Ulcerative Colitis in Children Workup: Approach Considerations, Endoscopy, Colonoscopy (original) (raw)

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. [9]

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 cell count; stool assays, including stool calprotectin; a comprehensive metabolic profile; an upper gastrointestinal series with small bowel follow-through; and an abdominal obstruction series.

See also the Guidelines section for recommendations by the American College of Gastroenterology and the American Gastroenterological Association.

eMedicine Logo

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 for diagnostic purposes unless severity of disease prevents passage to the terminal ileum. One must visualize the whole colon to determine the extent of disease.

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

eMedicine Logo

Colonoscopy

Colonoscopy with biopsy is the most valuable procedure in the evaluation of the patient with inflammatory bowel disease. Typical findings in someone with ulcerative colitis (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 it 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, noncontiguous or skip lesions, and the presence of perianal disease.

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). [10]

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.

eMedicine Logo

Serologic Markers for Inflammatory Disease

Serologic markers can provide more information; however, these alone are not diagnostic of inflammatory bowel disease (IBD) and lack accuracy to direct clinical care. [11]

Antineutrophil cytoplasmic antibody (ANCA) test is most commonly associated with ulcerative colitis (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. [12, 13, 14] 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. [15]

Anti-S cerevisiae antibody (ASCA) test is a serologic marker that is more highly associated with Crohn disease, 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. [16] The utility of serology to predict the use of medications was inconsistent across two pediatric studies. [4] Although one study showed that pANCA predicted the use of biologics in UC, the other showed no association between serologic markers and the use of steroids or immunomodulators.

eMedicine Logo

Laboratory Studies

Complete blood cell (CBC) count

A 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.

Metabolic panel

Obtain a comprehensive metabolic panel. Serum albumin levels may be low in fulminant colitis.

ESR and CRP

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

eMedicine Logo

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.

eMedicine Logo

Imaging Studies

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

Go to Ulcerative Colitis Imaging for more 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 UC, such as a polyp.

Upper gastrointestinal (GI) series

An upper GI series with small-bowel follow-through is used to evaluate for small-bowel inflammation that would support a diagnosis of Crohn disease (CD) rather than UC.

Computed tomography (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 CD rather than UC. 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 CD from UC.

Magnetic resonance imaging (MRI)

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.

MR enterography (MRE) is currently the imaging modality of choice in pediatric IBD at diagnosis. [17] It may detect small intestinal involvement, inflammatory changes in the intestinal wall, and identify disease complications (fistula, abscess, stenosis). MRE is preferred over CT scanning and fluoroscopy because of its high diagnostic accuracy and the lack of radiation exposure. [18]

Video capsule

Video capsule endoscopy is used as another modality to distinguish CD from UC. The sensitivity of video capsule in diagnosing small bowel lesions is greater than that of barium radiography. [19]

eMedicine Logo

  1. Levine A, Griffiths A, Markowitz J, et al. Pediatric modification of the Montreal classification for inflammatory bowel disease: the Paris classification. Inflamm Bowel Dis. 2011 Jun. 17(6):1314-21. [QxMD MEDLINE Link].
  2. Ye Y, Manne S, Treem WR, Bennett D. Prevalence of inflammatory bowel disease in pediatric and adult populations: recent estimates from large national databases in the United States, 2007-2016. Inflamm Bowel Dis. 2020 Mar 4. 26(4):619-25. [QxMD MEDLINE Link]. [Full Text].
  3. Rinawi F, Assa A, Eliakim R, et al. Risk of colectomy in patients with pediatric-onset ulcerative colitis. J Pediatr Gastroenterol Nutr. 2017 Oct. 65(4):410-5. [QxMD MEDLINE Link]. [Full Text].
  4. [Guideline] Orlanski-Meyer E, Aardoom M, Ricciuto A, et al. Predicting outcomes in pediatric ulcerative colitis for management optimization: systematic review and consensus statements from the Pediatric Inflammatory Bowel Disease-Ahead Program. Gastroenterology. 2021 Jan. 160(1):378-402.e22. [QxMD MEDLINE Link]. [Full Text].
  5. Koike Y, Uchida K, Inoue M, et al. Early first episode of pouchitis after ileal pouch-anal anastomosis for pediatric ulcerative colitis is a risk factor for development of chronic pouchitis. J Pediatr Surg. 2019 Sep. 54(9):1788-93. [QxMD MEDLINE Link].
  6. Ding Z, Sherlock M, Chan AKC, Zachos M. Venous thromboembolism in pediatric inflammatory bowel disease: an 11-year population-based nested case-control study in Canada. Blood Coagul Fibrinolysis. 2022 Dec 1. 33 (8):449-56. [QxMD MEDLINE Link].
  7. [Guideline] Turner D, Ruemmele FM, Orlanski-Meyer E, et al. Management of paediatric ulcerative colitis, part 1: ambulatory care-an evidence-based guideline from European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Aug. 67(2):257-91. [QxMD MEDLINE Link]. [Full Text].
  8. Turner D, Otley AR, Mack D, et al. Development, validation, and evaluation of a pediatric ulcerative colitis activity index: a prospective multicenter study. Gastroenterology. 2007 Aug. 133(2):423-32. [QxMD MEDLINE Link].
  9. Deutsch DE, Olson AD. Colonoscopy or sigmoidoscopy as the initial evaluation of pediatric patients with colitis: a survey of physician behavior and a cost analysis. J Pediatr Gastroenterol Nutr. 1997 Jul. 25(1):26-31. [QxMD MEDLINE Link].
  10. Najarian RM, Ashworth LA, Wang HH, Bousvaros A, Goldsmith JD. Microscopic/"backwash" ileitis and its association with colonic disease in new onset pediatric ulcerative colitis. J Pediatr Gastroenterol Nutr. 2019 Jun. 68(6):835-40. [QxMD MEDLINE Link].
  11. Torres J, Caprioli F, Katsanos KH, et al. Predicting outcomes to optimize disease management in inflammatory bowel diseases. J Crohns Colitis. 2016 Dec. 10(12):1385-94. [QxMD MEDLINE Link]. [Full Text].
  12. Vasiliauskas E. Serum immune markers in inflammatory bowel disease. Gastroenterology and Endoscopy News. [Full Text].
  13. Peeters M, Joossens S, Vermeire S, Vlietinck R, Bossuyt X, Rutgeerts P. Diagnostic value of anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic autoantibodies in inflammatory bowel disease. Am J Gastroenterol. 2001 Mar. 96(3):730-4. [QxMD MEDLINE Link].
  14. Dubinsky MC, Ofman JJ, Urman M, Targan SR, Seidman EG. Clinical utility of serodiagnostic testing in suspected pediatric inflammatory bowel disease. Am J Gastroenterol. 2001 Mar. 96(3):758-65. [QxMD MEDLINE Link].
  15. Hoffenberg EJ, Fidanza S, Sauaia A. Serologic testing for inflammatory bowel disease. J Pediatr. 1999 Apr. 134(4):447-52. [QxMD MEDLINE Link].
  16. Kaditis AG, Perrault J, Sandborn WJ, Landers CJ, Zinsmeister AR, Targan SR. Antineutrophil cytoplasmic antibody subtypes in children and adolescents after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr. 1998 Apr. 26(4):386-92. [QxMD MEDLINE Link].
  17. Yoon HM, Suh CH, Kim JR, et al. Diagnostic performance of magnetic resonance enterography for detection of active inflammation in children and adolescents with inflammatory bowel disease: a systematic review and diagnostic meta-analysis. JAMA Pediatr. 2017 Dec 1. 171(12):1208-16. [QxMD MEDLINE Link]. [Full Text].
  18. [Guideline] Levine A, Koletzko S, Turner D, et al, for the European Society of Pediatric Gastroenterology, Hepatology, et al. ESPGHAN revised porto criteria for the diagnosis of inflammatory bowel disease in children and adolescents. J Pediatr Gastroenterol Nutr. 2014 Jun. 58(6):795-806. [QxMD MEDLINE Link]. [Full Text].
  19. Eliakim R, Fischer D, Suissa A, et al. Wireless capsule video endoscopy is a superior diagnostic tool in comparison to barium follow-through and computerized tomography in patients with suspected Crohn's disease. Eur J Gastroenterol Hepatol. 2003 Apr. 15(4):363-7. [QxMD MEDLINE Link].
  20. Fell JM, Muhammed R, Spray C, Crook K, Russell RK, BSPGHAN IBD working group. Management of ulcerative colitis. Arch Dis Child. 2016 May. 101(5):469-74. [QxMD MEDLINE Link]. [Full Text].
  21. [Guideline] Cohen JL, Strong SA, Hyman NH, et al, for the Standards Practice Task Force American Society of Colon and Rectal Surgeons. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum. 2005 Nov. 48(11):1997-2009. [QxMD MEDLINE Link].
  22. Kam L. Ulcerative colitis in young adults. Complexities of diagnosis and management. Postgrad Med. 1998 Jan. 103(1):45-9, 53-6, 59. [QxMD MEDLINE Link].
  23. Sarigol S, Wyllie R, Gramlich T, et al. Incidence of dysplasia in pelvic pouches in pediatric patients after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr. 1999 Apr. 28(4):429-34. [QxMD MEDLINE Link].
  24. Asacol (mesalamine) [package insert]. Rockaway, NJ: Warner Chilcott. 2013. Available at [Full Text].
  25. [Guideline] Turner D, Ruemmele FM, Orlanski-Meyer E, et al. Management of paediatric ulcerative colitis, part 2: acute severe colitis-an evidence-based consensus guideline from the European Crohn's and Colitis Organization and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Aug. 67(2):292-310. [QxMD MEDLINE Link]. [Full Text].
  26. Pini Prato A, Pio L, Leonelli L, et al. Morbidity and risk factors of laparoscopic-assisted ileostomies in children with ulcerative colitis. J Pediatr Gastroenterol Nutr. 2016 Jun. 62(6):858-62. [QxMD MEDLINE Link].
  27. Eidelwein AP, Cuffari C, Abadom V, Oliva-Hemker M. Infliximab efficacy in pediatric ulcerative colitis. Inflamm Bowel Dis. 2005 Mar. 11(3):213-8. [QxMD MEDLINE Link].
  28. Becker JM. Surgical therapy for ulcerative colitis and Crohn's disease. Gastroenterol Clin North Am. 1999 Jun. 28(2):371-90, viii-ix. [QxMD MEDLINE Link].
  29. Bismar N, Knod JL, Patel AS, Schindel DT. Outcomes following two-stage surgical approaches in the treatment of pediatric ulcerative colitis. J Pediatr Surg. 2019 Aug. 54(8):1601-3. [QxMD MEDLINE Link].
  30. [Guideline] Holubar SD, Lightner AL, Poylin V, et al, on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical practice guidelines for the surgical management of ulcerative colitis. Dis Colon Rectum. 2021 Jul 1. 64(7):783-804. [QxMD MEDLINE Link]. [Full Text].
  31. [Guideline] De Simone B, Davies J, Chouillard E, et al. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg. 2021 May 11. 16(1):23. [QxMD MEDLINE Link]. [Full Text].
  32. [Guideline] Kucharzik T, Ellul P, Greuter T, et al. ECCO guidelines on the prevention, diagnosis, and management of infections in inflammatory bowel disease. J Crohns Colitis. 2021 Jun 22. 15(6):879-913. [QxMD MEDLINE Link]. [Full Text].
  33. [Guideline] Ko CW, Singh S, Feuerstein JD, et al, for the American Gastroenterological Association Institute Clinical Guidelines Committee. AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis. Gastroenterology. 2019 Feb. 156(3):748-64. [QxMD MEDLINE Link]. [Full Text].
  34. American Gastroenterological Association. New guideline provides recommendations for the treatment of mild-to-moderate ulcerative colitis. January 9, 2019. Gastro.org. Available at https://www.gastro.org/press-release/new-guideline-provides-recommendations-for-the-treatment-of-mild-to-moderate-ulcerative-colitis. Accessed: March 20, 2019.
  35. [Guideline] Farraye FA, Melmed GY, Lichtenstein GR, Kane SV. ACG clinical guideline: preventive care in inflammatory bowel disease. Am J Gastroenterol. 2017 Feb. 112(2):241-58. [QxMD MEDLINE Link]. [Full Text].
  36. Salzmann M, von Graffenried T, Righini-Grunder F, et al, for the Swiss IBD Cohort Study Group. Drug-related adverse events necessitating treatment discontinuation in pediatric inflammatory bowel disease patients. J Pediatr Gastroenterol Nutr. 2022 Dec 1. 75 (6):731-6. [QxMD MEDLINE Link]. [Full Text].
  37. Miele E, Pascarella F, Giannetti E, Quaglietta L, Baldassano RN, Staiano A. Effect of a probiotic preparation (VSL#3) on induction and maintenance of remission in children with ulcerative colitis. Am J Gastroenterol. 2009 Feb. 104(2):437-43. [QxMD MEDLINE Link].
  38. Ziring DA, Wu SS, Mow WS, Martin MG, Mehra M, Ament ME. Oral tacrolimus for steroid-dependent and steroid-resistant ulcerative colitis in children. J Pediatr Gastroenterol Nutr. 2007 Sep. 45(3):306-11. [QxMD MEDLINE Link].
  39. Wiernicka A, Szymanska S, Cielecka-Kuszyk J, Dadalski M, Kierkus J. Histological healing after infliximab induction therapy in children with ulcerative colitis. World J Gastroenterol. 2015 Oct 7. 21(37):10654-61. [QxMD MEDLINE Link]. [Full Text].
  40. Mamula P, Markowitz JE, Brown KA, Hurd LB, Piccoli DA, Baldassano RN. Infliximab as a novel therapy for pediatric ulcerative colitis. J Pediatr Gastroenterol Nutr. 2002 Mar. 34(3):307-11. [QxMD MEDLINE Link].
  41. Scarpato E, Russo M, Staiano A. Probiotics in pediatric gastroenterology: emerging indications: inflammatory bowel diseases. J Clin Gastroenterol. 2018 Nov/Dec. 52 suppl 1, Proceedings from the 9th Probiotics, Prebiotics and New Foods, Nutraceuticals and Botanicals for Nutrition & Human and Microbiota Health Meeting, held in Rome, Italy from September 10 to 12, 2017:S7-9. [QxMD MEDLINE Link].
  42. Tan Tanny SP, Yoo M, Hutson JM, Langer JC, King SK. Current surgical practice in pediatric ulcerative colitis: a systematic review. J Pediatr Surg. 2019 Jul. 54(7):1324-30. [QxMD MEDLINE Link].

Author

Mutaz I Sultan, MD, MBChB Assistant Professor and Chief of Pediatrics, Al-Quds University Medical College; Pediatric Gastroenterologist and Hepatologist, Division of Pediatrics, Makassed Hospital, Palestine

Mutaz I Sultan, MD, MBChB is a member of the following medical societies: European Society for Paediatric Gastroenterology, Hepatology and Nutrition, Palestine Medical Council

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. for: Abbott Nutritional, Abbvie, speakers' bureau.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Judith R Kelsen, MD Ann and Richard Frankel Chair in Gastroenterology Research, Director, Very Early-Onset Inflammatory Bowel Disease Program, Associate Professor of Pediatrics, Division of GI, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania

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.

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.