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 chronic pouchitis. Pts with laparoscopic assisted surgery had significantly fewer wound infections (p< .02). There was no increased incidence of early or late complications in those pts receiving or not receiving TP or CI (within 30 days), or IFX (within 90 days) when controlled for disease extent (left-sided vs. pancolitis). The duration of post sub-total colectomy hospitalization in pts receiving both TP and IFX was significantly shorter than those who received neither (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 complications in children undergoing colectomy for UC. 453 Predictors of Abdominal Pain in Depressed Pediatric Crohn's Disease Patients Arvind 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 and functional pain which may lead to overestimation of disease activity on IBD severity measures. Aims: 1) Characterize abdominal pain in youth with CD and co-morbid depression in terms of frequency, intensity and the relationship between pain and both disease-related (e.g., diarrhea) and psychological factors (depressive severity, anxiety, and maternal psychological stress) 2) Evaluate predictors of self-reported abdominal pain and diarrhea to see if different variables predict pain frequency and intensity after controlling for IBD-related inflammation. Methods: 600 patients ages 9-17 with confirmed CD seen in Pediatric Gastroenterology Clinic 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 degree of diarrhea were determined using PCDAI while inflammatory markers were obtained from the medical record. Results: 116 patients with CD met criteria for clinically significant depression. Mean age = 14.2 years (SD 2.4); 48% males; 87% Caucasian. There was a significant 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) and anxiety (r=.22) but not ESR or maternal distress. Only pain frequency (r=.34) correlated significantly with degree of diarrhea while both pain frequency and severity correlates with depressive and anxiety severity. Neither pain item individually correlated with high ESR or low 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 pain with only depressive severity making a unique significant contribution. 28% of variance in abdominal pain frequency and 26% of variance in pain intensity were accounted for by the combined model of depression, anxiety, and diarrhea but only depressive severity made a unique significant contribution for all components of abdominal pain (beta =0.33). Conclusions: These results suggest that the child's psychological state is the most important determinant of both the frequency and severity of self-reported abdominal pain while diarrhea and parental distress are less robust predictors after controlling for degree of IBD-related inflammation. Factors such as IBD-related strictures, disease location, and autonomic disturbances may account for the variance in abdominal pain not explained by this current model. 454 Rates and Predictors of Oral Medication Adherence in Pediatric IBD Debra Lobato, Elizabeth McQuaid, Jack Nassau, Julie Boergers, Ronald Seifer, Sheryl Kopel, Kristina I. Suorsa, Barbara Bancroft, Neal S. Leleiko
Footnote: Perianal disease and any L4 category can exist with any other disease location and behavior
Poor medication adherence is a pervasive problem in pediatric chronic illness.(1) The scant research on actual medication use in pediatric IBD indicates that children and adolescents may be missing about 50% of their prescribed medications and that patient self-reports significantly over-estimate adherence to oral medications relative to more objective measures such as pill count or blood assay. (2) The goal of the current study was to examine rates and predictors of adherence to oral medications 5-ASA and 6-MP in children and adolescents with IBD. The current study used electronic devices to monitor daily oral medication use over a 6 month period. Participants were 36 newly-diagnosed patients (54% male, mean age=13 yrs, 78% Crohn's) and 30 patients who were diagnosed an average of 3.5 years previously (53% male, mean age = 14 yrs, 83% Crohn's). Participants were required to be co-enrolled in an active pediatric biological IBD registry. Participants and parents completed standard measures of emotional and behavioral functioning, including the Children's Depression Inventory(3), the Child Behavior Checklist (4), and the Perceived Stress Scale (5). Rates of 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 newly diagnosed or had the disease for a year or more (F=.172, p=.68). Adherence to 5-ASA was higher among patients with UC (63%) than Crohn's (50%) though differences were not significant (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 and depressive symptoms. Compared to patients who scored within normal limits, lower adherence was found among patients with clinically elevated behavioral problems (56% v. 21%, p = .03) and depressive symptoms (62% v. 31%, p = .002). Clinical correlations suggest that in the absence of consideration of adherence, there is significant potential for alterations in 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).
452 Pre-Operative Immunosuppression is Not Associated With Increased PostOperative Complications Following Colectomy in Children With Ulcerative Colitis Candi 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 increase post-operative complications following colectomy for ulcerative colitis (UC). Aim: To review post-operative course in pediatric patients undergoing colectomy for UC. Methods: A chart review of all patients (pts) with a diagnosis of UC undergoing colectomy at Connecticut Children's Medical Center from 1996-2010 was conducted. Data collected included age, gender, disease extent at diagnosis, indication for colectomy, immunosuppressive medications taken within 30-90 days of colectomy (corticosteroids (CS), thiopurines (TP), calcineurin inhibitors (CI) and infliximab (IFX)), open vs. laparoscopic assisted sub-total colectomy, staging of colectomy, time between stages, and early(<60 days) post-op complications including prolonged initial hospitalization, small bowel obstruction (SBO), sepsis, wound infection, other infections, wound dehiscence, deep vein thrombosis (DVT), and pouchitis (acute or chronic). Results: 51 patients underwent colectomy for UC (55% male, 63% pancolitis at diagnosis, mean age at diagnosis 10.8±3.8 yrs, mean age at colectomy 13.1±3.8 yrs). Patient exposure 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 chronic disease in 74%. Staged operations included: 37 pts 2 stages (10 with primary pouch), 10 pts with 3 stages, and 4 pts with permanent ileostomy. Laparoscopic assisted sub-total colectomy was performed in 66%. After sub-total colectomy the mean hospital stay was 9.5 days and 14% of pts had a non-elective re-admission ≤30 days. SBO was the most common post-op complication occurring in 19% (treated surgically in 30%), followed by wound infection 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
years). Patients were classified by the new Paris criteria as to maximal IBD location and behavior at diagnosis and at latest follow-up. Treatments were recorded. Results: Data are presented 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 L1 disease (2/41 vs 29/109, p=0.001 OR 0.12 (95% CI 0.03-0.54)) and consequently more colonic disease (L2+L3 38/41 vs 76/109, p=0.002 OR 5.5 (95% CI 1.58-19.09)). Among the youngest (A1a) children with initially colonic CD (L2), extension to the ileum occurred in 6 (40%) of 15 patients. UC was already extensive (E3 or E4) at diagnosis in 78% of all children. By 1.5 and 3 yrs, respectively, medical treatment included immunomodulators in 47.2% 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 to 9.5 % and 24.1% of children and for UC to 6.4% and 7.4% by 1.5 and 3 years (KM estimates).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: The Paris 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 their colonic CD to subsequently extend. CD location in children ≥ 10 years at diagnosis remained stable 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 inflammatory to stricturing or penetrating over time in children of all ages. Table: Evolution of disease phenotype in pediatric IBD