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Severe acute ulcerative colitis: the pediatric perspective
1Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem 91031, Israel. turnerjd2001@yahoo.com
Insights
Pediatric ulcerative colitis (UC) often presents as extensive disease, with many children requiring advanced therapies beyond corticosteroids. The Pediatric UC Activity Index (PUCAI) aids in early identification of severe cases and treatment escalation needs.
Area of Science:
- Pediatric Gastroenterology
- Inflammatory Bowel Disease Research
- Clinical Pediatrics
Background:
- Childhood-onset ulcerative colitis (UC) exhibits a higher rate of extensive disease compared to adults.
- A significant proportion of pediatric UC patients (30-40%) do not respond to corticosteroids.
- Severe UC admissions in children reach 28% by age 16, necessitating timely intervention.
Purpose of the Study:
- To evaluate the utility of the Pediatric UC Activity Index (PUCAI) in assessing disease severity and guiding treatment decisions in pediatric ulcerative colitis.
- To identify predictive markers for corticosteroid failure and the need for second-line therapies or colectomy in children with UC.
Main Methods:
- Utilized the Pediatric UC Activity Index (PUCAI) to quantify disease severity in pediatric ulcerative colitis patients.
- Assessed PUCAI scores at specific time points (day 3 and day 5) to predict treatment response and outcomes.
- Reviewed data on the efficacy and duration of second-line therapies including cyclosporine, tacrolimus, and infliximab.
Main Results:
- A PUCAI score >65 indicates severe disease, guiding decisions on second-line therapy or colectomy.
- PUCAI scores >45 on day 3 predict corticosteroid failure (90-95% NPV), while scores >70 on day 5 predict short-term escalation needs (95-100% PPV).
- Short-term response rates for cyclosporine, tacrolimus, and infliximab range from 60-80%, with infliximab offering prolonged use.
Conclusions:
- The PUCAI is a valuable tool for early identification of severe pediatric ulcerative colitis and predicting treatment response.
- Second-line therapies like infliximab are effective, but calcineurin inhibitors require careful bridging to thiopurines.
- Colectomy indications include toxic megacolon or refractory disease, with careful consideration of quality of life and developmental impact.
Abstract:
Many features of pediatric ulcerative colitis (UC) are similar to adult-onset disease, but the rate of extensive disease is doubled in children. It is, therefore, not surprising that the admission rate for severe UC is higher in childhood-onset UC, reaching 28% by the age of 16 years. Approximately 30-40% of children will fail corticosteroids and require second-line medical therapy or colectomy. A pediatric UC activity index (PUCAI) score of >65 indicates severe disease and the index can assist in determining the need and timing of second-line medical therapy or colectomy early during the admission. A PUCAI score of >45 points on day 3 identify patients likely to fail corticosteroids (negative predictive value 90-95%), and a score >70 points on day 5 identify patients who will require short-term treatment escalation (positive predicting value 95-100%). Data in children are limited, but it seems that cyclosporine, tacrolimus and infliximab achieve a similar short-term response rate, in the range of 60-80%. Infliximab has the advantage that it may be given for a prolonged period of time while calcineurin inhibitors should not be used for more than 3-4 months, bridging to a thiopurine regimen. Colectomy is indicated in toxic megacolon or in cases refractory to one salvage therapy. The choice of colectomy in other cases should carefully consider its effect on the patient's quality of life, its impact on the physical and emotional development at a critical age of personality development, and its association with a high infertility rate in females undergoing pouch procedure before childbearing age.
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