Severe paediatric ulcerative colitis: incidence, outcomes and optimal timing for second-line therapy
- D Turner1,
- C M Walsh1,
- E I Benchimol1,
- E H Mann2,
- K E Thomas2,
- C Chow1,
- R A McLernon1,
- T D Walters1,
- J Swales1,
- A H Steinhart3,
- A M Griffiths1
- 1Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Canada
- 2Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Canada
- 3Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Canada
- Dr Anne Griffiths, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada;
- Revised 13 September 2007
- Accepted 10 October 2007
- Published Online First 2 November 2007
Background: Despite the predominance of extensive disease in children with ulcerative colitis, data concerning severe paediatric ulcerative colitis are sparse. We reviewed rates and predictors of response to intravenous-corticosteroid therapy in a single-centre cohort with long-term follow-up.
Methods: 99 children (49% males; age 2–17 years) were hospitalised (1991–2000) for treatment of severe ulcerative colitis (90% extensive; 49% new onset ulcerative colitis). Clinical, laboratory and radiographic data were reviewed. A population-based subset was used to assess incidence. Predictors of corticosteroid response were analysed using univariate and multivariate analyses at days 3 and 5 of therapy. Colectomy rates were calculated using Kaplan–Meier survival analyses.
Results: 28% (95% CI, 23 to 34%) of children with ulcerative colitis resident in the Greater Toronto Area required admission for intravenous corticosteroid therapy, of whom 53 (53%; 95% CI, 44 to 63%) responded. Several predictors were associated with corticosteroid failure, but in multivariable modelling only C-reactive protein [OR = 3.5 (1.4 to 8.4)] and number of nocturnal stools [OR = 3.2 (1.6 to 6.6)] remained significant at both days 3 and 5. The Pediatric Ulcerative Colitis Activity Index (PUCAI), Travis and Lindgren’s indices strongly predicted non-response. Radiographically, the upper range of colonic luminal width was 40 mm in children younger than 11 years versus 60 mm in older patients. Cumulative colectomy rates at discharge, 1 year and 6 years were 42%, 58% and 61%, respectively.
Conclusions: Children with ulcerative colitis commonly experience at least one severe exacerbation. Response to intravenous corticosteroids is poor. The PUCAI, determined at day 3 (>45 points) should be used to screen for patients likely to fail corticosteroids and at day 5 (>70 points) to dictate the introduction of second-line therapies.
Competing interests: None.