How to differentiate ulcerative colitis from Crohn's?

Question

Hello doctor,

My six year old daughter was born with tyrosinemia type 1. She had diarrhea and bloody stools for 10 days, a month back. She was tested for many things, and everything came back normal, except her calprotectin level was 1250 while she had loose and bloody stools. She was admitted and had a cleanse and got an endoscopy done, and it showed lots of inflammation. She was put on a high dosage of steroids and Sulfasalazine for five weeks. The bleeding has stopped, and we weaned off the steroids. The biopsy results said it was IBD. Two weeks ago, she had her calprotectin level checked again, and it was in the 200. This week, we checked it again, and it was 39. I will include pictures of the biopsy results and pictures of the endoscopy. Her doctor said that the reports are not 100 % fine, and it is either UC or Crohn's. The doctor said that further down the line, we would be able to know which one she has. I would love to get a second opinion on what it could be.

Answer 1

Hi,

Welcome to icliniq.com.

I have seen all the attached reports (attachment removed to protect patient identity). We see many tyrosinemias and IBD (irritable bowel disease) patients. In smaller children, it is sometimes difficult to differentiate between ulcerative colitis and Crohn's disease. Crohn's disease presents with blood in stool, pain in the abdomen, fever, and growth retardation. Whereas in ulcerative colitis, there is predominantly loose stools with blood. We can differentiate both with endoscopy and biopsy findings. Here we can see all the site of endoscopy showed inflammation. So it is most likely Crohn's disease. Continue the treatment, as we can see the response in the form of decreased calprotectin level. Apart from this, we need to take care of her growth. So, adequate calcium should be taken. Because of tyrosinemia, you must be giving restricted diet to her. What is the status of tyrosinemia? What is the dose of Nitisinone? How are her enzymes? Does she have any nodule formation? Is she taking alpha-fetoprotein? Did you plan for a liver transplant? For IBD, we need to continue same medication, but the dose needs to be confirmed. You can provide the details of liver function tests so that, we can decide about tyrosinemia as well.

Have a nice day.

Revert with more information to pediatrician online.

Answer 2

Hi,

Welcome back to icliniq.com.

Nice to see you back with good questions.

Normal liver enzymes are not the only criteria to hold the transplant. There are other indications as well, for example, the risk of cancer. How was the diagnosis of tyrosinemia made? I hope you are doing the levels of alpha-fetoprotein and imaging regularly? Does she still have renal stones?
Crohn's disease causes growth retardation due to intense inflammation and extensive involvement of the GI (gastrointestinal) tract. Eye symptoms can be part of Crohn's disease in the form of uveitis and dimness of the vision. Among the medications, Nitisinone can cause eye symptoms.
All of her findings can occur in both diseases. In Crohn's, there is a presence of granuloma, which is not there in this case. The second thing is, in endoscopy, we can see the involvement of rectum as well, so there are fewer chances of ulcerative colitis in this case. Growth retardation can be part of a liver disease.
Yes, there is a high chance of relapse if we stop the medicines earlier. In such cases, we give medication for years. Sometimes, it is difficult to control as well. It will be better to continue because, in the case of relapse, there is a high risk of poor control.
Crohn's disease can cause liver dysfunction. Yes, calprotectin can decrease by infection and carcinoma. But in this case, we can see the response of the medication. So, she is unlikely to have other diseases.

I hope all these will be helpful to you.

For more information consult a pediatrician online.