four patients (30.7%) had a BMI <5th percentile at the time of surgery. Short-term (<30days) post-operative events occurred in two patients with recurrent perianal disease. Bothhad normal BMI: one was on IM and one on biologics peri-operatively. Long-term (30-180days) post-operative events included repeat surgery (1/13, on steroids/biologics), and rectalbleeding requiring readmission (1/13, on biologis); both had normal BMI. One patient hadan anastomotic stricture requiring repeat surgery, however this was at >2 years. Of note, 9/13 (69%) were seen by our practice as a second opinion. Conclusions: Immunosuppressionis more common than malnutrition in pediatric patients with Crohn's disease who havepost-operative events.Pre-Operative Nutritional Status and Immunosuppression as Predictors of Post-OperativeEvents in Pediatric Crohn's Disease Patients

Sa1981

Pre-Operative Nutritional Status and Immunosuppression as Predictors ofPost-Operative Events in Pediatric Ulcerative Colitis PatientsMelissa Rose, Vesta Salehi, Robbyn E. Sockolow, Aliza B. Solomon

Objective: To evaluate the frequency of post-operative events in children with ulcerativecolitis (UC) in relation to nutritional status and use of immunosuppressive medications priorto surgery. Patients/Methods: A case series was conducted of 9 pediatric patients with UCwho underwent surgical intervention between 2007 and 2011. Age of diagnosis, age of firstsurgical intervention, type(s) of surgical intervention(s), pre-operative immunosuppressivemedication use and nutritional status (BMI <5th percentile) were reviewed and evaluatedin the context of post-operative events. Results: The average age of diagnosis was 10.74years (median 11.16). The average age at first surgical intervention was 13.92 years (median12.5), with the average time from diagnosis to first surgical intervention being 3.22 years(median 2.83). Procedures included four (44.4%) two-stage ileal-pouch anal anastomosis(IPAA), three (33.3%) three-stage IPAA, and two total abdominal colectomy with ileostomywith plans to complete a three-stage IPAA (22.2%). One patient had four subsequent surgicalpouch revisions, one had a small bowel resection at stage 3 of her IPAA, and one had pouchfailure requiring end ileostomy placement. Five patients had elective procedures and fourhad emergent procedures. Reasons for emergent surgery included acute failure of medicaltherapy (3/9) and acute toxic colitis (1/9). Five patients (55.5%) were on immunosuppressivemedications at the time of initial surgery; two were on steroids/biologics, one on an immuno-modulator (IM) and two on steroids alone. The four remaining patients had been off ofimmunosuppression for 4-8 weeks pre-operatively. Pre-operative BMI percentile ranged from0.19-97.83% (median 51.69%) and two patients (22.2%) had a BMI <5th percentile. Short-term (<30 days) post-operative events occurred in four patients and included readmissionfor pain, wound infection (both with normal BMI and on steroids/biologics); prolongedsmall bowel edema delaying second stage (normal BMI, on IM); and pouchitis with sinustract formation (low BMI, on no immunosuppression peri-operatively). Long-term (30-180 days) post-operative events occurred in two patients, one with recurrent pouchitis,anastomotic leak and stricture, abscess, sinus tract formation and infection (initial surgeryoccurred at another hospital, patient was on biologics at time of surgery and BMI wasnormal) and one with an incisional hernia after her initial surgery (on steroids, normal BMI)and later pouch failure at 6 months (on no immunosuppression, BMI 6%). All patientsexcept for one (88.8%) were seen by our practice as a second opinion. Conclusions: Immunos-uppression is more common than malnutrition in pediatric patients with ulcerative colitiswho have post-operative events, however malnutrition also likely plays a role in outcomes.Pre-Operative Nutritional Status and Immunosuppression as Predictors of Post-OperativeEvents in Pediatric Ulcerative Colitis Patients

Sa1982

Detecting Enterotoxigenic Bacteroides Fragilis Carriage in PediatricInflammatory Bowel DiseaseLea Ann Chen, Shervin Rabizadeh, Sankar Chirumamilla, Shehzad A. Saeed, EmiliaAlbesiano, Andrew Goodwin, Shaoguang Wu, Charles O. Elson, Maria Oliva-Hemker,Cynthia L. Sears

Enterotoxigenic Bacteroides fragilis (ETBF) causes asymptomatic, chronic colitis in C57BL/6mice and increased colon tumorigenesis in multiple intestinal neoplasia (MinApc/+) mice viaits primary virulence factor the B. fragilis toxin (BFT). Studies suggest an association betweenETBF infection and active inflammatory bowel disease (IBD), but only small studies inhumans are available. Our study aims to develop a sensitive diagnostic touchdown PCRprotocol for bft detection and to apply this protocol to determine ETBF carriage rates inpediatric IBD patients. We spiked known quantities of a serially diluted laboratory ETBFstrain into sham mouse stool. ETBF detection limits range from 2.3 x 103 to 4.6 x 105 CFU/mL for pure ETBF culture and 4.1 x 105 to 4.6 x 106 CFU/gm stool for spiked sham stool.To test for ETBF carriage in humans, we prospectively enrolled pediatric patients withulcerative colitis or Crohn's disease from two academic IBD centers. Control samples weresimilarly collected from confirmed non-IBD patients presenting to the pediatric GI clinicsat the same institutions. Extracted stool DNA from 25 IBD patients and 25 controls weretested by our touchdown PCR protocol for bft with no positive results. Next frozen fecal

S-373 AGA Abstracts

samples from 8 IBD and 3 control patients were thawed and cultured on selective BacteroidesBile Esculin (BBE) agar to help select for Bacteroides spp. Sixteen isolates were collectedfrom each of the 4 IBD and 2 control samples that grew on BBE. Touchdown PCR performedon boiled water preps of each isolate were positive for bft in 2 of the 4 IBD patients (4 of16 isolates and 5 of 16 isolates, respectively) and both controls (1 of 16 and 6 of 16,respectively). Our stool DNA results suggest that the ETBF quantity, if present in our IBDand control samples, is less than ~105CFU/gm stool, though ETBF spiking experimentsusing these bft-negative human stools are needed to account for possible fecal PCR inhibitorsthat may affect our assay sensitivity. Second, our data suggests that testing of bacterialisolates is a more sensitive method to detect bft+ Bacteroides. Testing of more samples isneeded to distinguish if there is a statistically significant difference in the percentage of IBDpatients vs. controls who carry ETBF or in the quantity of ETBF they carry. We are in theprocess of testing for human stool inhibitors, as well as testing other IBD and control samplesfor bft. We will analyze associated clinical data to determine if BFT carriage correlates withclinical manifestations of IBD, such as disease location, severity, or timing of flares.

Sa1983

Characterization of Mucosally - Adherent Escherichia coli in PediatricInflammatory Bowel Disease PatientsRebecca Flint, Ward Jarvis, Matthew Overton, Robert Baldassano, Sandra C. Kim

Background: Children with inflammatory bowel disease (IBD) have unique characteristicsnot seen in adult patients, including growth and nutritional deficiencies and aggressivedisease. Thus, a better understanding of factors that potentially perpetuate disease is crucial.Prior studies have shown that both adults and children with IBD, particularly Crohn's disease(CD), have increasedmucosally - adherent Escherichia coli. However, the relationship betweenE. coli in pediatric IBD patients and bacterial - associated virulence genes has not beenclearly delineated. Aim: Determine whether mucosally - associated E. coli isolated frompediatric CD patients is found in greater numbers and express more virulence genes comparedto children with ulcerative colitis (UC) and healthy controls. Methods: Mucosal biopsysamples (2 - 3 per section) were obtained from the ileum (IL), cecum (CEC), and distalcolon (DC) of pediatric pts undergoing routine procedures. Samples were processed usingestablished lab protocols for culture (plated on MacConkey) and quantification. Individualcolonies were selected from bacterial cultures and incubated. PCR was used to confirm thepresence of E. coli and to test for E. coli - associated virulence genes (Table 1) from bacterialDNA extracted from the cultures. Bacterial DNA was extracted from biopsies for E. coliquantification by real time PCR (qPCR). Results: Mucosal biopsy samples were analyzed (n=42 pts; 50% M, 50% F; 10-23 yrs, mean: 16.2 ± 3.0 yrs). There were 34 CD (15.9±2.9yrs), 4 UC (18.3±3.4 yrs), 2 healthy control, and 2 indeterminate colitis (IC) pts. Therewere no statistically significant differences in E. coli-associated virulence genes between CDand UC pts or between different regions (IL/CEC/DC) within disease subsets, but sometrends were seen. Virulence genes kpsmII and fliC were expressed in CD but not UC pts,and all IBD pt, but no control, samples expressed fimA and hcp. In the E. coli quantificationdata, we group samples by quartile. 100% of IL and DC and 66.7% of CEC samples in theupper quartiles were from CD pts. In the lower quartiles, only 55.6% of IL, 22.2% of CEC,and 55.6% of DC samples were from CD pts. Conclusion: E. coli adherence virulence genesmay be necessary to induce and maintain the dysregulated response in IBD. Differences invirulence genes may affect E. coli mucosal adherence in different pediatric IBD pt subsets.Ongoing studies are focused on sample size expansion, antimicrobial resistance and correlat-ing patient risk alleles associated with impaired bacterial sensing/processing to E. coli quanti-fication/characteristics. A better understanding of the relationship between E. coli, in pediatricIBD patients, and antimicrobials may lead to targeted therapies including less toxic therapieswhich modulate specific components of the intestinal microbiota.Table 1: Virulence genes

Sa1984

Quantification and Characterization of Klebsiella pneumoniae in PediatricPatients With Inflammatory Bowel DiseaseMatthew Overton, Ward Jarvis, Rebecca Flint, Robert Baldassano, Sandra C. Kim

Background: Inflammatory Bowel Diseases (IBD), including Crohn's disease (CD) and ulcerat-ive colitis (UC), are chronic relapsing diseases resulting from a dysregulated host immuneresponse against normal commensal bacteria. Members of the Enterobacteriaceae family,including Klebsiella spp, are known to be increased in IBD patients. Previous studies haveshown an association between increased anti-Klebsiella antibodies in patients with Crohn'sand ankylosing spondylitis. Furthermore, studies in rodent IBD models have shown acorrelation between increased intestinal Klebsiella pneumoniae and the development of colitis.

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sAim: Determine the frequency of mucosally - adherent Klebsiella pneumoniae from mucosalbiopsy samples (a) from the ileum and rectum of children with CD versus children withUC and controls and (b) between different regions of the intestine within children with CD.Methods: Mucosal biopsy samples (2-3 per section) were obtained from pediatric patientsundergoing routine procedure from the ileum (IL), cecum (CEC), and distal colon (DC).Samples were processed using established lab protocols for culture (plated on MacConkey)and quantification. Individual colonies were selected from bacterial cultures and incubated.PCR and real time PCR (qPCR) were used to identify K. pneumoniae present in the samplesas well as to quantify the Klebsiella pneumoniae in the mucosa. Results: Intestinal biopsysamples from the ileum (IL), cecum (CEC), and distal colon (DC) were obtained and studiedfrom pediatric IBD patients (n=87; 53%M, 47%F, mean= 15.8 ± 3.2 yrs). 7 samples had asignificant absolute K. pneumoniae load (>500 copies) quantified (Fig 1). When K. pneumoniaeload was expressed as a percentage of the total bacterial load, 21 samples had a significant(>5%) proportion of K. pneumoniae (Fig 2). 10 CD and 1 UC patient had elevated Klebsiellalevels: (a) CD with copy number and percentage significant (n=4); (b) CD with percentagesignificant (n=6); (c) UCwith percentage significant (n=1). This suggests a stronger associationof K. pneumoniae to CD vs. UC. Of the samples from CD patients with elevated K. pneumoniaelevels, there was no significant trend towards regional specificity. Conclusion: Our studysuggests that K. pneumoniae may have a role in Crohn's disease and complements previousstudies focusing on CD in adult patients and murine models. Ongoing studies are expandingon the current work by completing data collections from a larger patient cohort and throughinvestigations delineating the virulence genes potentially involved in disease pathogenesis.

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S-374AGA Abstracts

Sa1985

Decreased Intestinal Alkaline Phosphatase Expression in PediatricInflammatory Bowel DiseaseDiana Lerner, Nita H. Salzman, Katherine Fredrich, Vincent Biank, Michael Hayward,Bhaskar Gurram, Michael C. Stephens, Pippa Simpson, David M. Gourlay

Background: Inflammatory bowel disease (IBD) is a chronic, inflammatory condition of thegastrointestinal tract with the highest incidence in childhood and early adolescence. Thepathophysiology of IBD is unknown but is thought to involve abnormal activation of TollLike Receptor (TLR) pathways in response to bacterial antigens. Intestinal alkaline phosphat-ase (IAP) is a small intestinal brush border enzyme currently under investigation for thetreatment of ulcerative colitis (UC) in adults. IAP dephosphorylates lipopolysaccharide (LPS)and decreases LPS mediated TLR4 activation and has been implicated in the preservationof normal gut homeostasis. Aims: To compare IAP expression in terminal ileum (TI) samplesof pediatric IBD patients and controls to investigate potential role of IAP in the pathophysiol-ogy of pediatric IBD. Methods: All pediatric patients under 19 years of age undergoingcolonoscopy at our institution were approached for enrollment after IRB approval wasobtained. IAP gene expression was measured by RT-PCR on ileal tissue with GAPDH usedas an internal control. Statistical analysis was performed using Mann-Whitney and Kruskal-Wallis tests. Results: A total of 98 pediatric (0.7-18 years) patients were enrolled, 26 patientswith IBD and 72 controls. At the time of the biopsy 22 patients in the IBD group weremedically treated and 4 were newly diagnosed. Normal histologic appearance of the TI andcolon was found in 6 out of the 26 IBD patients. IAP mRNA expression in the TI wassignificantly reduced in the IBD group in comparison to controls (p ≤ 0.009). Subanalysisidentified Crohns patients had the lowest levels of IAP mRNA expression followed by UCand Controls (p ≤ 0.028). Conclusion: IAP mRNA expression in the TI of pediatric patientswith IBD is significantly decreased compared to controls. IAP may play an important rolein regulating intestinal inflammation in pediatric IBD patients. A larger sample size willallow us to investigate differences in IAP expression in relation to disease severity, treatmentresponsiveness, symptom profile and growth parameters.

Sa1986

Periappendiceal Inflammation in Ulcerative Colitis in ChildrenCaterina Strisciuglio, Eleonora Giannetti, Francesca P. Giugliano, Lorenza di Domenico,Severo Campione, Maria D'Armiento, Annamaria Staiano, Erasmo Miele

Background: An involvement of the appendiceal orifice as a distinctive skip lesion in adultswith left side Ulcerative Colitis (UC) has been reported. Only one pediatric study lookedat the prevalence of periappendiceal involvement (PAI)in children with IBD who requiredcolonic resection and found an involvement in all children. The aim of our prospectivestudy was to evaluate, by endoscopy and histology, the prevalence of PAI in children affectedby UC. Methods:Twenty-threechildren (mean age±SD:13.6±3.1, years), who underwent totalcolonoscopy from August 2011 to November 2011, who had active UC and whose diseasehad not been beyond the hepatic flexure, were enrolled in the study. The extent of thedisease was defined according to the Paris classification. The diagnosis of UC was based onclinical symptoms, endoscopic and histologic findings.The clinical activity was measuredwith the Pediatric Ulcerative Colitis Activity Index (PUCAI). Histologic grade of activeinflammation was determined according to Zhong's score (World J Gastroenterol 2005).Results:In our study population PAI was endoscopically present in 5 of 23 patients (21.7%)with UC with no statistical difference (p= 0,67) between patients with new diagnosis 1/5(23%) and patients with preexisting UC 4/18 (22.2%). Patients were then divided in twogroups: group A included the 5 patients with PAI and group B 18 patients without PAI.There were no differences between group A and group B with respect to the male/femaleratio (group A: 2:3 vs. group B: 10:8), the age at onset of the disease (group A: 10.6 +3.43vs. group B: 10.5±3.37, M±SD, years) and the mean duration of UC from the onset untilindex colonoscopy (group A 2.2 ± 1.64 vs. group B 3.2 ± 2.98, M±SD, years). At indexcolonoscopy, extensive colitis was present in 4 patients (80%) in group A vs. 5 patients(27.7%) in Group B, and statistically significant trend (p=0.066) was found between PAIand the extent of the disease. The histological grade of inflammation at the appendicealorifice was significantly (p<0.001) higher in group A than in group B; however, there wasno significant difference in the grade of inflammation for the remaining colonic segmentsbetween the two groups. PUCAI and medical therapy did not show significant differencesbetween the 2 groups( p= 0.23 and p= 0.39, respectively). Conclusions: Our preliminarydata show that the prevalence of PAI as a skip lesion of ulcerative colitis in children is notdifferent from that reported in adults. However, in contrast with adults, PAI in childrenseems to be related to the extent of the disease and associated with a higher grade ofhistological inflammation. In addition, in our children PAI does not cont ribute to the clinicalactivity and is not influenced by medical therapy or duration of the disease.

Sa1987

Nutrition and Dietary Behaviors Over Time in Pediatric Inflammatory BowelDiseaseSarah Hagin, Debra Lobato, Bruce E. Sands, Joshua R. Korzenik, Nicole T. Flowers,Marjorie Merrick, Samir A. Shah, Barbara Bancroft, Renee Bright, Meaghan M. Law,Heather Durfee, Neal S. Leleiko

Background: Pediatric populations with Inflammatory Bowel Disease (PedIBD) are at riskfor growth and bone health problems. Disease activity and treatment contribute to theseproblems as well as additional factors such as health behaviors or diet. Previous PedIBDresearch has focused on nutrition supplements or enteral rescue therapy, failing to examinedaily oral nutrition. Our previous research suggests inadequate nutrient intake in PedIBDat diagnosis despite adequate caloric intake. Given that active disease is common at the timeof diagnosis, dietary behaviors measured at diagnosis may not represent typical eatingpatterns. Objective: To examine daily oral nutrition, including caloric and nutrient intakeand dietary behaviors, in PedIBD at diagnosis and one year post diagnosis. Methods: Baselineand annual follow-up food frequency data were derived from OSCCAR, the prospective IBD