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Severe paediatric ulcerative colitis: incidence, outcomes and optimal timing for second-line therapy
  1. D Turner1,
  2. C M Walsh1,
  3. E I Benchimol1,
  4. E H Mann2,
  5. K E Thomas2,
  6. C Chow1,
  7. R A McLernon1,
  8. T D Walters1,
  9. J Swales1,
  10. A H Steinhart3,
  11. A M Griffiths1
  1. 1
    Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Canada
  2. 2
    Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Canada
  3. 3
    Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Canada
  1. Dr Anne Griffiths, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada; Anne.griffiths{at}


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.

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  • Competing interests: None.

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