title: Severe paediatric ulcerative colitis: incidence, outcomes and optimal timing for second-line therapy.
abstract: BACKGROUND
  Despite the predominance of extensive disease in children with ulcerative colitis, data concerning severe paediatric ulcerative colitis are sparse. We reviewed rates and predictors of response to intravenous-corticosteroid therapy in a single-centre cohort with long-term follow-up.
  
  
  METHODS
  99 children (49% males; age 2-17 years) were hospitalised (1991-2000) for treatment of severe ulcerative colitis (90% extensive; 49% new onset ulcerative colitis). Clinical, laboratory and radiographic data were reviewed. A population-based subset was used to assess incidence. Predictors of corticosteroid response were analysed using univariate and multivariate analyses at days 3 and 5 of therapy. Colectomy rates were calculated using Kaplan-Meier survival analyses.
  
  
  RESULTS
  28% (95% CI, 23 to 34%) of children with ulcerative colitis resident in the Greater Toronto Area required admission for intravenous corticosteroid therapy, of whom 53 (53%; 95% CI, 44 to 63%) responded. Several predictors were associated with corticosteroid failure, but in multivariable modelling only C-reactive protein [OR = 3.5 (1.4 to 8.4)] and number of nocturnal stools [OR = 3.2 (1.6 to 6.6)] remained significant at both days 3 and 5. The Pediatric Ulcerative Colitis Activity Index (PUCAI), Travis and Lindgren's indices strongly predicted non-response. Radiographically, the upper range of colonic luminal width was 40 mm in children younger than 11 years versus 60 mm in older patients. Cumulative colectomy rates at discharge, 1 year and 6 years were 42%, 58% and 61%, respectively.
  
  
  CONCLUSIONS
  Children with ulcerative colitis commonly experience at least one severe exacerbation. Response to intravenous corticosteroids is poor. The PUCAI, determined at day 3 (>45 points) should be used to screen for patients likely to fail corticosteroids and at day 5 (>70 points) to dictate the introduction of second-line therapies.
authors.affiliation: Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada.
authors.forename: D
authors.initials: D
authors.lastname: Turner
authors.forename: C M
authors.initials: CM
authors.lastname: Walsh
authors.forename: E I
authors.initials: EI
authors.lastname: Benchimol
authors.forename: E H
authors.initials: EH
authors.lastname: Mann
authors.forename: K E
authors.initials: KE
authors.lastname: Thomas
authors.forename: C
authors.initials: C
authors.lastname: Chow
authors.forename: R A
authors.initials: RA
authors.lastname: McLernon
authors.forename: T D
authors.initials: TD
authors.lastname: Walters
authors.forename: J
authors.initials: J
authors.lastname: Swales
authors.forename: A H
authors.initials: AH
authors.lastname: Steinhart
authors.forename: A M
authors.initials: AM
authors.lastname: Griffiths
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003082:Colectomy; D003093:Colitis, Ulcerative / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000601:surgery; D003672:Defecation; D004812:Epidemiologic Methods; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use*; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D011379:Prognosis; D011859:Radiography; D012720:Severity of Illness Index; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome
chemical_list: D005938:Glucocorticoids