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Management of Pediatric Ulcerative Colitis: Joint ECCO and ESPGHAN Evidence-based Consensus Guidelines

Turner, Dan*; Levine, Arie; Escher, Johanna C.; Griffiths, Anne M.§; Russell, Richard K.||; Dignass, Axel; Dias, Jorge Amil#; Bronsky, Jiri**; Braegger, Christian P.††; Cucchiara, Salvatore‡‡; de Ridder, Lissy; Fagerberg, Ulrika L.§§; Hussey, Séamus||||; Hugot, Jean-Pierre¶¶; Kolacek, Sanja##; Kolho, Kaija Leena***; Lionetti, Paolo†††; Pærregaard, Anders‡‡‡; Potapov, Alexander§§§; Rintala, Risto***; Serban, Daniela E.||||||||||; Staiano, Annamaria¶¶¶; Sweeny, Brian||||; Veerman, Gigi###; Veres, Gabor****; Wilson, David C.††††; Ruemmele, Frank M.‡‡‡‡

Journal of Pediatric Gastroenterology & Nutrition: September 2012 - Volume 55 - Issue 3 - p 340–361
doi: 10.1097/MPG.0b013e3182662233
Clinical Guidelines

Background and Aims: Pediatric ulcerative colitis (UC) shares many features with adult-onset disease but there are some unique considerations; therefore, therapeutic approaches have to be adapted to these particular needs. We aimed to formulate guidelines for managing UC in children based on a systematic review (SR) of the literature and a robust consensus process. The present article is a product of a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).

Methods: A group of 27 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to ESPGHAN and ECCO members. A list of 23 predefined questions were addressed by working subgroups based on a SR of the literature.

Results: A total of 40 formal recommendations and 68 practice points were endorsed with a consensus rate of at least 89% regarding initial evaluation, how to monitor disease activity, the role of endoscopic evaluation, medical and surgical therapy, timing and choice of each medication, the role of combined therapy, and when to stop medications. A management flowchart, based on the Pediatric Ulcerative Colitis Activity Index (PUCAI), is presented.

Conclusions: These guidelines provide clinically useful points to guide the management of UC in children. Taken together, the recommendations offer a standardized protocol that allows effective, timely management and monitoring of the disease course, while acknowledging that each patient is unique.

*Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem

Wolfson Medical Center, Tel-Aviv University, Tel-Aviv, Israel

ErasmusMC-Sophia Children's Hospital, Rotterdam, The Netherlands

§The Hospital for Sick Children, University of Toronto, Toronto, Canada

||Yorkhill Hospital, Glasgow, UK

Agaplesion Markus Hospital, Frankfurt/Main, Germany

#Hospital S. João, Porto, Portugal

**2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic

††University Children's Hospital, Zurich, Switzerland

‡‡Pediatric Gastroenterology and Liver Unit, “La Sapienza” University, Rome, Italy

§§Centre for Clinical Research, Västmanland County Hospital, Västerås, Karolinska Institutet, Stockholm, Sweden

||||Our Lady's Children's Hospital, Crumlin Dublin, Ireland

¶¶Univ Paris-Diderot-Sorbonne Paris-Cité, Hopital Robert Debré, Paris, France

##Children's Hospital, Medical Center “Sestre Milosrdnice,” Zagreb University Medical School, Croatia

***Children's Hospital, Helsinki, University Central Hospital and University of Helsinki, Finland

†††University of Florence, Meyer Hospital, Florence, Italy

‡‡‡Hvidovre University Hospital, Copenhagen, Denmark

§§§Children's Health Russian Academy of Medical Sciences, Moscow, Russia

||||||||||University of Medicine and Pharmacy Iuliu Hatieganu, Cluj–Napoca, Romania

¶¶¶University of Naples “Federico II,” Italy

###UZ Brussels, Belgium

****Semmelweis University, Budapest, Hungary

††††Child Life and Health, University of Edinburgh, UK

‡‡‡‡Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France.

Address correspondence and reprint requests to Dan Turner, MD, PhD, Shaare Zedek Medical Center, Jerusalem, Israel (e-mail:

Received 15 June, 2012

Accepted 22 June, 2012

All authors contributed equally to this work.

R.K.R. is supported by a NHS Research Scotland career fellowship award. The work of the IBD team at Yorkhill, Glasgow, was supported by the Catherine McEwan Foundation and the Yorkhill IBD fund. R.K.R. received consultation fee, research grant, or honorarium, from MSD, Abbott, Dr Falk, Ferring, and Nestle; A.M.G. received consultation fee, research support, or speaking fee from Centocor, Janssen, Merck, Abbott, and Shire; J.C.E. received consultation fee and research grant from MSD and Janssen Biologics; J.A.D. received consultation fee from Advisory Boards for MSD, Abbott; L.d.R. received consultation fee from MSD and Shire; J.B. received consultation fee from MSD; U.L.F. received lecture fee or travel grant from Tillotts AB, Otsuka Pharma Scandinavia AB, and Schering-Plough AB; A.P. received speaker's fee from MSD, and is a consultant for Swedish Orphan Biovitrum (Shire); K.L.K. received consultation fee from Abbott, MSD, and Tillotts Pharma; A.D. served as scientific advisory member for Ferring, MSD, Centocor, Abbott, UCB, PDL, Shire, and received lecture honoraria from Ferring, Falk Foundation, MSD, Merckle Recordati, Abbott, UCB, Shire, Otsuka, Vifor, and Immundiagnostik; S.K. received honorarium from MSD, Abbott, Nestle, and Nutricia; D.T. received consultation fee, research grant, or honorarium, from MSD, Shire, Janssen, Hospital for Sick Children (PUCAI royalties), Proctor & Gamble, and Johnson & Johnson; A.L. received consultation fee, research grants, or honoraria, from MSD, Falk, Janssen, and Nestle; G.V. is a consultant to MSD, Shire, and Danone; D.C.W. received consultation fees or honoraria from MSD, Abbott, Ferring, and Nestle; F.M.R. received consultation fees, research grants, or lecture honoraria from Abbott, Biocodex, Centocor, Danone, Falk Foundation, Ferring, Johnson & Johnson, Meadjohnson, MSD, Nestlé, and Shire.

The other authors report no conflicts of interest.

Copyright 2012 by ESPGHAN and NASPGHAN