Ulcerative Colitis in a Young Boy

A 6-year-old boy is brought for evaluation of bloody diarrhea, fatigue, decreased appetite, weight loss, and occasional, mild abdominal pain of 2 months' duration. The child had 6 to 8 bowel movements daily, 1 or 2 of which occurred at night.

Physical examination was normal. The patient was afebrile and not dehydrated. The white blood cell count was 6 × 109/L with normal differentials; hemoglobin was 102 g/L with a hypochromic microcytic smear. The erythrocyte sedimentation rate was elevated at 84 mm/h; serum ferritin level, 10 µg/L; and albumin level, 40 g/L. Stool cultures were negative for ova and parasites.

Air-contrast barium enema revealed diffuse, fine mucosal ulcerations and granularity throughout the entire colon. The terminal ileum was normal. Suction biopsies of the rectal mucosa showed mild, active, diffuse inflammation with early crypt abscesses.

Drs Alexander K. C. Leung and Justine H. S. Fong of Calgary, Alberta, diagnosed ulcerative colitis. This idiopathic, chronic inflammatory disorder is localized to the colon and does not involve the upper GI tract.¹ The disease is uncommon in children.

Typically, patients present with bloody diarrhea; tenesmus, urgency, abdominal cramps, and nocturnal bowel movements indicate a more severe colitis. Fever, severe anemia, hypoalbuminemia, and leukocytosis suggest fulminant colitis. The clinical course of ulcerative colitis is marked by exacerbations without apparent cause and remissions with treatment.

Air-contrast barium enema findings in early disease consist of fine granularity that progresses to coarser granularity. In a later stage, loss of haustrations (lead pipe colon), pseudopolyps, and strictures may be found.

Sulfasalazine, an azo-bonded combination of 5-aminosalicylic acid and sulfapyridine, is the drug of choice. Try corticosteroids in children with moderate to severe pancolitis or colitis who are unresponsive to sulfasalazine. Patients with uncontrolled hemorrhage or severe colitis that fails to respond to intensive medical treatment within 2 weeks, and those with complications, such as toxic megacolon, stricture, or perforation, are candidates for colectomy.

The patient was given sulfasalazine, 500 mg tid; the bloody diarrhea resolved with treatment. He also was treated with a ferrous sulfate preparation containing 20% elemental iron, 1 mL tid, for the iron deficiency anemia. He continues to have disease remissions and exacerbations.

REFERENCE:1. Hyams J. Chronic ulcerative colitis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: WB Saunders Company; 2000;1249-1252.