Irritable bowel syndrome

Principal changes with respect to the 2004 ECCO guidelines 

Ileocolonoscopy is recommended within the first year after surgery where treatment decisions may be affected (Statement 8C).

Thiopurines are more effective than mesalazine or imidazole antibiotics alone in post-operative prophylaxis (Statement 8F).

### 8.1 Epidemiology of post-operative Crohn's disease

In the natural history of CD, intestinal resection is almost unavoidable since about 80% of patients require surgery at some stage. Surgery is unfortunately not curative as the disease inexorably recurs in many patients. The post-operative recurrence rate varies according to the definition used: clinical, endoscopic, radiological, or surgical. It is lowest when the repeat resection rate is considered, intermediate when clinical indices are used and highest when endoscopy is employed as the diagnostic tool.1–10

Data from endoscopic follow-up of patients after resection of ileo-caecal disease have shown that in the absence of treatment, the post-operative recurrence rate is around 65–90% within 12 months and 80–100% within 3 years of the operation. The clinical recurrence without therapy is about 20–25%/year.1,10 It has been demonstrated that the post-operative clinical course of CD is best predicted by the severity of endoscopic lesions. Symptoms, in fact, appear only when severe lesions are present and it is not uncommon to observe patients with fairly advanced recurrent lesions at endoscopy who remain asymptomatic.1 For these reasons, clinical indices such as the CDAI have low sensitivity at discriminating between patients with or without post-operative recurrence.11

These data mandate strategies aimed at interrupting or delaying the natural course of post-operative recurrence. Several medications have been tried in an attempt to prevent post-operative recurrence, mostly with disappointing results. The aim of this Consensus was therefore critically to evaluate the optimal strategies for the management of post-operative recurrence in CD. Most, if not all, of the evidence available deals with …

/pdf/the-second-european-evidence-based-consensus-on-the-430j75rc37.pdf

The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations

http://www.humanities.uct.ac.za/sites/default/files/image_tool/images/38/MASTER_JCC_ECCO-ESPGHAN_Consensus_PaediatricCD_ARTICLE_IN_PRESS.pdf

Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease.

A genome-wide association study of educational attainment was conducted in a discovery sample of 101,069 individuals and a replication sample of 25,490. Three independent SNPs are genome-wide significant (rs9320913, rs11584700, rs4851266), and all three replicate. Estimated effects sizes are small (R2 ≈ 0.02%), approximately 1 month of schooling per allele. A linear polygenic score from all measured SNPs accounts for ≈ 2% of the variance in both educational attainment and cognitive function. Genes in the region of the loci have previously been associated with health, cognitive, and central nervous system phenotypes, and bioinformatics analyses suggest the involvement of the anterior caudate nucleus. These findings provide promising candidate SNPs for follow-up work, and our effect size estimates can anchor power analyses in social-science genetics.

/pdf/gwas-of-126-559-individuals-identifies-genetic-variants-2pf6p1f1de.pdf

GWAS of 126,559 Individuals Identifies Genetic Variants Associated with Educational Attainment

This is the first attempt at defining criteria for functional gastrointestinal disorders (FGIDs) in infancy, childhood, and adolescence. The decision-making process was as for adults and consisted of arriving at consensus, based on clinical experience. This paper is intended to be a quick reference. The classification system selected differs from the one used in the adult population in that it is organized according to main complaints instead of being organ-targeted. Because the child is still developing, some disorders such as toddler’s diarrhea (or functional diarrhea) are linked to certain physiologic stages; others may result from behavioral responses to sphincter function acquisition such as fecal retention; others will only be recognizable after the child is cognitively mature enough to report the symptoms (e.g., dyspepsia). Infant regurgitation, rumination, and cyclic vomiting constitute the vomiting disorders. Abdominal pain disorders are classified as: functional dyspepsia, irritable bowel syndrome (IBS), functional abdominal pain, abdominal migraine, and aerophagia. Disorders of defecation include: infant dyschezia, functional constipation, functional fecal retention, and functional non-retentive fecal soiling. Some disorders, such as IBS and dyspepsia and functional abdominal pain, are exact replications of the adult criteria because there are enough data to confirm that they represent specific and similar disorders in pediatrics. Other disorders not included in the pediatric classification, such as functional biliary disorders, do occur in children; however, existing data are insufficient to warrant including them at the present time. For these disorders, it is suggested that, for the time being, clinicians refer to the criteria established for the adult population.

Childhood functional gastrointestinal disorders

Objective To conduct a meta-analytic review of psychosocial adjustment of youth with inflammatory bowel disease (IBD). Methods Nineteen studies with a total of 1167 youth with IBD (M age = 14.33, 50% female) were included. Effect size (ES) estimates were calculated for anxiety symptoms & disorders, depressive symptoms & disorders, internalizing symptoms & disorders, externalizing symptoms, quality of life (QOL), social functioning, and self-esteem. Separate ESs were calculated for comparisons between IBD and youth with chronic illnesses versus healthy youth. Results Youth with IBD had higher rates of depressive disorders and internalizing disorders than youth with other chronic conditions. Youth with IBD had higher parent-reported internalizing symptoms, lower parent- and youth-reported QOL, and lower youth-reported social functioning compared to healthy youth. Conclusions Clinical attention to depressive disorders, QOL, and social functioning may be particularly salient in the context of pediatric IBD.

/pdf/a-meta-analytic-review-of-the-psychosocial-adjustment-of-2xwob9d2nn.pdf

A Meta-analytic Review of the Psychosocial Adjustment of Youth with Inflammatory Bowel Disease

Pediatric inflammatory bowel disease (IBD) can affect many areas of psychosocial functioning, and comprehensive medical care includes consideration of psychosocial issues as well as disease factors. The purpose of this clinical report is to review research on psychosocial functioning in pediatric IBD and to provide recommendations for care providers in the areas of psychopathology, health-related quality of life, and social, family, and school functioning. Youth with IBD are at increased risk for difficulty in all areas reviewed, and many psychosocial factors are associated with disease activity, which highlights the importance of monitoring psychosocial functioning as part of clinical care. Several interventions have empirical support or show promise for addressing psychosocial difficulty, and recommendations for monitoring and treating these issues are provided.

/pdf/psychosocial-issues-in-pediatric-inflammatory-bowel-disease-exn4sirqjy.pdf

Psychosocial issues in pediatric inflammatory bowel disease: report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

The purpose of this study was to examine reports of adherence to oral medications, parent-child concordance in reports of adherence, and factors associated with poor adherence in adolescents with inflammatory bowel disease (IBD) Participants were 50 children with IBD 11 to 17 years of age and their parents Parents completed an adherence interview and the Child Behavior Checklist, Family Assessment Device, and demographics questionnaires Separately, adolescents completed the adherence interview and the Piers Harris Self-Concept Scale, Children's Depression Inventory, and Coping Strategies Inventory questionnaires The treating gastroenterologists of participating children completed the Pediatric Crohn's Disease Activity Index during a clinic visit within a week of completion of the questionnaires Mean parent- and child-reported adherence scores fell between the "most of the time" and "always" categories, although perfect adherence was low Among IBD-specific medications (5-ASAs, immunomodulators, steroids), 48% of children and 38% of parents reported being always adherent to all medications Parent-child concordance was high Family dysfunction and poor child coping strategies were associated with worse adherence The correlation between more behavioral/emotional problems and lower adherence approached significance Adherence should be monitored in families that lack appropriate child discipline and in children who cope by simply wishing stressors would go away Because these issues are associated with poor adherence, it has been suggested that psychotherapy addressing these areas may contribute to improved adherence

Oral medication adherence in pediatric inflammatory bowel disease.

Background The purpose of this article is to review research on psychosocial functioning in pediatric inflammatory bowel disease (IBD) and to provide recommendations for future research. Methods A literature search was conducted using the MEDLINE and PsychInfo computerized databases and bibliographies of relevant articles. Results Compared with healthy children, children with IBD are at greater risk of difficulties behavioral/emotional functioning, particularly depression and anxiety, social functioning, and self-esteem. Conflicting results have been reported for the areas of family dysfunction and body image, and few studies have been published in the areas of stress and coping and eating problems. Psychosocial difficulties are clinically significant in only a subset of those with IBD and are generally similar to those found in other pediatric chronic illnesses. Conclusions The scant existing research limits conclusions about which children are most likely to experience problems. Future research should investigate a range of psychosocial outcomes, including developmentally appropriate outcomes for adolescents, and risk factors for developing problems. Prevention and intervention strategies aimed at improving psychosocial functioning in children with IBD should be developed and evaluated.

Laura M. Mackner

Papers

A Meta-analytic Review of the Psychosocial Adjustment of Youth with Inflammatory Bowel Disease

Psychosocial issues in pediatric inflammatory bowel disease: report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Oral medication adherence in pediatric inflammatory bowel disease.

Psychosocial functioning in pediatric inflammatory bowel disease.

Long-term psychosocial outcomes reported by children and adolescents with inflammatory bowel disease.