Crohn's Disease

Diagnosing pediatric Crohn’s disease requires a comprehensive approach that combines medical history, physical examination, and various tests. These may include blood and stool tests to check for signs of inflammation, anemia, or nutritional deficiencies; endoscopy and colonoscopy with biopsies to directly observe and sample affected areas; and imaging studies such as magnetic resonance enterography (MRE), ultrasound, abdominal-pelvic computed tomography (CT) or video capsule endoscopy to evaluate the small intestine in detail. These methods help identify active inflammation and assess the extent of disease throughout the digestive tract.

Because symptoms can be nonspecific, confirming a diagnosis may take time. In some cases, it can be challenging to distinguish Crohn’s disease from ulcerative colitis, another form of inflammatory bowel disease, a condition referred to as indeterminate colitis. 

The main goals of treating pediatric Crohn’s disease are to control inflammation, relieve symptoms, promote growth and nutrition, and achieve long-term remission. Children are often treated with medications, and in some cases, surgery may be required if complications develop.

Traditionally, treatment has followed a “step-up” approach, starting with milder medications like corticosteroids and gradually introducing biologics if symptoms worsen or relapse occurs. However, in pediatric Crohn’s disease—where relapses are more frequent and the disease duration is longer than in adults—a “top-down” strategy is increasingly recommended. This approach involves starting biologic therapy early after diagnosis to provide intensive treatment from the outset. Early aggressive therapy is especially important in children, as inadequate treatment can negatively affect growth and lead to surgery later in life.

Common Medications for Crohn’s Disease

• 5-Aminosalicylic Acid (5-ASA): Taken orally or rectally to reduce inflammation in mild to moderate cases.
• Corticosteroids: Taken orally, rectally, or intravenously to quickly control inflammation in moderate to severe cases. While effective, corticosteroids are used for the shortest duration possible due to potential side effects such as acne, excessive hair growth, mood changes, increased appetite, facial swelling, and growth delay in children.
• Immunomodulators: Includes azathioprine and methotrexate (MTX). These medications are taken orally or by injection to suppress the immune system and reduce inflammation.
• Biologics: Administered by injection or infusion to block specific inflammatory pathways, especially in moderate to severe cases. Depending on the child’s condition or disease activity, the dosing interval and amount of biologics can be adjusted. Drug levels are regularly monitored to ensure they remain within the optimal therapeutic range.
• Antibiotics: Used as needed to reduce intestinal bacteria and manage related infections.

While many children with Crohn’s disease can be managed with medication and nutritional therapy, surgery may be necessary when medical treatment alone is no longer effective. The decision for surgery is made collaboratively by the child, family, gastroenterologist, and an IBD-specialized surgeon. Surgery aims to relieve persistent symptoms, promote growth and weight gain, and address complications.

Surgical intervention is considered in cases such as:

• A child who stops growing or has difficulty gaining weight despite medical and nutritional therapy
• Chronic or daily symptoms that do not improve with medical treatment

Development of complications, including:

• Bowel stricture or obstruction: Narrowing or blockage of the intestine
• Fistula: An abnormal connection between the intestine and another organ or skin
• Abscess: A pocket of infected fluid