Crohn Disease: Murch S

Oliva-Hemker M, Escher JC, Moore D, Dubinksy M, Hildebrand H, Koda YK, Murch S, Sandhu B, Seo JK, Tanzi MN, Warner B, Anonymous00097. · Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD 21287-2631, USA. · J Pediatr Gastroenterol Nutr. · Pubmed #18664886 No free full text.

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Afzal NA, Addai S, Fagbemi A, Murch S, Thomson M, Heuschkel R. · Centre for Paediatric Gastroenterology, Royal Free Hospital, Hampstead, London, UK. · Clin Nutr. · Pubmed #12468372 No free full text.

Abstract: Refeeding syndrome is a potentially fatal complication of the nutritional management of severely malnourished patients. The syndrome almost always develops during the early stages of refeeding. It can be associated with a severe derangement in electrolyte and fluid balance, and result in significant morbidity and mortality. It is most often reported in adults receiving total parenteral nutrition (TPN), although refeeding with enteral feeds can also precipitate this syndrome.We report what we believe to be the first case of refeeding syndrome in an adolescent with newly diagnosed Crohn's disease. This developed within a few days of starting exclusive polymeric enteral nutrition. A systematic literature review revealed 27 children who developed refeeding syndrome after oral/enteral feeding. Of these, nine died as a direct result of complications of this syndrome. We discuss the implications of this syndrome on clinical practice and propose evidence-based guidelines for its management.

Afzal NA, Ozzard A, Keady S, Thomson M, Murch S, Heuschkel R. · Department of Paediatrics, Southampton University Hospital NHS Trust, Southampton, UK. · Dig Dis Sci. · Pubmed #17805970 No free full text.

Abstract: The aim of this study was to review the impact of infliximab therapy on children with treatment-resistant Crohn's disease. Treatment resistance was defined as clinically active disease despite >4 months of immunosuppressive therapy. The outcome variables were time to first remission, duration of remission and the need for surgery. 24 children received 90 infusions of infliximab (16 boys; median 10.3y, range 1.0-14.4y); all had three infusions as an induction course. 17 (70.8%) achieved clinical remission, with 14/17 (82.3%) relapsing within 4 months of the third infusion. 6/7 in the non-responding group and 8/17 of the responders required surgery with an insignificant difference in the median time to surgery (p=0.49). Four remain dependent on regular infliximab. Infliximab is well-tolerated and highly effective in achieving clinical remission in children with refractory Crohn's disease but may only delay and not avoid the need for surgery. Failure to achieve clinical remission by the 3rd infusion significantly increases the risk of surgery.

Thomson M, Fritscher-Ravens A, Mylonaki M, Swain P, Eltumi M, Heuschkel R, Murch S, McAlindon M, Furman M. · Centre for Paediatric Gastroenterology, Royal Free Hospital, London, UK. · J Pediatr Gastroenterol Nutr. · Pubmed #17255830 No free full text.

Abstract: BACKGROUND AND AIM: Small bowel disease in the paediatric population is varied and to date has relied on indirect l modalities such as small bowel follow-through with attendant radiation exposure. Wireless capsule endoscopy (WCE) has the potential to provide a safer and more effective means of investigating the paediatric small bowel. The aim of our study was to prospectively assess the diagnostic yield of WCE compared with standard investigation in children with suspected small bowel disease. METHODS: Twenty-eight consecutive patients, median age 12.5 y (range, 9.4-15.9) with suspected small bowel disease were investigated with WCE. This included 16 patients with suspected small bowel Crohn disease (CD) (10 newly diagnosed; 6 known cases), 6 with obscure or occult gastrointestinal bleeding (GIB), 3 with Peutz-Jegher polyposis (PJP), 2 with protein-losing enteropathy and 1 with recurrent abdominal pain. All of the patients had preceding upper gastrointestinal endoscopy (OGD) and ileocolonoscopy, and 24 had a barium meal and follow-through (BMFT). Images were downloaded and analysed and results compared with the endoscopic and radiological findings. RESULTS: Three patients were unable to swallow the capsule (1 CD, 1 PJP and 1 GIB). Two of these patients (1 GIB, 1 PJP) had the capsule placed in the stomach endoscopically and completed the WCE uneventfully thereafter. In 3 patients (CD group) the capsule remained in the stomach and/or proximal duodenum and no small bowel images were obtained. Hence, 24 patients had successful completion of the WCE through the small bowel, 23 of whom had clinically relevant findings identified. In all patients with CD who had successful WCE studies (12/16), small bowel disease was identified (11/12 active disease, 1/12 chronic disease). A possible small bowel bleeding source was identified in all 6 patients with GIB. Two patients with GIB also underwent push enteroscopy and 1 of these had a bleeding source identified. The 2 patients with protein-losing enteropathy had extensive patchy lymphangiectasia of the jejunum and ileum, not detected at OGD. The patient with abdominal pain had an intussusception of the upper jejunum. The 2 PJP patients had small bowel polyps identified, which were not detected at BMFT. WCE was more sensitive for small bowel pathology than both BMFT (19 vs 5; 26% sensitivity compared with WCE) and endoscopic investigations (23 vs 10; 43.4% sensitivity compared with WCE). Two patients with CD had delayed capsule transit. CONCLUSIONS: WCE led to a positive alteration in management in 18/24 (75%) of patients whose small bowel was examined by WCE and in 18/28 (64.3%) who were admitted to the study. WCE was safe, well tolerated, and more sensitive than radiological and standard endoscopic modalities in the detection of small bowel CD distribution, GIB source, and presence of polyps in children.

Afzal NA, Davies S, Paintin M, Arnaud-Battandier F, Walker-Smith JA, Murch S, Heuschkel R, Fell J. · Centre for Pediatric Gastroenterology, Royal Free Hospital, London, UK. · Dig Dis Sci. · Pubmed #16110838 No free full text.

Abstract: Data supporting a response to treatment with exclusive enteral nutrition in pediatric colonic Crohn's disease are few. We examined clinical and biochemical responses of ileal, colonic, and ileocolonic Crohn's disease and assessed the endoscopic and histological colonic mucosal response in the colonic and ileocolonic groups. We prospectively enrolled 65 children (age: 8-17 years) with acute intestinal Crohn's disease (Pediatric Crohn's Disease Activity Index [PCDAI] >20). After ileocolonoscopy, gastroscopy, and a barium meal and follow-through, they were distributed into three groups (ileal, n = 12, ileocolonic, n = 39; and colonic, n = 14). All patients received exclusive polymeric feed as treatment, with a repeat endoscopy at completion of treatment. At enrollment the ileal group had significantly less severe disease (P = 0.05) compared to the colonic and ileocolonic groups. However, the colonic disease group showed the least fall in PCDAI scores at completion of treatment with enteral nutrition (P = 0.03), with the lowest remission rate (50%, vs 82.1% in the ileocolonic and 91.7% in the ileal group [chi2 test, P = 0.021]). Endoscopic and histologic colonic mucosal assessment showed a post-treatment improvement in the ileocolonic (P < or = 0.01) but not in the colonic disease group (P = ns). Children with disease in the colon respond better to enteral nutrition if the ileum is also involved. This may be due to different underlying inflammatory mechanisms. Detailed pretreatment assessment in studies of Crohn's disease according to disease distribution with appropriate individualized tailoring of treatment may be important in this regard.

Afzal NA, Van Der Zaag-Loonen HJ, Arnaud-Battandier F, Davies S, Murch S, Derkx B, Heuschkel R, Fell JM. · Centre for Paediatric Gastroenterology, Royal Free Hospital, London, UK. · Aliment Pharmacol Ther. · Pubmed #15233696 links to  free full text

Abstract: BACKGROUND: Crohn's disease is a chronic debilitating disorder affecting a child's physical and emotional well-being. Recent emphasis on 'quality of life' (QOL) has led to re-evaluation of available medical treatments. AIM: To assess prospectively change in QOL, clinical disease activity and intestinal mucosal inflammation in active paediatric Crohn's disease after treatment with exclusive enteral nutrition. In addition, we evaluated whether change in QOL could predict changes in paediatric Crohn's disease activity index (PCDAI) and mucosal inflammation (endoscopic and histologic). METHODS: The IMPACT II questionnaire was used prospectively and longitudinally in 26 consecutively recruited children [16 males (67%), median 14 years, s.d. = 1.7 years] with active Crohn's disease (PCDAI > 20). They were treated with a new polymeric enteral feed (ACD004, Nestle) for a period of 8 weeks. All had PCDAI, QOL and endoscopic assessment at the time of diagnosis and after 8 weeks of treatment. RESULTS: Twenty-three of 26 children achieved a clinical remission at 8 weeks, with improvement in the QOL scores (P < 0.05). The change in QOL score after treatment was predictive of achieving a clinical remission, but not of histological improvement. CONCLUSIONS: Although children may find dietary restrictions difficult, this study confirms a clear improvement in QOL after treatment with exclusive enteral nutrition. However, improvement in QOL scores is not reflected by improvement in mucosal inflammation. Whilst improving QOL remains a core principal in patient management, the long-term consequences of ongoing mucosal inflammation must be better understood before relying only on short-term QOL measures to dictate treatment choices.

Higuchi LM, Joffe S, Neufeld EJ, Weisdorf S, Rosh J, Murch S, Devenyi A, Thompson JF, Lewis JD, Bousvaros A. · Combined Program in Pediatric Gastroenterology and Nutrition, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. · J Pediatr Gastroenterol Nutr. · Pubmed #11740233 No free full text.

Abstract: OBJECTIVE: Previous reports suggest an association between inflammatory bowel disease (IBD) and immune thrombocytopenic purpura (ITP) in adults. To date, only five children with both diseases have been described. The aim of the study was to describe the characteristics of children with IBD and ITP. METHODS: Cases were obtained from the pediatric gastroenterology community by means of the pediatric gastroenterology internet bulletin board in June 1999. Eight cases were submitted from seven medical centers. Medical records were reviewed by two pediatric gastroenterologists and a pediatric hematologist. RESULTS: The age range of the patients was 2.1 to 16.5 years, with a mean age of 9.6 +/- 5.2 years. Four children had ulcerative colitis, three had Crohn disease, and one had indeterminate colitis. All had colonic involvement of IBD. Of eight patients, three had IBD first, three had ITP first, and two had both simultaneously. At ITP diagnosis, platelet count was less than 10,000/mL in five children, 17,000/mL in one child, and 50,000 to 60,000/mL in two children. Of the three children diagnosed with ITP first, two initially had rectal bleeding at the time of ITP diagnosis. Bone marrow evaluations, performed in six of eight children, were consistent with ITP. Six of the eight children had chronic ITP, including three children who were 5 years of age or younger. Therapy for ITP included steroids (n = 6), intravenous immunoglobulin (n = 6), Rh o (D) intravenous immunoglobulin (n = 2), and splenectomy (n = 1). CONCLUSIONS: The authors describe the largest pediatric case series of children with IBD and ITP. More than 50% of the children had the chronic form of ITP. Most patients responded to conventional therapy for ITP and IBD.