Inflammatory bowel disease in children

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

• nonspecific ulcerative colitis (NNC);
• Crohn's disease;
• nondifferentiable colitis.

Read also: Inflammatory bowel disease in adults

Nonspecific ulcerative colitis is a chronic disease in which diffuse inflammation, localized within the mucous membrane (less likely to penetrate the submucosal layer), affects only the large intestine at different distances.

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

Epidemiology, etiopathogenesis, clinical picture of these diseases have many common features, and in this connection it is difficult to verify the diagnosis at early stages. In such cases, the wording is "nondifferentiable colitis", implying a chronic bowel disease that has traits characteristic of both ulcerative colitis and Crohn's disease.

The group of noninfectious enterocolitis includes a number of other diseases: eosinophilic colitis, microscopic colitis, lymphocytic colitis, collagen colitis, enterocolitis in systemic diseases.

ICD-10 codes

In the class XI "Diseases of the digestive system," the block K50-K52 "Noninfectious enteritis and colitis" is highlighted, which includes various variants of inflammatory bowel diseases.

• C50. Crohn's disease (regional enteritis).
• K50.0. Crohn's disease of the small intestine.
• C50.1. Crohn's disease of the colon.
• K50.8. Other varieties of Crohn's disease.
• C50.9. Crohn's disease unspecified.
• K51. Ulcerative colitis.
• K51.0. Ulcerative (chronic) enterocolitis.
• K51.1. Ulcerative (chronic) ileocolitis.
• K51.2. Ulcerative (chronic) proctitis.
• K51.3. Ulcerous (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 nonspecific ulcerative colitis is 30-240, Crohn's disease - 10-150 per 100 000 population, these diseases are constantly "getting younger". In Germany, inflammatory bowel disease affects about 200,000 people, 60,000 of them are children and adolescents; annually registers about 800 new cases of inflammatory bowel disease in pediatric practice.

There was a significant increase in the incidence of severe inflammatory bowel diseases, mainly among the urban population of industrialized countries. The ratio of morbidity "city / village" is 5: 1, mostly sick young people (the average age of the sick is 20-40 years), although the disease can begin at any age. The incidence of inflammatory bowel disease in childhood is quite high.

The 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	NNC
Kugathasan el a!., 2003	United States, 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

Until now, there is not enough data on the age distribution of patients at the first manifestation of inflammatory bowel diseases in children and adolescents, although it is noted that in almost 40% of patients the first symptoms appear before they reach 10 years.

Men and women get sick with the same frequency. The prevalence of inflammatory bowel diseases varies considerably in different regions of the world. In 1960-1980, most epidemiological studies recorded a gradient of incidence of inflammatory bowel diseases from north to south (higher rates in the northern regions). Since the 90's, gradual smoothing of the gradient and its displacement in the direction of the west-east are noted. Based on the materials presented at the First International Congress on Inflammatory Bowel Diseases (Madrid, 2000), in the coming decades, the epidemic of inflammatory bowel diseases in Eastern Europe is predicted. In most countries, ulcerative colitis is detected several times more often than Crohn's disease; the ratio of "NNC / Crohn's disease" ranges from 2: 1 to 8-10: 1. In Europe, a trend towards an increase in the incidence of Crohn's disease has been recorded.

The prevalence of nonspecific 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 in extremely negative trends, including the prevalence of severe forms of inflammatory bowel disease with a high mortality (3 times higher than in most countries), late diagnosis of diseases (diagnosis of ulcerative colitis in only 25% cases established during the first year of the disease), a large number of complicated forms of inflammatory bowel diseases. With late diagnosis, life-threatening complications develop in 29% of cases. When establishing the diagnosis of Crohn's disease within 3 years from the manifestation, the incidence of complications is 55%, with a later diagnosis - 100% of cases have a complicated course.

Screening

Screening of inflammatory bowel diseases consists of regular examinations of people with a hereditary anamnesis on inflammatory bowel diseases, evaluation of markers of the inflammatory response (leukocyte count and leukocyte formula of peripheral blood, C-reactive protein) and indicators of coprogram (leukocytes, erythrocytes and mucus).

Classification

Until now, generally recognized and approved classifications of Crohn's disease and ulcerative colitis have not been developed in our country, private modifications of working classifications are used in different clinics. At the World Congress of Gastroenterologists (Montreal, 2005), an international classification of Crohn's disease that replaced the Vienna classification was adopted and an international classification of ulcerative colitis.

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

Criterion	Index	Explanation
Age of diagnosis	A1	16 years younger
	A2	[From 17 to 40 years old
	A3	Older than 40 years
Location (location)	L1	Ileit
	L2	Colitis
	L3	Ileocolite
	L4	Isolated lesion of the upper gastrointestinal tract
The current (behaviour)	IN 1	Non-stenosing, not penetrating (inflammatory)
	AT 2	Stenosing
	VZ	Penetrating
	R	Perianal lesion

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

Criterion	Index	Explanation	Explanation
Extent (extent)	E1	Ulcerative proctitis	The lesion is distal to the rectosigmoid transition
	E2	Left-sided (distal) ulcerative colitis	The lesion is distal to the splenic angle
	EE	Common ulcerative colitis (pancolitis)	The entire large intestine is affected (inflammation proximal to the spleen angle)
Severity	SO	Clinical remission	No Symptoms
	SI	Easy	Stool 4 times a day and less often (with or without blood); there are 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 an admixture of blood; heart rate 90 in minutes and more; temperature 37.5 ° C or more; hemoglobin 105 g / l or less; ESR 30 mm / h and more

The causes of inflammatory bowel disease are not fully understood. According to modern ideas, inflammatory bowel diseases are multifactorial diseases, in the pathogenesis, the influence of genetic predisposition, immunoregulation disorders and autoimmune component is possible. At the heart of the pathology are the damages of the immune mechanisms, but the antigens provoking these changes are not identified. Definitely not studied. According to modern ideas, inflammatory bowel diseases are multifactorial diseases, in the pathogenesis, the influence of genetic predisposition, immunoregulation disorders and autoimmune component is possible. At the heart of the pathology are the damages of the immune mechanisms, but the antigens provoking these changes are not identified. The role of such agents can be claimed by bacterial antigens and their toxins, autoantigens. Secondary effector mechanisms lead to a perversion of the body's immune response to antigenic stimulation and the development of nonspecific immune inflammation in the wall or mucosa of the gut.

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

• intestinal syndrome;
• syndrome of extraintestinal changes;
• endotoxemia syndrome;
• syndrome of metabolic disorders.

Diagnosis of inflammatory bowel diseases in children is based on clinical, laboratory, X-ray-endoscopic and histological signs. The laboratory indicators to be studied are necessary both for assessing the severity of the main process and for differential diagnosis. In blood tests, anemia due to deficiency of iron and folic acid, thrombocytosis, increased ESR and the content of acute phase proteins can be detected. With a long-term disease, protein loss and malabsorption lead to hypoalbuminemia, a deficiency of vitamins, electrolytes and microelements.

Treatment of inflammatory bowel diseases in children is similar to that of adults, should comply with modern principles of evidence-based medicine. The tactics of treating inflammatory bowel diseases are different from those in adults only with regard to individual doses and some other limitations. To date, relatively few controlled studies have been published, and the strategy of treating inflammatory bowel diseases in children is based on the results obtained in the treatment of 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.

Objectives of treatment

Achieving remission, bringing physical and neuro-psychological development in line with the age standard, preventing unwanted side effects and complications.

Medication

Drugs can be used both as monotherapy. And in various combinations according to individual need. It has been shown that simultaneous administration of systemic glucocorticosteroids and preparations of 5-aminosalicylic acid (5-ASA) or salazosulfapyridine does not have special advantages in comparison with monotherapy with glucocorticosteroids.

Forecast

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

Prevention

The causes of the development of inflammatory bowel diseases are still unknown, and therefore specific preventive measures have not been developed. Preventive measures are aimed at promoting healthy lifestyles, fighting harmful habits, preventing stress and introducing rational nutrition with the use of sufficient amounts of dietary fiber and essential substances.

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