COMMENTARY

Colons Are Like Snowflakes: IBD in Kids

Christopher J. Chiu, MD ; Justin L. Berk, MD, MPH, MBA 

Disclosures

June 16, 2022

This transcript has been edited for clarity.

Justin L. Berk, MD, MPH, MBA: Welcome back to The Cribsiders and our Medscape video recap of a recent podcast episode. For those of you who don't know us, we produce a pediatric medicine podcast in which we interview leading experts in the field of pediatric medicine to get practice-changing knowledge and answer lingering questions about core topics in pediatric medicine. Chris, what episode are we recapping today?

Christopher J. Chiu, MD: We discussed inflammatory bowel disease (IBD) with Dr Ghassan Wahbeh, who is a pediatric gastroenterologist and the director of the IBD Center at Seattle Children's Hospital. We discussed some really cool things, including the background of IBD, red flags to watch for, and what types of initial testing should be done by general pediatricians, especially if there's a high index of suspicion.

Berk: How did our expert describe IBD?

 

Chiu: Classically, IBD is an umbrella term that describes disorders that cause chronic inflammation in the gastrointestinal tract, most commonly Crohn's disease and ulcerative colitis (UC). With Crohn's, the inflammation can be anywhere from the mouth to the anus and it affects all the layers of the intestines. The inflammation in UC is usually confined to the large intestine and it affects just the first layer of mucosa.

But in Dr Wahbeh's practice, because there's such a large spectrum of overlapping phenotypes, he prefers not to label it as Crohn's or UC. He makes it personal to each patient with IBD and avoids using these broad categories when talking with them.

Berk: Everyone's colon is a snowflake; everyone is unique. I love it. And what are some of the underlying causes of IBD?

Chiu: It turns out that it's multifactorial. But I found it interesting that there's only a moderate genetic link, and only about half of patients with Crohn's disease may have a family member with the same diagnosis. They have found similar results in twin studies. The big thing I got out of this was that we should reassure families that they didn't do anything wrong to cause this condition in their kids.

In terms of who is diagnosed, the incidence is bimodal by age, with peaks around age 10-20 and at age 20-40 years. But people can be diagnosed with IBD at any age.

Berk: We asked Dr Wahbeh this question: If I have a patient with gastrointestinal symptoms in my primary care pediatric office, what red flags should I keep an eye out for? What should I be concerned about?

Chiu: The first thing is chronic diarrhea. Viral infectious diarrhea should only last 3-5 days. If the patient has chronic diarrhea (lasting longer than 2 weeks), that's a red flag. Bloody diarrhea, unintentional weight loss, and waking up in the middle of the night to use the bathroom are other red flags.

Berk: Let's talk about a workup. What are some of the labs that our expert recommended and what's the differential that we're trying to rule in or out?

Chiu: We're looking at possibly infectious causes, as I mentioned. Exposure to Giardia can cause chronic diarrhea. If the patient has bloody diarrhea, we are looking for anemia. So we start with a CBC with differential. He recommends testing for inflammatory markers but didn't really say whether the ESR or CRP is better; just having one may be sufficient. And then, of course, we should do iron studies.

Some lower-value tests could be warranted based on history. One example is celiac studies, but he said that if you plan to send the patient for upper endoscopy, you can skip those. We also discussed stool calprotectin and lactoferrin, which can indicate inflammation, but whether these tests are available is institution specific, and they don't differentiate between infection and IBD. Be aware that those types of tests can be negative, especially if the inflammation is occurring only in the small bowel, and this can be falsely reassuring to patients.

Berk: I've always felt that those lab values were difficult to interpret, and he said it's just not a clear-cut test for this diagnosis.

What treatment pearls can general pediatricians take away from this episode?

Chiu: We began by talking about which medicines are still being used. Traditionally for an inflammatory condition, we think about steroids. He made a point of saying that steroids are really only a Band-Aid for most of these diagnoses. They may help with symptoms such as pain or bloody diarrhea but don't really help with long-term deep mucosal healing. We talked about mesalamines (topical anti-inflammatory agents that are released in the colon), immune modulators, and biologics that target specific immune cells and cytokines to reduce inflammation.

We had an interesting discussion about the approach to medical therapy of IBD. When I was still in training, we learned the traditional step-up approach, in which you start up with one of the weaker, cheaper medications, and if the patient flares or is poorly controlled, you begin stepping up to stronger medicines. Now, that's being supplanted by a top-down approach, starting with the most effective medications first and treating IBD aggressively early on, and de-escalating later. This has led to better long-term outcomes with more children experiencing mucosal healing.

Berk: That was very cool — seeing how treatment regimens and treatment plans have shifted over time. This was a great episode, so be sure to check out Inflammatory Bowel Disease — Go With Your Gut. You can download this podcast or any other full episode on any podcast player. You can also check us out at www.thecribsiders.com. Thank you for joining us for this Medscape recap video.

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