Crohn's Disease in Children

What is Crohn's disease?

Crohn's disease is an inflammatory bowel disease (IBD). It is a chronic condition that may recur at various times over a lifetime. It usually involves the small intestine, most often the lower part called the ileum. However, inflammation may also affect the entire digestive tract, including the mouth, esophagus, stomach, duodenum, appendix, or anus.

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What causes Crohn's disease?

There are many theories regarding Crohn's disease, but none has yet been proven. One theory suggests that some agent, perhaps a virus or bacteria, affects the body's immune system and triggers an inflammatory reaction in the intestinal wall. Although there is a lot of evidence that patients with this disease have abnormalities of the immune system, it is not known whether the immune problems are a cause or a result of the disease.

Physicians believe that there is little proof that Crohn's disease is caused by emotional distress.

Who is affected by Crohn's disease?

While Crohn's disease may affect persons of all ages, the age group most often affected is 15 to 35 years. However, Crohn's disease may also be seen in young children. Males and females are affected equally. It appears to run in some families, with about 20 percent of people with Crohn's disease having a blood relative with some form of inflammatory bowel disease. In those who have a family history, it is very likely that Crohn's disease will begin in the teens and twenties.

What are the symptoms of Crohn's disease?

The following are the most common symptoms for Crohn's disease. However, each individual may experience symptoms differently. Symptoms may include:

• Abdominal pain, often in the lower right area

• Diarrhea, sometimes bloody

• Rectal bleeding

• Weight loss

• Obvious blood in the stools or black, tar-like stools

• Fever

• Weight loss

• Failure to grow

• Joint pain

• Rectal fissure

• Rashes

Some people have long periods of remission when they are free of symptoms, sometimes for years. There is no way to predict when a remission may occur or when symptoms will return.

The symptoms of Crohn's disease may resemble other conditions or medical problems. Consult your child's physician for a diagnosis.

How is Crohn's disease diagnosed?

People who have experienced chronic abdominal pain, diarrhea, fever, weight loss, and anemia may be examined for signs of Crohn's disease. In addition to a complete medical history and physical examination, diagnostic procedures for Crohn's disease may include:

• Blood tests. To determine if there is anemia resulting from blood loss, or if there is an increased number of white blood cells, suggesting an inflammatory process.

• Stool culture. To determine if there is blood loss, or if an infection by a parasite or bacteria is causing the symptoms.

• Endoscopy. A test that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of the digestive tract. Tissue samples from inside the digestive tract may also be taken for examination and testing.

• Colonoscopy. A procedure that allows the physician to view the entire length of the large intestine, and can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It involves inserting a colonoscope, a long, flexible, lighted tube, in through the rectum up into the colon. The colonoscope allows the physician to see the lining of the colon, remove tissue for further examination, and possibly treat some problems that are discovered.

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• Biopsy. Taking a sample of tissue (from the lining of the colon) for examination in a laboratory.

• Upper GI (gastrointestinal) series (also called barium swallow). A diagnostic test that examines the organs of the upper part of the digestive system: the esophagus, stomach, and duodenum (the first section of the small intestine). A fluid called barium (a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an X-ray) is swallowed. X-rays are then taken to evaluate the digestive organs. An upper GI with a small bowel-follow through may be used to diagnose Crohn's disease.

• Barium enema. A procedure performed to examine the large intestine for abnormalities. Barium is given into the rectum as an enema. An X-ray of the abdomen will show strictures (narrowed areas), obstructions (blockages), and other problems.

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What is the treatment for Crohn's disease?

At this time there is no cure for Crohn's disease; however, several methods are helpful in controlling it. The usual goals of treatment are to:

• Correct nutritional deficiencies.

• Control inflammation.

• Relieve abdominal pain, diarrhea, and rectal bleeding.

Specific treatment will be determined by your child's physician based on the following:

• Your child's age, overall health, and medical history

• The extent of the disease

• Expectations for the course of the disease

• Your child's tolerance for specific medications, procedures, or therapies

• Your opinion or preference

Treatment may include:

• Drug therapy (anti-inflammatory medications, cortisone or steroids, immune system suppressors, biologic therapies, antibiotics, anti-diarrheal medications, and fluid replacements). Abdominal cramps and diarrhea may be helped by medications, which often lessen the inflammation in the colon. More serious cases may require steroid drugs, antibiotics, or drugs that affect the body's immune system.

• Diet and vitamin supplements. No special diet has been proven effective for preventing or treating Crohn's disease. Some symptoms are made worse by milk, alcohol, hot spices, or fiber, but this may not be true for everyone. Large doses of vitamins are ineffective and may even cause harmful side effects. Children lose weight because of inadequate calorie intake, which can be due to several factors:

  • They may avoid eating to prevent pain associated with digestion.

  • They may absorb nutrients poorly through the inflamed digestive tract.

  • They have greater nutritional needs than average because of their disease.

  If favorite foods are eliminated from the diet, they may not feel enthusiastic about eating.

  Nutritional supplements or special high-calorie liquid formulas may sometimes be suggested, especially for children with delayed growth.

• Feeding through a vein. A small number of patients, who temporarily need extra nutrition, may need periods of feeding by vein (intravenously).

• Surgery. Crohn's disease may be helped by surgery, but it cannot be cured by surgery. The inflammation tends to return to the areas of the intestine next to the area that has been removed. Surgery may help to either relieve chronic symptoms of active disease that does not respond to medical therapy or to correct complications, such as intestinal blockage, perforation, abscess, or bleeding. Types of surgery include:

  • Drainage of abscesses or removal of a section of bowel due to blockage, resulting in a shortened bowel.

  • Ostomy. Some people must have part of their intestines removed, and a new method of removing the stool from the body is created. The surgery to create the new opening is called ostomy and the new opening is called a stoma.

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Different types of ostomy are performed depending on how much and what part of the intestines are removed, and may include:

• Ileostomy. The colon and rectum are removed and the bottom part of the small intestine (ileum) is attached to the stoma.

• Colostomy. A surgically-created opening in the abdomen through which a small portion of the colon is brought up to the surface of the skin. Sometimes, a temporary colostomy may be performed when part of the colon has been removed and the rest of the colon needs to heal.

• Ileoanal reservoir surgery. An alternative to a permanent ileostomy, this procedure is completed in two surgeries. First, the colon and rectum are removed and a temporary ileostomy is performed. Second, the ileostomy is closed and part of the small intestine is used to create an internal pouch to hold stool. This pouch is attached to the anus. The muscle of the rectum is left in place, so the stool in the pouch does not leak out of the anus. People who have this surgery are able to control their bowel movements.

What happens if part of the bowel is removed, resulting in "short bowel syndrome?"

The intestines help to digest and absorb foods. Malabsorption occurs when food is not digested well and nutrients are not absorbed into the body. This can lead to poor growth and development. Children with short bowel syndrome (SBS) can have a reduced ability to absorb nutrients from the foods they eat. Malabsorption occurs because part of the intestines have been removed or are not functioning properly.

Common symptoms of malabsorption include the following:

• Diarrhea

• Steatorrhea (large amounts of fat in the stool)

• Weight loss or poor growth

• Dehydration

• Vitamin and mineral deficiencies

Is special nutrition needed if my child has short bowel syndrome?

Because diarrhea is the primary symptom of short bowel syndrome, the goal of the diet plan is to help control and/or reduce diarrhea and malabsorption. Guidelines that may help control diarrhea include the following:

• Eat small, frequent meals.

• Avoid foods with milk or milk products containing lactose if there is a history of lactose intolerance.

• Drink liquids at room temperature.

• Drink liquids between meals rather than with meals.

• Avoid caffeine.

• Avoid foods with sorbitol, xylitol, and mannitol.

• Avoid concentrated sweets such as candy, cakes, and pies.

• Avoid gas-producing foods such as:

  • Beans

  • Peas

  • Broccoli

  • Onions

  • Cauliflower

  • Cabbage

• Include sources of soluble fiber such as:

  • Bananas

  • Rice

  • Applesauce

  • Tapioca

  • Oatmeal

Children with short bowel syndrome often need total parenteral nutrition (TPN) to help meet their nutritional needs. TPN is a special mixture of glucose, protein, fat, vitamins, and minerals that is given through an IV into the veins. Many people call it intravenous feedings. TPN provides the nutrients your child needs when he/she cannot eat or absorb the nutrients from foods. The TPN solution is usually infused continuously over several hours of the day.

What is the long-term outlook for a child with Crohn's disease?

Crohn's disease is a chronic condition that may recur at various times over a lifetime. Children may experience physical, emotional, social, and family problems as a result of the disease, increasing the importance of proper management and treatment of the condition.

The following chart summarizes some of the problems children may face.