From the July 2014 issue of Pediatric Emergency Medicine Practice, “Pediatric Inflammatory Bowel Disease in the Emergency Department: Managing Flares and Long-Term Complications.” Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice, Pediatric EM Practice, and EM Practice Guidelines Update issues, go to ebmedicine.net/emra, call 1-800-249-5770, or send e-mail to ebm@ebmedicine.net.
- “You can't diagnose IBD when patients don't have any GI symptoms.”
Although IBD typically manifests with abdominal pain/distention and diarrhea that is often bloody, it can also present with only extraintestinal manifestations. These are particularly prominent in the pediatric population (especially arthralgias, delayed puberty, and delayed growth). - “I am worried about an intra-abdominal abscess, but I decided not to order CT of the abdomen in this pediatric patient because the radiation risk is too high.”
There are various imaging modalities that could aid in the diagnosis of IBD or in the detection of IBD-related complications. Such imaging modalities include radiograph, CT, MRI, ultrasound, and endoscopy. The choice of imaging modality largely depends on the patient's clinical presentation, consideration of risks versus benefits, and availability of the chosen modality. If the patient appears toxic and the clinical examination is concerning for possible bowel perforation and/or toxic megacolon, then abdominal CT may provide the necessary information in the shortest period of time. Computed tomography with oral contrast can evaluate the bowel wall and lumen, and it can identify perforation, obstruction, and abscesses. If using oral contrast and there is a concern for perforation, use a water soluble contrast medium. - “If all laboratory testing results are normal (including inflammatory markers), then this patient does not have IBD.”
Normal laboratory test results do not exclude the diagnosis of IBD, but laboratory testing should be done when IBD is suspected. Common abnormalities seen in laboratory testing include anemia (usually normocytic or microcytic), thrombocytosis, elevated erythrocyte sedimentation rate and C-reactive protein, mild elevation of aspartate aminotransferase and alanine transaminase, and hypoalbuminemia. In addition, studies have shown that red blood cell distribution width is markedly increased in active IBD and may be useful in monitoring disease progression. - “I saw a pediatric patient with painful oral ulcers. She has a history of IBD and is taking multiple immunosuppressants. She appeared well otherwise, so I sent her home with ibuprofen only.”
In addition to pain medication, such oral lesions may be treated with topical prednisolone syrup (5 mg/5 mL) or dexamethasone (0.5 mg/5 mL), either applied directly to the lesions or by the swish-and-spit method twice daily. If the lesions are localized to the lips, triamcinolone 0.1% may be used 2 to 4 times per day. - “Patients with IBD always need antibiotics when they present with abdominal pain.”
Antibiotics are indicated when there is suspicion of infectious colitis, toxic megacolon, or intestinal perforations. Blood and stool cultures should be sent prior to initiating antibiotics. - “I can't tell if the patient is having an acute flare or having complications secondary to Crohn disease, so I was unsure of the best way to treat the patient.”
It is often difficult to distinguish between acute flares or IBD complications solely based on physical examination and laboratory testing, as findings can be very similar in both circumstances. Imaging can aid in differentiating these 2 etiologies; however, it may not be needed because management is similar for both conditions. Patients often require intravenous steroids, intravenous fluid hydration, and broad-spectrum intravenous antibiotics (if underlying infection is suspected). - ’ “This parent is asking for a flu shot for her child, but the boy is taking immunomodulators for IBD.”
Patients taking immunomodulators have suppressed immune systems and are more prone to developing infections. Sepsis is one of the leading causes of mortality in patients with IBD. Thus, it is important to vaccinate patients. Immunization with inactivated vaccines (particularly influenza, pneumococcus, and meningococcus) should be maintained and updated. Depending on the level of immunosupression, live attenuated vaccines (Measles, Mumps, and Rubella; Varicella; intranasal influenza) may be contraindicated. Decisions regarding whether specific vaccinations are appropriate for patients on immunomodulatory medications for IBD should be made by the prescribing clinician. - “X-ray findings of toxic megacolon are the same in adults as in children.”
Findings of toxic megacolon in both adults and children include colonic dilatation with an abnormal mucosal contour, which is typically most pronounced in the transverse colon. Acute dilatation of the transverse colon to 5-6 cm with loss of haustral folds during a severe exacerbation of colitis is diagnostic of toxic megacolon in older children and adults. In children aged < 10 years, transverse colonic diameter > 4 cm is suggestive of toxic megacolon. - “This patient is having a flare of IBD, but I wasn't sure if all outpatient medications should be continued.”
During a flare, patients typically require high dose intravenous steroids. The decision to continue other classes of outpatient medication (such as biologic agents or immunomodulators) should be made in conjunction with gastrointestinal specialists. It is important to note that 5-ASA agents (sulfasalazine, mesalamine, olsalazine) are ineffective during an acute exacerbation and should be discontinued to prevent worsening of colitis symptoms. - “This patient looks like he is having an acute flare, but I was concerned about further immunosuppression, so no steroid was given.”
While many patients with IBD are relatively immunocompromised due to immunomodulator therapy, intravenous steroids are indicated as one of the essential treatments during an acute flare. High-dose steroids (methylprednisolone 1 mg/kg/dose every 12 hours to a maximum of 30 mg every 12 hours) are most commonly used.