Pediatric Inflammatory Bowel Disease in the Emergency Department

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Inflammatory bowel disease (IBD) is an increasingly common cause of morbidity in the pediatric population. Despite the establishment of dedicated multidisciplinary IBD teams in many centers, the care offered by emergency physicians is often crucial in the period before diagnosis and at times of relapses or acute complications. Crohn's disease and ulcerative colitis can present with a myriad of acute and chronic symptoms to the emergency department. Pediatric Crohn's disease encompasses a variety of phenotypic forms and often does not present with the classic triad of diarrhea, abdominal pain, and weight loss. Pediatric ulcerative colitis tends to be more extensive than adult-onset disease, with a greater predilection to acute severe exacerbations requiring urgent recognition. Disease- and treatment-related complications of IBD, both intestinal and extraintestinal, can be life threatening and require an integration of medical and surgical care from triage until discharge from the emergency department.

Section snippets

IBD Epidemiology

Inflammatory bowel disease affects up to 0.5% of the general population in North America, and IBD-related health care costs are estimated to exceed $6.3 billion in the United States.2, 13, 14 The peak age of onset for IBD overall is in the second and third decade of life.2, 15 Administrative health data recently examined by Benchimol et al16 reveal that in Ontario, Canada, the age- and sex-standardized prevalence per 100 000 population of children or adolescents younger than 18 years has

Recognition of IBD in a Patient Not Previously Diagnosed

Patients with infectious colitis, UC, and Crohn colitis may all present with abdominal pain and bloody diarrhea.19 The primary findings used to differentiate infection from IBD are stool cultures and duration of diarrhea, with infection becoming less likely with every additional week of symptoms. Pathogens causing colitis in North America include Salmonella, Shigella, Yersinia, Campylobacter, Escherichia coli, and Clostridium difficile. Amoebiasis and Mycobacterium tuberculosis must also be

Treatment of IBD in a Previously Diagnosed Patient

The relapsing and remitting nature of IBD means that many young patients will seek urgent care between scheduled follow-up appointments. An overview of possible treatments for induction of remission of CD and UC is beyond the scope of this article. The reader is referred to an excellent systematic review by Wilson et al.25 It is nevertheless noteworthy that pediatric gastroenterologists strive to avoid prolonged steroid treatment with its well-known adverse effects. Rather than starting steroid

Acute Severe UC

Up to 80% of children diagnosed with pediatric UC have extensive disease (extending proximal to the splenic flexure).21 Such extensive disease is associated with a predilection for acute severe exacerbations, either at first presentation or subsequently. More than 25% of children diagnosed with UC experience an attack severe enough to warrant hospitalization during childhood as shown by Turner et al.35 It is essential that ED physicians be able to recognize an exacerbation of UC that

Major Hemorrhage

Lower GI bleeding is a common presenting sign in patients with UC or Crohn colitis.40 Although chronic lower or upper GI bleeding can lead to iron deficiency anemia, as is commonly observed in IBD patients, acute IBD-related lower GI bleeding is rarely sufficient to cause cardiovascular instability.

In contrast to UC where bleeding is more likely to be diffuse from large areas of ulcerated mucosa, in CD, bleeding is often from a more localized source.42 Conflicting results have been reported

Extraintestinal Manifestations of IBD

Inflammatory bowel disease is associated with several extraintestinal manifestations for which emergency care may be sought. Skin involvement (pyoderma gangrenosum and erythema nodosum) can precede the onset of GI symptoms and should therefore prompt a referral to a pediatric gastroenterologist.62

Musculoskeletal complications are frequent and well-recognized manifestations in IBD, affecting up to 33% of patients.63 Rheumatic manifestations of IBD have been divided into pauciarticular,

Summary

Emergency physicians play an important role in the care of young IBD patients. Disease- and treatment-related complications of IBD, both intestinal and extraintestinal, can be life threatening and require an integration of medical and surgical care from triage until discharge from the ED. Early recognition of these complications and institution of appropriate treatment can greatly alter the outcome.

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