Inflammatory bowel disease in children

Inflammatory bowel disease is a group of diseases characterized by non-specific immune inflammation of the intestinal wall, superficial or transmural. Currently, the group of inflammatory bowel diseases includes the following nosologies:

• non-specific ulcerative colitis (UC);
• Crohn's disease;
• undifferentiated colitis.

Read also: Inflammatory bowel disease in adults

Non-specific ulcerative colitis is a chronic disease in which diffuse inflammation, localized within the mucous membrane (less often penetrating into the submucosal layer), affects only the large intestine at different lengths.

Crohn's disease (intestinal granulomatosis, terminal ileitis) is a chronic relapsing disease characterized by transmural granulomatous inflammation with segmental lesions of different parts of the gastrointestinal tract.

The epidemiology, etiopathogenesis, and clinical picture of these diseases have many common features, which is why it is difficult to verify the diagnosis at early stages. In such cases, the formulation "undifferentiated colitis" is valid, implying a chronic intestinal disease that has features characteristic of both ulcerative colitis and Crohn's disease.

The group of non-infectious enterocolitis includes a number of other diseases: eosinophilic colitis, microscopic colitis, lymphocytic colitis, collagenous colitis, enterocolitis in systemic diseases.

ICD-10 codes

In class XI “Diseases of the digestive system”, block K50-K52 “Non-infectious enteritis and colitis” is allocated, which includes various types of inflammatory bowel diseases.

• K50. Crohn's disease (regional enteritis).
• K50.0. Crohn's disease of the small intestine.
• K50.1. Crohn's disease of the colon.
• K50.8. Other types of Crohn's disease.
• K50.9. Crohn's disease, unspecified.
• K51. Ulcerative colitis.
• K51.0. Ulcerative (chronic) enterocolitis.
• K51.1. Ulcerative (chronic) ileocolitis.
• K51.2. Ulcerative (chronic) proctitis.
• K51.3. Ulcerative (chronic) rectosigmoiditis.
• K51.4. Pseudopolyposis of the colon.
• K51.5. Mucosal proctocolitis.
• K51.8. Other ulcerative colitis.
• K51.9. Ulcerative colitis, unspecified.
• K52.9. Noninfectious gastroenteritis and colitis, unspecified.

Epidemiology

The prevalence of non-specific ulcerative colitis is 30-240, Crohn's disease - 10-150 per 100,000 population, these diseases are constantly "getting younger". In Germany, about 200,000 people suffer from inflammatory bowel diseases, of which 60,000 are children and adolescents; about 800 new cases of inflammatory bowel diseases are registered annually in pediatric practice.

There has been a significant increase in the prevalence of severe inflammatory bowel diseases, mainly among the urban population of industrialized countries. The urban/rural incidence ratio is 5:1, and young people are predominantly affected (the average age of those affected is 20-40 years), although the disease can begin at any age. The incidence of inflammatory bowel diseases in childhood is quite high.

Incidence of inflammatory bowel disease in children and adolescents in different regions of the world (per 100,000 children per year)

Authors	Region	Period	Crohn's disease	NYAK
Kugathasan el a!., 2003	USA, Wisconsin	2000-2001	4.6	2.4
Dumo C, 1999	Toronto, Canada	1991-1996	3.7	2.7
Sawczenko et al., 2003	United Kingdom	1998-1999	3.0	2,2
Barton JR et al. 1989 Armitage E. et al., 1999	Scotland	1981-1992	2.8	1.6
Cosgrove M. et al., 1996	Wales	1989-1993	3.1	0.7
Gottrand et al., 1991	France. Pas de Calais	1984-1989	2.1	0.5
CMafsdottir EJ, 1991	Northern Norway	1984-1985	2.5	4.3
Langholz E. et al., 1997	Denmark, Copenhagen	1962-1987	0.2	2.6
Lindberg E. et al., 2000	Sweden	1993-1995	1.3	3.2

To date, there is insufficient data regarding the age distribution of patients at the first manifestation of inflammatory bowel diseases in children and adolescents, although it has been noted that in almost 40% of patients the first symptoms of the disease occur before they reach 10 years of age.

Men and women are equally affected. The prevalence of inflammatory bowel disease varies considerably in different regions of the world. In the 1960s–1980s, most epidemiological studies recorded a gradient in the incidence of inflammatory bowel disease from north to south (with higher rates in northern regions). Since the 1990s, a gradual smoothing of the gradient and its shift in the west–east direction have been noted. According to the materials presented at the 1st International Congress on Inflammatory Bowel Diseases (Madrid, 2000), an epidemic of inflammatory bowel disease is predicted to occur in Eastern Europe in the coming decades. In most countries, nonspecific ulcerative colitis is detected several times more often than Crohn's disease; the ratio of "UC/Crohn's disease" ranges from 2:1 to 8-10:1. In Europe, a tendency towards an increase in the incidence of Crohn's disease has been recorded.

The prevalence of non-specific ulcerative colitis is 22.3, and Crohn's disease - 3.5 cases per 100,000 population. The indicators registered in Russia differ from other countries by extremely negative trends, including the prevalence of severe forms of inflammatory bowel diseases with high mortality (3 times higher than in most countries), late diagnosis of diseases (the diagnosis of non-specific ulcerative colitis is established within the first year of the disease only in 25% of cases), a large number of complicated forms of inflammatory bowel diseases. With late diagnosis, life-threatening complications develop in 29% of cases. When Crohn's disease is diagnosed within 3 years from the manifestation, the frequency of complications is 55%, with later diagnosis - 100% of cases have a complicated course.

Screening

Screening for inflammatory bowel disease involves regular examinations of individuals with a family history of inflammatory bowel disease, assessment of markers of the inflammatory response (white blood cell count and white blood cell count in peripheral blood, C-reactive protein) and coprogram parameters (white blood cells, red blood cells and mucus).

Classification

To date, our country has not developed generally recognized and approved classifications of Crohn's disease and nonspecific ulcerative colitis; various clinics use private modifications of working classifications. At the World Congress of Gastroenterologists (Montreal, 2005), the international classification of Crohn's disease, which replaced the Vienna classification, and the international classification of nonspecific ulcerative colitis were adopted.

International Classification of Crohn's Disease (Montreal World Congress of Gastroenterology, 2005)

Criterion	Index	Explanation
Age of manifestation (age at diagnosis)	A1	Under 16 years old
	A2	[From 17 to 40 years old
	A3	Over 40 years old
Localization	L1	Ileitis
	L2	Colitis
	L3	Ileocolitis
	L4	Isolated lesion of the upper gastrointestinal tract
Flow (behavior)	B1	Non-stenoeic, non-penetrating (inflammatory)
	B2	Stenosing
	VZ	Penetrating
	R	Perianal lesion

International Classification of Ulcerative Colitis (Montreal World Congress of Gastroenterology, 2005)

Criterion	Index	Transcript	Explanation
Prevalence (extent)	E1	Proctitis of the jaundice	Lesion distal to the rectosigmoid junction
	E2	Left-sided (distal) ulcerative colitis	Lesion distal to the splenic angle
	EZ	Disseminated ulcerative colitis (pancolitis)	The entire colon is affected (inflammation proximal to the splenic angle)
Severity	SO	Clinical remission	There are no symptoms
	SI	Easy	Stool 4 times a day or less (with or without blood); no systemic symptoms; normal concentration of acute phase proteins
	S2	Medium heavy	Stool more than 4 times a day and minimal symptoms of systemic intoxication
	S3	Heavy	Stool frequency 6 times a day or more with blood; pulse rate 90 beats per minute or more; temperature 37.5 'C or more; hemoglobin 105 g/l or less; ESR 30 mm/h or more

The causes of inflammatory bowel diseases have not been fully studied. According to modern concepts, inflammatory bowel diseases are multifactorial diseases, the pathogenesis of which may include genetic predisposition, immune regulation disorders, and an autoimmune component. The pathology is based on damage to immune mechanisms, but the antigens that provoke these changes have not been identified. has not been fully studied. According to modern concepts, inflammatory bowel diseases are multifactorial diseases, the pathogenesis of which may include genetic predisposition, immune regulation disorders, and an autoimmune component. The pathology is based on damage to immune mechanisms, but the antigens that provoke these changes have not been identified. Bacterial antigens and their toxins, autoantigens may claim the role of such agents. Secondary effector mechanisms lead to a distortion of the body's immune response to antigenic stimulation and the development of nonspecific immune inflammation in the intestinal wall or mucous membrane.

Clinical symptoms of inflammatory bowel diseases can be grouped into several main syndromes:

• intestinal syndrome;
• extraintestinal changes syndrome;
• endotoxemia syndrome;
• metabolic disorder syndrome.

Diagnosis of inflammatory bowel diseases in children is based on clinical, laboratory, X-ray endoscopic and histological signs. The studied laboratory parameters are necessary both for assessing the severity of the underlying process and for differential diagnosis. Blood tests may reveal anemia due to iron and folic acid deficiency, thrombocytosis, increased ESR and acute phase protein levels. In long-term disease, protein loss and malabsorption lead to hypoalbuminemia, vitamin, electrolyte and microelement deficiencies.

Treatment of inflammatory bowel disease in children is similar to that in adults and should comply with modern principles of evidence-based medicine. The tactics of treating inflammatory bowel disease differ from that in adults only in terms of individual doses and some other restrictions. To date, a relatively small number of controlled studies have been published, and therefore the strategy for treating inflammatory bowel disease in children is based on the results obtained in treating adults. Doses are calculated based on body weight, with the exception of methotrexate, the dose of which is calculated based on body surface area. The maximum dose corresponds to the recommended dose in adults.

Treatment goals

Achieving remission, bringing physical and neuropsychic development into line with age norms, preventing unwanted side effects and complications.

Drug treatment

Medicines can be used both as monotherapy and in various combinations according to individual needs. It has been shown that the simultaneous administration of systemic glucocorticosteroids and 5-aminosalicylic acid (5-ASA) or salazosulfapyridine preparations does not have any particular advantages over glucocorticosteroid monotherapy.

Forecast

The prognosis for most forms of inflammatory bowel disease is unfavorable, especially in the case of complications (in nonspecific ulcerative colitis - toxic dilation or perforation of the colon, intestinal bleeding, sepsis, thrombosis and thromboembolism, colon cancer; in Crohn's disease - stenosis and strictures, fistulas, abscesses, sepsis, thrombosis and thromboembolism, colon cancer).

Prevention

The causes of inflammatory bowel diseases are still unknown, and therefore specific preventive measures have not been developed. Preventive measures are aimed at promoting a healthy lifestyle, combating bad habits, preventing stress, and introducing a balanced diet with sufficient amounts of dietary fiber and essential substances.

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