Pharmacologic and Supportive Therapy
The treatment of one cause of colitis, necrotizing enterocolitis (NEC), includes cessation of feedings, nasogastric decompression, and intravenous (IV) fluid resuscitation with attention to electrolytes and acid-base balance. Antibiotics should be started as soon as cultures are obtained. Close monitoring with cardiorespiratory support is provided as required. Surgical therapy (see below) is initiated if medical therapy fails.
Treatment of allergic colitis primarily involves dietary measures (see below).
Treatment of a child with pseudomembranous colitis depends on the severity of disease. Mild cases require cessation of antibiotics and supportive therapy with fluids and electrolytes. Evaluate patients with severe or persistent antibiotic-associated colitis for C difficile toxin in the stool. The patient should be treated with oral metronidazole (30 mg/kg/day in 4 divided doses) or oral vancomycin (40 mg/kg/day in 4 divided doses). Fidaxomicin was approved in 2011 by the US Food and Drug Administration for the treatment of C difficile associated disease in adults. Fecal Microbiota Transplantation is now a well-established therapy for refractory/recurrent disease.
Management of bacterial colitis is somewhat controversial. Shigellosis stands alone as the only form of bacterial colitis for which antibiotics have proved efficacious.
Antimicrobial therapy shortens the course of the illness and the duration of excretion of the organisms in the stool by alleviating the signs and symptoms and limiting the transmission of the disease. Trimethoprim-sulfamethoxazole (TMP-SMZ) is the initial drug of choice; fluoroquinolones and ceftriaxone are the alternatives.
If Salmonella bacteremia is suspected, IV cefotaxime (200 mg/kg/day in 4 divided doses) or ceftriaxone (100 mg/kg/day in 2 divided doses) should be initiated. Alternative treatments include chloramphenicol (100 mg/kg/day in 4 divided doses) or, in adolescents, fluoroquinolones. TMP-SMZ is the drug of choice when oral treatment is indicated.
If Yersinia enterocolitica infection is likely, antibiotic therapy with IV gentamicin (5-7.5 mg/kg/day in 3 divided doses) is indicated in patients with persistent diarrhea or suspected sepsis. Alternative antibiotics may include chloramphenicol, colistin, and kanamycin.
Campylobacter enteritis is usually self-limited. The organism is sensitive to erythromycin and ciprofloxacin, but antibiotic treatment has not been proven to decrease the duration of diarrhea.
Treatment of amebic colitis includes metronidazole and iodoquinol or paromomycin.
Management of inflammatory bowel disease (IBD) depends on the disease location, the disease behavior, and the severity of the disease at presentation. The general goals for managing IBD are to eliminate symptoms of disease, improve quality of life, and avoid hospitalization and surgery. One of the primary aims is to promote and allow normal, unrestricted activity. Although clinical improvement is imperatives, in order to increase the chance of lasting remission and decrease the potential for adverse effects of long-standing inflammation, mucosal healing is important. [14]
Therapy for IBD includes pharmacotherapy, surgery (see below), nutrition and bone health (see below), supportive therapy, psychotherapy, and cancer screening. [15] (See Crohn Disease and Ulcerative Colitis.)
Medications used to treat IBD can be classified into 6 categories, as follows:
-
Corticosteroids (eg, prednisone and budesonide) [18]
-
Immunomodulators (eg, azathioprine, 6-mercaptopurine [6-MP]) [19]
-
Antibiotics (eg, metronidazole and ciprofloxacin) [20]
-
Probiotics (eg, Lactobacillus GG and Saccharomyces boulardii) [21]
Children with mild manifestations can be treated as outpatients, with arrangements made for follow-up treatment with a gastroenterologist.
The initial therapy for children with mild ulcerative colitis (UC) or Crohn disease (CD) is usually sulfasalazine, a 5-aminosalicylate (5-ASA) drug that is given alone or in combination with topical enemas (eg, corticosteroid or mesalamine) or corticosteroid foam. [24] Adolescents may prefer the foam because of its ease of administration and the reduced sensation of rectal distention and urgency.
Patients with moderate and severe disease (eg, fever, bloody stools, severe abdominal pains, anemia, or hypoalbuminemia) require supportive treatment, often with IV hydration. Hospitalization is often indicated for management of acute disease with corticosteroids or immunosuppressive agents. [22]
IV methylprednisolone or hydrocortisone at a dosage equivalent to 1-2 mg/kg/day of prednisone is recommended. The goal is to use steroids for a short period and then switch to maintenance therapy as soon as possible. Maintenance therapy may require administration of 5-ASA or an immunomodulator, such as azathioprine or 6-MP.
Patients with refractory IBD or patients who present in a moderate to severe fashion may need a biologic agent, such as infliximab. [23, 25, 26] Additionally, studies in adult patients have demonstrated that for moderate-to-severe CD, combination therapy with a biologic plus an immunomodulator may be more effective than using a medication from either class alone. [27]
If toxic megacolon is suspected, aggressive resuscitation with fluids and electrolytes is required. A surgical consultation is required in patients with suspected toxic megacolon, appendicitis, intestinal obstruction, fulminant colitis, or significant GI bleeding.
Begin a combination of broad-spectrum IV antibiotics, such as ampicillin (200 mg/kg/day), gentamicin (5-7.5 mg/kg/day), and clindamycin (40 mg/kg/day). Alternate therapy may include either ampicillin-sulbactam or cefoxitin in combination with gentamicin.
No specific therapy is indicated for Henoch-Schönlein purpura (HSP). Steroids are used to treat severe abdominal pain or arthritis in selected patients.
A study by Hyams et al that evaluated 416 children 12 weeks after they were treated for ulcerative colitis with mesalazine (132 children), oral corticosteroids (141), or intravenous corticosteroids (143) reported that at week 12, corticosteroid-free remission was achieved by 64 (48%) patients in the mesalazine group, 47 (33%) in the oral corticosteroid group, and 30 (21%) in the intravenous corticosteroid group (p< 0·0001). Seven percent of patients in the mesalazine group, 15% in the oral corticosteroid group, and 36% in the intravenous corticosteroid group required treatment escalation. Eight patients who were first treated with intravenous corticosteroids underwent colectomy. Factors that predicted remission at 12 weeks included a Pediatric Ulcerative Colitis Activity Index score of less than 35, higher baseline albumin by 1 g/dL increments among children younger than 12 years, and week 4 remission. The study also reported that predictors of treatment escalation by week 12 in patients initially treated with intravenous corticosteroids included baseline total Mayo score of 11 or higher, rectal biopsy eosinophil count less than or equal to 32 cells per high power field, rectal biopsy surface villiform changes, and not achieving week 4 remission. [28]
Nutritional Therapy
Treatment of allergic colitis consists of eliminating the offending protein from the infant’s diet. Infants should receive a formula containing casein-hydrolysate as the protein source. Mothers of exclusively breastfed infants with allergic colitis should eliminate the offending proteins (typically milk or milk and soy) from their diets. Persistence of gross bleeding after 14 days after a formula change is an indication for proctosigmoidoscopy. Infants who respond to diet change should be challenged around 12-14 months of age.
A study by Baldassarre et al found that the addition of Lactobacillus rhamnosus GG (LGG) to extensively hydrolyzed casein formula (EHCF) significantly improved hematochezia and fecal calprotectin in comparison with the results noted with EHCF alone. [29] However, the long-term effects of treating infants with probiotics are unknown.
The treatment of IBD includes adequate nutritional intake and social and emotional support. Nutrition therapy may be primary or adjunctive in CD but is generally only adjunctive in UC. Defined formula diets with polymeric, semi-elemental, or elemental formulas may induce remission in as many as 80% of patients with CD. [30] The mechanism of action is unknown but may be secondary to excluding potentially harmful components in the usual diet or through changes in the composition of the gut microbiome and/or metabolome. [39]
Bowel Resection and Strictureplasty
In patients with NEC, surgical intervention is required in 30-35% of babies. [31] Exploratory laparotomy with resection of bowel and external ostomy diversion is indicated if there is failure of medical management, erythema of the abdominal wall, a single fixed loop, a palpable mass, or evidence of perforation (eg, pneumoperitoneum or brown paracentesis). Central venous access is needed after bowel resection to permit total parenteral nutrition. Closely monitor the child for complications of short bowel syndrome and central catheters.
Surgery is indicated in patients with UC or CD if uncontrolled gastrointestinal (GI) bleeding, bowel perforation, bowel obstruction, failure to respond to medical therapy, and unacceptable medical toxicity are present. [32]
Total colectomy may be indicated to treat UC when the patient has toxic megacolon or acute fulminant colitis or in selected severe forms of the disease for which medical therapy (including rescue immunosuppressive agents such as infliximab) has failed. [33]
In UC, colectomy usually involves the creation of a pouch from the distal ileum and typically is curative (see Ulcerative Colitis). As many as 70% of the children develop at least one episode of so-called pouchitis (inflammation of the pouch) following proctocolectomy. [34] This entity is of unclear origin but typically responds quickly to a course of antimicrobial treatment. Evidence from studies of adults suggests that prophylaxis with probiotics may be an effective preventative tool. [35]
In CD, surgery is not curative, because recurrent disease at the site of surgery is common. Segmental bowel resection is the most common procedure for treating CD and usually involves the diseased terminal ileum and adjacent inflamed colon. Strictureplasty should be considered if there is stenosed bowel segment without active inflammation. At times, surgical resection is used to treat growth failure. Adult studies suggest a role for biologics in prevention of postoperative recurrence of the disease, particularly prevention of endoscopic recurrence of disease. [36, 37]
-
Necrotizing enterocolitis totalis.
-
Inflammatory bowel disease. Severe colitis noted during colonoscopy. The mucosa is grossly denuded, with active bleeding noted. This patient had her colon resected very shortly after this view was obtained.
