Phenotypic Variation in Paediatric Inflammatory Bowel Disease by Age: A Multicentre Prospective Inception Cohort Study of the Canadian Children IBD Network.

Background Paediatric data on the association between diagnostic delay and inflammatory bowel disease [IBD] complications are lacking. We aimed to determine the effect of diagnostic delay on stricturing/fistulising complications, surgery, and growth impairment in a large paediatric cohort, and to identify predictors of diagnostic delay. Methods We conducted a national, prospective, multicentre IBD inception cohort study including 1399 children. Diagnostic delay was defined as time from symptom onset to diagnosis >75th percentile. Multivariable proportional hazards [PH] regression was used to examine the association between diagnostic delay and stricturing/fistulising complications and surgery, and multivariable linear regression to examine the association between diagnostic delay and growth. Predictors of diagnostic delay were identified using Cox PH regression. Results Overall (64% Crohn's disease [CD]; 36% ulcerative colitis/IBD unclassified [UC/IBD-U]; 57% male]), median time to diagnosis was 4.2 (interquartile range [IQR] 2.0-9.2) months. For the overall cohort, diagnostic delay was >9.2 months; in CD, >10.8 months and in UC/IBD-U, >6.6 months. In CD, diagnostic delay was associated with a 2.5-fold higher rate of strictures/internal fistulae (hazard ratio [HR] 2.53, 95% confidence interval [CI] 1.41-4.56). Every additional month of diagnostic delay was associated with a decrease in height-for-age z-score of 0.013 standard deviations [95% CI 0.005-0.021]. Associations persisted after adjusting for disease location and therapy. No independent association was observed between diagnostic delay and surgery in CD or UC/IBD-U. Diagnostic delay was more common in CD, particularly small bowel CD. Abdominal pain, including isolated abdominal pain in CD, was associated with diagnostic delay. Conclusions Diagnostic delay represents a risk factor for stricturing/internal fistulising complications and growth impairment in paediatric CD. Podcast This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.

Diagnostic Delay Is Associated With Complicated Disease and Growth Impairment in Paediatric Crohn's Disease

BACKGROUND AND AIMS

Length of diagnostic delay is associated with bowel strictures and intestinal surgery in adult patients with Crohn's disease [CD]. Here we assessed whether diagnostic delay similarly impacts on the natural history of paediatric CD patients.

METHODS

Data from the Swiss IBD Cohort Study were analysed. Frequency of CD-related complications [bowel stenosis, perianal fistula, internal fistula, any fistula, resection surgery, fistula/abscess surgery, any complication] at diagnosis and in the long term [up to 30 years after CD diagnosis] was compared between paediatric patients [diagnosed <18 years] and adult patients [diagnosed ≥18 years] using multivariate Cox proportional hazard regression modelling.

RESULTS

From 2006 to 2016, 387 paediatric and 1163 adult CD patients were included. Median [interquartile range: IQR] diagnostic delay was 3 [1-9] for the paediatric and 6 [1-24] months for the adult group, respectively. Adult onset CD patients presented at diagnosis more frequently with bowel stenosis [p <0.001] and bowel surgery [p <0.001] compared with paediatric CD patients. In the long term, length of diagnostic delay was significantly associated with bowel stenosis [p = 0.001], internal fistula [p = 0.038], and any complication [p = 0.024] in the adult onset CD population. No significant association between length of diagnostic delay and CD-related outcomes in the long term was observed in the paediatric population.

CONCLUSIONS

Adult CD patients have longer diagnostic delay compared with paediatric CD patients and present at diagnosis more often with bowel stenosis and surgery. Length of diagnostic delay was found to be predictive for CD-related complications only in the adult but not in the paediatric CD population.

Systematic Analysis of the Impact of Diagnostic Delay on Bowel Damage in Paediatric Versus Adult Onset Crohn's Disease.

For many conditions, delayed diagnosis results in worse outcomes, increased mortality and amplified disease burden. In children, an emphasis on rapid, accurate diagnosis in leukaemia, lymphoma and solid tumours has been associated with an increasing survival rate and reduced morbidity over the last 25 years. The challenge is to extend early diagnosis to chronic conditions in children where early intervention will improve long-term outcomes. Similarly in adult patients, rapid access clinics for specific conditions are now routine, enabling quick referral to the specialist care service to make the precise diagnosis and start the correct treatment.

In their paper, Riccuito et al reported diagnostic delay and subsequent impact on outcome in Canadian children with inflammatory bowel disease (IBD).1 

IBD, consisting of Crohn’s disease, ulcerative colitis and IBD unclassified, is a chronic, heterogeneous, relapsing and remitting condition primarily as a consequence of inflammation within the bowel lumen. Early and effective treatment is crucial to control symptoms, minimise impact on nutrition and growth and enable the child to function well (eg, attend school). Over the last 20 years, there has been a steady increase in the incidence of paedaitric inflammatory bowel disease (PIBD), with a consequent increase in children presenting to primary, secondary and tertiary care.2 Paediatric gastroenterologists have been concerned for over 25 years that diagnostic delay is common. This delay is clearly multifactorial, and to determine how best to effect change would require an analysis of all aspects of the patient pathway.

Riccuito …

https://adc.bmj.com/content/archdischild/103/4/307.full.pdf

Paediatric inflammatory bowel disease: improving early diagnosis.

Background/Aim: Delay in the diagnosis of inflammatory bowel disease (IBD) is associated with complications. Our aim was to describe the pattern and risk factors associated with delay in the diagnosis of IBD in Saudi children. Patients and Methods: This was a multicenter study with a retrospective/prospective design. Data on diagnostic delay in children with Crohn's disease (CD) and ulcerative colitis (UC) were retrieved from physician's notes. Multivariate regression analysis was used to assess the risk factors associated with long delay in diagnosis. Results: There were 240 and 183 Saudi children with CD and UC, respectively. The median delays in diagnosis were 8 and 5 months in CD and UC, respectively, significantly longer in children with CD than UC (P 75th percentile) were 24 and 8.8 months for CD and UC, respectively. Ileal location was a significant risk factor in CD and the age of onset above 10 years was protective in UC. Conclusions: Long diagnostic delay in IBD was mainly due to the longer delay in gastroenterologist consultation. Review of the referral system is needed to focus on measures to reduce long delays in diagnosis. The ileal location as a risk factor in CD and age older than 10 years as protective in UC should help recognition and early referral.

Diagnostic delay of pediatric inflammatory bowel disease in Saudi Arabia.

Objectives To determine time to diagnosis in a paediatric inflammatory bowel disease (IBD) cohort and the relative contribution of the component intervals, and to identify factors associated with diagnostic delay. Design Prospective cohort study Setting Single-centre study including children with incident IBD at the Hospital for Sick Children diagnosed between December 2013 and December 2015. Interventions Time to diagnosis and its subintervals were determined and patient, disease and institutional factors were tested for associations. Results Among 111 children, the median overall time to diagnosis was 4.5 (IQR 2.1–8.8) months. Time to diagnosis was longer in Crohn’s disease (CD) than ulcerative colitis (UC) (median 6.8 (IQR 2.9–12.5) vs 2.4 (IQR 1.3–5.3) months) and patients with isolated small bowel disease. Twenty per cent of patients were diagnosed≥1 year after symptom onset (86% CD, 14% UC, p=0.003). Time from symptom onset to gastroenterology referral was the greatest contributor to overall time to diagnosis (median 2.9 (IQR 1.6–8.2) months). Height impairment was independently associated with diagnostic delay (OR 0.59, p=0.02, for height-for-age z-score (HAZ), signifying almost 70% increased odds of delay for every 1 SD decrease in HAZ). This height discrepancy persisted 1 year after diagnosis. Bloody diarrhoea was protective against delay (OR 0.28, p=0.02). The subinterval from referral to diagnosis was shorter in patients with laboratory abnormalities, particularly hypoalbuminaemia. Conclusions Diagnostic delay was more common in CD and associated with height impairment that persisted 1 year after presentation. The greatest contributor to time to diagnosis was time from symptom onset to referral.

https://adc.bmj.com/content/archdischild/early/2017/08/09/archdischild-2017-313060.full.pdf

Diagnostic delay in Canadian children with inflammatory bowel disease is more common in Crohn’s disease and associated with decreased height

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Diagnostic delay in Canadian children with inflammatory bowel disease is more common in Crohn’s disease and associated with decreased height