Inflammatory bowel disease: Viva

Branch 1: Diagnosis and the Porto criteria

The candidate should recognise that the combination of chronic diarrhoea, weight loss, growth faltering, a raised faecal calprotectin, and a family history of Crohn disease makes inflammatory bowel disease the leading diagnosis and warrants endoscopic confirmation rather than further observational delay. The key is to name the ESPGHAN revised Porto criteria and describe the diagnostic strategy precisely. [1]

Ileocolonoscopy with biopsies from every segment including the terminal ileum is the minimum diagnostic procedure, and the candidate should emphasise that upper gastrointestinal endoscopy is also recommended at diagnosis in all suspected paediatric IBD. A strong candidate explains why: isolated upper-gut Crohn disease is common in children and is missed by colonoscopy alone. The candidate should also list the supporting tests, including full blood count, inflammatory markers, coeliac serology with total immunoglobulin A, and stool studies to exclude infection. [1]

If the examiner presses on the role of faecal calprotectin, the candidate should explain that it is the single best non-invasive marker of intestinal inflammation and a useful screen for organic disease, but that a raised value always requires endoscopic confirmation rather than treatment on the strength of the number alone. The candidate should also mention magnetic resonance enterography for small-bowel assessment and the PCDAI or PUCAI for quantifying disease severity. [1]

Branch 2: Induction of remission and protecting growth

If asked about initial management, the candidate should lead with exclusive enteral nutrition as first-line induction for paediatric Crohn disease in many centres, explaining that a nutritionally complete liquid formula given as sole nutrition for six to eight weeks induces remission while correcting the malnutrition and avoiding the growth-suppressing effects of corticosteroids. This is especially appropriate in a child with growth faltering. [2]

The candidate should explain that corticosteroids are an effective alternative for induction where exclusive enteral nutrition fails or is refused but are never used for maintenance, because of their effects on growth, bone, and adrenal function. A strong candidate frames the treatment target as steroid-free remission with normal growth and mucosal healing, and explains that mucosal healing predicts a more durable remission and fewer complications. [2]

If asked why growth fails, the candidate should explain the cytokine-driven catabolic state, the direct suppression of the growth axis by inflammation, the impaired small-intestinal absorption and appetite loss, and why treating the inflammation rather than simply increasing calories is what restores growth. This shows understanding of the paediatric-specific dimension of the disease. [2]

Branch 3: Maintenance, biologics, and transition

If the examiner moves to maintenance, the candidate should describe azathioprine at a typical 2 to 3 mg per kg per day, guided by thiopurine methyltransferase status, for steroid-dependent or relapsing disease, and name anti-TNF therapy for moderate to severe refractory disease. The candidate should quote the infliximab regimen of 5 mg per kg at weeks 0, 2, and 6 then every 8 weeks, and mention pre-treatment screening for tuberculosis and hepatitis B and co-prescription of an immunomodulator to reduce immunogenicity. [3]

A strong candidate addresses the risks of therapy honestly: myelosuppression, pancreatitis, and hepatotoxicity with thiopurines, and serious infection and infusion reactions with anti-TNF agents, and stresses regular monitoring. The candidate should explain that surgery, such as bowel-sparing resection for complications, is a defined part of the pathway rather than a failure of medical therapy, and that growth often improves dramatically afterwards. [2]

Finally, the candidate should address the chronic relapsing nature of the disease, the multidisciplinary team involving dietitians, nurses, psychologists, and surgeons, and the structured transition to adult care beginning in early adolescence. A candidate who pairs confident, growth-centred management with honest counselling about a chronic disease and its modern, transformed outlook demonstrates the communication skills the exam rewards. [2]