Background: Crohn’s disease (CD) is characterized by gut microbiota alterations including reduced microbial diversity, loss of commensal species, and increased abundance of opportunistic taxa. Methods: This prospective study was conducted between 2022 and 2024 at the Emergency Clinical Hospital for Children, Cluj-Napoca. Children with CD and healthy controls were evaluated. The gut microbiota was analyzed using shotgun metagenomics. Bioinformatic processing assessed alpha and beta diversity, core microbiome composition, and differential taxa. Results: Ten patients with CD and eight healthy children were included; five patients were re-evaluated after a median interval of 14 weeks. The Shannon index was significantly lower in CD patients compared with controls (p = 0.037). Beta diversity analysis suggested partial separation between CD at diagnosis and controls (p = 0.041). An inverse correlation was observed between the Shannon index and the clinical score (p = 0.028). Ruminococcus gnavus was among the taxa contributing to group separation. At follow-up, all patients were in clinical remission, while 80% had achieved biological remission and mucosal healing. They showed persistently reduced alpha diversity and distinct microbial communities compared with controls (p = 0.028 and p = 0.005, respectively). Conclusions: Pediatric CD was correlated with dysbiosis that persisted despite remission. Reduced alpha diversity was associated with greater disease severity at diagnosis.

Background/Objectives: Pediatric inflammatory bowel disease (pIBD), including Crohn’s disease (CD), ulcerative colitis (UC), and IBD-unclassified (IBD-U), exhibits unique clinical features compared to adult-onset disease. This study aimed to describe phenotypic characteristics of pIBD in the north-west region of Romania over a 21-year period and to compare our findings with those of other studies worldwide. Methods: We conducted a retrospective study of children under 18 years of age, from the north-west region of Romania, diagnosed with pIBD between 2000 and 2020 at the Emergency Clinical Hospital for Children, Cluj-Napoca. Disease phenotype at diagnosis was established according to the Paris classification. Data were collected from the hospital records and analyzed using descriptive statistics and univariate analysis of categorical variables. A p-value < 0.05 was considered statistically significant. Results: Ninety-four patients were included (CD: 51.0%; UC: 43.6%; IBD-U: 5.4%), with a median age at diagnosis of 14 years (11–15.7). Very early-onset IBD accounted for 5.3% of cases. The likelihood of being diagnosed with CD after 10 years of age was significantly higher compared to UC (OR = 4.75, 95% CI: 1.10–29.07, p = 0.03). UC most frequently presented as pancolitis (51.2%), while CD most often involved the ileocolonic region (56.3%). Inflammatory behavior was the most common CD phenotype (69%). Upper gastrointestinal involvement was documented in 18.7% of CD cases, with detection rates increasing after 2014. Perianal disease and growth impairment were significantly associated with complicated CD behavior (p = 0.03, and p = 0.007 respectively). Our findings are broadly consistent with other published reports. Conclusions: This study provides the first detailed phenotypic characterization of pIBD in this region. Our findings reflect trends observed in other populations and underscore the importance of standardized diagnostic evaluation.

Background and Aims:Exclusive enteral nutrition (EEN) is a well-established first-line therapy for inducing remission in mild-to-moderate pediatric Crohn's disease (pCD). While clinical remission (CR) and mucosal healing (MH) are widely accepted therapeutic goals, the concept of transmural healing (TH) has gained increasing recognition. This study aimed to evaluate the effectiveness of EEN in pCD patients from Romania, focusing on nutritional status, remission outcomes, and the impact of various factors on treatment efficacy. Methods:We conducted a retrospective observational study of pCD consecutive patients who received EEN for induction of remission between 2007 and 2017 at a referral center in Cluj-Napoca, Romania. CR was defined as a weighted Pediatric Crohn's Disease Activity Index (wPCDAI) <12.5, MH as a fecal calprotectin level <250 microg/g, and TH as the combination of MH and imagistic remission assessed by intestinal ultrasonography. Statistical analyses included descriptive and comparative approaches, including logistic regression, with p <0.05 considered significant. Results:Twenty patients with pCD, representing 45% of the cohort, were included. The median age at diagnosis was 14.2 years (9.9-18.4), and 65% were male. EEN was administered with a mean duration of 7.84±1.26 weeks. Body mass index Z-scores significantly improved following EEN (p=0.02). Hypoalbuminemia, detected in 55% of patients at diagnosis, resolved completely after EEN (p=0.00015). CR was achieved in 82% of patients with active clinical disease, MH in 26% of patients with microscopic activity, and TH in 20% of patients with imagistic activity. Age at diagnosis, disease behavior, location, activity, and anti-Saccharomyces cerevisiae antibody status were not significantly associated with CR or MH. Disease activity at initiation, measured by the wPCDAI, was inversely associated with TH (p=0.004). Conclusions:This is the first study to report on EEN outcomes in pCD patients from Romania. EEN was effective in improving nutritional status and inducing CR, while MH was achieved in about one-quarter of patients. TH was also observed, though less frequently, and was negatively associated with higher baseline clinical disease activity. Regional factors may have influenced these outcomes.

OBJECTIVE:Pediatric inflammatory bowel diseases (PIBDs), despite being more prevalent in westernized nations, show an increasing incidence worldwide. Accurate evaluation, diagnosis, therapy, and monitoring are mandatory for the adequate management of patients, as is a sensible use of expensive resources, which may be limited in some parts of the world. This limitation often poses challenges to diagnose and treat patients. As the long-term prognosis very much depends on early diagnosis and remission of active disease, it is important to consider reasonable alternatives that may help clinicians to act accordingly within resource constraints, without downgrading previously published guidelines. METHODS:A group of experts from the "Paediatric IBD Porto Group" of European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) as well as pediatric and adult IBD experts, trained in IBD centers and having working experience in limited-resource settings (LR settings), joined efforts to suggest alternative options in settings where resources are limited, while prioritizing an acceptable cost-effectiveness ratio. Almost all recently published ESPGHAN guidelines and position papers on PIBD were evaluated, and the writing group framed proposals for adaptation in situations with limited access to more expensive resources or tools. RESULTS:Ninety consensus-based recommendations, derived from the available evidence, were formulated. Diagnostic protocol, biochemical evaluation, imaging and endoscopy, monitoring and options for nutritional, medical and surgical treatment were addressed. Cooperation between professionals and institutions was suggested to improve quality of care and optimize use of available expertise. Patient education, counseling, mental health and transition of care were also addressed. CONCLUSION:Diagnosis and management of PIBD are complex and costly in medical resources, but some alternative protocols could provide acceptable results and help with accurate diagnosis and management. These recommendations and practice points may offer useful guidance in settings where resources may be limited while still providing good medical practice.

Background: Inflammatory bowel disease (IBD) represents a group of disorders with increasing incidence in the pediatric population worldwide. There are limited data on pediatric IBD (pIBD) epidemiology in Eastern Europe and none so far from Romania. The aim of our study was to evaluate incidence rates and time trends for pIBD in the north-west region of Romania and to compare them with results from studies on the same topic published worldwide. Methods: We performed a retrospective study of patients under 18 years of age diagnosed with pIBD in the time frame between 1 January 2000 and 31 December 2020 at the Emergency Clinical Hospital for Children in Cluj-Napoca. Age-adjusted incidence rates, annual percentage change (APC), average annual percentage chance (AAPC) and their corresponding 95% confidence intervals (CIs) were calculated for pIBD, Crohn’s disease (CD) and ulcerative colitis (UC). Temporal trends were plotted using Joinpoint regression. Results: Ninety-four patients were identified. For the entire studied period, the incidence rate for pIBD was 0.79/105 (±0.74), 0.4/105 for CD (±0.42) and 0.34/105 for UC (±0.4). Time trends for incidence were positive, but statistical significance was found only for pIBD and CD. The APC observed for pIBD, CD and UC was 12 (95% CI: 6.5–17.7), 13.1 (95% CI: 8–18.5) and 5.67 (95% CI: 1.5–13.4), respectively. Comparison to other similar studies placed Romania among the countries with the lowest incidence of pIBD. Conclusions: Although pIBD incidence in our region appears to be low, there has been an important and significant increase in the incidence of overall pIBD and especially CD.

Abstract Background Ulcerative proctitis (UP) is an uncommon presentation in paediatric patients with ulcerative colitis, accounting for <10% of cases. Here we aimed to characterize the clinical features and natural history of paediatric patients with UP, and to identify predictors of poor outcomes. Methods A retrospective cohort study involving 37 sites affiliated with the IBD Interest group of ESPGHAN. Data were collected at different timepoints from patients diagnosed with UP aged <18 years between 01/01/2016-31/12/2020. Outcomes included time to initiation of systemic steroids, thiopurines or biologics, time to acute severe colitis (ASC), IBD-related admission and colectomy. Univariate cox regression was used to study the association between potential predictors and study outcomes. Results Two hundred and fifty patients with UP were included, with a median age at diagnosis of 14.5 (IQR 12.3-15.9) years, and a median follow-up of 2.7 (IQR 1.7-3.9) years. The most common presenting symptoms were bloody stools (94%), abdominal pain (59%) and diarrhea (53%). At diagnosis, the median pediatric ulcerative colitis activity index (PUCAI) score was 25 (IQR 20-35), and only 3 patients (1.3%) presented with ASC. Most children had normal inflammatory markers and albumin levels. the median fecal calprotectin level was 720 mcg/g (IQR 310-1800), while 16 patients (9.9%) had a calprotectin level <100mcg/g at diagnosis. Administration of oral or topical 5-ASA resulted in clinical remission rates of 52% and 48%, respectively, by the end of induction, while the combination of both led to remission in 73% of patients. The rates of treatment escalation to thiopurines and biologics at 1, 3 and 5 years were 11%, 27% and 45%, and 11%, 23% and 45%, respectively (Figure 1). Within 5 years from diagnosis, 20% of patients had presented with ASC. The PUCAI score at diagnosis of UP was highly associated with initiation of systemic steroids, thiopurines or biologics, as well as later ASC event and IBD admission, while a Mayo endoscopic score of 3 was associated with the initiation of biologics and subsequent ASC event and IBD admission (Table 1). Seven patients (4%) underwent colectomy by the end of follow-up. Among the 151/250 patients who had a repeat endoscopy, only 16% achieved mucosal healing and in 48% inflammation extended proximally. Cecal patch (P=0.009) and higher PUCAI score (P=0.009) at diagnosis, as well as higher PUCAI score (P=0.009) and lack of steroid-free clinical remission (P=0.005) by the end of induction were associated with proximal disease extension. Conclusion Disease burden is significant in paediatric patients that present with UP, with high rates of proximal disease extension and requirement for treatment escalation.

Objective/Background: Endoscopic balloon dilatation (EBD) has been shown to be effective and safe in adults with stricturing Crohn disease (CD) yet pediatric data is sparse. We aimed to assess efficacy and safety of EBD in stricturing pediatric CD. Methods: International collaboration included 11 centers from Europe, Canada, and Israel. Recorded data included patient demographics, stricture features, clinical outcomes, procedural adverse events, and need for surgery. Primary outcome was surgery-free over 12 months and secondary outcomes were clinical response and adverse events. Results: Eighty-eight dilatations were performed over 64 dilatation series in 53 patients. Mean age at CD diagnosis was 11.1 (±4.0) years, stricture length 4 cm [interquartile range (IQR) 2.8–5], and bowel wall thickness 7 mm (IQR 5.3–8). Twelve of 64 (19%) patients underwent surgery in the year following the dilatation series, at a median of 89 days (IQR 24–120; range 0–264) following EBD. Seven of 64 (11%) had subsequent unplanned EBD over the year, of whom two eventually underwent surgical resection. Two of 88 (2%) perforations were recorded, 1 of whom was managed surgically, and 5 patients had minor adverse events managed conservatively. There was a significant improvement in all clinical measures following EBD with weighted pediatric CD activity index-defined remission increasing from 13% at baseline to 44%, 46%, and 61%, and absence of obstructive symptoms in 55%, 53%, and 64% of patients at week 2, 8, and 24 respectively. Conclusions: In this largest study of EBD in pediatric stricturing CD to date, we demonstrated that EBD is effective in relieving symptoms and avoiding surgery. Adverse events rates were low and consistent with adult data.

BACKGROUND AND AIMS:Ulcerative proctitis [UP] is an uncommon presentation in paediatric patients with ulcerative colitis. We aimed to characterize the clinical features and natural history of UP in children, and to identify predictors of poor outcomes. METHODS:This was a retrospective study involving 37 sites affiliated with the IBD Porto Group of ESPGHAN. Data were collected from patients aged <18 years diagnosed with UP between January 1, 2016 and December 31, 2020. RESULTS:We identified 196 patients with UP (median age at diagnosis 14.6 years [interquartile range, IQR 12.5-16.0]), with a median follow-up of 2.7 years [IQR 1.7-3.8]. The most common presenting symptoms were bloody stools [95%], abdominal pain [61%] and diarrhoea [47%]. At diagnosis, the median paediatric ulcerative colitis activity index [PUCAI] score was 25 [IQR 20-35], but most patients exhibited moderate-severe endoscopic inflammation. By the end of induction, 5-aminosalicylic acid administration orally, topically or both resulted in clinical remission rates of 48%, 48%, and 73%, respectively. The rates of treatment escalation to biologics at 1, 3, and 5 years were 10%, 22%, and 43%, respectively. In multivariate analysis, the PUCAI score at diagnosis was significantly associated with initiation of systemic steroids, or biologics, and subsequent acute severe colitis events and inflammatory bowel disease-associated admission, with a score ≥35 providing an increased risk for poor outcomes. By the end of follow-up, 3.1% of patients underwent colectomy. Patients with UP that experienced proximal disease progression during follow-up [48%] had significantly higher rates of a caecal patch at diagnosis and higher PUCAI score by the end of induction, compared to those without progression. CONCLUSION:Paediatric patients with UP exhibit high rates of treatment escalation and proximal disease extension.

Abstract BACKGROUND Adult studies suggest that patients with isolated colonic Crohn’s disease (L2 CD) exhibit unique characteristics differentiating them from patients with ileo-cecal (L1) CD and ulcerative colitis (UC). We aimed to characterize clinical features and outcomes of paediatric patients with L2. METHODS Retrospective data was collected through the Porto IBD group of ESPGHAN on paediatric patients with L2, L1 or UC at different time-points. Outcome measures included time to 1st flare, hospital admissions, initiation of anti-TNFa drug, stricture and surgery. RESULTS Three hundred patients were included: 102 L1, 94 L2 and 104 UC. Rates of hematochezia at presentation were 14.7%, 44.7% and 95.2%, while rates of fever were 12.7%, 26.6% and 2.9%, for patients with L1, L2 and UC, respectively (P<0.001 for all comparisons). Skip lesions were identified in 65% of patients with L2, and granulomas in 36%, similar to L1 patients. Rates of ASCA and pANCA positivity significantly differed between the groups: 25.4% and 16.7% for patients with L2, compared with 55.2% and 2.3%, and 1.8% and 52.9% for patients with L1 and UC, respectively. Response rates to exclusive enteral nutrition were comparable between L1 and L2 (78.3-82.4%), as was the response to oral steroids (70.4-76.5%) in the three groups. While times to 1st flare and admission were similar between groups, patients with L1 were commenced on anti-TNFa earlier. Moreover, stricturing phenotype and need for colectomy were very rare in patients with L2. CONCLUSIONS Significant differences are observed in the clinical presentation and outcomes of paediatric patients with L2, compared to patients with L1 and UC.

Abstract INTRODUCTION Inflammatory bowel disease (IBD) patients with colonic involvement are known to have microbiome changes which may increase their risk of C. difficile infection (CDI). We conducted an analysis to describe the implications of CDI on hospitalized IBD patients. METHODS We used the National Inpatient Sample database from 2007 through 2018, to identify patients admitted with primary or secondary diagnosis of IBD using the ICD-9 or ICD-10 codes. We identified CDI as well as colectomy using diagnostic codes. We identified trends in nationwide estimates for annual admissions, age at admission, length of stay (LOS), in-patient mortality, Elixhauser comorbidity index and total hospital charge (adjusted for inflation). We used the Cochran-Armitage test for trend significance. RESULTS Between 2007 and 2018, there were an estimated total of 3,728,348 admissions with IBD, of which 161,744 patients had CDI (4.3%). Median age at admission was 52 years, with 56.7% females. There was a rising trend of CDI among IBD patients, from 2.9% in 2007 to a peak of 5.4% in 2015 with a decline towards the end of study period at 4.4% in 2018. Mean score for Elixhauser comorbidity index increased from 4.6 to 7.4 (p-trend <0.05) for non-CDI subgroup and from 9.9 to 11.4 (p-trend <0.05) for CDI subgroup during the study period. The median LOS was 4 days for patients without CDI vs 6 days with CDI. Trend in LOS was stable for patients without CDI but decreased from 8 days to 5 days over the 12-year study period for patients with CDI (p-trend <0.05). Overall, among patients with IBD, the risk of colectomy was 5.3%. Risk was higher in CDI subgroup (7.3% vs 5.2%, RR 1.41, 95% CI 1.39 - 1.44). The overall mortality among IBD patients was 1.6% with no significant trend observed over time. All cause in-hospital mortality was significantly higher among patients with concomitant CDI (6.8%) vs without CDI (1.4%) (RR 4.99, 95% CI 4.89 - 5.10). Within CDI subgroup, there was a trend of decrease in mortality from 7-11% in the beginning of the study, to about 3-3.5% towards the end of the study period (p-trend <0.05). After adjusting for inflation, there was a significant increase in charges among both subgroups: increased from $28,575 in 2007 to $68,614 in 2018 (p-trend <0.005) for non-CDI subgroup and from $57,987 in 2007 to $95,799 in 2018 (p-trend <0.005) for CDI subgroup. Overall charges were significantly higher for CDI subgroup. CONCLUSION The incidence of CDI in IBD patients increased over the study period with stability towards the latter half. Hospitalized IBD patients with concomitant CDI have a higher comorbidity index, a longer length of stay, a higher risk of colectomy and an increased risk of mortality when compared to those without CDI. Total hospitalization charges are also significantly higher with CDI subgroup and have been increasing overtime.

The ability of medical centers in Eastern and South-Eastern Europe to diagnose and treat fungal infections remains unknown. In order to investigate that, here we conducted a cross-sectional online survey, released at both The International Society for Human & Animal Mycology (ISHAM) and European Confederation of Medical Mycology (ECMM) websites. A total of 31 institutions responded to the questionnaire. Most centers (87.1%, n = 27) had access to Aspergillus spp. ELISA galactomannan testing as well as to Cryptococcus spp. antigen testing (83.9%, n = 26). Serological tests were mostly available for Aspergillus species (80.6%, n = 25); and most institutions reported access to mold-active antifungal drugs (83.9%; n = 26), but 5-flucytosine was available to only 29% (n = 9) of the participant centers. In conclusion, this study represents the first attempt to document the strengths and limitations of the Eastern and South-Eastern European region for diagnosing and treating fungal diseases. Lay Summary Our article is about the availability of diagnostic and treatments tools related to fungal infections in the countries of Eastern and South-Eastern region. Surveys like these are important to understand the gaps and point towards the fungal infections as a global health issue.

BACKGROUND:Maintaining of remission early in the disease course of Crohn's disease (CD) is essential and has major impact on the future prognosis. This study aimed to identify baseline predictors to develop model allowing stratification of patients who will not benefit from long-term azathioprine (AZA) treatment and will require more intensive therapy. METHODS:This study was designed to develop clinical prediction rule using retrospective data analysis of pediatric CD patients included in prospective inception cohort. Clinical relapse was defined as necessity of re-induction of remission. Sequence of Cox models was fitted to predict risk of relapse. RESULTS:Out of 1190 CD patients from 13 European centers, 441 were included, 50.3% patients did not experience clinical relapse within 2 years of AZA treatment initiation. Median time to relapse was 2.11 (CI 1.59-2.46) years. Of all the tested parameters available at diagnosis, six were significant in multivariate analyses: C-reactive protein (p = 0.038), body mass index Z-score >0.8 SD (p = 0.002), abnormal sigmoid imaging (p = 0.039), abnormal esophageal endoscopy (p = 0.005), ileocolonic localization (p = 0.023), AZA dose in specific age category (p = 0.031). CONCLUSIONS:Although the possibility of predicting relapse on AZA treatment appears limited, we developed predictive model based on six baseline parameters potentially helpful in clinical decision. IMPACT:The possibility of predicting relapse on AZA treatment appears to be possible but limited. We identified six independent predictors available at diagnosis of early AZA/6-MP treatment failure in pediatric CD patients. Using combination of these factors, a model applicable to clinical practice was created. A web-based tool, allowing estimation of individual relapse risk in pediatric CD patients on a particular therapeutic regimen, has been developed.

AIM:To evaluate the value of abdominal ultrasonography (US) in the follow-up of paediatric patients with ulcerative colitis (UC) compared to faecal calprotectin (FC) and colonoscopy. MATERIAL AND METHOD:In this retrospective study we enrolled 30 paediatric patients previously diagnosed with UC, examined by abdominal US and colonoscopy within the same week. FC was also determined during the same week. Disease activity was established using the paediatric ulcerative colitis activity index (PUCAI). The global endoscopic activity was evaluated using the Mayo endoscopic subscore. RESULTS:Endos-copy revealed pathological findings of active disease in 27 out of 30 patients; 3 patients were in endoscopic remission. Only 18 of them had clinical active disease (PUCAI >10), [sensitivity (Se) 66.7% and specificity (Sp) 33% of PUCAI in detecting endoscopic active disease). Twenty-three (76.7%) patients had FC >250 mcg/g, but in 2 of these cases the colonoscopy was normal (Se 77.8% and Sp 33.3% in detecting active disease). At US examination, pathological findings (increased bowel wall thickness, hypervascularity, lymphadenopathies, and/or mesenteric inflammatory fat) were found in 27 patients (90%), all with endoscopic active disease (agreement US - colonoscopy, at patient level, k=1.0, p<0.001, Se 100% and Sp 100%). At seg-ment level (totally 180 bowel segments examined by US), the overall agreement between US and colonoscopy was k=0.767, p<0.001, Se 86.5%, Sp 90.1%. Of the 27 patients with US pathological findings in any of colonic segments, 23 had FC >250 mcg/g (85.1%). The inter-observer agreement for the US measurements had an overall ICC of 0.926 with p<0.001. CONCLUSION:Abdominal US findings demonstrate a good to excellent concordance with endoscopic examination and are correlated with elevated FC levels. Therefore, US appears as an accurate technique in assessing activity in patients with UC and might replace colonoscopic evaluation for the follow-up.

Abstract Background Isolated colonic (L2) Crohn’s disease (CD) in adults is thought to have unique clinical and genetic features compared with ileal (L1) CD and ulcerative colitis (UC). Similar studies in paediatrics are scarce. Our goal was to characterize the clinical features of paediatric patients with isolated colonic CD and compare them to patients with ileo-cecal CD and those with UC. Methods This was a multi-center retrospective study including 21 sites affiliated with the Porto IBD group and IBD interest group of ESPGHAN. Data of paediatric patients diagnosed between 2014–2017 with L1 or L2 CD, or with UC, was collected, including information on demographic, clinical and laboratory parameters at diagnosis, end of induction, 1 year and 3 years after diagnosis (or at last follow-up). Results Data was collected on 300 children (102 L1, 94 L2, 104 UC) with similar demographic features. At diagnosis, bloody stools were identified in 45% of L2 patients, compared with 15% and 95% of L1 and UC patients, respectively (P<0.001), while fever was documented in 27% of L2 patients, compared to 13% and 3% of L1 and UC patients, respectively (P<0.001). At the time of diagnosis, the median pediatric Crohn’s disease activity index for patients with L1 and L2 was 25 (IQR 17.5–37) and 27.5 (20–40), respectively, while the median pediatric ulcerative colitis activity index was 40 (30–55) for patients with UC. C-reactive protein levels were significantly higher among CD patients (both L1 and L2), compared to patients with UC, and calprotectin values were comparable. ASCA was positive in 55%, 25% and 2% (P<0.001) and pANCA in 2%, 17% and 53% (P<0.001) in L1, L2 and UC patients, respectively. Granulomas were identified in 36% of L2 patients, similar to patients with L1 (33%). For induction therapy, exclusive enteral nutrition, oral steroids and mesalazine were used in 50%, 45% and 38% of patients with L2 CD, compared with 72%, 28% and 9%, and 0%, 52% and 75% of L1 and UC patients, respectively (P<0.001). Steroid-free clinical remission at the end of induction was overall similar between groups, around 55%. At 1-year post-diagnosis, 62%, 68% and 40% were on an immunomodulator (P=0.03) and 41%, 26% and 22% were receiving anti-TNFα agent (P=0.01), of patients with L1, L2 and UC, respectively. While time to initiation of an anti-TNFα agent was significantly shorter in L1 patients compared with L2 and UC (P=0.03), time to admission and time to surgery were similar. Conclusion Paediatric patients with isolated colonic CD exhibit several clinical features which differentiate them from ileo-cecal CD and UC. Prospective studies are required to understand the pathogenesis of this unique entity and define short- and long-term outcomes.

Supplemental Digital Content is available in the text ABSTRACT Objectives: Adult studies suggest that patients with isolated colonic Crohn disease (L2 CD) exhibit unique characteristics differentiating them from patients with ileo-caecal (L1) CD and ulcerative colitis (UC). We aimed to characterize clinical features and outcomes of paediatric patients with L2. Methods: Retrospective data was collected through the Porto Inflammatory Bowel Disease group of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) on Paediatric patients with L2, L1 or UC at different time-points. Outcome measures included time to first flare, hospital admissions, initiation of anti-tumor necrosis factor-alpha (TNFα) drug, stricture and surgery. Results: Three hundred patients were included: 102 L1, 94 L2 and 104 UC. Rates of hematochezia at presentation were 14.7%, 44.7% and 95.2%, while rates of fever were 12.7%, 26.6% and 2.9%, for patients with L1, L2 and UC, respectively (P < 0.001 for all comparisons). Skip lesions were identified in 65% of patients with L2, and granulomas in 36%, similar to L1 patients. Rates of anti-Saccharomyces cerevisiae antibodies (ASCA) and perinuclear antineutrophil cytoplasmic (pANCA) positivity significantly differed between the three groups: 25.4% and 16.7% for patients with L2, compared with 55.2% and 2.3%, and 1.8% and 52.9% for patients with L1 and UC, respectively. Response rates to exclusive enteral nutrition were comparable between L1 and L2 (78.3–82.4%), as was the response to oral steroids (70.4–76.5%) in the three groups. While times to first flare and admission were similar between groups, patients with L1 were commenced on anti-TNFα earlier. Moreover, stricturing phenotype and need for colectomy were very rare in patients with L2. Conclusions: Significant differences are observed in the clinical presentation and outcomes of Paediatric patients with L2, compared to patients with L1 and UC.

Abstract Background Endoscopic balloon dilatation (EBD) is an effective management strategy in stricturing Crohn’s disease (CD). While adult studies showed a high success rate of improved symptoms and avoiding surgical intervention, very little has been published in children. We thus present a multi-centre retrospective cohort study of EBD in paediatric CD from 9 centres affiliated with the Paediatric IBD Porto group of ESPGHAN. Methods Demographics, imaging, serological data, clinical indices (including the newly-developed modified CD obstructive score (mCDOS)), post-EBD complications and need for surgical intervention were recorded on electronic case report forms. Results Thirty-nine balloon dilatations were performed on 34 children (20 (59%) male, mean age 14.3 ± 3.4 years, median disease duration 3.5 years (IQR 1.1–5.8)). Successful avoidance of surgical intervention was recorded in 26 (76%) children, during a median follow-up period of 24 weeks (IQR 8–24). There was an increase in number of patients in clinical remission (wPCDAI < 12.5) following EBD from 20% pre-dilation to 36% (ns), 53% (p = 0.017) and 57% (p = 0.015) at weeks 2, 8 and 24, respectively. There was a trend to reduced mCDOS, from 5 (IQR 0–15) at baseline to 5 (0–6.25) (ns), 5 (0–5) (p = 0.04), and 0 (0–7.5) (ns), respectively. The stricture was primary in 31 (79%) children (17 in the ileocecal valve (ICV) region, 3 in the terminal ileum, 9 in the colon and 1 in the duodenum), 7 of whom had multiple strictures. Eight (21%) children had an anastomotic stricture. Median stricture length was 3 cm (IQR 2–4.7), bowel wall thickness 7 mm (IQR 5–8) and median pre-stenotic dilatation of 4.5 cm (IQR 4–5). Median maximal dilatation diameter was 15 mm (IQR 12–18) with the successful passage of the colonoscope in 26/39 (67%). There were 3 (8%) post-dilatation complications including one bleed following rectal dilatation (with spontaneous resolution) and 2 perforations (1 duodenal perforation managed conservatively and 1 ICV perforation requiring surgical resection). Conclusion EBD is an effective and safe technique in paediatric stricturing CD with over 75% avoiding surgery by one year and 8% complications. Further data are required to better identify optimal stricture features and dilatation diameter in children.

Background. Constipation-associated fecal incontinence (retentive functional fecal incontinence – RFFI) represents a significant problem, impacting both patients and families’ quality of life. Despite solid evidence regarding the proper management of RFFI, major mistakes are still made, leading to a poor long-term prognosis. Our aim was to highlight the most common mistakes in the management of RFFI and to suggest what could be done to avoid them. Patients and method. We performed a retrospective observational study on children diagnosed with RFFI admitted for fecal incontinence in the Second Clinic of Pediatrics, Department of Gastroenterology, Emergency Clinical Hospital for Chil­dren Cluj-Napoca, Romania. All data (clinical, labo­ra­to­ry and ultrasonography) were retrieved from the elec­tro­nic files, both at admission and during the follow-up visits. Results. We selected 11 cases representative for the com­mon mistakes, which were: extremely long delay in cor­rect diagnosis, misdiagnosis and consequent inadequate the­ra­peu­tic interventions, short period use of laxatives, use of therapies without any scientific evidence, and adopting the “wait and see” approach. Conclusions. We formulate sug­ges­tions on what could be improved in order to avoid the identified mistakes. Obtaining a detailed medical history and performing a complete physical examination, as well as ad­he­ring to the standard treatment protocol are essential. Ul­tra­so­nography represents a useful tool in diagnosis.

Chronic abdominal pain (CAP) represents one of the most frequent medical problems in pediatrics, both for patients and their families (affecting their quality of life), and for doctors and the healthcare system. In Western countries, its reported prevalence varies between 0.3% and 19% of chil­dren. When approaching CAP, doctors usually focus on visceral causes of the pain. If they are excluded, then implicitly the pain is considered to be functional (since the usual blood tests and the abdominal ultrasonography are nor­mal). Parietal (somatic) causes of abdominal are usually ignored. Anterior cutaneous nerve entrapment syndrome (ACNES) represents a chronic neuropathic pain due to the compression of the anterior cutaneous branches of the thoracic intercostal nerves (Th 7-12), which penetrate the lateral margin of the rectus abdominis muscle. Although frequent, ACNES is rarely diagnosed, subjecting the patients to numerous unnecessary investigations (often invasive), leading to an improper management and increased medical costs. We present a scientific update on ACNES, regarding epidemiology, etiopathogenesis, physiopathology, patho­logy, diagnosis, therapeutic options and prognosis. We em­pha­size that ACNES represents a pure clinical diagnosis, no in­ves­ti­ga­tio­nal technique being able to assess it. Early and cor­rect recognition of ACNES is essential for pediatricians in their daily medical practice.

According to current guidelines, most paediatric patients in Europe diagnosed with Crohn′s disease (CD) are prescribed long-term immunosuppressive therapy with azathioprine (AZA). This study aimed to develop a predictive model allowing to stratify patients who will not benefit from AZA maintenance treatment and who require a more intensive therapeutic approach early after diagnosis.

Background Assessing the inflammation is important in the follow-up of paediatric patients with inflammatory bowel disease (IBD). We aim to evaluate the value of B cell-activating factor (BAFF) in paediatric IBD as a potential biomarker for follow-up. Method We determined BAFF in serum and faeces and faecal calprotectin (CP) in 32 IBD children—16 Crohn’s disease (CD) and 16 ulcerative colitis (UC). Twenty-six healthy children and 10 children with irritable bowel syndrome (IBS) were included as controls. Results No differences were found in serum BAFF between IBD, IBS, and healthy group: 1037.35, 990.9 and 979.8 pg/ml, respectively, all p > 0.05, but faecal BAFF was higher in the IBD group: 15.1, 8.5 and 8.2 pg/ml, respectively, p < 0.05, and higher in the UC group (55.975 pg/ml) compared to the CD group (10.95 pg/ml), p = 0.015. Splitting the IBD group in relation to the CP level, the serum BAFF had no significantly different values between the subgroups, but the faecal BAFF was significantly higher in the >250 μg/g subgroup. Cut-off values of BAFF were calculated. Conclusion Faecal BAFF is a promising marker for monitoring the children with IBD, higher levels of BAFF being correlated with high CP. Impact Faecal BAFF is a promising marker in monitoring the children with IBD, higher levels of BAFF being correlated with high faecal calprotectin. To our knowledge, this is the first paediatric study concerning BAFF evaluation in IBD. Faecal BAFF levels could be considered a potential non-invasive marker in monitoring IBD activity in paediatric population with clinically mild or inactive disease.