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P281. The natural history of acute severe colitis in childhood ulcerative colitis

A. Thangarajah, J. Church, R. Vora, D.R. Rawat, J.E.M. Fell

Department of Paediatric Gastroenterology, Chelsea and Westminster Foundation Trust, London, United Kingdom

Aims: Ulcerative Colitis (UC) in children is extensive 90% of children have pancolitis. There is little data on the clinical course and management of acute severe colitis (ASC) in this age group. Recently the paediatric ulcerative colitis index (PUCAI) has been developed to quantify severity of clinical course. There is little data of its use in clinical practice. We reviewed admissions to our tertiary paediatric gastroenterology unit with ASC (PUCAI ≥ 40) requiring intravenous corticosteroids and subsequent long term outcome.

Methods: The natural history of ASC in children was described in a retrospective case note review of a single-centred cohort. 13 Children were identified, (7 males, 6 females), with ASC between 2006–2010. All children had a diagnosis of UC and required admission for intravenous (IV) corticosteroids with PUCAI ≥ 40. We reviewed severity of disease at diagnosis, and preadmission therapies. PUCAI scores were calculated on day (D) of initiation of IV corticosteroid therapy D1, and D3, D5 at discharge and D6 onwards if still an inpatient. Treatments, clinical and laboratory data were reviewed. For group analysis we defined response to IV corticosteroids on D3 PUCAI scores as follows:

  • Refractory >65
  • Incomplete responders >45
  • Complete responders <35–45

We also reviewed children who required escalation to second line therapies (IV cyclosporin or infliximab) and noted colectomy rates during admission, and at 6 months, 1 and 3 years follow up.

Results: ASC at first admission n = 13 with median age of 10.7 years (2 cases had 2 admissions and 1 with 3 admissions). The total number of admissions reviewed was 17, with median of 4.5 months from diagnosis. Prior to admission at 1 week 13/17 were on oral prednisolone, with a mean dose of 2 mg/kg/day. 3/17, 1/17 were on Azathioprine at 3 months and 1 month prior to admission with a mean dose of 2.1 mg/kg/day. Median PUCAI scores at admission 65 (40–85), D1 50 (45–55), D3 35 (0–70), D5 20 (0–55), and discharge 10 (0–45). The median duration of IV Corticosteroids was 3 days, with a mean dose of 1.28 mg/kg/day. 15/17 commenced on IV antibiotics. Response to IV corticosteroids on D3: 3/17 refractory, 1/17 incomplete responders, 13/17 complete responders. From the refractory/incomplete responders 2 went on to have IV cyclosporin and recurrent admissions. No children had infliximab or colectomy during admission. The colectomy rate at 2 months was 5%, and at 7 month 5%.

Conclusions: The majority (76.4%) of consecutive admissions of ASC in childhood are sensitive to IV corticosteroids by D3. This group are close from initial diagnosis, and 15.3% Azathioprine naïve at presentation. The need for second line therapy is low, required in only 2 cases. IV corticosteroid refractory cases were oral steroid dependent at 6 months follow up of first admission and had recurrent admissions thereafter. 2/3 of these cases subsequently had colectomies.