gms | German Medical Science

Introduction: The predictors of poor outcome (POPO) are recently considered to be important criteria in the choice of therapy for pediatric patients with Crohn's disease.

These criteria include (POPO1) a deep colon ulceration at initial endoscopy, (POPO2) persistently severe disease despite adequate induction, (POPO3) extensive disease, (POPO4) pronounced growth retardation (<-2.5 Height SDS), (POPO5 ) severe osteoporosis, (POPO6) initial stricturating or penetrating disease and (POPO7) severe perianal disease.

The aim of analyzing these predictors is to identify differences between patients who fulfill one or more of these criteria (POPO-positive) and patients who don’t (POPO-negative) in terms of therapy and outcome. With this information, predictions about the course of the disease can be made.

Methods: To examine the criteria, data from the clinical register CEDATA-GPGE was used. Since 2004, the cohort has documented information on disease progression, diagnosis and treatment of more than 4000 pediatric patients with chronic inflammatory bowel disease (IBD).

Since the data structure of the registry contains no information on deep ulceration and osteoporosis, it was not possible to examine POPO1 and POPO5.

Only patients who were reported to the registry within three months of initial diagnosis and had at least one additional documented visit registered in the following three months were included in the analysis. POPO-positive patients were compared to POPO-negative and evaluated for specific negative outcome parameters in their disease course (surgery, growth retardation, absence of persistent remission, abscesses, fistulas or stenosis).

Results: The analysis involved 978 patients, of which 660 were POPO-positive (67.5%). 19.9% ??of patients met POPO2, 53.4% ??POPO3, 1.5% POPO4, 3% POPO6 and 9.4% POPO7. In general, POPO-positive patients were younger at initial diagnosis and had a higher disease activity index (PCDAI). In the onset of other symptoms, there was no significant difference between these two groups of patients.

An increased indication for surgery was connected with POPO4 and POPO6.

In addition to the group of POPO4, only POPO2-positive patients showed a significantly higher rate of growth retardation.

For POPO4-, POPO6- or POPO7-positive patients lack of sustained remission was increased, whereas a significantly higher rate of abscesses, fistulas or stenoses was detected in patients with POPO2, POPO3 or POPO7.

The use of immunomodulators or biologics was necessary in more than 90% of patients who fulfilled POPO4, POPO6 or POPO7. Azathioprine (AZA) is the first-line immunomodulator to increase relapses. Exhibition of it within the first three months after the initial diagnosis was associated with a significantly lower rate of poor outcome than receiving AZA after more than three months. An additional benefit was only obtained in patients with POPO6.

Discussion: The identification of the predictors of poor outcome and possible criteria for risk stratification are important prerequisites for optimizing treatment. The early use of azathioprine can be associated with less occurrence of adverse outcome events.

Perianal disease was predictive for the need of surgery, exhibition of AZA and development of abscesses, fistula or stenosis. Also stricturizing disease behavior and extensive disease predicted surgery, whereas persistent disease was often followed by abscesses, fistula and stenosis.

The authors declare that they have no competing interests.

The authors declare that an ethics committee vote is not required.