Randomised controlled trial of paediatric magnetic positioning device assisted colonoscopy: a pilot and feasibility study.

BACKGROUND AND AIMS: Complete colonoscopy is critical for the evaluation of many paediatric gastrointestinal diseases. The aim of the study was to investigate the feasibility of magnetic positioning device for paediatric colonoscopy and to compare completion rate and procedure time with and without the device. METHODS: Prospective randomised controlled trial of standard colonoscopy compared to magnetic positioning device assisted colonoscopy in children and adolescents ages 7-20 years was performed. RESULTS: Analysis showed that the proportion of successfully completed colonoscopies were 19/20 (95%) in the MP arm versus 17/18 (94.4%) in the SC arm, p=NS. The median time to complete colonoscopy to the cecum was 16.5 min (range 6-52 min) in the MP arm and 12 min (range 6-33 min) in the SC arm, p=NS. CONCLUSIONS: Our preliminary data suggest that the use of magnetic positioning device for colonoscopy is feasible in paediatric patients. These data suggest that the use of magnetic positioning device may not be of benefit for experienced endoscopists who achieved very high colonoscopy completion rates without the MP device. Further studies are needed to determine its role in paediatric colonoscopy since this device may be of more benefit for physicians in training.

Growth, body composition, and nutritional status in children and adolescents with Crohn's disease.

OBJECTIVE: To examine growth, body composition, and nutritional status in a large sample of children, adolescents, and young adults with Crohn's disease (CD). METHODS: One hundred thirty-two subjects (48 females) with CD, aged 5 to 25 years, and 66 healthy control subjects (37 females) of similar age. Growth, nutritional status, and body composition were measured by anthropometry and dual-energy x-ray absorptiometry. Genetic potential of linear growth was predicted using the adjusted heights of Himes et al. Pubertal status and skeletal age were assessed. Average Pediatric Crohn's Disease Activity Index (PCDAI) and lifetime steroid exposure (in milligrams per day) were obtained from medical charts. The variables were examined in relation to gender and measures of disease activity. RESULTS: Males and females with CD did not differ by age, disease duration, or PCDAI. Males with CD had significantly lower values for growth and nutritional status than control subjects (z-scores for weight: -0.66 +/- 1.18 vs. 0.26 +/- 0.95, P = 0.00002; height -0.81 +/- 1.14 vs. 0.28 +/- 0.93, P = 0.00001; adjusted height -1.05 +/- 1.03 vs. 0.40 +/- 1.03, P = 0.00001) and delayed skeletal age of 0.9 +/- 1.6 years. Impaired linear growth in the males was present regardless of pubertal stage. Associations between disease severity indicators and growth parameters were more consistent for females. CONCLUSIONS: Crohn's disease is associated with impaired growth. Despite similarities in disease duration, activity, and lifetime steroid exposure, growth in males was more impaired. Gender may confer risk for impaired growth in CD.

Risk factors for low bone mineral density in children and young adults with Crohn's disease.

OBJECTIVE: Low bone mineral density (BMD) is a recognized complication of Crohn's disease (CD). The aim of this study was to identify the risk factors for low BMD in pediatric patients with CD. STUDY DESIGN: One hundred nineteen subjects with CD ranging in age from 5 to 25 years were enrolled. BMD of the lumbar spine was measured by dual-energy x-ray absorptiometry. Growth parameters were assessed by examination. Disease-specific variables and use of selected medications were determined by chart review. RESULTS: Powerful risk factors for low BMD z-score included hypoalbuminemia, exposure to nasogastric tube feeds, total parenteral nutrition, 6-mercaptopurine, and corticosteroids. Corticosteroid dosing at a level >7.5 mg/d, 5000 mg lifetime cumulative dose, or >12 months of lifetime exposure were significant risk factors for low BMD z-score. Weaker but significant associations with low BMD z-scores included measures of disease severity such as pediatric Crohn's disease activity index, hospital admissions, and length of hospital stay. Site and duration of disease were not predictive. CONCLUSIONS: The presence of several clinically available factors was predictive of poor bone mineral status in this sample of subjects with CD. Hypoalbuminemia, corticosteroid exposure, nasogastric tube feeds, total parenteral nutrition, and 6-mercaptopurine were the most powerful risk factors for low bone mineral status.

Bone mineral density in children and young adults with Crohn's disease.

Reduced bone mineral density (BMD) has been reported in adults with Crohn's disease (CD). Less is known about abnormal BMD in children and young adults with CD. The aims of this study are to determine the prevalence of low BMD and to evaluate the effect of growth and pubertal development on BMD in children and young adults with CD. One hundred-nineteen patients with CD underwent dual-energy X-ray absorptiometry (DXA) to determine BMD. Anthropometry and pubertal development were measured. Bone age was measured only in patients older than 8 years of age and who had not grown in height during the last year. One hundred-nineteen patients (72 male, 47 female) were evaluated. Seventy percent of patients had BMD z-scores < or = -1.0 and 32% had z-scores < or = -2.0. Weight and height z-scores were significantly associated with BMD z-scores. BMD z-scores based on bone age and on chronological age were highly correlated, except when the chronological age BMD z-score was < or = -2.0. BMD z-score was significantly different between males and females for the group (-1.75 +/- 1.06 vs. -1.08 +/- 1.00), respectively. Children and young adults with CD have a high prevalence of low BMD and routine evaluation by DXA is indicated. In patients with a chronological age-based BMD z-score < or = -2.0, a bone age-based BMD should be considered.

Vertebral compression fractures in pediatric patients with Crohn's disease.

Osteoporosis is known to be a significant complication of Crohn's disease in adult patients. The association of osteoporosis and the development of vertebral compression fractures is well delineated. This case report describes 5 pediatric patients with Crohn's disease in whom vertebral compression fractures associated with a marked reduction in bone density developed. As in adults, the association of osteoporosis and Crohn's disease in pediatric patients is multifactorial, including corticosteroid use, calcium and vitamin D homeostasis, malnutrition, alteration in sex hormones, and site of disease. At the time of diagnosis of the vertebral fractures, the patients' ages ranged from 10.6 to 16.8 years, they had persistent and severe back pain, and 3 of 5 patients had a decrease in height. They were taking 13.7-41.6 mg/day of corticosteroid, and all 5 patients had terminal ileal involvement. Bone mineral density measured by dual-energy x-ray absorptiometry was well below 2SD from the mean in all patients (z-score, -2.31 to -5.11). Because of the high morbidity and mortality associated with fractures that result from low bone mineral density, medical care of all pediatric patients with Crohn's disease should include an evaluation of bone mineral density.

Treatment of pediatric autoimmune enteropathy with tacrolimus (FK506).

Autoimmune enteropathy is characterized by chronic secretory diarrhea, villous atrophy, associated autoantibodies, and a partial response to immunosuppression. Currently available therapy (including steroids and cyclosporine) has resulted in remission only in a subset of patients. We evaluated the effects of tacrolimus (FK506) in patients with autoimmune enteropathy refractory to steroids and cyclosporine. Three patients with diagnosed autoimmune enteropathy who continued to have intractable diarrhea despite treatment with steroids and/or cyclosporine were treated with oral tacrolimus. Despite documented histological villous atrophy and poor absorption of oral cyclosporine, therapeutic tacrolimus levels were easily achieved in all 3 patients. All patients showed clinical improvement as documented by decreased stool output and ability to be weaned off parenteral nutrition; response time ranged from 1 to 4 months after tacrolimus was begun. Histological improvement was noted in all patients, and the small bowel biopsy specimens of 2 of the 3 patients showed a return to normal. All patients have been followed up for at least 6 months and are in clinical remission; 1 has received a bone marrow transplant for underlying immunodeficiency. Tacrolimus is a useful drug in the treatment of autoimmune enteropathy, even in patients who have not responded to steroids or cyclosporine. No long-term follow-up of patients with autoimmune enteropathy treated with tacrolimus is currently available.