Evaluation of the child with suspected inflammatory bowel disease

History

Abdominal pain, appetite

Stool frequency, consistency, rectal bleeding, nocturnal diarrhea

Family history – Relatives with IBD, familial growth patterns

Previous growth data*

School attendance and daily activity

Psychosocial history, including impact upon daily life of patient and parent(s)

Physical examination

Height and weight, evaluating for trends and growth velocity*

Abdominal examination – Tenderness, mass

Rectal examination – Evaluate for perianal disease and occult blood

Rash, arthritis, clubbing, oral lesions

Sexual maturity staging (Tanner stage)*

Laboratory tests

CBC with differential count, platelets, ESR, CRP

Serum total protein, albumin

ALT, AST, GGTP (to assess for hepatobiliary disease, including primary sclerosing cholangitis)

Stool for occult blood and calprotectin or lactoferrin; urine analysis

Stool bacterial culture, ova and parasite testing, C. difficile testing

Tuberculosis screening (interferon-gamma testing or tuberculin skin test)^Δ

Titers for varicella and measles; HBV serologies^Δ

Additional tests as indicated, depending upon clinical findings:

To further characterize the type of inflammatory bowel disease – P-ANCA, ASCA^◊
To investigate other causes of diarrhea – Lactose/glucose hydrogen breath test for lactose intolerance/bacterial overgrowth, 72-hour fecal fat quantitation, and stool alpha-1 antitrypsin
If poor nutrition is suspected – Serum iron; calcium; magnesium; folate; vitamins A, E, and B12; and zinc*

Imaging

For localization of small bowel disease, 1 of the following^§:

MRE
UGI/SBFT
Abdominal CT with oral contrast

Additional tests as indicated, depending upon clinical findings – Bone age*, abdominal plain films, fistulogram or ultrasound

Endoscopy

Colonoscopy (including ileoscopy) with biopsies

Upper endoscopy with biopsies

Additional procedures as indicated:

Video capsule endoscopy if more information on small bowel involvement is needed
MRCP or ERCP if sclerosing cholangitis is suspected

IBD: inflammatory bowel disease; CBC: complete blood count; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; ALT: alanine aminotransferase; AST: aspartate aminotransferase; GGTP: gamma-glutamyl transpeptidase; C. difficile: Clostridium difficile; HBV: hepatitis B virus; P-ANCA: perinuclear antineutrophil cytoplasmic antibodies; ASCA: anti-Saccharomyces cerevisiae antibodies; MRE: magnetic resonance enterography; UGI/SBFT: upper gastrointestinal series with small bowel follow-through; CT: computed tomography; MRCP: magnetic resonance cholangiopancreatography; ERCP: endoscopic retrograde cholangiopancreatography.
* For a more detailed discussion of nutritional issues, refer to UpToDate topic review on growth failure in children with IBD.
Δ Before beginning treatment with immunosuppressing medications (especially infliximab and other tumor necrosis factor antibodies), patients should be tested for latent tuberculosis infection. In addition, immunization status should be carefully reviewed and brought up to date, including measurement of titers for varicella and measles, as well as HBV serologies. Live viral vaccines should not be given to patients with high-level immunosuppression.
◊ ASCA and P-ANCA have modest accuracy for distinguishing ulcerative colitis from Crohn disease. Additional testing for other antibodies such as anti-OmpC (outer membrane porin C) increases the sensitivity for IBD diagnosis and severity but does not help to categorize children with IBD-unclassified.
§ For a discussion of the selection of imaging techniques, refer to the UpToDate topic on diagnosis of IBD in children.

Modified with permission from: Shashidhar H, Integlia MJ, Grand RJ. Clinical manifestations of pediatric inflammatory bowel disease. In: Inflammatory Bowel Disease, Kirsner JB (Ed), WB Saunders, Philadelphia 2000. Copyright © 2000 Elsevier Science.

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Evaluation of the child with suspected inflammatory bowel disease