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16976

Predictors of Progression to Colectomy In Children Hospitalized with Ulcerative Colitis

Saturday, October 20, 2012: 1:28 PM
Napoleon Ballroom (Hilton Riverside)
Jarod McAteer, MD1, Cindy Larison, MA2, Ghassan Wahbeh, MD3, Matthew Kronman, MD, MSCE4 and Adam B. Goldin, MD, MPH1, (1)Pediatric General and Thoracic Surgery, Seattle Children's Hospital and University of Washington, Seattle, WA, (2)Child Health, Behavior and Development, Seattle Children's Hospital and University of Washington, Seattle, WA, (3)Pediatric Gastroenterology, Seattle Children's Hospital and University of Washington, Seattle, WA, (4)Pediatric Infectious Disease, Seattle Children's Hospital and University of Washington, Seattle, WA

Purpose

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that occurs in both children and adults.  Compared to adults, UC in children is associated with more severe acute exacerbations and failure of corticosteroids.  First line treatment of exacerbations is generally IV corticosteroids, followed by infliximab or calcineurin inhibitors.  Total colectomy is reserved for patients who fail medical therapy.  Little is known regarding factors that contribute to surgical indications.  We hypothesized that the risk of receiving a colectomy varies according to specific clinical and demographic factors.  Our aim was to identify factors associated with progression to colectomy in a large cohort of pediatric UC patients.

Methods

We conducted a retrospective cohort study of inpatients in the Pediatric Health Information System database.  We identified all patients younger than 18 years old discharged between January 1, 2004 and September 30, 2011 with a primary diagnostic code for UC.  Patients with codes for Crohn’s disease were excluded.  The primary outcome measure was the odds of progressing to total colectomy.  Multiple logistic regression was used to estimate the risk of colectomy according to multiple demographic and clinical covariates.

Results

We identified 4862 patients meeting study criteria.  246 (5.1%) patients underwent total colectomy during the study period.  4512 (92.8%) patients were age 5 or older.  The most common medical therapies employed were corticosteroids (73.2%), antibiotics (51%), and 5-ASA agents (48.5%).  The odds of undergoing colectomy was increased significantly in children with diagnostic codes for sepsis, anxiety, and malnutrition.  Those patients who received TPN, biological therapy (e.g. infliximab, etanercept), or calcineurin inhibitors also had an increased risk of progressing to colectomy.  Certain medications were associated with a decreased risk of receiving a colectomy, and corticosteroids were associated with the most significant protective effect.  Each additional UC hospitalization was associated with an 18% increased risk of undergoing colectomy (Table).

Conclusion

These data identify a number of specific patient-level factors associated with an increased risk of undergoing colectomy in children with UC.  While clinical tools such as the Pediatric Ulcerative Colitis Activity Index have been validated in predicting failure of medical management and timing for second line therapy, no such tools exist for determining timing of surgery.  Our findings will help to identify factors that may predict failure of medical management and need for surgical therapy.

 

OR

95% C.I.

TPN

4.27

[2.65 – 6.90]

Sepsis

4.06

[1.78 – 9.26]

Biological Therapy

3.32

[2.06 – 5.34]

Calcineurin Inhibitors

2.62

[1.04 – 6.60]

Anxiety

2.44

[1.14 – 5.23]

Malnutrition

2.35

[1.25 – 4.40]

Metronidazole

2.09

[1.13 – 3.90]

Each hospitalization with UC

1.18

[1.10 – 1.26]

Purine Analogues

0.53

[0.32 – 0.87]

5-ASA Agents

0.30

[0.20 – 0.44]

Carbapenems

0.22

[0.05 – 0.86]

Any Antibiotics

0.21

[0.11 – 0.40]

Corticosteroids

0.20

[0.13 – 0.29]