healing occurs rarely. Metronidazole should be given for at
least 6 weeks but no longer than 3 months because of
concerns about peripheral neuropathy. Other antibacterials
should be given if specifically indicated (e.g. in sepsis
associated withfistulae and perianal disease) and for
managing bacterial overgrowth in the small bowel.
Either azathioprine p. 518 or mercaptopurine p. 543
[unlicensed indications] is used to control the inflammation
in perianal and enterocutaneousfistulating Crohn’s disease
and they are continued for maintenance.
Infliximab p. 33 is recommended for children with
perianal and enterocutaneous activefistulating Crohn’s
disease who have not responded to conventional therapy
(including antibacterials, drainage and immunosuppressive
treatments), or who are intolerant of or have contra-
indications to conventional therapy. Infliximab should be
used after ensuring that all sepsis is actively draining.
Abscess drainage,fistulotomy, and seton insertion may be
appropriate, particularly before infliximab treatment.
Azathioprine, mercaptopurine or infliximab should be
continued as maintenance treatment for at least one year.
For the management of non-perianalfistulating Crohn’s
disease (including entero-gynaecological and enterovesical
fistulae) surgery is the only recommended approach.h
Useful Resources
Crohn’s disease: management in adults, children and young
people. Clinical guideline 152. October 2012 (updated May
2016 ).
http://www.nice.org.uk/guidance/cg 152
Ulcerative colitis 20-Feb-2017
Description of condition
Ulcerative colitis is a chronic inflammatory condition,
characterised by diffuse mucosal inflammation—it has a
relapsing-remitting pattern. It is a life-long disease that is
associated with significant morbidity. Ulcerative colitis is
more common in adults; however in children it
predominately presents between the ages of 5 and 16 years.
The pattern of inflammation is continuous, extending
from the rectum upwards to a varying degree. Inflammation
of the rectum is referred to asproctitis, and inflammation of
the rectum and sigmoid colon asproctosigmoiditis.Left-
sided colitisrefers to disease involving the colon distal to
the splenicflexure.Extensive colitisaffects the colon
proximal to the splenicflexure, and includes pan-colitis,
where the whole colon is involved. Child-onset ulcerative
colitis is classified as extensive in 60 – 80 % of all cases.
Common symptoms of active disease or relapse include
bloody diarrhoea, an urgent need to defaecate, and
abdominal pain.
Ulcerative colitis is classified assubacuteif it is moderate-
to-severely active disease which can be managed in an
outpatient setting, and does not require hospitalisation or
consideration of urgent surgical intervention.
Complications associated with ulcerative colitis include an
increased risk of colorectal cancer, secondary osteoporosis,
venous thromboembolism and toxic megacolon. Growth and
pubertal development can be affected in children.
Aims of treatment
Treatment is focussed on treating active disease to manage
symptoms and to induce and maintain remission.
Drug treatment
Overview
gManagement of ulcerative colitis is dependent on
factors such as clinical severity, extent of disease, and the
child’s preference. As limited distal disease is uncommon in
children, paediatric treatment strategy depends mainly on
disease severity rather than the extent of disease. Clinical
and laboratory investigations are used to determine the
extent and severity of disease and to guide treatment.
Severity is classified as mild, moderate or severe (or in
remission) by using the Paediatric Ulcerative Colitis Activity
Index to assess bowel movement, limitations on daily
activity and the presence of abdominal pain or melaena—see
the NICE guideline for Ulcerative Colitis for further
information (Useful resourcesbelow).
The extent of disease should be considered when choosing
the route of administration for aminosalicylates and
corticosteroids; whether oral treatment, topical treatment or
both are to be used.h
If the inflammation is distal, a rectal preparation is
adequate, but if the inflammation is extended, systemic
medication is required. Either suppositories or enemas can
be offered, taking into account the child’s preferences.
gRectal foam preparations and suppositories can be
used when children have difficulty retaining liquid enemas.
Diarrhoea that is associated with active ulcerative colitis is
sometimes treated with anti-diarrhoeal drugs (such as
loperamide hydrochloride p. 49 [unlicensed under 4 years])
on the advice of a specialist; however their use is contra-
indicated in acute ulcerative colitis as they can increase the
risk of toxic megacolon.
A macrogol-containing osmotic laxative (such as
macrogol 3350 with potassium chloride, sodium bicarbonate
and sodium chloride p. 42 ) may be useful for proximal faecal
loading in proctitis.l
Oral aminosalicylates for the treatment of ulcerative
colitis are available in different preparations and release
forms.gThe preparation and dosing schedule should be
chosen taking into account the delivery characteristics and
suitability for the patient. When used to maintain remission,
single daily doses of oral aminosalicylates can be more
effective than multiple daily dosing, but may result in more
side-effects.hTreatment of acute mild-to-moderate ulcerative colitis
gAcute treatment to induce remission generally consists
of an aminosalicylate with or without a corticosteroid.
Aminosalicylatesare recommended asfirst-line
treatment for children atfirst presentation or with an
exacerbation. Oral aminosalicylates (balsalazide sodium
p. 29 [unlicensed], mesalazine p. 29 [unlicensed under
6 years], olsalazine sodium p. 31 [unlicensed under 12 years]
or sulfasalazine p. 31 [unlicensed under 2 years]) are
recommended asfirst lineexceptin children withproctitis
orproctosigmoiditiswhere a rectal aminosalicylate
(mesalazine or sulfasalazine [both unlicensed under 6 years])
is more effective. A rectal corticosteroid (budesonide p. 32
[unlicensed], hydrocortisone p. 440 [unlicensed under
2 years] or prednisolone p. 442 ) or oral prednisolone
[unlicensed under 2 years] alone can be considered in
children with proctitis or proctosigmoiditis who are
intolerant to or decline treatment with aminosalicylates, or
in whom aminosalicylates are contra-indicated.
Addition of oral beclometasone dipropionate [unlicensed]
or a rectal aminosalicylate to oral aminosalicylate treatment
may also be considered in children withleft-sidedor
extensive disease. Oral prednisolone [unlicensed under
2 years] alone is recommended for children who cannot
tolerate or who decline aminosalicylates, or in whom
aminosalicylates are contra-indicated.
Oral prednisolone [unlicensed under 2 years] should be
considered for the treatment of children with subacute
proctitis or proctosigmoiditis.
In all extents of disease, if there are no improvements
within four weeks of initial treatment or if symptoms
worsen, addition of oral prednisolone to aminosalicylate
therapy can be considered (discontinue beclometasone
dipropionate if adding oral prednisolone). If there is still no
response after 2 – 4 weeks of treatment with prednisolone,BNFC 2018 – 2019 Inflammatory bowel disease 27
Gastro-intestinal system1