Children and IBD

 Reprinted with the permission of the author, Dr. Stanley Cohen  

(Adjunct clinical professor of pediatrics, Emory University School of Medicine;
Director of IBD Research, Children's Center for Digestive Health Care;  

Chief of Gastroenterology and Nutrition Clinics, Children's Healthcare of Atlanta at Scottish Rite Hospital in Atlanta, GA) 

Question:   

My child has IBD. I have talked with others about the disease, and I am somewhat worried upon hearing of other possible complications.  Are complications aside from the actual disease a great risk to children with IBD? How worried should I be?

Answer: 

IBD has no respect-not for age, nationality, race or even intestinal tract. Not for age certainly; one of our patients with indeterminate colitis is only 11 months old now and younger infants with Crohn’s and Colitis have been reported. In addition, the range of patients in our office attests to the diversity of patients that suffer with IBD.

These inflammatory illnesses are often accompanied by Extra Intestinal Manifestations (EIMs). In fact, 25-35% of patients with Crohn’s or colitis will have other organs involved.  Some of these patients will have symptoms with skin conditions or arthritis before their intestinal problems manifest. Not uncommonly, we have seen patients that presented to orthopedic surgeons and rheumatologists first, because their joint problems were more annoying than their comparatively mild abdominal complaints.

Arthritis is the most common of the EIMs and shows up anywhere from 5-25% of adults with IBD, depending on the study cited. The percentages in children with IBD are similar, with some variability among the different authors regarding whether these numbers are higher in Crohn’s or ulcerative colitis. As yet, we do not understand the cause, though we postulate that bacteria or other antigens that would otherwise be removed with the fecal stream are absorbed (possibly more so in the large intestine). These initially are an immune response, with immune complexes circulating and eventually depositing in and around the joints of the body.

Many of these same patients will have eye disease as well, with these circulating complexes apt to deposit  there too causing inflammation and irritation to the iris.  In addition, we as physicians, patients and parents must constantly remind ourselves that chronic steroid use can affect the eyes, contributing to the development of glaucoma and cataracts even though these eye conditions usually do not become problems until adulthood.

The skin conditions that occur more specific in that one type (erythema nodosum) is more common in Crohn’s disease, while ulcerative colitis is more frequently associated with pyoderma gangrenosum.  These conditions tend to appear in active disease, paralleling the course of the underlying bowel disease.

The liver can become involved, most notably with schlerosing cholangitis is UC, where again we think a bacterial product crosses from the intestine and sets up a reaction.  The other EIMs occur primarily as a result of malabsorption (anemia, growth impairment and vitamin deficiency states) or as a side effect of the drugs that are needed to treat the disease.

While the list of possible EIMs numbers into the hundreds, again only 25-35% of patients are ever affected. Hearing from others that manifestations “might” appear should not scare parents but rather alert them to seek information that may be helpful in recognizing potential problems as early as possible.