1. Colitis in the Very Young

2. Case 8 month old presented with bloody bowel movements and diarrhea
Maternal history of UC
Endoscopy – pan colitis
Infectious w/u negative
Started on Mesalamine
Prednisone – 1 mg/kg

3. Persistent episodes bleeding
Additional testing?
Medical management?

4. Medical course – Medical options? Hypertension (3 drug) Osteopenia DVT
Persistent pancolitis
Medical options?

5. Medical Therapy Medical treatment options? IV steroids? Infliximab?
Tacrolimus?
Fecal transplant?

6. Surgical Options?
Optimization for surgery?
IPAA candidate?

7. Clinical Course
Age two - Total abdominal colectomy with plan for delayed reconstruction
Persistent bleeding from rectum
Completion proctectomy with J-pouch reconstruction
Pouchitis responsive to antibiotics

8. Patient 2 – refractory UC
18 year old male – 3 weeks bloody diarrhea
8 BM per day
Cultures and C. difficile negative
Colonoscopy –pancolitis, normal ileum
Placed on prednisone (60 mg daily) with improvement
Mesalamine maintenance
1600 mg bid
Symptoms rapidly recurred as soon as prednisone tapered despite mesalamine
Prednisone dose increased

9. What would you do for maintenance therapy?
Azathioprine or mercaptopurine
Methotrexate
Infliximab
Adalimumab

10. One year remission rates in UC
Thiopurine - Pediatric IBD registry %*
Infliximab - ACT 1 clinical trial 30%**
Adalimumab - ULTRA 2 clinical trial 22%***
Methotrexate - retrospective VA 30%****
*Hyams AJ Gastro 2011
** ACT 1 and 2 NEJM 2006
*** Sandborn, Gastroenterology 2012
****Khan, IBD Journal 2012

11. Management Patient started on mercaptopurine
Dose increased to 2 mg/kg/day
Still steroid dependent after 3 months
Level – 6TG 168, 6MMP – 4200
Infliximab and surgery discussed but reluctant
6MP – 37.5 mg daily
Allopurinol, 100 mg daily
After 2 months – 6TG 306, MMP 0, improvement but still requires low dose steroid (10-15 mg daily)
3-5 BM per day

12. Management 2
Repeat colonoscopy – active disease from transverse to rectum (Mayo score 1-2)
Begun on infliximab
Continued allopurinol / 6MP
Improvement after 3 months
Steroid free
2-3 BM per day

13. Questions
Would you continue the mercaptopurine in addition to the infliximab?
Would you continue the allopurinol?
What about the risk of hepatosplenic T cell lymphoma?
Is surgery preferable to all this immunosuppression?
What information would surgeons give to help this patient weigh risks and benefits?

14. Outcome Allopurinol discontinued, but disease worsened
Infliximab dose increased to 10 mg/kg every 6 weeks, but disease remained active
Referred to a surgeon for information, but not interested in surgery
Second opinion
Restart allopurinol, continue 6MP
Disease enters remission, continues combination therapy for UC

15. Fulminant Colitis

16. Presenting history 16 year old male Presented with bloody diarrhea
EGD normal; colonoscopy with normal TI and pan-colitis
Responded to IV steroids
Flared during oral prednisone taper
Received infliximab 5 mg/kg x 2 seven days apart
Second opinion, admitted
PUCAI 80, Cdiff negative

17. Options Additional diagnostic tests? Medical treatment options ?
Surgical treatment options ?

18. Diagnostic Tests CTE: pan-colitis, normal small bowel
Flex Sig: severe colitis, CMV PCR negative
Infliximab level 9 days after second 5 mg/kg dose: 18 mcg/mL, neg. antibodies

19. Medical Therapy Medical treatment options? IV steroids?
Higher dose infliximab?
Tacrolimus?
Vedolizumab?
Fecal transplant?

20. Clinical course
IV steroids and infliximab 10 mg/kg x 2 seven days apart
TPN
PUCAI 75

21. Medical or Surgical Therapy?
Tacrolimus?
Vedolizumab?
Diverting ileostomy?
Subtotal colectomy with end ileostomy?
Procto-colectomy with J-pouch and ileostomy?

22. Clinical course Subtotal colectomy with end ileostomy
Colectomy specimen: no creeping fat, terminal ileum normal, severe chronic active colitis
No granulomas or transmural inflammation
Discharged home, feeling well
Two months later developed mouth sores, otherwise feels well, with second stage J-pouch planned soon
Tests?

23. Diagnostic Tests
EGD: Antrum with apthous ulcers – mild chronic active gastritis and duodenitis
Ileum: first 5 cm friable with chronic active ileitis, remainder normal
Flex Sig: inflamed rectum with chronic active colitis

24. What Now? Does he have Crohns or UC ? Other tests ?
Proceed with procto-colectomy with J-pouch and ileostomy?
Treat proctitis and then proceed with ileo-rectal anastomosis if healed?
Wait?