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Inflammatory Bowel Disease in Children Glos Care Pathway

This pathway provides guidance to support the diagnosis, referral and optimal management of Inflammatory Bowel Disease (IBD) in children (aged 0-16 years) in Gloucestershire.

 

Please click the relevant flowchart box to be taken directly to textual information.

Presentation

Inflammatory bowel disease refers to chronic diseases that cause inflammation of the intestines. Ulcerative colitis and Crohn’s disease are the commonest types presenting in children, however, the terms IBD-U and microscopic colitis may also be used following confirmation of diagnosis.

Symptoms can include:

  • Diarrhoea - ranging from mild to severe (as many as 20 or more trips to the bathroom a day) for over 14 days without another cause such as travel. This may or may not be bloody
  • Young person wakes during night, or early morning, needing to have bowels open.
  • Blood in stools in the absence of constipation
  • Weight loss
  • Fever and fatigue
  • Abdominal pain
  • Anorexia, early satiety
  • Vomiting
  • Reduced appetite
  • Delayed puberty and poor growth when associated with symptoms suggesting IBD. This is more common in Crohn’s disease and occurs in about 15% young people affected.
  • Extra-intestinal manifestations – arthropathy, arthritis, episcleritis, frequent severe mouth ulcers, erythema nodosum 
  • Perianal disease in presence of other suggestive symptoms (eg unusually large fleshy skin tags, fistula)
  • Symptoms PLUS positive family history
Red Flags

Admit patients direct via on call paediatric team with the following:

  • Symptoms or signs suggesting obstruction
  • Symptoms or signs suggesting acute abdomen (e.g. toxic megacolon or unrelated e.g. appendicitis)
  • Vomiting where there is a history suggestive of IBD
  • Symptomatic anaemia particularly if ongoing rectal bleeding
  • Significant perianal disease e.g. perianal abscess or severe pain
Differential Diagnosis
  • Infectious diarrhoea
  • Coeliac disease
  • GI Polyp(s)
Initial Primary Care Assessment

  • Full blood count (FBC)
  • Plasma Viscosity or ESR
  • Liver Function Tests (LFT)
  • C-reactive Protein (CRP)
  • Renal function
  • Tissue Transglutaminase (TTG)
  • Stool culture

Practice Point

Faecal calprotectin can also be useful. However, it does not “diagnose” IBD in children and is used less often than in adults as part of primary assessment. Therefore faecal calprotectin should not be requested from primary care as a screening investigation in children under the age of 16 for isolated abdominal pain unless requested by local gastro lead or tertiary centre. If requested to be sent from primary care, please indicate which secondary or tertiary centre paediatrician has suggested, and include full history in clinical details.

  • Low haemoglobin
  • High Platelets
  • High C Reactive Protein
  • High Erythrocyte Sedimentation Rate
  • High Plasma Viscosity
  • Low Albumin
  • Low ferritin
  • High ferritin (ferritin can be raised in the presence of inflammation)

Active IBD may also be associated with abnormality of liver enzymes.

Initial Primary Care Management

Key Point

Do not start steroids in first presentation of suspected paediatric IBD.

When to Refer

If IBD suspected via regular paediatric referral pathway refer via eRs to the Paediatric Gastroenterology Service - marked 'Urgent suspected IBD'. Secretary phone 0300 422 8494 if need to discuss

If child is acutely unwell or gastroenterology lead not available and you need to discuss please refer directly via paediatrician on call (bleep 1133)

Secondary Care Management

Diagnosis is confirmed by upper and lower GI endoscopy, and MRI is often carried out.

Initial treatment after diagnosis will be individualized and initiated by specialist paediatric gastroenterology.

​Acute management in Crohn’s disease will usually be exclusive feeds, usually with Modulen for on average 6 – 8 weeks. This will be guided by dietician and shared care prescribing will be guided by dietician.

Oral steroids may be used in initial management or where feed therapy has not been successful with omeprazole for gastro protection. For courses of steroids that are more than short term or infrequent a calcium/vitamin D preparation may also be prescribed. In more unwell children and young people treatment may be initiated as an inpatient.

Mesalazine may also be used in children with suspected Ulcerative colitis +/- IBD-U In distal disease treatment may be supplemented with rectal treatment (steroid or Mesalazine enema or suppository) 

Longer term management includes second line treatment with azathioprine or methotrexate on guidance of tertiary centre and shared care prescribing and monitoring will be requested.

Anti – TNF treatment may be required in some children and young people.

All children and young people have their universal health care provided in primary care, Management of their IBD is shared with local secondary care (paediatric gastroenterology with an interest),led by tertiary paediatric gastroenterology.

Ongoing Care

Shared care drug monitoring including regular blood tests. Usual “routine” blood tests carried out are FBC, Plasma Viscosity (or ESR), LFT, CRP.  Blood test monitoring will be indicated in shared care information from tertiary centre, or in letter from local lead.

Shared care management of flare ups. Family or young person likely to make direct contact with secondary or tertiary care for advice regarding deteriorating symptoms. Phone call or letter by fax to surgery will indicate any change in treatment, Thank you for prescribing as needed.

Transition. The concept of transition will be discussed with child and family from soon after diagnosis and at regular intervals thereafter. Transition clinic appointment usually takes place post 16 and post GCSEs.

Immunisations. Annual flu jab (inactivated) recommended for patients on immunosuppression. Please refer to local and national guidelines for all immunisation advice in patients on immunosuppression.

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