Inflammatory Bowel Disease (IBD) In Children: New Guidelines Aim To Reduce Diagnostic Uncertainty And Improve Treatment
New guidelines for the diagnosis and classification of inflammatory bowel disease (IBD) in children, which are currently in press,1 should help overcome current diagnostic uncertainties and ensure treatment is optimised as early as possible. Professor Arie Levine from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) – an association within United European Gastroenterology (UEG) – has described the new guidelines as a “radical departure” from previous guidelines in both adults and children, as they define and classify four sub-types of the condition and require a diagnosis to be based on a full work-up, including complete imaging of the small bowel by magnetic resonance enteroscopy (MRE) and a gastroscopy.
“Recent guidelines and epidemiological studies in children with IBD have highlighted the confusion surrounding the diagnosis and classification of this condition,” says Prof. Levine, a paediatric gastroenterologist at Wolfson Medical Center, Tel Aviv University in Israel. “Children often present very differently to adults and this is reflected in the recommendations made in the new guidelines.”1
IBD in children: rising incidence
IBD is usually classified into two categories: ulcerative colitis (UC), in which disease is confined to the large bowel only, and Crohn’s disease (CD), which can involve any site in the gastrointestinal tract. In adults, the diagnosis usually requires a colonoscopy to determine which one of these two sub-types is present.
The incidence of IBD in children appears to be on the increase, with several studies suggesting an approximate doubling in the incidence rate over the past decade, with up to eight in every 100,000 children now affected.2,3 Many recent studies4-7 have shown that children with IBD may present very differently to adults, that age is an important factor at disease presentation, and that the course of IBD may be more severe in children than in adults. Younger children with Crohn’s disease are more likely to have disease in the colon, whereas older children will also frequently have disease in the small intestine in areas that are not accessible by colonoscopy. Approximately 10% of paediatric patients who present with UC will have features that may be consistent with either CD or UC according to current guidelines.
“The fact that these features sometimes overlap in children with IBD means that a significant proportion of children remain unclassified,” explains Prof. Levine. “This leads to uncertainty about both treatment and prognosis, which we hope will be overcome with the new guidelines.”
The revised Porto criteria
The revised Porto criteria for the diagnosis and classification of paediatric IBD defines and classifies four sub-types of the condition: typical UC, atypical UC (UC with a single atypical feature still consistent with UC, such as macroscopic rectal sparing UC, a simple gastric ulcer or a short-duration variant UC that can present as focal inflammation in children), CD and unclassified IBD (IBDU). According to the new guidelines, a diagnosis of any of these sub-types requires a full diagnostic work-up, including complete imaging of the small bowel using MRE and a gastroscopy.
“The recommendation to use MRE as a standard of care in these guidelines is a first step towards reducing radiation exposure in vulnerable young children while still capturing key information about a complicated disease,” says Prof. Levine.
“We hope these new diagnostic criteria will help reduce uncertainty about the classification and extent of IBD at diagnosis as well as improve our ability to diagnose complications such as stricturing or penetrating disease from symptom onset. This will enable the use of optimal therapy from the moment of diagnosis.”
1. Levine A, Wilson DC, Turner D et al. Diagnosis of inflammatory bowel disease in children and adolescents: the Revised Porto Criteria. J Pediatr Gastroenterol Nutr: In press.
2. Henderson P, Hansen R, Cameron FL et al. Rising incidence of pediatric inflammatory bowel disease in Scotland. Inflamm Bowel Dis 2012;18(6):999-1005.
3. Abramson O, Durant M, Mow W et al. Incidence, prevalence, and time trends of pediatric inflammatory bowel disease in Northern California, 1996 to 2006. J Pediatr 2010;157(2):233-39.
4. Levine A, de Bie CI, Turner D et al. Atypical disease phenotypes in pediatric ulcerative colitis: 5-year analyses of the EUROKIDS registry. Inflamm Bowel Dis 2013;19(2):370-77.
5. Bousvaros A, Antonioli DA, Colletti RB et al. Differentiating ulcerative colitis from Crohn’s disease in children and young adults: report of a working group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the Crohn’s and Colitis Foundation of America. J Pediatr Gastroenterol Nutr 2007;44(5):653-74.
6. Glickman JN, Bousvaros A, Farraye FA et al. Pediatric patients with untreated ulcerative colitis may present initially with unusual morphologic findings. Am J Surg Pathol 2004;28:190-7.
7. de Bie CI, Paerregaard A, Kolacek S et al. Disease phenotype at diagnosis in pediatric Crohn’s disease: 5-year analyses of the EUROKIDS Registry. Inflamm Bowel Dis 2013;19(2):378-85.
Source: United European Gastroenterology (UEG), In co-operation with the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)