Calprotectin concentration and PUCAI score are indicative

The prevalence of chronic inflammatory bowel diseases (IBD) such as Crohn’s disease (MC) and ulcerative colitis (UC) has also been increasing in recent years.
in the age groups of children and young people. The right diagnosis
can prove tricky and requires an overview of various findings. In principle, the same treatment recommendations apply as for adults, although the treatment should be adapted to the particularities of the growing organism. Among other things, nutritional therapy is recommended for MC.

“Crohn’s disease and ulcerative colitis are complex diseases,” says Prof. Dr. med. Rainer Ganschow, Director of the Center for Pediatrics at the University Hospital Bonn [1]. In addition to gastrointestinal symptoms such as abdominal pain, diarrhea and rectal bleeding, Crohn’s disease (MC) and ulcerative colitis (CU) are also associated with weight loss and growth disorders. An increase in the number of cases can be observed among children, particularly in highly industrialized western regions. Around a fifth of IBD cases occur in childhood and adolescence, with a peak age between 10-15 years [2]. It is not clear what this increase is due to; the etiology of these diseases appears to be multifactorial. In addition to genetic predisposition, immunological factors, the environment, diet and the intestinal microbiome also play a role. While nutritional therapy with exclusive enteral nutrition has proven to be very effective in MC, there are no proven dietary interventions available for the treatment of CU.

Finding a diagnosis is a tricky business

MC is the more serious, but also the more common disease; only 1/3 of IBD cases are CU. There is a high degree of inter-individual variability in childhood and adolescence, particularly with MC. The symptoms often occur gradually and can be confused with non-specific or functional complaints due to their varying severity and intensity [3,4]. “In comparison, ulcerative colitis is relatively easy to diagnose clinically and endoscopically,” reported Prof. Ganschow [1]. In contrast to MC, CU only affects the large intestine and chronic bloody diarrhea is the predominant symptom. There is often a considerable diagnostic latency before children and adolescents are diagnosed with IBD, as the speaker illustrated with a case study [1]: a girl born in 2010 suffered from non-specific gastrointestinal symptoms such as abdominal pain and nausea for a long time. An initial sonography was performed in 2020, but it was not until August 2023 that a further sonography in combination with elevated fecal inflammation values (calprotectin, lactoferrin) led to the diagnosis of IBD. In the meantime, individual symptoms were treated and various other investigations were carried out. Especially in childhood and adolescence, the differential diagnostic spectrum is relatively broad.

Exclude coeliac disease, immunodeficiencies and other DDs

Bacterial cultures from stool samples can be used to exclude germs (E. coli, Campylobacter, Yersinia, Salmonella, Shigella) that colonize the intestine [5]. The faecal inflammation parameters are very helpful, as they have a high negative predictive power, emphasized Prof. Ganschow [1]. In particular, it is an important distinguishing feature between IBD and non-inflammatory diseases such as irritable bowel syndrome (irritable colon). If calprotectin is within the normal range, IBD can be ruled out with a high degree of probability. Calprotectin in the stool (box) is produced as an inflammatory marker, but also in the case of intestinal infections, coeliac disease, food allergies and immunodeficiency. These diseases must be ruled out by further examinations [5].

The erythrocyte sedimentation rate (ESR) is another meaningful parameter, explained Prof. Ganschow [1]. If this is normal, this speaks against IBD, as he has found out in years of experience. The PUCAI score, which takes into account abdominal pain, rectal blood loss, stool consistency, stool frequency, nocturnal bowel movements and impaired activity, is indicative. A value of over 65 points indicates a severe relapse [6].

If IBD is suspected in children and adolescents, a colonoscopy with simultaneous tissue sampling is indicated. In individual cases, capsule endoscopy can also be useful in children and adolescents, said the speaker, adding that sonography is also very informative, as early intestinal wall thickening in the terminal ileum, for example, is seen as an indication of the presence of MC [1]. In addition, the small intestine should be visualized using imaging techniques – MR enteroclysis or MR enterography is recommended.

Early and intensive treatment

If inflammation has been detected, drug therapy tailored to the severity of the flare-up is indicated. The goal of treatment should always be complete remission, according to Prof. Ganschow [1]. Effective drugs for healing the mucosa are immunosuppressants and TNF-α blockers in particular [5]. Nowadays, the motto is to treat as early and intensively as possible, as this seems to have a favorable prognosis. This is shown, for example, by the CEDATA GPGE study, in which early use of azathioprine (AZA) or infliximab (IFX) in children and adolescents with CU was associated with better remission rates and fewer long-term complications [7]. Below is some information on various active substances:

• Like 6-mercaptopurine, AZA is a thiopurine and can be used to maintain remission with a steroid-sparing effect.
• IFX (e.g. Remsima®, Inflectra®, Remicade®) is a TNF-α inhibitor that has proven particularly effective in maintaining remission in steroid-refractory patients. Low albumin levels and high disease activity increase infliximab clearance.
• In the event of secondary loss of efficacy or intolerance to IFX, it is advisable to try treatment with adalimumab (e.g. Humira®) or golimumab, both of which are TNF-α-i.
• A newer treatment option is vedolizumab, an intestine-specific anti-α4β7 integrin antibody that inhibits the migration of intestinal T lymphocytes and can be considered second-line in case of TNF-α blocker failure. In a multicenter pediatric observational study (n=52), a remission rate of 76% was achieved after 14 weeks [8].
• The 5-aminosalicylates mesalazine and sulfasalazine (prodrug) are equivalent. Mesalazine is better tolerated and sulfasalazine is the preferred substance for arthropathy.

Prof. Ganschow also pointed out that the combination of orally and rectally administered substances is more effective than oral therapy alone [1]. In addition to folic acid monitoring, regular monitoring or substitution of vitamin D and iron is recommended.

Special features in the treatment of MC

In MC, exclusively enteral nutrition therapy (Box) is the treatment of first choice to induce remission [1]. Around 60-80% of children with MC achieve remission with exclusive enteral nutrition treatment [2]. The required nutrients are administered by exclusively administering a specially prepared liquid diet (e.g. Modulen®) for 6-8 weeks. Ideally, the diet should consist exclusively of this drinkable food during the entire treatment period, i.e. additional food should be avoided. IFX is often induced initially to induce remission in perianal fistulas. Corticosteroids should be used as sparingly as possible due to physical development. Immunomodulators and/or biologics can be used to maintain remission. The duration of maintenance therapy is usually several years or until the end of puberty. Surgical intervention may be necessary in Crohn’s disease in the case of stenoses/strictures, fistulas and abscesses, bleeding, perforations, resistance to treatment and failure of drug therapies. The latter is also an indication for surgery in CU.

Literature:

1. «Chronisch-entzündliche Darmerkrankungen: Tückisch und oft zu spät diagnostiziert», Prof. Dr. med. Rainer Ganschow, Forum für medizinische Fortbildung, Allgemeine und innere Medizin, Refresher, Köln, 05.–09.03.2024.
2. «Ernährung bei Kindern und Jugendlichen mit chronisch entzündlicher Darmerkrankung», www.luks.ch/newsroom/ernaehrung-bei-kindern-und-jugendlichen-mit-chronisch-entzuendlicher-darmerkrankung, (last accessed 26.04.2024)
3. Benninga MA, et al.: Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology 2016; 150: 1443–1455.
4. Hyams JS, et al.: Functional disorders: children and adolescents. Gastroenterology 2016; 150: 1456–1468.
5. Sturm A, et al.: Collaborators:. Aktualisierte S3-Leitlinie «Diagnostik und Therapie des Morbus Crohn» der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004.
   Z Gastroenterol 2022 Mar; 60(3): 332–418.
6. Dotson JL, et al.: Feasibility and validity of the pediatric ulcerative colitis activity index in routine clinical practice. J Pediatr Gastroenterol Nutr 2015; 60(2): 200–204.
7. De Laffolie J, et al.: CEDATA-GPGE Study Group. Occurrence of Thromboembolism in Paediatric Patients With Inflammatory Bowel Disease: Data From the CEDATA-GPGE Registry. Front Pediatr 2022 Jun 3; 10: 883183.
8. Singh N, et al.: Multi-Center Experience of Vedolizumab Effectiveness in Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis 2016; 22(9): 2121–2126.
9. «Calprotectin, der besondere Entzündungsparameter», https://rheuma-schweiz.ch/weekly/special-focus/calprotectin-der-besondere-entzuendungsparameter, (last accessed 26.04.2024)

GASTROENTEROLOGIE PRAXIS 2024; 2(1): 26–27 (veröffentlicht am 15.5.24, ahead of print)
HAUSARZT PRAXIS 2024; 19(5): 50–51