Pediatric gastroenterology practitioners adopted different guidelines that focus on high-quality nutrition care for rare disorders such as inflammatory bowel disease in its two main forms: Crohn's disease and ulcerative colitis. This chapter presents a case report of ulcerative colitis with extra intestinal manifestations in the form of right knee arthritis and hypo-chromic microcytic anemia in a 13 years old Egyptian boy who presented to the outpatient services with complains of frequent attacks of right knee pain and swelling, nausea, decreased appetite and food intake, along with significant weight loss. Attacks of diarrhea associated with abdominal cramping and progressive fatigue was reported at the first visit. The authors of this case chapter aimed to share their experience in diagnosing, managing and systematically follow up a pediatric ulcerative colitis patient. The chapter refers to a comprehensive management of the patient's disease who was effectively managed by an integrated multidisciplinary approach.
TopAuthors’ Overview Of The Case
Inflammatory bowel diseases (IBD) are idiopathic disorders that lead to chronic inflammation of the gastrointestinal tract mucosa. It includes Crohn’s disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC) (Hyams, 2005). IBD affects a large parentage of the population in the United States (Kugathasan, et al., 2003). Although earlier studies reported frequent prevalence in Europe and North America, the incidence was either more or the same in countries those are developed or less developed (Soda, et al., 2003).
No exact pathogenesis of UC is known till now. However, genetic, immunologic, and environmental factors may be considered as risk factors (Bradley & Oliva-Hemker, 2012). Up to 25% of UC cases affect children and young adults, and 80% of them have pancolitis (Sawczenko & Sandhu, 2003).
Children with UC usually presented with diarrhea, bleeding per rectum, abdominal pain, and loss of weight (Levine & Burakoff, 2011). This is in addition to psychological and nutritional problems (Bradley & Oliva-Hemker, 2012).
Extra intestinal manifestations (EIMs) affect 25-40% of patients with IBD. EIMs can encompass nearly every body system such as the musculoskeletal, hepato-biliary, ocular, urinary, pulmonary systems as well as the skin. Twenty-five percent of IBD patients have more than one EIM. These manifestations may be primary in the form of inflammation or other effects of disease activity, nearly 100% of IBD patients have an abnormality outside of the gastrointestinal tract. EIMs may precede the onset of colonic symptoms in some patients (Bernstein, Blanchard, Rawsthorne, and Yu,2001).The involvement of joint is the most corporate EIM in children with IBD and may involve 16 -33% of patients at the time of presentation or throughout the follow-up process (Cardile & Romano, 2014).
Arthritis found similarly in males and females and is in general more prevalent in patients with UC than those with CD. Peripheral arthritis classically involves large joints in an asymmetric patterns (Schorr-Lesnick & Brandt, 1988). The knee is the most common affected joint. Treatment of peripheral arthritis depends on the treatment of the underlying UC. Nonsteroidal anti-inflammatory drugs (NSAID) and selective cyclooxygenase-2 (COX-2) inhibitors are used to relieve symptoms (Levine & Burakoff, 2011).
The combination of a complete clinical history, detailed physical examination, radiographic features, endoscopic assessment, and histology of tissue is the best diagnostic approach of UC requires (Bradley & Oliva-Hemker, 2012).
It is crucial to differentiate CD from UC to plan proper treatment for those patients (Evon & Ravikumara M, 2010). There are some points in distinguishing UC and CD. UC starts in the rectum in the form of confluent inflammation and progresses proximally throughout the colon in a continuous and circumferential pattern, while rectal sparing is characteristic of CD (D’Haens, Geboes, Peeters, Baert, Ectors, Rutgeerts, 1997).
Although terminal ileal involvement is in favor with CD, it could also found in some UC patients (Evon & Ravikumara, 2010).
UC affects strictly the large bowel. Therefore, barium study of the upper GIT had a great part in diagnosing small-bowel involvement in IBD and in the differentiation of UC from CD. (Stringer, 1987).
The first line of investigations for children with suspected IBD include both upper and lower gastrointestinal endoscopy using flexible endoscopy, which is harmless and is found to be well tolerated, and valid. This is crucial to differentiate UC from CD (de Bie et al., 2005). Biopsy findings are proved to be a highly sensitive in measuring the disease extent than endoscopy (Williams & Nicholls, 1994). Endoscopy should include the terminal ileum and multiple biopsies should be taken from all segments of the colon whether the mucosa is normal or not (Evon & Ravikumara, 2010). It is important to mention that architectural distortion denoting chronicity in IBD are frequently missing in initial colonic biopsies in children because they are probably to present with a relatively acute onset of symptoms (Glickman, Bousvaros A, Farraye FA, Zholudev A, Friedman S et al., 2004).
In UC, inflammatory changes are characteristically confine to the mucosa, but segmental and deep inflammation is distinctive of CD where the inflammation is transmural, with lymphoid aggregates extending to the subserosa (Evon & Ravikumara, 2010).