Time honoured Prednisolone and Azathioprin. I am not sure about some of the newer immunosuppresives. BJC

Prednisolone can not be used for long term therapy. Azathioprine is effective and relatively safe. In severe cases Infliximab ca be used in selected patients. 

First of all. In a child is very rare the presence of Crohn´s disease. i think that is obliged to discard first the presence of any food intolerance associated and between them the most common is gluten intolerance related to celiac disease or non-celiac gluten sensitivity

Thank you all.

Dear Luis,

I appreciate your point. However, Celiac is a rare disease in our country (only one repart) The histology of this child showed (I did not include this information in my question) ulceration, inflammatory cell infiltrate and granulomata. There was no villous flattening. So that unlikely to be celiac. Any other suggestions please????

Dear Shaman

Agree, this is very likely Crohn's disease (CD). I assume only colonoscopy / ileoscopy performed. UGI endoscopy as well sometimes shows asymptomatic evidence of CD. Any chance of intestinal TB in your country? Chronic granulomatous disease (usually boys) also has UGI changes, especially in the antrum of stomach.

re rarity of coeliac disease in your country, I would be surprised if it is as rare as you state - perhaps if children were screened (Serum IgA to exclude IgA deficiency + Transglutaminase or Endomysial antibody) you may be surprised, as most countries are now increasingly finding this disease when specifically looked for.

re long-term management of ileal crohn's disease, I agree azathiaprine or 6MP are best for long-term management of moderately severe CD, and Infliximab etc for more severe disease. Obviously, children on immunosuppressive drugs need to have their bloods monitored regularly, especially in the early months to years of treatment.

Only use steroids for flare-ups as steroids in acceptable dosage does not prevent relapse. A mild flare-up may also respond to metronidazole for a month or so but don't use long-term - risk of peripheral neuropathy.

Exclusive Enteral Nutrition, (EEN), using any complete fluid formula only (NO solids) for 6-8 weeks is as effective as steroids for active CD and is surprisingly well tolerated by most motivated kids. It also avoids steroid side-effects, perhaps particularly on growth..

Surgical resection, while virtually never curative, still has a role when a child is failing to respond to medical treatment, especially if not growing or not putting on weight / not going into puberty / chronic pain from ileal stricture..... Resection may give the child a respite for months to years allowing the child to grow / go into puberty, even though relapse is eventually inevitable.

Dear Timothy,

Thank you for the comprehensive answer. I did the upper GI endoscopy and biopsy and the esophagus, stomach, gastric antrum and duodenum did not show any abnormalities. We did TB PCR and quantitative assay to rule out TB and they came as negative. He is on steroids (Prednisolone 40 mg) daily and I shall tail it off after one month. I shall start azathioprine when he come to see me in the next week.

Your suggestion is very interesting. Perhaps I shall start to survey children with nonspecific GI symptoms for Celiac. Is that a good idea?

Dear Sir,

Your patient should be treated as for Crohn disease based on the available evidence.

Initially prednisolone inducation (1mg/kg to maximum 40mg/D) and tapering gradually while commencing azathioprine once prednisolone tapering dose reaches 20mg/D to reach maintenance dose of 2mg/kg of azathioprine.

Although elemental diet has shown good results in paediatric Crhon it is not available for us as an alternative for immunosuprresion

Infliximab would be our second line therapy if fail to respond to above

As for Ceoliac disease, it will be not cost effective to screen our patient's for Coeliac routinely as this condition is exceedingly rare among South Asians; will only be helpful in looking for among patients with refractory GI symptoms which could be explained by Coeliac like illness