Is Surgery Necessary for a Child with Crohn’s Disease?

Source: Patel HI, et al. Surgery for Crohn’s disease in infants and children. J Pediatr Surg 1997;32:1063-1068.

Patel and associates find that in following more than 200 children with Crohn’s disease (median 4-year follow-up), 46% of children required surgical intervention. Almost half of the patients who were operated on had recurrence of disease, with the average being about two years after surgical resection.

The percentage of children with Crohn’s disease operated on in this study may be a little higher than the norm, but, since severe cases of childhood Crohn’s disease that require surgery are more likely to be referred to a tertiary pediatric center, the take-home message of this study is valid: A child with Crohn’s disease is quite likely to require surgery, and the rate of recurrence after surgery is quite high even with optimal medical management.

In recent years, the advent of new non-steroidal agents may be reducing the morbidity and possibly the need for surgical interventions associated with Crohn’s disease.

The first group of agents is the salicylates that are released proximal to the colon. While Azulfidine has long been used to treat ulcerative colitis, it does not release much of its therapeutic salicylate moiety proximal to the colon.

Mesalamine, a salicylate that can be administered in forms that are active in the small intestine, is likely to be of benefit to many patients with small bowel Crohn’s disease.

The second agent, which has even greater potential to reduce the morbidity of Crohn’s disease during childhood, is 6-mercaptopurine (6-MP). Children who would otherwise be steroid-dependent are able to do quite well off of steroids while on 6-MP or its metabolite, azathioprine.

While surgical intervention is unavoidable in many patients with Crohn’s disease, a coordinated effort with the medical therapies currently available can result in decreased morbidity in this patient population. —ach