Transitioning from Pediatric to Adult IBD

Stephen Hanauer, MD: Welcome to this HCPLive® Peers and Perspectives® presentation entitled, “Expert Perspectives on the Optimal Management of Inflammatory Bowel Disease.” I’m Dr Stephen Hanauer, from Northwestern University in Chicago, and I’m delighted to be joined by Dr Marla Dubinsky, from the Icahn School of Medicine at Mount Sinai in New York City. We’re going to be discussing the therapeutic approach and the available landscape for the optimal management of patients with inflammatory bowel disease [IBD]. As an initial introduction, I’m an adult gastroenterologist, and Marla treats both children and adults. It gives us a broader advantage of looking at the spectrum of IBD across the ages. Marla, why don’t you start by, since you see both adults and kids, what’s the difference in the impact of these diseases on different ages of patients?

Marla Dubinsky, MD: Yes, thanks for noting that. Realistically, we say that pediatric patients have much more impact of chronic inflammation because the overlap of the mean age of diagnosis overlaps with that of puberty. We often see children who have growth failure, particularly for Crohn disease. I look at that as an urgent reason to move to more effective therapy because to me that means there’s a systemic inflammatory effect outside of the gut. I look at that as an important extraintestinal manifestation. And interestingly Steve, you know I trained with adult IBD, so I developed this mindset that I could see what it could look like if I don’t get it right when I’m treating younger individuals who have a much longer course of possible bowel wall damage, a longer duration of disease. And we know that if we get the inflammation under control, we’ll have better impact on long-term outcomes.

Stephen Hanauer, MD: Is there an impact, or are the diseases presenting differently, according to different age groups?

Marla Dubinsky, MD: Interestingly enough, when we separate IBD in pediatrics, we talk about from ages 0 to 2, we view that as much more like an immunodeficiency. We call that true very early onset IBD, and some would even say infantile IBD when you get it that young. I still say that even if you get it between the ages of 2 and 6, we are referring to that as very early onset IBD as well. And they tend to present much more like a colitis. It is very uncommon for me to see a 4-year-old who has classic small bowel Crohn disease. I see much more colonic type presentation, which we call IBD unspecified. Even though it’s located in the colon, there’s no way to know whether this is going to end up being Crohn disease, to be 100% fair. I almost feel like their immune system hasn’t quite set up where it wants to land. And as we get away from the 6-year-old and closer to the 9-to-13 age range, it looks similar. Typically, we tend to see small bowel, more ileocolic disease, so small and large bowel. We don’t see as much isolated small bowel as I do in my older onset IBD. For example, we have more ileocolonic. Isolated small bowel is not as much of an entity, which is interesting, so I don’t know if there’s different microbiome, different genetics as we traverse from very colonic to small bowel and colonic as we get to our average onset.

Stephen Hanauer, MD: Do the kids who present with colonic evolve into different phenotypes? Do they evolve into a small bowel phenotype as well?

Marla Dubinsky, MD: Funnily enough, 20 years ago CHOP [Children’s Hospital of Philadelphia], which saw a ton of patients with IBD, showed that the earlier you were diagnosed toward puberty, toward the average age of diagnosis of pediatric patients, you may evolve to a smaller bowel-type phenotype, which I find interesting. Unfortunately, where we’re seeing this is, the earlier you operate on a patient with presumed UC [ulcerative colitis], we are then seeing Crohn disease-like inflammation in the pouch. And that happens quickly after final stage surgery. This is where we’re finding that, it’s not like the diagnosis was wrong, it’s just we didn’t have the right biology, and the patient presented like classic ulcerative colitis: sick, needed to come out. Would this mean that you wouldn’t create either the formal ileal pouch-anal anastomosis or not restore continuity until the children have grown more and have developed more in their immune system? That is an area of big interest in pediatrics, that with early onset, you could evolve later to a more classic Crohn disease, but of the pouch. Granted, it’s the ileum. That’s one interesting phenomenon that we see in this evolution, that the younger you are, we’re less certain about the diagnosis.

Transcript Edited for Clarity