Perioperative Management of Pediatric Crohn’s Disease

Abstract

C rohn disease (CD) is a chronic inflammatory condition that may affect any part of the gastrointestinal tract. It is transmural in nature and complications such as fistula, strictures, and perianal disease may occur. There is more extensive anatomic involvement (50% ileocolonic, 20% colonic, 30% with upper Gastrointestinal (GI) symptoms) and a higher surgical risk in pediatrics than adults (50% vs 14% by age 30). Studies have shown 3.4%-7.9% of patients require surgery in first year after diagnosis, 13.8%-47.2% by 5 years, and 28%-35% by 10 years (1). There are 3 major surgical categories: ileocecal resection, treatment of complication, (fistula/stricture-Figures 1 and 2) or salvage procedure for severe refractory disease. In addition, surgery may be considered with active short segment disease or children illustrating poor growth despite optimized medical therapy European Society of Gastroenterology, Hepatology and Nutriiton (ESPGHAN). Unfortunately, much data on pediatrics is derived from single centers rather than population-based cohorts and the most recent societal reports were based on studies with minimal biologic use (18%-24%) (1). Despite larger use of biologics, resection is still needed in 20%-34%, thus effective perioperative management of pediatric CD is imperative (1). RISK FACTORS PREDICTING AGGRESSIVE DISEASEIn adults, early age of diagnosis (<40 years) and steroid use within first year of diagnosis have been identified as risk factors for more aggressive disease, indicating a clear need for separate pediatric criteria (1,2). Pediatric risk factors include complicated disease behavior, poor growth, ASCA positivity, NOD2 genotype, in addition to leukocytosis and hypoalbuminemia (Table 1) (1,3) Dubinsky et al (4) has shown that an increased risk of surgery is associated with number and magnitude of serologic markers. A recent consensus statement additionally described old age at presentation, small bowel disease, perianal disease, and ethnicity as risk factors for penetrating and/or stricturing disease (5). Isolated colonic disease was protective, as well as immunomodulator use within first 30 days, upper GI tract disease, and younger age at presentation (1,5).