Malady Wise

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Paeds IBD

Maladywise

Summary notes from Paeds update talk in 2023 Dr Li-Zsa Tan

Pathophysiology

  • Cause unknown

  • The theory is a complex interplay of genomics, epigenomics, gut microbiome and immune dysregulation

  • Disruption of mucous layer lining mucosa

  • More susceptible to pathogenic organisms that may trigger an immune response

  • Pathogens can enter lamina propria

  • Increases intestinal permeability

  • The immune system is exposed to the higher inflammatory burden

  • IL6, IL23, IL12

  • IBD gut has a perpetual cycle of inflammatory

  • IBD patients show a reduction in the number and diversity of gut microbiome species

  • No causal relationship to a specific bacteria, viral or fungus

Genetics

  • 200 IBS risk-associated gene loci

  • Most are polygenic in nature

  • If monogenic cause, higher risk, more severe disease, manifests early, very symptomatic young

Course

  • Subclinical symptoms initially

  • Treatment initiated, symptoms terminated

  • Remission

  • Maintenance therapy

  • Flares and then further therapy to induce remission

  • If endoscopic remission is gained then much better outcomes

  • Histological remission

Categories

  • Crohn’s - patchy, whole gut, transmural

  • Ulcerative - mucosa, colon

  • IBD unclassified - colon, features of both UC and CD, usually in younger patients

Features

CD

  • Abdominal pain

  • Growth failure

  • Diarrhoea +/- bleeding

  • +/- Fistula (bowel to bowel, bowel to the skin, bowel to the vagina, bowel to the bladder)

UC

  • Blood diarrhoea

  • Urgency

  • Tenesmus

  • Abdominal pain

Goals

  • Improve QoL

  • Achieve timely physical growth and development

  • Optimise medical therapy

    • Go early go hard

      • 40% of those who fail to achieve mucosal healing within 2 years go on to surgical management

    • Support consistent adherence

    • Minimise toxicity

  • Prevent disease complications

  • Support psycho-socio-emotional wellbeing

    • Support school attendance

Treatment

Infliximab and Adalibumab changed everything

  • TNF alpha inhibitors

  • IL12 / 23inhibitor

  • Anti alpha 4B7 integrin Ab

  • New small molecule therapeutics

  • JAK inhibitors

Diet and IBD

Deidre Burgess - Gastro Dietitian

EEN as first-line therapy in active paediatric crohn’s mild to moderate disease

  • 6 to 8 weeks of nutritious liquid (Sustagen, Ensure plus + clear fluids)

  • 73% remission rate in mild to moderate disease

Alternate CD Exclusion Diet

  • 6 weeks of 50% energy from Ensure Plus

  • Chicken, Bananas, Apple, Potato

  • Nothing processed or packaged

  • Next 6 weeks are 25% energy from Ensure Plus

  • More foods

  • Effective at inducing remission with symptomatic score + blood tests, no endoscopic assessment

  • Still being investigated

Specific Carbohydrate Diet

  • No grains, very limited dairy

  • Study of SCD versus Mediterranean

  • No difference

Dietary Resources for patients and doctors

Monitoring

  • Minimise blood tests

  • Review colonoscopy when indicated

  • Faecal CP + stool cultures

  • MR enterography + U/S

Probiotics

  • 2kg of bacteria

  • Most studies are in vitro

  • No great evidence yet, lots of studies ongoing

  • If active disease, step one is do no harm, go with proven evidence-based therapy with confirmed specific outcomes

Flares in GP

  • Paediatric patients have a specific phone line and email address for advice