CHRONIC DIARRHEA

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INFLAMMATORY BOWELDISEASE IN CHILDREN

• Abdulwahab Telmesani
• FRCPC, FAAP
• Associate Prof. of Pediatrics
• Umm Al-Qura University

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INFLAMMATORY BOWELDISEASE IN CHILDREN

• CROHNS DISEASE
• ULCERATIVE COLITIS
• INDETERMENANT (non specific) COLITIS

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INFLAMMATORY BOWELDISEASE IN CHILDREN

• 1/3 of the incidence of IBD occurs
• in lt 20 years of Age

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INFLAMMATORY BOWELDISEASE IN CHILDREN

• Highest in Scandinavian
• Western European
• North American
• Jews gt Non Jews
• Urban gt Rural
• Lowest in Asian
• African
• South American

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STRONG GENETIC PREDISPOSITION

• 10-25 in first degree relatives
• 7 in siblings
• Linkage with chromosome 16, 12, 14,
• 19, 6 1

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IBD IN SAUDI ARABIA

• Not Uncommon
• Adult gt Children
• UC gt CD
• Milder than the west

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PATHOPHYSILOLOGY

• Proinflammatory Cytokines Eicosanoids
• Active inflammation
• Increase permeability vasodilatation
• Symptoms Signs
• Cont.

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PATHOPHYSIOLOGY

• SYMPTOMS / SIGNS
• Diarrhea
• Abdominal pain
• Protein Loss
• Bleeding
• Electrolyte Loss
• Stricture Formation

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EXPRESSION DISTRIBUTION

• CROHNS DISEASE
• 90 of patients have small bowel affected
• Classically terminal ileum
• 10-15 Only colon affected
• 60 Ileocolitis
• 20 have perirectal disease
• Cont.

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EXPRESSION DISTRIBUTION

• Trans mural inflammation
• Fistulas arise when inflammation extends
• through the serosa (Bladder, Vagina,
• Perineum)
• Granuloma is the Hallmark of Chrons
• disease, found in 30 of all cases.

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EXPRESSION DISTRIBUTION

• 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

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PRESENTATION

• ULCERATIVE COLITIS
• Commonly
• Bloody mucoid diarrhea
• frequent loose stool
• lower abdominal pain more with defecation

• Fulminant disease (10-15 of PTs)
• gt 6 Bloody stools per day
• Abdominal tenderness
• Fever, tachycardia
• Anemia Hypoalbuminemia
  Cont.

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PRESENTATIONCONTD

• Constipation in proctitis
• Colonic carcinoma 1 by 10 years
• 1-2per year
  thereafter
• Anorexia Weight loss lt Crohns Disease

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PRESENTATION

• CROHNS 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.

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PRESENTATION

• Perianal disease(Fissures, fistulas skin tags)
• Intestinal obstruction is common
• Abscesses (Interloop, intramesentric,
• retroperitoneal, iliopsoas or subdiaphragmatic)
• Carcinoma (Crohns Colitis)

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EXTRAINTESTINAL MANIFESTATIONS
SYSTEMIC LOCALISED Fever Eyes C.D.
gt U.C. Joints Malaise Skin Anorexi
a wt loss Liver C.D. 40 gt U.C.
10 Bone Delayed Growth Kidneys Sexual
Development Vascular C.D. gt
U.C. Hematological Heart
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EXTRAINTESTINAL MANIFESTATIONS
EYE Uveitis, Episcleritis, Keratitis,
RetinalVasculitis LIVER Sclerosing cholangitis
U.C.gtC.D. SKIN Erythema nodosum C.D.gtU.C.
Pyoderma gangrenosum U.C.gt C.D.
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EXTRAINTESTINAL MANIFESTATIONS
- JOINTS Arthralgia or Arthritis, Knees gt
Ankles gt Hipsgt Wristsgt Elbow
Most common localised manifestations
ankylosing spondylitis, sacroilitisU.C.gtC.D.
- BONE Demineralization
SteroidRestVit D def,Decreased Protein -
KIDNEYS Ca oxalate,Ca phosphate,Uric acid.
Inflammation
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EXTRAINTESTINAL MANIFESTATIONS
-VASCULAR Thrombocytosis Thrombophlebitis
Activation of clotting cascade -
HEMATOLOGICAL Anemia B12 Folic Acid
def. Effect of chemotherapy -
HEART Perimyocarditis (good prognosis)
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DIAGNOSIS

• Hx P/E
• Stool Analysis C/S
• WBC N or slightly elevated
• ESR Elevated 70
• Thrombocytosis 60
• Albumin

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DIAGNOSIS
Endoscopy Vs Radiology
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ENDOSCOPY
Sigmoidoscopy Colonoscopy Ileum Upper
endoscopy
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ULCERATIVE COLITIS
Mucosa Erythematus Granular
Friable Loss of normal vascular
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CROHNS
Aphus Lesions Psudopolyps Patchy Distribution Bx
normal mucosa
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RADIOLOGY
-Upper G.I. Series Irrigular nodular and
thickend bowel loops stenosis, ulcers
fistulas -Abdominal U/S C.T. for
complication of Crohns Disease
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TREATMENT
AIM Relief of symptoms Improve quality of
life Improve growth
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TREATMENT
Pharmacotherapy Nutrition Surgery
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TREATMENT
Pharmacotherapy 5- Aminosalicylate (P.O.
Knema) Sulfasalzine
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TREATMENT
Corticosteroids Prednisone Budesonide
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TREATMENT
Antibiotics Metronidazol Ciprofloxacin
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TREATMENT
Immunomodulators 6- mercaptopurine
Asathioprine Cyclosporine
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TREATMENT

• Anti-tumer necrosis factor -Alpha
• Infliximab
• CDP571
• Thalidomide
• Others

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TREATMENT

• Clonidine (better than Sulfasulazine)
• Na chromoglycate (No favorable effect)

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ANTIDIARRHEAL DRUGS
Loperamide Frequency of Diarrhea
Contraindicated in sever colitis
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SURGERY
Indications Intractability Hemorrhage
Perforations Obstructions Carcinoma
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SURGERY
10-25 of U.C. will need colectomy with in 5
years of diagnosis. 50-75 of Crohns Disease
will require Sx with in 10-15 years of
diagnosis.
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NUTRITION
- Elemental diet alone may in duce remission in
Crohns disease - May need N.G. feeding -
Caloric intake growth catch-up