Appropriate screening strategy and timely referral in suspected pediatric inflammatory bowel disease: Impact on diagnostic delay and severity at presentation

OBJECTIVES: Pediatric-onset inflammatory bowel disease (pIBD) often presents with nonspecific symptoms, contributing to diagnostic delay (DD) and increased morbidity. Despite the importance of referral quality, diagnostic pathways in pIBD have rarely been evaluated. This study aimed to assess the appropriateness of diagnostic pathways in pIBD; to evaluate their impact on DD and early disease severity; and to identify predictors of pathway appropriateness and prolonged delay. METHODS: This retrospective, single-center study included 128 patients diagnosed with pIBD (January 2015 to June 2025, regional tertiary center, Italy). Diagnostic pathways were classified as appropriate, partially appropriate, or inappropriate according to predefined criteria reflecting referral trajectory and completeness of pre-referral screening (fecal calprotectin [FC] and/or abdominal ultrasound [AUS]). DD was defined as the time from symptoms onset to endoscopy. RESULTS: Pathways were inappropriate in 60.9%, partially appropriate in 21.9%, and appropriate in 17.2%. The median DD was 3.9 months, with no significant differences among groups. Acute severe colitis (ASC) (odds ratio [OR] = 32.2) and tenesmus (OR = 5.8) were associated with appropriate pathways, fever (OR = 0.10) and oral aphthosis (OR = 0.05) with inappropriate ones (p < 0.05). Shorter DD was independently associated with ASC (B = -6.13 months), hematochezia (B = -3.48), fever (B = -4.25), and weight loss (B = -3.42) (p < 0.05). FC and AUS were performed before referral in 60.2% and 42.2% of patients, respectively, and together in 32.8%. CONCLUSIONS: Inappropriate pathways and lack of pre-referral screening are highly prevalent. Severe intestinal presentations favor appropriate investigations. Systemic or extraintestinal manifestations are more frequently associated with inappropriate pathways. Standardized screening and referral protocols may optimize pIBD management.