The Pediatric Pouch in Inflammatory Bowel Disease

A Primer for the Gastroenterologist

Ghassan T Wahbeh; David L Suskind; Scott D Lee; John T Waldhausen; Karen F Murray

Disclosures

Expert Rev Gastroenterol Hepatol. 2013;7(3):215-223. 

In This Article

Background

Inflammatory bowel disease (IBD) has increased in incidence over the past few decades,[1] similar to numerous allergic and autoimmune conditions. One of every four patients presents in childhood.[2] The disease can significantly impact patients' quality of life, not only through symptoms, but also through growth restriction, puberty delay, impact on social and emotional development and compromised school attendance at the critical age period of 10–20 years, where these milestones take place. In addition, 10 years after diagnosis, owing to persistent inflammation, the risk of colon cancer increases by 0.5–1% annually.[3]

About half of the children with IBD have ulcerative colitis (UC) involving the mucosal layer of the colon. For these children, anti-inflammatory agents targeting the diseased mucosa are used. The goals of UC therapy are to control symptoms, restore growth and development and prevent complications, such as colon cancer. More recently, the use of mucosal healing has gained interest as an objective measure of therapy success and its ability to predict a better disease course.[4] Available medical treatments have been successful in meeting the therapy goals for most, but not all, patients. Colectomy may be necessary for intractable colitis (despite therapy with mesalamine, steroids, azathioprine, calcineurin inhibitors and anti-TNF agents), steroid dependent colitis or when significant dysplasia is present. Colectomy occurs in the setting of a hospitalized child with acute severe colitis, or in the outpatient setting. Eight out of 100 children with UC require surgery within a year of diagnosis,[5] and up to 26% within 5 years.[6] Before the use of anti-TNF-α therapy, more than 60% of children with acute severe colitis needed a colectomy within 1 year.[7] The overwhelming majority of these children go on to receive a pelvic pouch comprised of the small intestine. Despite the fact that most published data apply to adults with pouches, this review attempts to highlight some pertinent issues in the care of children who receive a pouch as part of their surgical management for UC, including the decision on and impact of the type of surgery, functional challenges, expectations and short- and long-term complications.

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