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Bernadetta Kenic Majerczyk
140518
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7 urzędów wojewódzkich
2 szpitale uniwersyteckie
5 szpitali wojewódzkich
21 powiatowych
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7 gmin
278 000 mieszkańców
100 000 dzieci
3 szpitale
- Eskilstuna (wojewódzki)
- Nyköping
- Katrineholm
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Sveriges barnläkarförening
SFGHN
Grupa lekarzy (5 gastrologow i 1 chirurg dzieciecy) pracuje nad PROGRAMEM LECZENIA NZJ.
Reprezentacja w ESPGHAN
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Zachorowalność u dzieci poniżej 16 roku życia wynosi 150/200.
1984-95 zbadano 50% populacji pediatrycznej ◦ Prewalencja wyniosła 66/100 000
1990-2001 zbadano dzieci w północnym Sztokholmie.
- Prewalencja wzrosła do 84/100 000
- Więcej przypadków z chorobą Chrohna w jelicie grubym.
- 4% z diagnozą NZJ przed 4 rokiem życia.
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Obraz kliniczny w oparciu na badanie endoskopowe – gastroskopię i kolonoskopię.
Radiologiczne badanie jelita cienkiego
-rezonans magnetyczny, kapsułka endoskopowa.
Wykluczenie innych chorób.
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Przygotowanie do kolonoskopii:
- 2dni przed badaniem 2 tabletki Bisakodyl 5mg
(Toilax) o godz. 12.00. Mała kolacja.
- 1dzieńprzed badaniem 2 razy po 2 tabletki o 12.00 i o 19.00. Wyłacznie przyjmowanie klarownych płynów jak woda, sok, buljon, coca-cola. Potrzebna bardzo duża ilość, 2-4 litrów.
Endoskopia na bloku operacyjnym w obecności anestezjologa.
W Eskilstunie najczęściej bez intubacji. Wyłącznie Propofol bez znieczulenia wziewnego. Mała dawka Alfentanilu (Rapifen).
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Dr. Adrian Press wykonuje gastroskopię
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Lekarz pediatra
Pielęgniarka specjalistyczna
Dietetyczka
Psycholog (niestety zastępowany pracownikiem socjalnym tzw. kuratorem)
Chirurg
Sekretarka
Nauczyciel w szkole szpitalnej
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Wizyty lekarskie 2-4 razy/rok
PDCAI lub PUCAI
Ocena tempa wzrostu (siatki rozwojowe)
Ocena gęstości mineralnej kości
Parametry zapalenia (kalprotektyna)
Anemia (Morfologia)
Skutki uboczne
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U dzieci najczęściej nie ma przeprowadzonych dużych badań.
• 5-ASA
◦ Salazopyrin, Salofalk, Asacol, Pentasa, Colazid
• Sterydy
◦ Prednisolon, Entocort
• Azatiopryna
◦ Imurel
• (6-merkaptopuryna )
◦ Puri-nethol
• W niezwykłych przypadkach • Cyklosporyna/tacrolimus
◦ Sandimmun/Prograf • Metotrexat • Mykofenolan mofetylu
◦ CellCept • anti-TNF-
◦ Remicade, Humira
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General There were no severe adverse reactions with the use of 5-ASA (mesalazine) in children
• (mean treatment time of 14.5 months).[1]
• Children seem to tolerate mesalazine better than sulphasalazine.[1]
• A wide range of doses of oral mesalazine are tolerated by pediatric patients with IBD.[2]
• Mesalazine was well tolerated with no major adverse reactions requiring dose reduction or discontinuation.[3]
Dosing (including active disease cases)
• The overall trend is to use high-dose mesalazine (up to 50-100mg/kg/day).[1]
• High dose mesalazine (71 - 108 mg/kg/day [mean 84 mg/kg/day]) was well tolerated and no adverse reactions occurred.[2] A pediatric dose of > 70 mg mesalazine/kg/day
corresponds approximately to 4.8 g/day for a 70 kg adult.
Rectal forms:Rectal 5-ASA derivatives may be tried in children with distal disease.[2]
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Nasilone działania niepożądane u dzieci są rzadkie (średni czas leczenia 14,5 mies.)
• Dzieci lepiej tolerują mesalazynę niż sulfosalazopirynę
• Szeroki zakres dawki mesalazyny – dobrze tolerowany u dzieci.
• Rzadko występują działania niepożądane wymagające zmniejszenia dawki lub odstawienia
Dawkowanie: 50-100 mg/kg (70 mg/kg odpowiada dawce 4,8 g u dorosłych) .
Formy doodbytnicze 5-ASA : u dzieci z zmianami w dystalnym
jelicie grubym.
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• Tylko u pacjentów z chorobą Crohna • Zapobiega niedoborom żywieniowym, wyrównuje
niedobory żywieniowe, okres dojrzewania • Wpływapozytywnie na samo zapalenie jelit. • 6-8 tygodni • Doustnie lub podawane przez sondę • Preparaty zawierające białko w całości lub peptydy
Rodzaje preparatów: Bez białka mleka: E028,Neocate Advance Sondnäringar: Frebini,Isosource junior,/Standard/Energy,
Nutrini, Fresubin orginal /Energy, Nutrison Energy Nutridrinki: Fortimel Energy, Fresubin Energy,Resource
komplett näring 1,5 mfl
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INFLIXIMAB (Remicade)
•ADADLIMUMAB (HUMIRA)
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Dla pacjentów z zapaleniem w jelicie grubym
Oczyszczenie krwi z aktywnych granulocytow
Bez skutkow ubocznych
Umożliwia lepsze działanie leków biologicznych
Wymaga dobrego dostępu dożylnego
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Step up Top down
1. 5-aminosalicylany (5-ASA) •Sterydy •Leczenie żywieniowe (Mb Crohn) •Antibiotyki (metronidazol lub
ciprofloxacyna) 2. •Tiopuryny (azatiopryna) lub 6-merkaptopuryna) •Metotrexat
3. •Leki biologiczne (infliximab lub adalimumab) 4. Adacolumn
1. Leki biologiczne 2. 5-ASA 3. Immunosupresory
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Nieswoiste zapalenie jelit od wiosny 2013.
Diagnoza czerwiec 2014.
Leczenie: sterydy, 5-ASA, Infliximab jako leczenie ratujące, Azatiopryna, Adacolumn.
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Trafiła do szpitala z podejrzeniem choroby hematologicznej/onkologicznej z anemią (Hb=6) i powiększoną śledzioną.
Od wielu lat bóle brzucha i biegunki.
Crohn. Pierwotne stwardniające zapalenie dróg żółciowych.
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Skierowana z podejrzeniem choroby nowotworowej.
Spadek na wadze. Gorączki. Rumień guzowaty na nogach. Obrzęk kolana. Wysokie OB i CRP. Anemia. Zaparcia z krwią w stolcu.
Wysoka kalprotektyna w stolcu.
Choroba Crohna!
Leczenie „krok w dół”!