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Objectives Upper gastrointestinal (UGI) tract involvement is frequently reported in pediatric Crohn disease (CD) and ulcerative colitis (UC). Aside from granulomas, most findings are nonspecific. The aims of this study were to review the prevalence of UGI tract findings in pediatric patients with CD or UC at diagnosis and to describe differences in endoscopic and histologic features. Methods Patients with CD and UC aged 2 to 17 years diagnosed between 2000 and 2015 who had upper and lower endoscopy at diagnosis were randomly chosen from the BC Children's Hospital inflammatory bowel disease (IBD) registry. Pathology review of the UGI biopsy specimens was blinded to IBD diagnosis. Results Of the 198 patients, 102 with CD and 96 with UC were included, with a mean age of 11.7 years (range, 2.3-17 years). Patients with CD were more likely to have aphthous ulcers (20.4% vs 3.5%, P =.002) and erosions (16.3% vs 3.5%, P =.018), most commonly affecting the antrum. Macroscopically normal UGI endoscopy was present in 60% of patients. Microscopic disease was reported in 100% of patients with CD and 87% of patients with UC. In both groups, nonspecific inflammation was the most common finding. Chronic deep, superficial, and diffuse inflammation were more frequent among patients with CD than UC (42% vs 4%, P <.001; 60% vs 17%, P <.001; 50% vs 34%, P =.04, respectively). Conclusions The UGI tract macroscopic changes were common in pediatric IBD, especially in CD. Despite macroscopically normal endoscopy, histologic abnormalities were frequent. Although chronic inflammation was more often reported in patients with CD, aside from granulomas there were no unique histologic abnormalities unique to CD. [ABSTRACT FROM AUTHOR]