Fall 2004

Advances in Treating Inflammatory Bowel Disease

The intestinal tract is naturally exposed to more bacteria, including pathogens, than any other tissue in the body. And unlike the skin, which also is exposed to microbes, the bowel provides a warm, moist environment and is made of permeable tissue to allow the passage of water and nutrients. As a result, the bowel wall or lining always has a smoldering, low-level inflammatory response to keep these organisms in check. Problems begin when this inflammatory response runs out of control, causing inflammatory bowel disease (IBD).

IBD is a blanket term that includes ulcerative colitis, which manifests itself in the colon, and Crohn's disease, which can occur anywhere in the intestinal tract. IBD can cause abdominal pain, diarrhea, fever, bleeding and nutritional deficiencies.

For those with inflammatory bowel disease, these symptoms are lifelong problems that often begin in childhood. "IBD first shows up in kids 25 to 30 percent of the time, but the diagnosis is frequently delayed because the disorder is not recognized right away," says Dr. Melvin Heyman, chief of pediatric gastroenterology, hepatology and nutrition and director of the UCSF Pediatric IBD Program.

In part, this is because IBD can easily be confused with other disorders, such as gastroenteritis, infection, lactose intolerance, school avoidance behavior, Henoch-Schoenlein Purpura (HSP), hemolytic-uremic syndrome (HUS), some kinds of allergy and, rarely, cancer. A definitive diagnosis of IBD is made through X-rays, upper endoscopy, colonoscopy and a biopsy.

Certain signs should not be ignored, however, such as rectal bleeding, which often accompanies ulcerative colitis and occurs in about 20 percent of cases of Crohn's disease. "Of course, rectal bleeding can be caused by other things, but its source must be evaluated when it happens," Heyman says.

The incidence of IBD is estimated to be about 10 to15 cases per 100,000, and 25 percent to 30 percent of these cases are pediatric, Heyman says. "The number of new pediatric cases bumps up at about 9 to 12 years of age, and then goes down at about 15 to 16," he says. Heyman suspects that the number of new cases of IBD begins to decline during these mid-teen years partly because some patients in this age range are going to adult physicians rather than pediatric specialists. Heyman worries that the particular needs of these young patients might not be adequately addressed by physicians specializing in IBD in adults.

At present, IBD has no known cure. Patients can be given medications such as aminosalicylates, prednisone, azathioprine, methotrexate and the more recently approved biologic agent infliximab. None of these is perfect. Many new medications are currently under investigation -- some at UCSF -- and will offer alternative pharmacological approaches. For Crohn's disease, an "elemental" diet can be an effective alternative to the medications and is sometimes prescribed.

Heyman and his colleagues in pediatric surgery offer a procedure, called an ileoanal pullthrough, sometimes done laparoscopically, which provides relief in most cases of ulcerative colitis that does not respond to medication. "Kids never say, `I wish I hadn't done it' after they get the proceedure," Heyman says. "They usually wish they had tried it sooner."

In addition to clinical trials, Heyman and his colleagues are involved in studies that look at possible environmental factors involved in the disease process. A separate project is to continue development of a database of all kids who have been diagnosed with IBD so that researchers can construct a natural history and progression of the disease in children.

UCSF takes a team approach to treating kids with IBD, involving pediatricians, pediatric surgeons, nutritionists, pathologists, pharmacists, and staff from social services and the Child Life services. They also consult with pediatric specialists in radiology, infectious diseases, endocrinology and urology. "That's one of our great strengths," Heyman says. "At UCSF Benioff Children's Hospital, we have pediatric specialists in all these areas, which makes us stand apart from other hospitals."

Pediatric Gastroenterology, Hepatology and Nutrition (415) 476-5892

Pediatric gastroenterologists at UCSF Benioff Children's Hospital diagnose and manage digestive, nutritional and liver disorders in infants, children and teens. We treat a wide range of conditions including malabsorption syndromes, feeding problems, functional gastrointestinal disorders, Crohn's disease, gastroesophageal reflux, diarrheal disorders, motility disorders, acute and chronic inflammatory bowel disease, acute and chronic hepatitis, inherited metabolic and immunological defects and liver failure requiring artificial liver support or liver transplant.


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