Reply

Abstract

In his comment on our recent paper describing the phenotype of childhood-onset inflammatory bowel disease (IBD), Dr Matary highlights several important issues pertaining to the investigation and classification of involvement of the upper gastrointestinal (GI) tract in pediatric Crohn's disease (CD).1El-Matary W. Upper gastrointestinal involvement in pediatric Crohn's disease. Gastroenterology. In press.Google Scholar, 2Van Limbergen J. Russell R.K. Drummond H.E. et al.Definition of phenotypic characteristics of childhood-onset inflammatory bowel disease.Gastroenterology. 2008; 135: 1114-1122Abstract Full Text Full Text PDF PubMed Scopus (654) Google Scholar To enable a comparison of the pediatric phenotype with adult-onset disease, we used the Montreal classification of IBD rather than a more detailed, anatomic classification of disease extent which we have previously used in the genotype–phenotype analysis of NOD2/CARD15 variants.3Russell R.K. Drummond H.E. Nimmo E.R. et al.Genotype-phenotype analysis in childhood-onset Crohn's disease: NOD2/CARD15 variants consistently predict phenotypic characteristics of severe disease.Inflamm Bowel Dis. 2005; 11: 955-964Crossref PubMed Scopus (107) Google Scholar Our investigation protocol based on the ESPGHAN Porto-criteria, adhered to by the pediatric gastroenterologists at the 3 recruiting centers, states that biopsies are taken routinely from the upper GI tract during the investigation of pediatric IBD.4IBD Working Group of the European Society for Paediatric Gastroenterology HaNInflammatory bowel disease in children and adolescents: recommendations for diagnosis—the Porto criteria.J Pediatr Gastroenterol Nutr. 2005; 41: 1-7Crossref PubMed Scopus (629) Google Scholar Involvement of any anatomic location was defined as either macroscopic, microscopic, or both. Macroscopically, the minimum criteria for involvement of a disease location were ulceration or the presence of an aphthous lesion. Erythema and/or edema did not suffice to score a site as affected by CD. Microscopically, nonspecific inflammation or inflammatory changes that could be otherwise explained (eg, reflux esophagitis or Helicobacter pylori gastritis) were not classified as CD. Interobserver variability was addressed by the quality control of phenotypic data by a dedicated database manager (HED) after review of the case notes (including endoscopy, pathology, and radiology reports). The application of the recent Montreal classification, which has addressed some of the difficulties of previous systems in classifying pediatric IBD (specifically the involvement of the upper GI tract, which precluded classification of lower GI disease in the Vienna classification), makes comparisons with historical datasets troublesome.5Silverberg M.S. Satsangi J. Ahmad T. et al.Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: Report of a Working Party of the 2005 Montreal World Congress of Gastroenterology.Can J Gastroenterol. 2005; 19: 5A-36ACrossref PubMed Scopus (2460) Google Scholar, 6Gupta N. Bostrom A.G. Kirschner B.S. et al.Gender differences in presentation and course of disease in pediatric patients with Crohn disease.Pediatrics. 2007; 120: e1418-e1425Crossref PubMed Scopus (93) Google Scholar In these older datasets, as for example that described in the study by Lenaerts et al,7Lenaerts C. Roy C.C. Vaillancourt M. et al.High incidence of upper gastrointestinal tract involvement in children with Crohn's disease.Pediatrics. 1989; 83: 777-781PubMed Google Scholar the upper GI tract was typically not investigated in the absence of clear upper GI-related symptoms, as acknowledged in their manuscript. In the absence of clear upper GI symptoms, esophagogastroduodenoscopy is also rarely performed in the investigation of adult-onset CD.8Nikolaus S. Schreiber S. Diagnostics of inflammatory bowel disease.Gastroenterology. 2007; 133: 1670-1689Abstract Full Text Full Text PDF PubMed Scopus (298) Google Scholar However, involvement of the upper GI tract has been reported to be as high as 75% in prospective adult CD studies where esophagogastroduodenoscopy was routinely performed.9Hommes D.W. van Deventer S.J. Endoscopy in inflammatory bowel diseases.Gastroenterology. 2004; 126: 1561-1573Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 10Witte A.M.C. Veenendaal R.A. van Hogezand R.A. et al.Crohn's Disease of the Upper gastrointestinal tract: the value of endoscopic examination.Scand J Gastroenterol. 1998; 33: 100-105Crossref Google Scholar Furthermore, in the Montreal classification, jejunal disease is scored as upper GI disease (the L1 category is limited to ileal disease), which further compromises comparison with older classification systems, dividing the GI tract into the upper, small bowel, and colon. Our finding that >60% of children affected by Crohn's disease display involvement of the upper GI tract is, therefore, comparable with contemporary prospective studies in adult onset CD and further highlights the importance of a comprehensive assessment of our pediatric CD patients. Upper Gastrointestinal Involvement in Pediatric Crohn's DiseaseGastroenterologyVol. 136Issue 7PreviewThe article by Limbergen et al1 published recently in Gastroenterology was interesting. The authors examined the anatomic location and disease behaviors in a large cohort of pediatric-onset inflammatory bowel disease (IBD) in comparison with a larger cohort of adult-onset IBD. Full-Text PDF