Ebook Clinical gastroenterology: Part 2
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Ebook Clinical gastroenterology: Part 2
Chapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2ease•Epidemiology • Etiopathogenesis • Children • Corticosteroids • Growth failure•Bone mass • Dual energy X-ray adsorptiometry • Quality of life • Transition of care • Quantitative computed tomographyKey Points•Approximately 20% of inflammatory bowel disease (IBD) cases present in the pediatric or Ebook Clinical gastroenterology: Part 2adolescent age group.•Genetics and specific serum immune markers may identify children with more aggressive Crohn’s disease.•Both upper and lower endoEbook Clinical gastroenterology: Part 2
scopies with biopsies should be performed in pediatric patients suspected of having IBD.•Earlier appropriate use of thiopurines, and subsequently biolChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2this population that are multifactorial in nature and must be correctly identified, quantitated. and treated, when possible.•Adherence to prescribed medication regimens is low in the pediatric and adolescent population, especially among children with dysfunctional families or with poor coping strate Ebook Clinical gastroenterology: Part 2gies.M. Dubinsky (El)Pediatric IBD Center. Cedars-Sinai Medical Center. David Geffen School of Medicine. UCLA.8700 Beverly Boulevard, Suite 1165W, LosEbook Clinical gastroenterology: Part 2
Angeles. CA 90048. USAe-mail: dubinskym@csmc.eduR D Cohen (ed I Iníĩanìiiưitnrv Rowel Dixenxe Clinical Gastroenlerolnov151M. Dubinsky152IntroductionIChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2the fastest growing incident population for 1BD. Recent advances in diagnostics technologies and therapeutics have improved the care provided to these children. There are specific distinguishing features that differentiate early (pediatric)-onset IBD from later (adult)-onset IBD. Physical and psycho Ebook Clinical gastroenterology: Part 2social development remains a critical focus for pediatric gastroenterologists when providing comprehensive management to the pediatric IBD patient. ChEbook Clinical gastroenterology: Part 2
ildren are not just little adults and consideration must be given to the stages of development and how these stages impact disease presentation and maChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2ild with IBD.EpidemiologyA European study reported that in the entire 1BD population (children and adults) the incidence of Crohn's disease (CD) increased significantly (+23%). while the incidence of ulcerative colitis (L'C) decreased (-17%) [ I J. A North American study reported an incidence of IBD Ebook Clinical gastroenterology: Part 2 in Wisconsin children to be 7.05 per 100.000. The incidence of Crohn's disease was 4.56. which was more than twice the rate of ulcerative colitis (2.Ebook Clinical gastroenterology: Part 2
14). Of interest, in this population-based study, an equal IBD incidence occurred among all ethnic groups, and children from sparsely and densely popuChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2dy which could explain the lack of familial inheritance. Like most studies of pediatric 1BD. the median age of onset was 12 years and there appears to be a slight male predominance in the younger age group. Given the rise in incidence and the onset of disease coinciding with growth and development, Ebook Clinical gastroenterology: Part 2it is very important to highlight the considerations that should be taken into account when managing childhood-onset 1BD.EtiopathogenesisThe underlyinEbook Clinical gastroenterology: Part 2
g pathogenesis of 1BD in children appears to be similar to that in adult-onset such that IBD results from a complex interaction of environmental, geneChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2 To date, however, a gene specific to pediatric-onset disease has not been identified.10 State-of-the-Art Management of the Pediatric IBD Patient153The most well-known genes, N0D2 in particular, are similarly present in both 30-35% of adult and pediatric CD patients. Although the tine pathogenic rol Ebook Clinical gastroenterology: Part 2e of NOD2 in CD remains unknown, it is an important gene involved in innate immunity which lends support to the notion that genetically determined defEbook Clinical gastroenterology: Part 2
ects in innate and likely adaptive immunity alter the way our mucosal immune system interacts with our resident bacterial flora (3] Despite similar clChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2d w ith Caucasian children with CD |4|. A study from Israel suggested that G908R (SNPI2) allele-variant of the NOD2/CARD15 gene is closely related to the appearance of CD at a young age in Jew ish Ashkenazi patients [5Ị. Research is ongoing to further examine the influence of ethnicity on disease su Ebook Clinical gastroenterology: Part 2sceptibility and disease modification in both children and adult-lBD patients. A pediatric genome-wide association study identified [6] early-onset geEbook Clinical gastroenterology: Part 2
nes unique to children. Initial genotype-phenotype correlation studies in children demonstrated that N0D2 is associated with flbrostenosing CD and morChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2t predicting the natural history of disease in pediatric patients. Initial work suggested that there are specific immune markers present in the serum of children with 1BD [8], These markers were initially used to help differentiate CD from ƯC and to aid in the distinction between functional GI sympt Ebook Clinical gastroenterology: Part 2oms and those due to underlying 1BD. CD in particular. The concept that seroreactivity to specific microbial antigens seen in a subgroup of patients wEbook Clinical gastroenterology: Part 2
ith IBD likely represents a surrogate measure of an individual’s (mal) adaptive immune response has led to an influx of research focused on understandChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2yces cerevisiae antibody), the Pseudomonas fluorescens-reỉaỉeá protein (12). Escherichia coli outer membrane-porin (OmpC). and CBirl flagellin (CBirl) [9-11 ]. The evolution of serum immune response from diagnostic markers to markers of disease behavior and predictors of prognosis has resulted in st Ebook Clinical gastroenterology: Part 2udies that have shown that the presence and magnitude of immune responses in a given child is associated with more aggressive disease phenotypes and mEbook Clinical gastroenterology: Part 2
ore rapid disease progression to complication and surgery [12. 13Ị.DiagnosisThe diagnostic approach to 1BD in children is a two-tiered approach. The fChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2ntiation between IBD and diseases that mimic the symptoms of IBD can be relatively simple. Diarrhea and abdominal pain are the most common symptoms in both CD and uc with rectal bleeding more commonly seen in uc and weight loss and anorexia more characteristic of CD. Perianal disease, like in adults Ebook Clinical gastroenterology: Part 2, remains characteristic of CD154M. Dubinskyand can he present in up to 30% of pediatric patients at presentation or soon thereafter. Growth failure,Ebook Clinical gastroenterology: Part 2
however, is a clinical presentation that certainly distinguishes pediatric-onset IBD from their adult counterparts. This is more commonly in CD then uChapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2t count) complete blood count with a focus on the hemoglobin for anemia and other labs such as iron panel and albumin to look at nutritional/absorptive state are performed along with stools studies to rule out infection especially in the presence of a travel history or recent antibiotic use. Endosco Ebook Clinical gastroenterology: Part 2pic evaluation and histopathological diagnosis remains the gold standard [14]. It is recommended that all children undergo both an upper endoscopy andEbook Clinical gastroenterology: Part 2
colonoscopy at the time of initial investigation. The findings on upper endoscopy, although often nonspecific, may provide additional information in Chapter 10State-of-the-Art Management of the PediatricIBD PatientMarla DubinskyKeywords Crohn’s disease • Ulcerative colitis • Inflammatory bowel dise Ebook Clinical gastroenterology: Part 2of 54 children (22 CD: 7 UC): however, overall the proportion of pediatric patients with upper tract disease is likely closer to 25-30% depending on what the definition of upper tract disease is [ 15]. In this small study, epigastric and abdominal pain, nausea and vomiting, weight loss, and pan-ileo Ebook Clinical gastroenterology: Part 2colitis were predictive of upper gastrointestinal involvement. Perhaps of even more interest is that, 31% of the children with upper gastrointestinalEbook Clinical gastroenterology: Part 2
involvement were asymptomatic at presentation. Thus, absence of specific upper gastrointestinal symptoms docs not preclude presence of upper gastrointGọi ngay
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