Pediatric Ulcerative Colitis and Pouchitis at Fellow Depth | Peds GI Boards Ep14

GastroPrep Episode 14 — Pediatric Ulcerative Colitis and Pouchitis at Fellow Depth. This pediatric gastroenterology board-review lecture, written for fellows and practicing pediatric gastroenterologists, walks through ulcerative colitis across the pediatric age range with explicit attention to acute severe UC, surgery, and post-surgical pouchitis: the Paris extent classification (E1 proctitis distal to rectosigmoid, E2 left-sided distal to splenic flexure, E3 extensive proximal to splenic flexure, E4 pancolitis); the Pediatric Ulcerative Colitis Activity Index (PUCAI) with the six clinical components and severity cutoffs (mild 10-30, moderate 35-60, severe 65 or greater) and the day 0 / day 3 / day 5 PUCAI checkpoints during acute severe UC admission that drive rescue therapy decisions per the ESPGHAN-ECCO acute severe UC algorithm (day 3 PUCAI greater than 45 triggers rescue planning; day 5 PUCAI 65 or greater triggers rescue therapy or colectomy referral); IV methylprednisolone 1-1.5 mg/kg/day (max 60 mg/day) first-line induction with infliximab rescue (accelerated dosing 5-10 mg/kg at 0/1/3 weeks for high-burden hypoalbuminemic disease) versus calcineurin-inhibitor (cyclosporine 2 mg/kg/day IV, tacrolimus oral) as alternative rescue; mild-to-moderate UC management with 5-aminosalicylates (mesalamine oral plus topical), oral budesonide MMX for left-sided disease, and the strict avoidance of long-term systemic corticosteroids; moderate-to-severe biologics with anti-TNF (infliximab, adalimumab pediatric weight-band 80→40→20 mg for under 40 kg), anti-integrin vedolizumab, anti-IL-23 (mirikizumab, risankizumab), JAK inhibitor tofacitinib (10 mg BID induction, 5 mg BID maintenance) in adolescents, S1P modulators (etrasimod, ozanimod) as emerging adolescent options; therapeutic drug monitoring with infliximab trough greater than 5 µg/mL during UC maintenance; surgical management with the staged total colectomy plus IPAA (J-pouch standard; S-pouch and W-pouch alternatives; three-stage approach for acute severe UC); pouchitis with the PDAI-based diagnosis (clinical + endoscopic + histologic) and treatment (acute: ciprofloxacin 500 mg BID monotherapy first-line per ICCP 2019 for 14 days, with combination ciprofloxacin + metronidazole reserved for chronic refractory; chronic antibiotic-refractory pouchitis: rifaximin, oral budesonide, biologic adjustment with vedolizumab or ustekinumab, Crohn-like-disease-of-pouch evaluation); cuffitis (rectal-cuff inflammation in stapled IPAA) with topical mesalamine; VSL#3 / De Simone formulation 1.8 trillion CFU adult dose (scaled pediatric) for pouchitis prophylaxis; acute severe UC surgical triggers including toxic megacolon (transverse colon greater than 6 cm with systemic toxicity), perforation, and uncontrolled hemorrhage; long-term surveillance starting 8-10 years after diagnosis with chromoendoscopy preferred (per BSG and SCENIC), the colorectal cancer cumulative risk ladder (~2 percent at 10 years, ~8 percent at 20 years, ~18 percent at 30 years), the PSC-UC association with ~5 percent of UC having PSC and ~70-80 percent of PSC having IBD demanding annual MRCP and earlier dysplasia surveillance; with a board-style ASUC case where the day 5 PUCAI of 80 drives infliximab rescue at intensified 10 mg/kg dosing.

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⏰ CHAPTERS:
00:00 Introduction
02:21 Learning Objectives
05:04 Paris Extent Classification and PUCAI Scoring
09:14 ESPGHAN-ECCO Acute Severe UC Algorithm
14:31 Mild-to-Moderate UC — 5-Aminosalicylates and Corticosteroids
18:43 Moderate-to-Severe UC — Biologic Landscape
24:36 Therapeutic Drug Monitoring in Pediatric UC
28:15 Surgical Management — Total Colectomy and IPAA
32:25 Pouchitis — Diagnosis and Management
37:32 Acute Severe UC Surgical Triggers and Toxic Megacolon
41:48 Long-Term Surveillance — Dysplasia, Cancer, and PSC
45:28 Board-Style Case
50:55 References and Closing

📺 NEXT EPISODE:
Coming soon — see full playlist below

📚 FULL PLAYLIST (Pediatric Gastroenterology):
https://youtube.com/playlist?list=PLUXCz1Up6ZmD-v4dyl2_gmQs0vAtFcgWD

🔥 RELATED EPISODES:
Episode 13: Pediatric IBD and Crohn Disease at Fellow Depth → https://youtu.be/EhYhbUN-Zk8
Episode 12: Lactose and Disaccharidase Deficiencies in Children → https://youtu.be/iDY0a8KrnuY

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APPNA Pediatrics is the Pediatric Component Society of the Association of Physicians of Pakistani Descent of North America, advancing pediatric medical education globally.

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