5. Abdulwahab Telmesani FRCPC, FAAP Associate Prof. of Pediatrics Umm Al-Qura University INFLAMMATORY BOWEL DISEASE IN CHILDREN

6. CROHN’S DISEASE ULCERATIVE COLITIS INDETERMENANT (non specific) COLITIS INFLAMMATORY BOWEL DISEASE IN CHILDREN

7. 1/3 of the incidence of IBD occurs in < 20 years of Age INFLAMMATORY BOWEL DISEASE IN CHILDREN

8. Highest in Scandinavian Western European North American Jews > Non Jews Urban > Rural Lowest in Asian African South American INFLAMMATORY BOWEL DISEASE IN CHILDREN

9. 10-25% in first degree relatives 7% in siblings Linkage with chromosome 16, 12, 14, 19, 6 & 1 STRONG GENETIC PREDISPOSITION

10. IBD IN SAUDI ARABIA Not Uncommon Adult > Children UC > CD Milder than the west

11. Proinflammatory Cytokines & Eicosanoids Active inflammation Increase permeability & vasodilatation Symptoms & Signs Cont.# PATHOPHYSILOLOGY

12. SYMPTOMS / SIGNS: Diarrhea Abdominal pain Protein Loss Bleeding Electrolyte Loss Stricture Formation PATHOPHYSIOLOGY

13. CROHN’S DISEASE 90% of patients have small bowel affected Classically terminal ileum 10-15% Only colon affected 60% Ileocolitis 20% have perirectal disease Cont.# EXPRESSION & DISTRIBUTION

14. Trans mural inflammation Fistulas arise when inflammation extends through the serosa (Bladder, Vagina, Perineum) Granuloma is the Hallmark of Chron’s disease, found in 30% of all cases. EXPRESSION & DISTRIBUTION

17. ULCERATIVE COLITIS 5% Proctitis 10-15% proctosigmoiditis 30-40% up to splenic flexure 50% pancolitis Almost always starts at the rectum Pathology limited to the mucosa Crypt abscesses, distorted architecture & goblet cell depletion, are typical EXPRESSION & DISTRIBUTION

18. ULCERATIVE COLITIS Commonly Bloody mucoid diarrhea frequent loose stool lower abdominal pain more with defecation PRESENTATION Fulminant disease (10-15% of PT’s) > 6 Bloody stools per day Abdominal tenderness Fever, tachycardia Anemia Hypoalbuminemia Cont.#

19. Constipation in proctitis Colonic carcinoma 1% by 10 years 1-2%per year thereafter Anorexia &Weight loss < Crohn’s Disease PRESENTATION{CONTD}

23. PRESENTATION CROHN’S DISEASE Abdominal pain ( awakens patient from sleep) Site of disease dictates the nature & site of pain Ileum RT quadrant pain Gastroduodinal dyspeptic pain Diarrhea & Rectal Bleeding may resemble U.C. Cont.#

24. PRESENTATION Perianal disease(Fissures, fistulas & skin tags) Intestinal obstruction is common Abscesses (Interloop, intramesentric, retroperitoneal, iliopsoas or subdiaphragmatic) Carcinoma (Crohn’s Colitis)

28. EXTRAINTESTINAL MANIFESTATIONS SYSTEMICLOCALISED Fever Eyes {C.D. > U.C. } Joints MalaiseSkin Anorexia + wt lossLiver {C.D. 40% > U.C. 10%}Bone Delayed Growth & Kidneys Sexual Development Vascular {C.D. > U.C.}Hematological Heart

29. EXTRAINTESTINAL MANIFESTATIONS EYE Uveitis, Episcleritis, Keratitis, RetinalVasculitis LIVER Sclerosing cholangitis U.C.>C.D. SKIN Erythema nodosum C.D.>U.C. Pyoderma gangrenosum U.C.> C.D.

30. EXTRAINTESTINAL MANIFESTATIONS - JOINTS Arthralgia or Arthritis, Knees > Ankles > Hips> Wrists> Elbow Most common localised manifestations {ankylosing spondylitis, sacroilitis}U.C.>C.D. - BONE Demineralization {Steroid+Rest+Vit D def,Decreased Protein} - KIDNEYS Ca oxalate,Ca phosphate,Uric acid. Inflammation

31. EXTRAINTESTINAL MANIFESTATIONS -VASCULAR Thrombocytosis Thrombophlebitis Activation of clotting cascade - HEMATOLOGICAL Anemia {B12 +Folic Acid def.} Effect of chemotherapy - HEART Perimyocarditis (good prognosis)

34. DIAGNOSIS Hx & P/E: Stool Analysis + C/S WBC N or slightly elevated ESR Elevated 70 % Thrombocytosis 60% Albumin

35. DIAGNOSIS Endoscopy Vs Radiology

36. ENDOSCOPY Sigmoidoscopy Colonoscopy Ileum Upper endoscopy

37. ULCERATIVE COLITIS Mucosa: Erythematus Granular Friable Loss of normal vascular

39. CROHN’S Aphus Lesions Psudopolyps Patchy Distribution Bx normal mucosa

41. RADIOLOGY -Upper G.I. Series Irrigular nodular and thickend bowel loops stenosis, ulcers & fistulas -Abdominal U/S & C.T. for complication of Crohn’s Disease

42. TREATMENT AIM: Relief of symptoms Improve quality of life Improve growth

43. TREATMENT Pharmacotherapy Nutrition Surgery

44. TREATMENT Pharmacotherapy: 5- Aminosalicylate (P.O. Knema) Sulfasalzine

45. TREATMENT Corticosteroids: Prednisone Budesonide

46. TREATMENT Antibiotics: Metronidazol Ciprofloxacin

47. TREATMENT Immunomodulators: 6- mercaptopurine Asathioprine Cyclosporine

48. TREATMENT Anti-tumer necrosis factor -Alpha Infliximab CDP571 Thalidomide Others

49. TREATMENT Clonidine (better than Sulfasulazine) Na chromoglycate (No favorable effect)

50. ANTIDIARRHEAL DRUGS Loperamide : Frequency of Diarrhea Contraindicated in sever colitis

51. SURGERY Indications: Intractability Hemorrhage Perforations Obstructions Carcinoma

52. SURGERY 10-25% of U.C. will need colectomy with in 5 years of diagnosis. 50-75% of Crohn’s Disease will require Sx with in 10-15 years of diagnosis.

53. NUTRITION - Elemental diet alone may in duce remission in Crohn’s disease - May need N.G. feeding - Caloric intake growth catch-up