years). Patients were classified by the new Paris criteria as to maximal IBD location andbehavior at diagnosis and at latest follow-up. Treatments were recorded. Results: Data arepresented in the table according to Paris category of age at diagnosis (A1a: <10 vs A1b:≥10 yrs). In comparison to older (A1b) children, the youngest (A1a) with CD had less L1disease (2/41 vs 29/109, p=0.001 OR 0.12 (95% CI 0.03-0.54)) and consequently morecolonic disease (L2+L3 38/41 vs 76/109, p=0.002 OR 5.5 (95% CI 1.58-19.09)). Amongthe youngest (A1a) children with initially colonic CD (L2), extension to the ileum occurredin 6 (40%) of 15 patients. UC was already extensive (E3 or E4) at diagnosis in 78% of allchildren. By 1.5 and 3 yrs, respectively, medical treatment included immunomodulators in47.2% and 61.4% of all 150 CD patients and in 33 % and 36% of all 109 UC patients,using Kaplan Meier (KM) survival estimates. Anti-TNF-alpha therapy was given for CD to9.5 % and 24.1% of children and for UC to 6.4% and 7.4% by 1.5 and 3 years (KMestimates).The cumulative incidence of intestinal resection in children with CD was 9.5%,15.6% and 22.3% by, respectively, 2, 4 and 6 years. Colectomy was performed in 11%,13.2% and 16% of children with UC by 2, 4 and 6 years (KM estimates). Conclusion: TheParis separation of A1 age at onset into A1a (<10 yrs) and A1b (<16 yrs, but >10yrs)highlights the rarity of isolated ileal CD in under 10-year olds, and the propensity of theircolonic CD to subsequently extend. CD location in children≥ 10 years at diagnosis remainedstable and mirrors that observed in adults, whereas all childhood onset UC is more extensive.Perianal fistulizing disease became more common, and CD behavior progressed from inflam-matory to stricturing or penetrating over time in children of all ages.Table: Evolution of disease phenotype in pediatric IBD

Footnote: Perianal disease and any L4 category can exist with any other disease locationand behavior

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Pre-Operative Immunosuppression is Not Associated With Increased Post-Operative Complications Following Colectomy in Children With UlcerativeColitisCandi Schaufler, Trudy Lerer, Brendan T. Campbell, Richard Weiss, Jeffrey L. Cohen,Donna Zeiter, Wael N. Sayej, Jeffrey S. Hyams

Background: Concern has been raised that pre-operative immunosuppression may increasepost-operative complications following colectomy for ulcerative colitis (UC). Aim: To reviewpost-operative course in pediatric patients undergoing colectomy for UC. Methods: A chartreview of all patients (pts) with a diagnosis of UC undergoing colectomy at ConnecticutChildren's Medical Center from 1996-2010 was conducted. Data collected included age,gender, disease extent at diagnosis, indication for colectomy, immunosuppressivemedicationstaken within 30-90 days of colectomy (corticosteroids (CS), thiopurines (TP), calcineurininhibitors (CI) and infliximab (IFX)), open vs. laparoscopic assisted sub-total colectomy,staging of colectomy, time between stages, and early(<60 days) post-op complications includ-ing prolonged initial hospitalization, small bowel obstruction (SBO), sepsis, wound infection,other infections, wound dehiscence, deep vein thrombosis (DVT), and pouchitis (acute orchronic). Results: 51 patients underwent colectomy for UC (55% male, 63% pancolitis atdiagnosis, mean age at diagnosis 10.8±3.8 yrs, mean age at colectomy 13.1±3.8 yrs). Patientexposure to immunosuppression in the 30 days prior to colectomy included: CS (88%), TP(51%), and CI (3.9%). Within 90 days prior to colectomy 65% were exposed to IFX.Indications for colectomy were fulminant colitis in 26% and medically refractory chronicdisease in 74%. Staged operations included: 37 pts 2 stages (10 with primary pouch), 10pts with 3 stages, and 4 pts with permanent ileostomy. Laparoscopic assisted sub-totalcolectomy was performed in 66%. After sub-total colectomy the mean hospital stay was 9.5days and 14% of pts had a non-elective re-admission ≤30 days. SBO was the most commonpost-op complication occurring in 19% (treated surgically in 30%), followed by woundinfection in 8%. Other early post-operative complications included: intra-abdominal abscess(6%), pouchitis (4%), UTI (4%), wound dehiscence (2%), DVT (2%), and sepsis (2%). Time

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between 1st and 2nd stage was 3.1±1.3 months and between 2nd and 3rd stage was 1.8±0.5 months. At 1 year, 51% of pts had at least 1 episode of pouchitis and 20% had chronicpouchitis. Pts with laparoscopic assisted surgery had significantly fewer wound infections(p< .02). There was no increased incidence of early or late complications in those ptsreceiving or not receiving TP or CI (within 30 days), or IFX (within 90 days) when controlledfor disease extent (left-sided vs. pancolitis). The duration of post sub-total colectomy hospital-ization in pts receiving both TP and IFX was significantly shorter than those who receivedneither (p<0.05). Conclusion: Pre-operative exposure to TP or CI (within 30 days) or IFX(within 90 days) does not appear to be associated with increased post-operative complicationsin children undergoing colectomy for UC.

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Predictors of Abdominal Pain in Depressed Pediatric Crohn's Disease PatientsArvind I. Srinath, Alka Goyal, David J. Keljo, David G. Binion, Eva Szigethy

Background: Patients with Crohn's disease (CD) have high rates of depression, anxiety andfunctional pain whichmay lead to overestimation of disease activity on IBD severity measures.Aims: 1) Characterize abdominal pain in youth with CD and co-morbid depression in termsof frequency, intensity and the relationship between pain and both disease-related (e.g.,diarrhea) and psychological factors (depressive severity, anxiety, and maternal psychologicalstress) 2) Evaluate predictors of self-reported abdominal pain and diarrhea to see if differentvariables predict pain frequency and intensity after controlling for IBD-related inflammation.Methods: 600 patients ages 9-17 with confirmed CD seen in Pediatric GastroenterologyClinic across two sites were screened for depression using Childhood Depressive Inventory(CDI) over a 2 year period. Those youth meeting threshold depressive criteria (CDI >10)were given a more comprehensive assessment for depression (CDRS), anxiety (SCARED),self-reported abdominal pain (API), and parental distress (BSI-18). IBD severity and degreeof diarrhea were determined using PCDAI while inflammatory markers were obtained fromthe medical record. Results: 116 patients with CD met criteria for clinically significantdepression. Mean age = 14.2 years (SD 2.4); 48% males; 87% Caucasian. There was asignificant positive association between overall abdominal pain score and overall IBD severity(r=.52), diarrhea (r= .28), and albumin (r =.36) as well as depressive severity (r=.42) andanxiety (r=.22) but not ESR or maternal distress. Only pain frequency (r=.34) correlatedsignificantly with degree of diarrhea while both pain frequency and severity correlates withdepressive and anxiety severity. Neither pain item individually correlated with high ESR orlow albumin. There was no significant difference in these pain relationships between genders,age or race of patients. After controlling for IBD-related inflammatory markers, anxiety,depression and diarrhea predicted 30% of variance in self-reported total abdominal painwith only depressive severity making a unique significant contribution. 28% of variance inabdominal pain frequency and 26% of variance in pain intensity were accounted for by thecombined model of depression, anxiety, and diarrhea but only depressive severity made aunique significant contribution for all components of abdominal pain (beta =0.33). Conclu-sions: These results suggest that the child's psychological state is the most important determin-ant of both the frequency and severity of self-reported abdominal pain while diarrheaand parental distress are less robust predictors after controlling for degree of IBD-relatedinflammation. Factors such as IBD-related strictures, disease location, and autonomic disturb-ances may account for the variance in abdominal pain not explained by this current model.

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Rates and Predictors of Oral Medication Adherence in Pediatric IBDDebra Lobato, Elizabeth McQuaid, Jack Nassau, Julie Boergers, Ronald Seifer, SherylKopel, Kristina I. Suorsa, Barbara Bancroft, Neal S. Leleiko

Poor medication adherence is a pervasive problem in pediatric chronic illness.(1) The scantresearch on actual medication use in pediatric IBD indicates that children and adolescentsmay be missing about 50% of their prescribed medications and that patient self-reportssignificantly over-estimate adherence to oral medications relative to more objective measuressuch as pill count or blood assay. (2) The goal of the current study was to examine ratesand predictors of adherence to oral medications 5-ASA and 6-MP in children and adolescentswith IBD. The current study used electronic devices to monitor daily oral medication useover a 6 month period. Participants were 36 newly-diagnosed patients (54% male, meanage=13 yrs, 78% Crohn's) and 30 patients who were diagnosed an average of 3.5 yearspreviously (53% male, mean age = 14 yrs, 83% Crohn's). Participants were required to beco-enrolled in an active pediatric biological IBD registry. Participants and parents completedstandard measures of emotional and behavioral functioning, including the Children's Depres-sion Inventory(3), the Child Behavior Checklist (4), and the Perceived Stress Scale (5). Ratesof adherence ranged from 0-97%, with overall adherence rates of 53% for 5-ASA and 48%for 6-MP. 20.4% of patients took < 20% of their 5-ASA, 35% took <20% of their 6-MP.Adherence rates were unrelated to gender (F=.006, p=.94) or to whether patients were newlydiagnosed or had the disease for a year or more (F=.172, p=.68). Adherence to 5-ASA washigher among patients with UC (63%) than Crohn's (50%) though differences were notsignificant (F=1.62, p=.21). Adherence negatively correlated with age (r= -.293, p=.03);patients 14 yrs and older took significantly less 5-ASA than children <11 years of age (37%v. 67%, p=.02). Adherence was significantly related to patient behavioral functioning anddepressive symptoms. Compared to patients who scored within normal limits, lower adher-ence was found among patients with clinically elevated behavioral problems (56% v. 21%,p = .03) and depressive symptoms (62% v. 31%, p = .002). Clinical correlations suggestthat in the absence of consideration of adherence, there is significant potential for alterationsin treatment to be based on substantially incorrect impressions of current therapy. 1. Riekert,K., & Drotar, D. (2000). 2. Hommel, K. A., Davis, C. M., & Baldassano, R. N. (2008). 3.Achenbach, T. M., & Rescorla, L. A. (2001). 4. Kovacs, M. (1992). 5. Cohen, S., Kamarck,T., & Mermelstein, R. (1983).

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