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Background: The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with similar to 20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points. Methods: These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate. Results: These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines. Conclusions: These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modem management strategies while maintaining vigilance around appropriate outcomes and safety issues.

Background: Exclusive enteral nutrition [EEN] and corticosteroids [CS] induce similar rates of remission in mild to moderate paediatric Crohn's disease [CD], but differ with regard to mucosal healing. Our goal was to evaluate if EEN at diagnosis was superior to CS for improving long-term outcomes. Methods: We prospectively followed newly diagnosed children aged < 17 years, with mild to moderate CD at baseline, for 2 years in the GROWTH CD study. Patients were evaluated at baseline and at 8, 12, 78, and 104 weeks. Remission, relapses, complications [fibrostenotic disease, penetrating disease, and active perianal disease] and growth were recorded throughout the study. A propensity score analysis was performed. Results: A total of 147 children [mean age 12.9 +/- 3.2 years], treated by EEN [n = 60] or CS [n = 87] were included. New complications developed in 13.7% of CS [12/87] versus 11.6% of EEN [7/60], p = 0.29. Remission was achieved in 41/87 [47%] in CS and 38/60 [63%] EEN, p = 0.036. Median time to relapse did not differ [14.4 +/- 1 months with CS, 16.05 +/- 1.1 EEN, p = 0.28]. Mean height Z scores decreased from Week 0 to Week 78 with CS [-0.34 +/- 1.1 to -0.51 +/- 1.2, p = 0.01], but not with EEN [-0.32 +/- 1.1 to -0.22 +/- 0.9, p = 0.56]. In a propensity score analysis, EEN was superior to CS for inducing remission [p = 0.05] and trended to superiority for height Z score [p = 0.055]. Conclusions: Use of EEN was associated with higher remission rates and a trend toward better growth but with similar relapse and complication rates in new-onset mild to moderate paediatric CD.

Background/objectives: Exclusive enteral nutrition (EEN) is a safe and effective treatment modality for inducing remission in paediatric Crohn's disease (CD). The primary aim of this study was to compare the outcomes of EEN to corticosteroid (CS) therapy in newly diagnosed, treatment-naïve patients with CD. A secondary aim was to describe the outcomes of EEN in a national cohort of paediatric CD patients over a 10-year period. Subjects/methods: A retrospective chart review was conducted at the Irish national referral centre for paediatric CD. A case-matched analysis was conducted on two cohorts matched for age, gender, disease location, disease behaviour and disease activity, who received CS or EEN as their initial treatment. Subsequently, cohort analysis was conducted on all patients who undertook a course of EEN therapy between 2004 and 2013. Results: The case-matched analysis found higher remission rates after treatment with EEN (24/28, 86%) compared with those with CS (15/28, 54%; P=0.02). Dietetic contacts were found to be pivotal to the success of treatment and the attainment of remission. In total, 59 patients completed EEN at some time-point in their disease course and were included in the cohort analysis. Sixty-nine per cent of this cohort entered clinical remission (41/59). EEN was found to be most effective when used as an initial treatment (P=0.004) and less effective in patients aged under 10 years (P=0.04). Conclusions: EEN should be strongly considered as a favourable primary treatment over CS, especially in those diagnosed over the age of 10 years.

BACKGROUND AND AIM: Acute severe colitis (ASC) is one of the few emergencies in pediatric gastroenterology. Tight monitoring and timely medical and surgical interventions may improve outcomes and minimize morbidity and mortality. We aimed to standardize daily treatment of ASC in children through detailed recommendations and practice points which are based on a systematic review of the literature and consensus of experts. METHODS: These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Fifteen predefined questions were addressed by working subgroups. An iterative consensus process, including 2 face-to-face meetings, was followed by voting of the national representatives of ECCO and all members of the Paediatric Inflammatory Bowel Disease (IBD) Porto group of ESPGHAN (43 voting experts). RESULTS: A total of 24 recommendations and 43 practice points were endorsed with a consensus rate of at least 91% regarding diagnosis, monitoring, and management of ASC in children. A summary flowchart is presented based on daily scoring of the Paediatric Ulcerative Colitis Activity Index. Several topics have been altered since the previous 2011 guidelines and from those published in adults. DISCUSSION: These guidelines standardize the management of ASC in children in an attempt to optimize outcomes of this intensive clinical scenario.

Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.

Background The Pediatric Ulcerative Colitis Activity Index (PUCAI) is a noninvasive clinician-based index, which reflects disease severity in pediatric ulcerative colitis (UC) when no endoscopy is performed. Here, we aimed to explore signs and symptoms important to children with UC and their caregivers as the first stage of developing a patient-reported outcome (PRO) measure for pediatric UC (ie, the TUMMY-UC index) to supplement endoscopic assessment. Methods Concept elicitation qualitative interviews were performed with children who have UC and their caregivers in 6 centers. Items were rank-ordered by the interviewees according to the frequency of endorsement and importance, graded on a 1 to 5 scale. Results A total of 46 children (ages 12.5 ± 3.3 years, range 7-18, 48% boys, 83% with pancolitis, 24% with moderate-severe disease) and 33 caregivers were interviewed (ie, 79 interviews). The following items were identified by the children, in decreasing order of weights: abdominal pain (importance × frequency weight 3.9), rectal bleeding (3.6), stool frequency (3.0), stool consistency (3.0), general well-being/fatigue (2.9), urgency (1.9), and nocturnal stools (1.6). Two other items were scored lower: lack of appetite (1.1) and weight loss (0.6). Children 13 to 18 years comprehended adult vocabulary, children 8 to 12 years comprehended simple vocabulary, and younger children had poor understanding in completing the questions. Conclusions In this first stage of the TUMMY-UC development, items were generated and ranked by input from patients. These items are now being explored for optimal vocabulary and response options. The TUMMY-UC will supplement the PUCAI in clinical trial outcome assessment.

AimsTo describe the change in incidence of paediatric inflammatory bowel disease (IBD) observed at the National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, and to determine whether the presenting disease phenotype and disease outcomes have changed during the past decade.MethodsThe annual incidence of IBD in Irish children aged Results406 new cases of IBD were identified. The incidence was 2.5/100 000/year in 2001, 7.3 in 2008 and 5.6 in 2010, representing a significant increase in the number of new cases of Crohn's disease (CD) and ulcerative colitis (UC). There were 238 cases of CD; 129 of UC; and 39 of IBD unclassified. Comparing groups A and B, no differences were found in disease location at diagnosis or, for CD, in its behaviour.ConclusionsThere has been a substantial and sustained increase in the incidence of childhood UC and CD in Ireland over a relatively short period of time. However, disease phenotype at diagnosis has not changed. At 2 years follow-up, CD appears to progress less frequently than in some neighbouring countries. These variations remain unexplained. Prospective longitudinal studies will help to elucidate further the epidemiology of childhood IBD.

Helicobacter pylori is a slowly growing, gram negative microaerophilic bacterium that colonises the gastric mucosa. Cross-sectional epidemiological studies from both developed and developing countries suggest that the prevalence of H. pylori infection worldwide is declining, and may even be less than 10% in ‘westernised’ countries.1 ,2 H. pylori infection is acquired during the first decade of life and infection usually persists without treatment. Spontaneous clearance has been reported, although co-incidental antibiotic exposure may influence such ‘clearance’. H. pylori is the causative agent for diseases including peptic ulcer disease (PUD), chronic gastritis, gastric mucosa associated lymphoid tissue lymphoma and is the single-most important risk factor for developing gastric cancer.3 ,4 Putative extraintestinal associations have included refractory iron deficient anaemia, short stature and idiopathic thrombocytopenic purpura, although data supporting these associations in children must be interpreted with caution.4 ,5 The majority of children infected with H. pylori are asymptomatic. Following successful treatment, the risk of true reinfection in childhood is extremely low, at least in developed countries.6 Recrudescence describes re-colonisation with the same strain within 12 months, while re-infection refers to colonisation with a new strain, more than 12 months after eradication. Clinicians must carefully bear in mind these salient aspects of the pathogenesis and natural history of H. pylori- associated diseases as they consider whether testing their patients for H. pylori is indicated. ### Investigations for H. pylori The primary indication for investigation in children remains to diagnose the cause of significant symptoms and not simply to detect the presence of H. pylori . Testing for H. pylori is not helpful unless it alters clinical management, and consideration of the age-related pre-test probability of particular diseases (rather than infection alone) is essential. There remain certain scenarios in which screening for the presence of H. pylori is not absolutely indicated but may …

Pediatric ulcerative colitis (UC) shares many features with adult-onset disease but there are some unique considerations ; therefore, therapeutic approaches have to be adapted to these particular needs. We aimed to formulate guidelines for managing UC in children based on a systematic review (SR) of the literature and a robust consensus process. The present article is a product of a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). A group of 27 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to ESPGHAN and ECCO members. A list of 23 predefined questions were addressed by working subgroups based on a SR of the literature. A total of 40 formal recommendations and 68 practice points were endorsed with a consensus rate of at least 89% regarding initial evaluation, how to monitor disease activity, the role of endoscopic evaluation, medical and surgical therapy, timing and choice of each medication, the role of combined therapy, and when to stop medications. A management flowchart, based on the Pediatric Ulcerative Colitis Activity Index (PUCAI), is presented. These guidelines provide clinically useful points to guide the management of UC in children. Taken together, the recommendations offer a standardized protocol that allows effective, timely management and monitoring of the disease course, while acknowledging that each patient is unique.

Background Small intestinal biopsy remains the reference standard for diagnosing coeliac disease (CD) in children. Recent international guidelines suggest that for select patients, biopsy may not be necessary. Aims The aim of this study were to: (a) correlate coeliac serology with histology findings in Irish children with a high pre test probability of the disease (b) determine if proposed changes to the CD diagnostic algorithm hold true in an Irish paediatric cohort. Methods A retrospective chart review of all cases of suspected CD that underwent endoscopy at the National Centre for Paediatric Gastroenterology, Our Lady’s Children’s Hospital from January 2004 to December 2011 was undertaken. Data retrieved included endoscopic and histologic findings, co-morbidities and serology results (where available). Results 596 patients (57% female) underwent endoscopy for suspected CD. Serology data were available for 544 (91%) patients. CD was confirmed on histology in 304 (51%) children. tTG (tissue transglutaminase) was positive in 405 (79%) patients, of whom 288 (71%) also had a positive biopsy and 7 patients (5%) with negative tTG had a positive biopsy. This result was highly significant with a p value of 0.0001. Of the available 195 positive EMA (endomysial antibody) results, 184 (94%) had a positive tTG as well. 110 of 117 children with tTG values > 20 μg/ml plus a + EmA had CD on histology. 3 of 105 (2.8%) patients with tTG >100 μg/ml had a normal histology. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value of tTG levels ranging from 2–99 were 97% (CI 95–98), 53% (CI 46–59), 71% (CI 63–75) and 95% (CI 90–98) respectively. The corresponding values for tTG levels >100 were 94% (CI 87–97), 98% (CI 93–99), 97% (CI 92–99) and 95% (CI 90–98). The PPV of tTG 2–10 μg/ml was 37%, but at 100 μg/ml, this was 97%. Conclusions Intestinal biopsy remains the reference standard for CD diagnosis. High titre serology correlates well but not perfectly with histology findings. Diagnostic accuracy rather than screening convenience is essential before prescribing a life-long gluten free diet.

P152 Rising incidence and increasing severity of very early onset IBD in Ireland R. Wylde1 *, A. Carey2,3, B. Bourke2,3,4, A. Broderick3, S. Quinn3, M. Hamzawi3, K. Gleeson3, S. Hussey2,3,4. 1Leiden University, Leiden University Medical Centre, Leiden, Netherlands, 2National Childrens Research Centre, NCRC, Dublin, Ireland, 3Our Lady’s Childrens Hospital Crumlin, Dept. of Gastroenterology, Hepatology and Nutrition, Dublin, Ireland, 4University College Dublin (UCD), School of Medicine and Medical Science, Dublin, Ireland