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Ulcerative Colitis in Children Workup

  • Author: Judith R Kelsen, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Nov 19, 2015
 

Approach Considerations

Endoscopy must be performed if ulcerative colitis (UC) is suspected. A full colonoscopy is always indicated. As a result, going directly to colonoscopy is more cost-effective in many cases.[2]

Antineutrophil cytoplasmic antibodies (ANCA) and anti– Saccharomyces cerevisiae antibodies (ASCA) have been the most intensely studied serologic markers for inflammatory disease.

Other studies include complete blood count, stool assays, comprehensive metabolic profile, an upper GI series with small bowel follow through, and abdominal obstruction series.

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Endoscopy

An upper endoscopy and colonoscopy are performed. Wireless video capsule endoscopy, also known as the Pillcam, is an increasingly used imaging technology that may reveal small bowel involvement in inflammatory bowel disease that differentiates Crohn disease from ulcerative colitis.

Proceeding directly to full colonoscopy may be especially applicable in young children, in whom flexible sigmoidoscopy is likely to necessitate the same degree of sedation as is used with colonoscopy. A flexible sigmoidoscopy is never indicated in the pediatric population. One must visualize the whole colon to determine the extent of disease.

Go to Rigid Sigmoidoscopy for more complete information on this topic.

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Colonoscopy

Colonoscopy with biopsy is the most valuable procedure in the evaluation of the patient with inflammatory bowel disease. Typical findings in someone with UC are inflammation that is first evident in the rectum and that proximally extends in a contiguous fashion. The mucosa typically appears erythematous, friable, and granular and has lost the normally visible vascular markings. Findings more consistent with Crohn disease (CD) than with UC are sparing of the rectal mucosa, aphthous ulceration, and noncontiguous or skip lesions.

When possible, visualizing the entire colon and the last portion of the ileum (terminal ileum) is optimal, because the terminal ileum is not actively involved in UC but is commonly involved in CD. Nevertheless, patients with pancolitis occasionally have microscopic inflammation in the terminal ileum, which is thought to be secondary to reflux of colonic contents through an inflamed ileocecal valve (ie, backwash ileitis).

Biopsy findings consistent with UC are polymorphonuclear leukocytes near the base of the crypts. Cryptitis describes aggregation of polyps in the crypt epithelium, and the term crypt abscess is used when polyps have accumulated in the lumen of the crypt.

Lymphocytes, eosinophils, and mast cells may also be observed in the lamina propria in acute UC. No pathognomonic biopsy findings have been described for UC, however. Noncaseating granulomas are diagnostic of CD.

Go to Colonoscopy for more complete information on this topic.

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Serologic Markers for Inflammatory Disease

ANCA is most commonly associated with UC. ANCA assay results are positive in 60-80% of UC patients. The finding of ANCA is roughly 50% sensitive and 94% specific, and it has a 76% positive predictive value for UC.[3, 4, 5] ANCA is present in only about 40% of patients with Crohn disease.

Specifically, perinuclear ANCA (pANCA), found on the inside of the nuclear membrane, is highly associated with UC. The presence of pANCA is associated with an earlier need for surgery.

For children with ambiguous and mild complaints and for whom UC is part of the differential diagnosis, algorithms have been proposed in which the presence of ANCA is used to identify those patients who require more invasive diagnostic tests.[6]

ASCA is a serological marker that is more highly associated with CD, being present in 60% of cases; ASCA is present in only 12% of UC patients.

ANCA and ASCA titers are not correlated with disease activity.[7]

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Complete Blood Cell Count

A complete blood cell (CBC) count commonly reveals a mild anemia, which can be due to chronic blood loss (ie, microcytic, hypochromic) or may represent chronic disease (ie, normocytic). In cases of fulminant colitis, severe anemia may be present. The CBC discloses the hematocrit level, which may be decreased in children with chronic disease or acute bleeding.

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Stool Assays

Obtain stool cultures to rule out infectious colitis. Obtain an assay for E coli H7:0157 if the patient's symptoms are consistent with hemolytic-uremic syndrome.

Obtain a stool assay for C difficile toxins A and B, because C difficile colitis can mimic ulcerative colitis, or it may be responsible for a flare. Evaluation for toxin A or toxin B alone is inadequate for an accurate diagnosis of C difficile infection.

The fecal calprotectin level may be elevated during times of active inflammation. Calprotectin is a calcium-binding S-100 protein found in the neutrophil cytosol that is released with cell activation or death. An assay for calprotectin is now commercially available and may be useful to differentiate a disease flare from other causes of abdominal pain or diarrhea.

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Comprehensive Metabolic Panel

Serum albumin levels may be low in fulminant colitis.

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ESR and C-Reactive Protein

Erythrocyte sedimentation rate (ESR) and C-reactive protein level are frequently elevated during active disease. Micronutrient and vitamin levels are typically low in CD but less commonly so in UC. Liver dysfunction may indicate sclerosing cholangitis or autoimmune hepatitis.

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Imaging in Ulcerative Colitis

In all children except those with sepsis, imaging studies should be undertaken only if they are deemed necessary after endoscopic evaluation is complete.

Go to Imaging in Ulcerative Colitis for complete information on this topic.

Abdominal obstruction series

An abdominal obstruction series (ie, supine and upright abdominal radiography) is useful to evaluate for air-fluid levels, dilated loops of bowel, evidence of obstruction, or possible toxic megacolon. No pathognomonic findings for UC with this type of study have been reported.

Barium enema

Barium enema study is useful to evaluate the colon for stricture and for mucosal abnormalities, especially when colonoscopy cannot be performed. Barium enema studies may also demonstrate a source of bleeding other than ulcerative colitis, such as a polyp.

Upper GI series

An upper gastrointestinal series with small-bowel follow-through is used to evaluate for small-bowel inflammation that would support a diagnosis of Crohn disease rather than ulcerative colitis.

CT scanning

CT scanning of the abdomen is useful to evaluate for bowel-wall thickening and obstruction. If present, abscesses and fistulae imply a diagnosis of Crohn disease rather than ulcerative colitis. Many children with a preliminary diagnosis of inflammatory bowel disease undergo CT scanning of the abdomen as part of the initial evaluation of abdominal pain.

Nuclear imaging

Radionuclide-tagged white blood cell scanning can be used to demonstrate small-bowel inflammation that differentiates Crohn disease from ulcerative colitis.

Magnetic resonance imaging

MRI of the abdomen is increasingly used to evaluate the large and small bowel for inflammatory changes and to look for transmural versus mucosal inflammation.

Video capsule

Video capsule endoscopy is used as another modality to distinguish Crohn disease from ulcerative colitis. The sensitivity of video capsule in diagnosing small bowel lesions is greater than that of barium radiography.[8]

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Contributor Information and Disclosures
Author

Judith R Kelsen, MD Assistant Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia

Judith R Kelsen, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Coauthor(s)

Petar Mamula, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine

Petar Mamula, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Gastrointestinal Endoscopy, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Acknowledgements

Robert Baldassano, MD, Director, Center for Pediatric Inflammatory Bowel Disease, Children's Hospital of Philadelphia; Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Pennsylvania School of Medicine

Robert Baldassano, MD is a member of the following medical societies:Alpha Omega Alpha, American Academy of Pediatrics, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Abbott Inc, Consulting fee, Consulting

Liz D Dancel, MD Intern, Department of Pediatrics, Greenville Hospital System University Medical Center

Disclosure: Nothing to disclose.

Jonathan Markowitz, MD Assistant Professor, Department of Pediatrics, Inpatient Gastroenterology, Division of Gastroenterology and Nutrition, University of Pennsylvania School of Medicine; Director, The Children's Hospital of Philadelphia.

Jonathan Markowitz is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

David A Piccoli, MD Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Jorge H Vargas, MD Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
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Ulcerative colitis. Specimen from colectomy reveals diffusely hemorrhagic granular mucosa in a continuous distribution.
Histological section: diffuse inflammatory process, limited to mucosa and superficial portion of the submucosa (full thickness biopsy,staining, magnification).
Histological section: diffuse inflammatory process, limited to mucosa and superficial portion of the submucosa (full thickness biopsy,staining, magnification).
 
 
 
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