evaluation of inflammation in the terminal ileum in 22 children in whom the endoscopist did not cannulate it; the scans were abnormal in 10 of these 22 children. In the children with no ileoscopy the results of the ^99mTc-WBC scan were consistent with the laboratory values, the gastroenterologist's clinical assessment, and long-term clinical follow-up. Finally, the scans of 46 controls did not reveal any false-positive findings in the terminal ileum. Five children with gastritis documented by gastroscopy had normal ^99mTc-WBC scans and upper gastrointestinal barium studies. This study demonstrates in a large number of normal and abnormal children with different pre-test probabilities of having inflammatory bowel disease that scintigraphy is reliable in identifying small-bowel inflammation. Accepted: 2 December 1998     

Normal small bowel biopsy followed by coeliac disease.

We report four patients (two children, one adolescent, and one adult) having normal small bowel mucosa shown on a biopsy specimen taken before the initial diagnosis of coeliac disease was made. The first biopsy was undertaken in two cases because of suspected malabsorption, in the third because of suspected dermatitis herpetiformis, and in the fourth as part of a coeliac disease family study. After a further 2.6 to 9 years on a diet containing gluten, small bowel villous atrophy with crypt hyperplasia compatible with coeliac disease was found on a second biopsy specimen. The HLA type of the patients was that typical for coeliac disease; all were DR3 positive. Within the families three other patients with coeliac disease have been diagnosed, two earlier and one at the time the first biopsy was undertaken. Four other HLA-DR3 positive haploidentical first degree relatives were found and had biopsies. All four had normal small bowel villous architecture, one had an increased intraepithelial cell count, and another was positive for reticulin and endomysium antibodies. Coeliac disease may exist latent in patients having normal mucosa when eating a normal diet containing gluten.     

Prolonged constant rate elemental enteral nutrition in Crohn's disease

Constant rate enteral nutrition (CREN) has been used in 17 pediatric patients with Crohn's disease. Exclusive CREN was maintained from 2 to 7 months and progressively reduced to assure fractioned oral intakes from 12 to 22 months. From this preliminary study, CREN appeared to be as effective as steroid therapy in initiating remission of active Crohn's disease and was able to suppress steroid dependence. In some cases with prolonged CREN, reduction or disappearance of stenotic lesions of the bowel was observed. Two other positive points must be emphasized: the favorable psychological impact of the method and the ability to avoid growth suppression secondary to steroids. The long-term effects and longer remissions must be confirmed by a multicenter study in a larger group of patients.     

The role of small bowel radiology in the diagnosis and management of Crohn's disease

A total of 50 children with Crohn's disease were examined by barium follow-through and colonoscopy with ileoscopy, to determine the value of small bowel radiology. Of these children, 40 (80%) had evidence of small bowel Crohn's disease on ileoscopy and/or barium follow-through. Twenty-two (44%) had disease confined to the terminal ileum. Radiology diagnosed disease proximal to the terminal ileum in 18 cases (36%), including 5 children in whom the terminal ileum was normal. Ileoscopy was not possible in nine patients (18%), six of whom had small bowel disease on barium follow-through. Colonic involvement, demonstrated in 34 (68%), was the sole site of disease in 6 (12%). Fifteen (30%) children had surgery, which in six (12%) was determined by the radiological findings of complicated small bowel disease. As the terminal ileum may be uninvolved in the presence of proximal ileal disease, normal ileoscopy does not exclude small bowel Crohn's disease. Small bowel radiology remains necessary to assess the full extent of Crohn's disease in children.     

Cellobiose: mannitol differential permeability in small bowel disease.

Cellobiose and mannitol absorption were studied in patients with suspected abnormal function of the small bowel mucosa. The urinary cellobiose:mannitol ratio was increased in subtotal villous atrophy, iron deficiency anaemia, and small intestinal Crohn''s disease. The test seems a sensitive indicator of the integrity of small bowel mucosa.     

Comparison of nitrogen utilization of two elemental diets in patients with Crohn's disease

Energy, nitrogen absorption, and nitrogen utilization of two commercial elemental diets, Vivonex and Vital, were compared in 10 teenage boys and girls with Crohn's disease. The diets were given in random order as overnight feedings and were the sole source of nutrients for two consecutive periods of 3 weeks each. Urine and stools were collected for 48 h at the end of each 3-week period. Energy absorption was slightly better on Vivonex (p less than 0.05), although 95-100% of energy was absorbed with both formulas. Nitrogen absorption was not different for the two formulas, but nitrogen utilization was significantly better on Vital (28.6 +/- 12.9% versus 9.7 +/- 17.7%, p less than 0.01). This difference may be attributable to the different concentrations of sulfur-containing and aromatic amino acids in the two formulas.     

Remission of aplastic anemia induced by treatment for Graves disease in a pediatric patient

Aplastic anemia (AA) is mediated by T-cell autoimmunity in the majority of cases; it is rare and mostly idiopathic in children. We describe a child, who developed AA following Graves' disease which could not be attributed to antithyroid drugs. We hypothesized that both diseases were caused by similar autoimmune process. We monitored the blood counts and did not administer any conventional treatment for AA assuming that the existing anti- hematopoietic stem cell humoral and cellular immunity might subside with induction of remission of Grave's disease. The child went into complete remission with the treatment of the Graves' disease.     

Serum antibodies to cow's milk proteins in pediatric inflammatory bowel disease. Crohn's disease versus ulcerative colitis

Serum antibodies to five cow's milk proteins (alpha-casein, bovine serum albumin, beta-lactoglobulin A and B, and alpha-lactalbumin) were investigated in young patients with inflammatory bowel disease (56 Crohn's disease, 24 ulcerative colitis). IgG antibodies against bovine serum albumin, beta-lactoglobulin A and beta-lactoglobulin B were higher in Crohn's disease patients than in those with ulcerative colitis or the controls. IgG anti-bovine serum albumin antibodies were higher in those Crohn's disease patients who had higher scores of disease activity. Finally, IgA antibodies to alpha-casein were higher in patients with Crohn's disease and ulcerative colitis when compared to controls. These findings may be due to increased uptake of dietary antigens or enhanced immunological response occurring in Crohn's disease patients.     

Osteopenia in Crohn's disease.

A 16 year old boy presented soon after diagnosis of Crohn''s disease with diffuse osteopenia of the lumbar spine with collapse of three vertebral bodies and grossly reduced bone mineral density noted on dual energy x ray absorptiometry scan. Treatment of the underlying Crohn''s disease and induction of puberty resulted in marked improvement in bone mineralisation.     

Serum antibodies to cow's milk proteins in pediatric inflammatory bowel disease: Crohn's disease vs. ulcerative colitis

Serum antibodies to five cow's milk proteins, alpha-casein, bovine serum albumin (BSA), beta-lactoglobulin A and B (BLG-a, BLG-b) and alpha-lactalbumin (ALA) were investigated in young patients with inflammatory bowel disease, 56 with Crohn's disease (CD), 24 with ulcerative colitis (UC). IgG antibodies against BSA and BLG-a and -b were higher in Crohn's disease patients as compared to those with ulcerative colitis and controls. The IgG anti-BSA were higher in the group of CD patients with higher score of disease activity. Additionally, IgA antibodies to alpha-casein were higher in CD and UC compared to control. These findings may be due to increased uptake of dietary antigens or enhanced immunological response occurring in CD patients.     

Crohn's disease in childhood.

In 32 patients with Crohn''s disease which started in childhood, abdominal pain, diarrhoea, and weight loss were the common presenting symptoms, but unexplained fever and failure to grow were also prominent. Stunted growth was the most frequent physical abnormality when first seen in hospital. The mean delay in diagnosis was almost 3 years and the principal contributing factor here was failure to consider the diagnosis and thus perform a barium follow-through examination. The cumulative relapse rate after medical therapy or surgical resection was disappointingly high, but because the median relapse time is much longer for surgically treated patients, surgery is recommended at an early stage, especially in those patients who are growth-retarded or whose education is suffering because of time lost from school.