A girl in middle childhood was referred to the paediatric surgical team with acute colicky abdominal pain and bile-stained vomiting. This was preceded by a viral illness. Investigations revealed raised inflammatory markers, and imaging of the abdomen demonstrated ileal and jejunal thickening. Concerns were raised regarding whether she had inflammatory bowel disease. Endoscopy revealed gastritis and duodenitis, and colonoscopy was unremarkable. Video capsule endoscopy demonstrated ulcers in the jejunum and ileum.On day 8 of admission, she developed a symmetrical purpuric rash over both ankles leading to the diagnosis of Henoch-Schonlein-related ileitis. Multidisciplinary team working led to appropriate management of the patient and avoided surgery. Video capsule endoscopy enabled visualisation of the small bowel. She was managed with 5 days of methylprednisolone followed by oral steroids. She made a good recovery with no sequelae. This case highlighted that terminal ileitis is a rare complication of IgA vasculitis with a good prognosis.

Introduction/Background Joint ESPGHAN-NASPGHAN guidelines1 for the management of Helicobacter pylori (h. pylori) in children and adolescents were last updated in 2016, in view of the rising prevalence of antibiotic-resistant strains. More recent NICE guidelines2 published in 2021 only focus on adult patients. Aim We performed an internal audit at our tertiary level unit in East London, an area with ethnic diversity and a high prevalence of H. pylori infection, to benchmark our practice against national and international recommendations. Subjects and Methods Between January 2015 and December 2017, 40 children had a confirmed diagnosis of H.pylori gastritis based on histological examination of gastric biopsies. Retrospective clinical data were collected independently by 2 reviewers using information from the electronic patient records. Baseline characteristics (age at time of diagnosis, gender, co-morbidities) and relevant details (H. pylori faecal antigen result, symptoms at diagnosis, endoscopic and histological findings, treatments and follow-up) were recorded in an anonymised Excel spreadsheet and evaluated. Results Within the study period, H. pylori antigen test was undertaken on faecal samples from 702 children in our catchment area, of which 638 (91%) were positive. Forty children (24 males, mean age 11.7 years, median 13 +/- SD 3.94, range 3–16) were referred to our tertiary level centre for a diagnostic confirmation based on histological examination of gastric biopsies. The most common symptom at referral was abdominal pain in 30/40 (75%) patients, with a specific epigastric location in 19 (47.5%). Eighteen (45%) patients presented with nausea, reflux or vomiting, 4 with chest pain and 5 (12.5%) with anaemia (4 of these required pre-endoscopy blood transfusion). Three patients had gastric ulcers and 5 had duodenal ulcers. Rapid urease test (CLO) was positive in 77% of the patients tested (24/31). Gastritis on histology was severe in 21%, moderate in 37%, and mild in 42%. The majority of patients (69%) responded to 1st (amoxicillin/clarithromycin/PPI) or 2nd line (clarithromycin/metronidazole/PPI) treatments. Twenty-six (65%) were re-tested with H. pylori faecal antigen to confirm eradication and this was successfully achieved in 69% of this group. From the records available to us only 30% of the time were family members tested in the community and successfully treated if positive. Conclusions Significant testing appears to be happening in the community without patients being referred to tertiary services for endoscopy. Patients who do have endoscopy are more likely to have had long standing H. pylori which in our cohort generally responded well to therapy. However, a significant proportion of our cohort was not assessed for eradication and it was difficult to tell if testing of family members had occurred and actioned upon. We suggest that this should be a future emphasis for future guidelines. It also highlights the ongoing requirement for more integrated and joined up care for paediatric services especially between general practice and specialist paediatric care. References Jones NL, Koletzko S, Goodman K, et al. Joint ESPGHAN/NASPGHAN guidelines for the management of helicobacter pylori in children and adolescents (update 2016). Journal of Pediatric Gastroenterology and Nutrition 2017;64(6):991–1003. http://pathways.nice.org.uk/pathways/dyspepsia-and-gastro-oesophageal-reflux-disease

ABSTRACT:Few studies have addressed whether proactive therapeutic drug monitoring (TDM) results in improved clinical outcomes in children with inflammatory bowel disease (IBD) treated with anti-tumour necrosis factor. The aim of this study was to investigate the impact of using proactive TDM in this patient group.Pilot single-centre observational study to accrue data on patients managed with proactive TDM.More patients in the proactive TDM cohort were managed by escalating the infliximab (IFX) regime (P < 0.001). The need for switching to different biologics was significantly lower in this patient group (P < 0.001).The introduction of proactive TDM resulted in a significant reduction of patients requiring switch of their primary biologic. The results of this study are indicators that proactive TDM offers a better method of managing children with IBD on IFX therapy.

EGID is a recently described condition with an unknown etiology and pathogenesis. There are three case reports of duodenal stricture associated with EGID: one in an adult requiring pancreaticoduodenectomy due to the suspicion of malignancy and 2 cases in a child and a young adult, who responded to oral steroids. We report the case of a 10-year-old who presented to A&E with a 9-month history of epigastric abdominal pain and 1 episode of haematemesis, on a background of asthma. He was treated for Helicobacter pylori, based on a positive stool antigen. Abdominal pain and vomiting persisted, therefore an oesophago-gastro-duodenoscopy (OGD) was performed. This identified widespread white plaques throughout the oesophagus, erythema and nodularity of the gastric antrum and white nodules in the first part of the duodenum. Histology revealed changes of EGID and eosinophilic oesophagitis (EOE) and patient was commenced on Montelukast, oral viscous Budesonide (OVB), Cetirizine and continued proton pump inhibitor (PPI). After the allergy workup identified house dust mites, cat sensitisation and fish allergy, a 6-food elimination diet was initiated. During the next 2 years, symptoms subsided, and endoscopy changes improved, with only mild signs of active EOE while on OVB, PPI and diary/egg/fish free diet. However, the patient relapsed due to poor compliance to treatment. He became more unwell during the Covid pandemic with recurrent vomiting and static weight. A trial of dupilumab was considered, however his reassessment OGD had to be delayed due to restricted access to theatre. He was treated empirically with a reducing course of oral prednisolone, with temporary response. The endoscopic assessment performed subsequently showed erythema, erosions and white plaques in the distal oesophagus and gastric antrum with narrowing between the first and the second part of the duodenum (D2), that could not be entered. Histology identified mild upper oesophagitis (4 eosinophils(eos)/HPF), active middle and lower oesophagitis (20 eos/HPF and 12 eos/HPF, respectively), chronic gastritis (80 eos/HPF) and nonspecific reactive changes of the proximal duodenum. A barium meal confirmed a duodenal stricture. At this stage, we recommended a sloppy diet and a second weaning course of oral prednisolone, along with Montelukast. He was subsequently commenced on azathioprine for maintenance of remission. A repeat barium study and small bowel MRI performed post course of steroids and on azathioprine revealed stable appearances of the proximal duodenal stricture, excluding the presence of further strictures. While the patient has responded to the course of oral steroids and azathioprine, a repeat upper GI endoscopy is currently planned to dilate the duodenal stricture. The challenges posed by this case were the rarity of the condition, limited treatment options and access to endoscopy during the Covid pandemic and the fact that unlike previous case reports a sustained remission could not be obtained on steroids, and a maintenance immunosuppressive medication was required. We can conclude that this subgroup of patients should be monitored closely for signs of bowel obstruction and will require more intense treatment, including immunomodulators, endoscopic dilatation and or surgery. References Kinoshita Y, Oouchi S, Fujisawa T. Eosinophilic gastrointestinal diseases - Pathogenesis, diagnosis, and treatment. Allergol Int 2019 Oct;68(4):420–429. doi: 10.1016/j.alit.2019.03.003. Epub 2019 Apr 16. PMID: 31000445. Jin H, Slater K. Pancreaticoduodenectomy for stricturing primary eosinophilic duodenitis. BMJ Case Rep 2021 May 10;14(5):e240101. doi: 10.1136/bcr-2020-240101. PMID: 33972297; PMCID: PMC8112431. Somani P, Sharma M, Shastri C, Patil A, Al Khatry M. Multiple duodenal strictures due to eosinophilic duodenitis. Am J Gastroenterol 2017 Mar;112(3):412. doi: 10.1038/ajg.2016.467. PMID: 28270676. Tan HL, Sithasanan N, Foley P, Davidson GP. The successful medical management of severe duodenal strictures secondary to eosinophilic gastroenteritis in an infant. Pediatr Surg Int 2003 Sep;19(7):562–3. doi: 10.1007/s00383-003-0995-4. Epub 2003 Aug 2. PMID: 12905002.

Introduction In 2018, our Trust approved the use of Vedolizumab in children with Ulcerative Colitis (UC) and Ustekinumab in children with Crohn's Disease (CD). At the time, access to these drugs for children was only possible through research studies. Aim Our aim was to assess the efficacy and safety of these novel treatments in our cohort. Methods We conducted an observational single centre cohort study. Data was obtained from our electronic system, Cerner Millennium, and Infoflex database. Analysis was performed using SPSS. Results 27 children were treated with Vedolizumab or Ustekinumab with 1 receiving both. All patients had failed anti-TNF medication, except 1 research patient who commenced on Vedolizumab at diagnosis. All patients underwent endoscopy prior to initiating Vedolizumab or Ustekinumab. View this table: Abstract P56 Table 1 Results. *Data expressed as median (range) Clinical remission was defined as PUCAI<10 and PCDAI<10. There was a higher induction rate of remission than quoted in adult studies with similar maintenance of remission. At 2 years follow up, 55% (15/27) remained in remission, on treatment. 1/27 is currently still on Ustekinumab with mildly active CD and 1/27 had their Vedolizumab stopped due to compliance and monitoring issues. All 10 children currently receiving Vedolizumab remain in remission. 5/6 currently on Ustekinumab remain in remission. Of the 10/27 who failed treatment, 50% were primary non-responders and 50% had secondary loss of response. 9/10 required subtotal colectomy and ileostomy, while the research patient, who was anti-TNF naïve, switched to Infliximab after failing Vedolizumab. There were no serious adverse events apart from one patient who developed eosinophilic pneumonitis, but it is unclear whether this was due to Vedolizumab or 5 ASA. Minor skin or upper respiratory tract infections were diagnosed in 5/10 patients on Ustekinumab and 1/10 patient developed Clostridium difficile. Adrenal insufficiency, as a result of prolonged courses of steroids, was detected in 7/27 children. Conclusion In children with refractory IBD failing anti-TNF treatment, Vedolizumab and Ustekinumab are effective and safe alternatives for inducing and maintaining remission, avoiding major invasive surgery.

Introduction Tuberculosis (TB) like Crohn’s disease can affect any part of the gastro-intestinal (GI) tract including anus, peritoneum and hepato-biliary system. The clinical manifestations of abdominal tuberculosis are non-specific and can mimic various GI disorders especially Crohn’s disease which can cause delay in diagnosis and management. History and Presentation A 14-year-old boy was diagnosed with small bowel ileal Crohn’s disease in 2016 based on clinical symptoms of abdominal pain and weight loss, biochemical features of a raised ESR but normal CRP at presentation and a distorted ileocaecal valve (ICV) with inflammatory changes seen both macroscopically and microscopically at colonoscopy with radiological confirmation of short segment ileal disease on MRI. He was treated with exclusive enteral nutrition for induction of remission, however his ESR remained elevated and he required escalation to Azathioprine within 3 months of diagnosis for continued symptoms of abdominal pain and ongoing weight loss. His clinical course over the next 2 years remained unchanged with a persistently raised ESR and continued disease around ICV and distal ileum in spite of immunomodulator therapy. Treatment and Investigation Prior to commencing biologic treatment for active Crohn’s disease, he had an Elispot and was found to be positive. This was felt to be consistent with latent TB infection for which he had 3 months of chemoprophylaxis with Rifampicin and Pyridoxine. Following this, his symptoms of abdominal pain resolved, and he gained 5 kg for the first time since his diagnosis of CD. Moreover, his ESR completely normalised. His repeat mri showed a significant improvement of the inflammation in the ileum as well as around the ICV. This was also confirmed with repeat colonoscopy which was markedly improved from previously although still had abnormal distortion of the ICV. His clinical response to the TB treatment and radiological and endoscopic improvement following the TB chemoprophylaxis led to the suspicion of intestinal TB as the correct diagnosis. Clinical Background and Progress He was born in the UK. He had a BCG scar. His grandmother was diagnosed with TB in India in 2010. She had visited the UK prior to the diagnosis and stayed with the family for 6 months. She was unwell with cough and weight loss at that time. Both his mother and father had been exposed to her also and his father was also receiving treatment for latent TB now. Based on the history of TB exposure and the clinical, biochemical, endoscopic and radiological improvement following latent TB treatment, he went on to complete a full 6-month course with 4 drug initiation for abdominal TB. Summary and Conclusion Abdominal tuberculosis should be considered as a differential diagnosis in patients with Crohn’s disease. Careful evaluation of clinical, biochemical, radiological and histological findings can aid in distinguishing between the two conditions, leading to early diagnosis and management.

Objectives: Patients with paediatric inflammatory bowel disease (IBD) constitute one of the largest cohorts requiring transition from paediatric to adult services. Standardised transition care improves short and long-term patient outcomes. This study aimed to detail the current state of transition services for !BD in the United Kingdom (UK). Methods: We performed a nationwide study to ascertain current practice, facilities and resources for children and young people with IBD. Specialist paediatric IBD centres were invited to contribute data on: timing of transition/transfer of care; transition resources available including clinics, staff and patient information; planning for future improvement. Results: Twenty of 21 (95%) of invited centres responded. Over 90% of centres began the transition process below 16 years of age and all had completed transfer to adult care at 18 years of age. The proportion of patients in the transition process at individual centres varied from 10% to 50%. Joint clinics were held in every centre, with a mean of 12.9 clinics per year. Adult and paediatric gastroenterologists attended at all sites. Availability of additional team members was patchy across the UK, with dietetic, psychological and surgical attendance available in <50% centres. A structured transition tool was used in 75% of centres. Sexual health, contraception and pregnancy were discussed by <60% of teams. Conclusions: This study provides real-world clinical data on UK-wide transition services. These data can be used to develop a national strategy to complement current transition guidelines, focused on standardising services whilst allowing for local implementation.

Background Primary non-response (PNR) and secondary loss of response (LoR) to anti-TNF therapy are a significant challenge in up to 45% of patients with IBD. Therapeutic drug monitoring (TDM) refers to the practice of measuring anti-TNF trough level and anti-drug antibody to guide clinical decisions. Reactive TDM is performed in response to a disease flare, whereas proactive TDM consists of periodic TDM to allow treatment optimization and prevention of possible flares. In the main, GI centres recommend the use of TDM as opposed to an empirical management of patients on anti-TNF. However, there are a limited number of studies that have addressed whether proactive TDM leads to improved clinical outcomes in comparison to reactive TDM. Aim The aim of this study was to investigate if proactive TDM improves patient disease management by reducing the risk of treatment failure due to LoR and/or development of anti-drug antibody. Patients and Methods We conducted a single-centre prospective observational study to accrue data on proactive TDM between June 2019 and June 2020. We compared this group to a historical cohort of patients with IBD treated at the same centre using reactive TDM between 2014 and 2017. Results 30 children with IBD (16 M, mean age at diagnosis 11.47 years ± SD 2.93, median 12, range 3–16) started on anti-TNF treatment between June 2019 and June 2020, were prospectively recruited (current follow-up duration: average 7.1 months ± SD 3, median 6.4, range 3.1–13). 10 had ulcerative colitis (UC), 19 had Crohn's (CD) and one had IBD-U CD-like. 37 children (20 M), 6 with UC and 31 with CD, were included in the retrospective cohort managed with reactive TDM. (Table 1). More patients in the proactive TDM cohort (22/30) were managed by escalating the IFX regime (i.e. 10 mg/Kg 8 – 6 or 4 weekly) compared to the reactive TDM cohort (14/37) (chi-square 8.396, P 0.00376). In the cohort managed with reactive TDM, a higher number of patients developed high titre anti-IFX antibody (> 50 U/ml) post induction (12/37 vs 3/30) (chi-square 4.798, P 0.0285). The need for switching to different biologics was significantly higher in the reactive TDM cohort (22/37) compared to the proactive TDM cohort (1/30) (chi-square 23.15, P < 0.00001). Conclusions The introduction of proactive TDM resulted in a significant reduction of patients requiring switch of their primary biologic and saw an increase in mean trough levels due to timely dose escalation. The results of this study are early indicators that proactive TDM offers a better method of managing children with IBD on IFX therapy compared to reactive TDM with the potential of additional clinical benefits such as reducing the risk of developing adverse drug reactions due to high antibody titres.

BackgroundCOVID-19 has impacted on healthcare provision. Anecdotally, investigations for children with inflammatory bowel disease (IBD) have been restricted, resulting in diagnosis with no histological confirmation and potential secondary morbidity. In this study, we detail practice across the UK to assess impact on services and document the impact of the pandemic.MethodsFor the month of April 2020, 20 tertiary paediatric IBD centres were invited to contribute data detailing: (1) diagnosis/management of suspected new patients with IBD; (2) facilities available; (3) ongoing management of IBD; and (4) direct impact of COVID-19 on patients with IBD.ResultsAll centres contributed. Two centres retained routine endoscopy, with three unable to perform even urgent IBD endoscopy. 122 patients were diagnosed with IBD, and 53.3% (n=65) were presumed diagnoses and had not undergone endoscopy with histological confirmation. The most common induction was exclusive enteral nutrition (44.6%). No patients with a presumed rather than confirmed diagnosis were started on anti-tumour necrosis factor (TNF) therapy.Most IBD follow-up appointments were able to occur using phone/webcam or face to face. No biologics/immunomodulators were stopped. All centres were able to continue IBD surgery if required, with 14 procedures occurring across seven centres.ConclusionsDiagnostic IBD practice has been hugely impacted by COVID-19, with >50% of new diagnoses not having endoscopy. To date, therapy and review of known paediatric patients with IBD has continued. Planning and resourcing for recovery is crucial to minimise continued secondary morbidity.