Inflammatory bowel diseases; Crohn’s disease is divided into three as ulcerative colitis and intermediate form. All three diseases are long-term and repetitive disorders that affect the digestive system of the body. In individuals with a genetic predisposition, the disease is caused by changes in the flora of the digestive system with the effect of environmental factors.
The incidence of inflammatory bowel diseases is increasing day by day. Inflammatory bowel diseases can occur at any age. Child and adolescent patients constitute 25% of all inflammatory bowel disease cases.
Environmental factors that play a role in the emergence of inflammatory bowel disease include smoking, past infections, appendectomy, breastfeeding and eating habits (Western diet) and stress factors.
Changes in lifestyle habits play a very important role in the emergence of the disease.
In the studies, exposure of the child to cigarette smoke (passive smoking) or smoking in adolescence increases the incidence of Crohn’s disease. The fact that ulcerative colitis is less common in smokers causes this information to be misunderstood. Considering the negative effects of smoking on health, this method should not be preferred.
Continuity of breast milk is very important in the first two years. The protective feature of breast milk from inflammatory bowel disease is known.
Snacks, fast food, packaged foods, junk food, canned drinks (Western diet) pave the way for the formation of the disease.
Stress and anxiety experienced in childhood play a very important role in the emergence of inflammatory bowel diseases. The death of a family member at an early age, divorce between spouses, changes in the city and school, as well as exam-race stress cause the development of the disease if there is a genetic predisposition on the ground.
Although there are many genes associated with inflammatory bowel diseases, the most studied is the NOD2 / CARD15 gene located on 16 chromosomes. This gene is involved in the body’s immune system and has been associated with Crohn’s disease.
The probability of developing the disease in relatives of people with Crohn’s disease was 5%, and this rate was 1.5% in relatives of ulcerative colitis patients. The risk of Crohn’s disease varies between 20-50% in identical twins and 0-10% in fraternal twins. For ulcerative colitis, it varies between 15-20% for identical twins and 0-7% for fraternal twins.
Diagnosis of inflammatory bowel diseases in children is very important. Classic findings such as abdominal pain, diarrhea and weight loss can be seen in only 25% of patients. Fever, growth retardation, nausea-vomiting, joint findings and decreased menstruation are the other accompanying findings.
European Society of Pediatric Gastroenterology, Hepatology and Nutrition; It was stated that inflammatory bowel disease should be suspected in the presence of diarrhea lasting 4 weeks or longer, or abdominal pain, diarrhea, bleeding from the lower digestive system and weight loss 2 or more times in the last 6 months.
While weight loss and diarrhea are prominent in Crohn’s disease, bloody diarrhea and abdominal pain are more common in ulcerative colitis. However, it should not be forgotten that the symptoms can be seen in many diseases. For example, the patient presenting with bloody diarrhea is often evaluated as amoebic infection by stool microscopy, and the patient can come to us by taking antibiotic treatment many times. It should not be forgotten that diarrhea with bloody mucus can also be seen in food allergies and digestive system polyps. The patient who bleeds from the rectum may be confused with cracks and hemorrhoids in the breech area. For this reason, examination of the breech region is important, fissures and fistulas can be recognized by examination in this way.
Weight loss is among the common findings in Crohn’s disease. Weight loss may cause the patient to be initially evaluated as anorexia nervosa, bulimia nervosa, celiac disease, tumorous conditions, or other diseases associated with weight loss.
Inflammatory bowel disease may present with only fever in 2% of patients. Inflammatory bowel disease should also be considered in the differential diagnosis of fever of unknown origin. In addition, inflammatory bowel diseases are frequently seen together with Familial Mediterranean Fever.
It should be kept in mind that, unlike adults, in childhood Crohn’s disease, upper digestive system symptoms such as rapid satiety, nausea, vomiting, and a feeling of being stuck in the esophagus during swallowing can be seen. For this reason, upper and lower gastrointestinal endoscopy should be performed together in children when inflammatory bowel disease is suspected. While coming to this procedure, the diet described before the colonoscopy should be strictly followed by the family, and should be applied as described in the draining enemas. Intestinal cleansing before colonoscopy is important for good visualization of intestinal surfaces. After that, your pediatric gastroenterologist will interpret the endoscopic images and, after the pathological evaluation of the biopsies, your child will be treated according to the result.
Again, in cases where the diagnosis cannot be made by endoscopy for children older than 6 years of age or whether there is intestinal involvement in areas where the endoscope cannot reach, capsule endoscopy and MR enterography can be investigated. Double balloon enteroscopy is another imaging method used when deemed necessary.
Purpose in the treatment of inflammatory bowel disease in children and adolescents;
- Ensuring that the effects of treatment are maximal
- Prevention of recurrence of disease symptoms
- Ensuring that the child patient grows up and enters puberty
- Quality of life should be ensured without drug-related side effects.
Initiation of enteral nutrition product alone or in combination with other drugs in the early period may be beneficial in children with Crohn’s disease.
It is important to observe that the initial symptoms regress during the treatment of ulcerative colitis. Relatives of the child patient can inform the pediatric gastroenterology specialist about how the response to the treatment develops in the child by observing the daily number of stools, the amount of blood on the stool, the response of abdominal pain to the treatment, defecation at night, whether he continues with his daily activities such as participating in the game, going to school.
Family members should record whether there is a decrease in abdominal pain, decrease in the number and amount of diarrhea in Crohn’s disease, changes in the breech area (abscess, fistula, skin folds in the breech area) should be checked by family members while daily cleaning and bathing the child.
Although the level of growth hormone is normal in inflammatory bowel disease, there is a lack of response to growth hormone due to chronic disease. The use of corticosteroids used in the initial and activation period of the disease may also have a negative effect on growth by reducing collagen synthesis in the connective tissue. When the disease is controlled with drugs, growth and development can reach the desired level.
The use of corticosteroids may increase the tendency to osteoporosis and fracture formation. The family should be informed that steroid use can cause cosmetic disorders such as facial swelling, swelling in the body (edema), acne, as well as dyspeptic complaints, high blood sugar, cataracts in the eye, increased intraocular pressure, and a tendency to infection. During the use of corticosteroids, a salt-free diet should be applied and blood pressure measurements should not be neglected.
5-ASA drugs are effective in changing the body’s response to the disease and reducing the negative changes that occur in the intestines. During the follow-up of the disease, the family should be informed about the side effects. Nausea, vomiting, joint pain, headache, rash and fever may occur. Pancreatic and kidney related side effects may occur. For this, complete blood count, liver function tests and kidney function tests should be checked twice a year.
Azothioprine and 6-mercaptopurine are used in the maintenance of Crohn’s disease and in the treatment of steroid-dependent ulcerative colitis. These drugs should not be used if the patient is taking allopurinol. It can cause fever, rash, bone pain, rash. Pressure on the bone marrow, pancreatitis may develop. After the treatment is started, routine tests should be performed at 6-week intervals, initially after two diseases. Because drug use should be adjusted according to the values of leukocyte and liver function tests.
Methotrexate may be preferred if azathioprine cannot be used. Cyclosporine, on the other hand, can be tried in ulcerative colitis that does not respond to treatment.
Infliximab and adalimumab are TNF-α blockers that control granulomatous infections in the body. It is also effective on intestinal permeability. It is more effective to use together with azathioprine in patients who need to use steroids continuously. They are used to provide healing in Crohn’s disease and ulcerative colitis. However, it should not be used in the presence of active infection in the patient. Tuberculosis, hepatitis B and hepatitis C should be investigated before starting this group of drugs. In addition, live vaccines should not be administered while using this group of drugs. The patient should also be evaluated in terms of heart disease, psoriasis-like skin findings and neurological diseases. While infliximab is administered, early allergic reactions such as wheezing and skin rash may develop within minutes. Symptoms such as muscle pain, fever, fatigue and joint pain are delayed reactions between 1-14.
None of the drugs used in inflammatory bowel disease should be discontinued without the knowledge of the pediatric gastroenterologist.
Antibiotic therapy in inflammatory bowel diseases; It can be used in the presence of fulminant colitis, toxic megacolon, breech disease, fistulizing Crohn’s disease and pouchitis.
Pediatric patients should attend their doctor’s appointments on time. Measurements to be made during the control are important in order to prevent the undesirable effects of the disease with height, weight and blood pressure measurements and the tests to be requested. For example, elevations in serum liver enzymes and elevated amylase values in blood tests are stimulant in terms of side effects of drugs, while elevations in biliary tract tests may herald an undesirable complication called sclerosing colonjit, apart from drug side effects. Again, with all abdominal ultrasonography requested in the controls, conditions such as fatty liver, changes in the biliary tract, kidney and gallbladder stones, intra-abdominal abscess, etc. can be detected.
During the examination, breech area examination is important. Especially adolescents are shy about this examination. Children and adolescents should be informed by the family about such examination before the examination.
Annual eye examinations in the follow-up of inflammatory bowel disease should be performed by the same ophthalmologist, if possible. Eye itching, discharge, stinging, burning may be a sign of an eye complication. If this is the case, you should consult an ophthalmologist immediately.
Routine vaccinations of patients with inflammatory bowel disease should be timely. The coronavirus vaccine should be given to children and adolescents over the age of 12.
If your child is sick during the coronavirus epidemic, medications for inflammatory bowel disease should be continued without stopping.
The treatment of Crohn’s disease is non-surgical. If a surgical procedure is to be performed in Crohn’s disease, the intestinal integrity of the patient should be preserved as much as possible. However, surgery should be considered in the presence of conditions such as megacolon, toxic megacolon, stenosis, fistula, abscess, intestinal obstruction and intestinal perforation.
In ulcerative colitis, surgical treatment can be considered in cases of bleeding, intestinal perforation, and failure to respond to drug therapy.
Transfer of our pediatric and adolescent patients to adult gastroenterology outpatient clinics after the age of 18 should be done slowly. The patient’s first admission findings, medications used, gastroscopy and colonoscopy reports, pathology reports should be included in the epicrisis, and if possible, several examinations should be accompanied by a pediatric and adult gastroenterology specialist.
Inflammatory bowel diseases; Crohn’s disease is divided into three as ulcerative colitis and intermediate form. All three diseases are long-term and repetitive disorders that affect the digestive system of the body. In individuals with a genetic predisposition, the disease is caused by changes in the flora of the digestive system with the effect of environmental factors.
The incidence of inflammatory bowel diseases is increasing day by day. Inflammatory bowel diseases can occur at any age. Child and adolescent patients constitute 25% of all inflammatory bowel disease cases.
Environmental factors that play a role in the emergence of inflammatory bowel disease include smoking, past infections, appendectomy, breastfeeding and eating habits (Western diet) and stress factors.
Changes in lifestyle habits play a very important role in the emergence of the disease.
In the studies, exposure of the child to cigarette smoke (passive smoking) or smoking in adolescence increases the incidence of Crohn’s disease. The fact that ulcerative colitis is less common in smokers causes this information to be misunderstood. Considering the negative effects of smoking on health, this method should not be preferred.
Continuity of breast milk is very important in the first two years. The protective feature of breast milk from inflammatory bowel disease is known.
Snacks, fast food, packaged foods, junk food, canned drinks (Western diet) pave the way for the formation of the disease.
Stress and anxiety experienced in childhood play a very important role in the emergence of inflammatory bowel diseases. The death of a family member at an early age, divorce between spouses, changes in the city and school, as well as exam-race stress cause the development of the disease if there is a genetic predisposition on the ground.
Although there are many genes associated with inflammatory bowel diseases, the most studied is the NOD2 / CARD15 gene located on 16 chromosomes. This gene is involved in the body’s immune system and has been associated with Crohn’s disease.
The probability of developing the disease in relatives of people with Crohn’s disease was 5%, and this rate was 1.5% in relatives of ulcerative colitis patients. The risk of Crohn’s disease varies between 20-50% in identical twins and 0-10% in fraternal twins. For ulcerative colitis, it varies between 15-20% for identical twins and 0-7% for fraternal twins.
Diagnosis of inflammatory bowel diseases in children is very important. Classic findings such as abdominal pain, diarrhea and weight loss can be seen in only 25% of patients. Fever, growth retardation, nausea-vomiting, joint findings and decreased menstruation are the other accompanying findings.
European Society of Pediatric Gastroenterology, Hepatology and Nutrition; It was stated that inflammatory bowel disease should be suspected in the presence of diarrhea lasting 4 weeks or longer, or 2 or more abdominal pains, diarrhea, bleeding from the lower digestive system and weight loss in the last 6 months.
While weight loss and diarrhea are prominent in Crohn’s disease, bloody diarrhea and abdominal pain are more common in ulcerative colitis. However, it should not be forgotten that the symptoms can be seen in many diseases. For example, the patient presenting with bloody diarrhea is often evaluated as amoebic infection by stool microscopy, and the patient can come to us by taking antibiotic treatment many times. It should not be forgotten that diarrhea with bloody mucus can also be seen in food allergies and digestive system polyps. The patient who bleeds from the rectum may be confused with cracks and hemorrhoids in the breech area. For this reason, examination of the breech region is important, fissures and fistulas can be recognized by examination in this way.
Weight loss is among the common findings in Crohn’s disease. Weight loss may cause the patient to be initially evaluated as anorexia nervosa, bulimia nervosa, celiac disease, tumorous conditions, or other diseases associated with weight loss.
Inflammatory bowel disease may present with only fever in 2% of patients. Inflammatory bowel disease should also be considered in the differential diagnosis of fever of unknown origin. In addition, inflammatory bowel diseases are frequently seen together with Familial Mediterranean Fever.
It should be kept in mind that, unlike adults, in childhood Crohn’s disease, upper digestive system symptoms such as rapid satiety, nausea, vomiting, and a feeling of being stuck in the esophagus during swallowing can be seen. For this reason, upper and lower gastrointestinal endoscopy should be performed together in children when inflammatory bowel disease is suspected. While coming to this procedure, the diet described before the colonoscopy should be strictly followed by the family, and should be applied as described in the draining enemas. Intestinal cleansing before colonoscopy is important for good visualization of intestinal surfaces. After that, your pediatric gastroenterologist will interpret the endoscopic images and, after the pathological evaluation of the biopsies, your child will be treated according to the result.
Again, in cases where the diagnosis cannot be made by endoscopy for children older than 6 years of age or whether there is intestinal involvement in areas where the endoscope cannot reach, capsule endoscopy and MR enterography can be investigated. Double balloon enteroscopy is another imaging method used when deemed necessary.
Purpose in the treatment of inflammatory bowel disease in children and adolescents;
- Ensuring that the effects of treatment are maximal
- Prevention of recurrence of disease symptoms
- Ensuring that the child patient grows up and enters puberty
- Quality of life should be ensured without drug-related side effects.
Initiation of enteral nutrition product alone or in combination with other drugs in the early period may be beneficial in children with Crohn’s disease.
It is important to observe that the initial symptoms regress during the treatment of ulcerative colitis. Relatives of the child patient can inform the pediatric gastroenterology specialist about how the response to the treatment develops in the child by observing the daily number of stools, the amount of blood on the stool, the response of abdominal pain to the treatment, defecation at night, whether he continues with his daily activities such as participating in the game, going to school.
Family members should record whether there is a decrease in abdominal pain, decrease in the number and amount of diarrhea in Crohn’s disease, changes in the breech area (abscess, fistula, skin folds in the breech area) should be checked by family members while daily cleaning and bathing the child.
Although the level of growth hormone is normal in inflammatory bowel disease, there is a lack of response to growth hormone due to chronic disease. The use of corticosteroids used in the initial and activation period of the disease may also have a negative effect on growth by reducing collagen synthesis in the connective tissue. When the disease is controlled with drugs, growth and development can reach the desired level.
The use of corticosteroids may increase the tendency to osteoporosis and fracture formation. The family should be informed that steroid use can cause cosmetic disorders such as facial swelling, swelling in the body (edema), acne, as well as dyspeptic complaints, high blood sugar, cataracts in the eye, increased intraocular pressure, and a tendency to infection. During the use of corticosteroids, a salt-free diet should be applied and blood pressure measurements should not be neglected.
5-ASA drugs are effective in changing the body’s response to the disease and reducing the negative changes that occur in the intestines. During the follow-up of the disease, the family should be informed about the side effects. Nausea, vomiting, joint pain, headache, rash and fever may occur. Pancreatic and kidney related side effects may occur. For this, complete blood count, liver function tests and kidney function tests should be checked twice a year.
Azothioprine and 6-mercaptopurine are used in the maintenance of Crohn’s disease and in the treatment of steroid-dependent ulcerative colitis. These drugs should not be used if the patient is taking allopurinol. It can cause fever, rash, bone pain, rash. Pressure on the bone marrow, pancreatitis may develop. After the treatment is started, routine tests should be performed at 6-week intervals, initially after two diseases. Because drug use should be adjusted according to the values of leukocyte and liver function tests.
Methotrexate may be preferred if azathioprine cannot be used. Cyclosporine, on the other hand, can be tried in ulcerative colitis that does not respond to treatment.
Infliximab and adalimumab are TNF-α blockers that control granulomatous infections in the body. It is also effective on intestinal permeability. It is more effective to use together with azathioprine in patients who need to use steroids continuously. They are used to provide healing in Crohn’s disease and ulcerative colitis. However, it should not be used in the presence of active infection in the patient. Tuberculosis, hepatitis B and hepatitis C should be investigated before starting this group of drugs. In addition, live vaccines should not be administered while using this group of drugs. The patient should also be evaluated in terms of heart disease, psoriasis-like skin findings and neurological diseases. While infliximab is administered, early allergic reactions such as wheezing and skin rash may develop within minutes. Symptoms such as muscle pain, fever, fatigue and joint pain are delayed reactions between 1-14.
None of the drugs used in inflammatory bowel disease should be discontinued without the knowledge of the pediatric gastroenterologist.
Antibiotic therapy in inflammatory bowel diseases; It can be used in the presence of fulminant colitis, toxic megacolon, breech disease, fistulizing Crohn’s disease and pouchitis.
Pediatric patients should attend their doctor’s appointments on time. Measurements to be made during the control are important in order to prevent the undesirable effects of the disease with height, weight and blood pressure measurements and the tests to be requested. For example, elevations in serum liver enzymes and elevated amylase values in blood tests are stimulant in terms of side effects of drugs, while elevations in biliary tract tests may herald an undesirable complication called sclerosing colonjit, apart from drug side effects. Again, with all abdominal ultrasonography requested in the controls, conditions such as fatty liver, changes in the biliary tract, kidney and gallbladder stones, intra-abdominal abscess, etc. can be detected.
During the examination, breech area examination is important. Especially adolescents are shy about this examination. Children and adolescents should be informed by the family about such examination before the examination.
Annual eye examinations in the follow-up of inflammatory bowel disease should be performed by the same ophthalmologist, if possible. Eye itching, discharge, stinging, burning may be a sign of an eye complication. If this is the case, you should consult an ophthalmologist immediately.
Routine vaccinations of patients with inflammatory bowel disease should be timely. The coronavirus vaccine should be given to children and adolescents over the age of 12.
If your child is sick during the coronavirus epidemic, medications for inflammatory bowel disease should be continued without stopping.
The treatment of Crohn’s disease is non-surgical. If a surgical procedure is to be performed in Crohn’s disease, the intestinal integrity of the patient should be preserved as much as possible. However, surgery should be considered in the presence of conditions such as megacolon, toxic megacolon, stenosis, fistula, abscess, intestinal obstruction and intestinal perforation.
In ulcerative colitis, surgical treatment can be considered in cases of bleeding, intestinal perforation, and failure to respond to drug therapy.
Transfer of our pediatric and adolescent patients to adult gastroenterology outpatient clinics after the age of 18 should be done slowly. The patient’s first admission findings, medications used, gastroscopy and colonoscopy reports, pathology reports should be included in the epicrisis, and if possible, several examinations should be accompanied by a pediatric and adult gastroenterology specialist.
In conclusion, inflammatory bowel disease is a long-term disease and requires lifelong follow-up and treatment.
