Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK.
Department of Gastroenterology, Guy's and Saint Thomas' NHS Foundation Trust, London, UK.
Gut. 2021 Jun;70(6):1044-1052. doi: 10.1136/gutjnl-2020-322449. Epub 2020 Sep 1.
Paediatric acute severe colitis (ASC) management during the novel SARS-CoV-2/COVID-19 pandemic is challenging due to reliance on immunosuppression and the potential for surgery. We aimed to provide COVID-19-specific guidance using the European Crohn's and Colitis Organisation/European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for comparison.
We convened a RAND appropriateness panel comprising 14 paediatric gastroenterologists and paediatric experts in surgery, rheumatology, respiratory and infectious diseases. Panellists rated the appropriateness of interventions for ASC in the context of the COVID-19 pandemic. Results were discussed at a moderated meeting prior to a second survey.
Panellists recommended patients with ASC have a SARS-CoV-2 swab and expedited biological screening on admission and should be isolated. A positive swab should trigger discussion with a COVID-19 specialist. Sigmoidoscopy was recommended prior to escalation to second-line therapy or colectomy. Methylprednisolone was considered appropriate first-line management in all, including those with symptomatic COVID-19. Thromboprophylaxis was also recommended in all. In patients requiring second-line therapy, infliximab was considered appropriate irrespective of SARS-CoV-2 status. Delaying colectomy due to SARS-CoV-2 infection was considered inappropriate. Corticosteroid tapering over 8-10 weeks was deemed appropriate for all. After successful corticosteroid rescue, thiopurine maintenance was rated appropriate in patients with negative SARS-CoV-2 swab and asymptomatic patients with positive swab but uncertain in symptomatic COVID-19.
Our COVID-19-specific adaptations to paediatric ASC guidelines using a RAND panel generally support existing recommendations, particularly the use of corticosteroids and escalation to infliximab, irrespective of SARS-CoV-2 status. Consideration of routine prophylactic anticoagulation was recommended.
由于依赖于免疫抑制和手术的可能性，小儿急性重度结肠炎（ASC）在新型 SARS-CoV-2/COVID-19 大流行期间的治疗极具挑战性。我们旨在使用欧洲克罗恩病和结肠炎组织/欧洲儿科学会胃肠病学、肝病学和营养学的指南提供 COVID-19 特定指导，并将其与比较。
我们召集了一个由 14 名小儿胃肠病学家和小儿外科、风湿病学、呼吸和传染病专家组成的 RAND 适宜性小组。小组成员根据 COVID-19 大流行的情况，对 ASC 干预措施的适宜性进行了评分。结果在一次有主持人参与的会议上进行了讨论，然后进行了第二次调查。
小组成员建议 ASC 患儿入院时应进行 SARS-CoV-2 拭子和快速生物筛查，并应进行隔离。拭子阳性应引发与 COVID-19 专家的讨论。在升级为二线治疗或结肠切除术前，应进行乙状结肠镜检查。所有患者均考虑使用甲基强的松龙作为一线治疗，包括有症状 COVID-19 的患者。所有患者均建议进行血栓预防。在需要二线治疗的患者中，无论 SARS-CoV-2 状态如何，均认为使用英夫利昔单抗是合适的。因 SARS-CoV-2 感染而延迟结肠切除术被认为是不合适的。皮质类固醇在 8-10 周内逐渐减量被认为适用于所有患者。在成功挽救皮质类固醇后，对于 SARS-CoV-2 拭子阴性且 SARS-CoV-2 拭子阳性但无症状的患者以及症状性 COVID-19 的患者，噻唑嘌呤维持治疗被认为是合适的。
我们使用 RAND 小组对小儿 ASC 指南进行的 COVID-19 特定调整通常支持现有建议，特别是使用皮质类固醇和升级为英夫利昔单抗，而不论 SARS-CoV-2 状态如何。建议考虑常规预防性抗凝治疗。
