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Increased abdominal visceral adipose tissue (VAT) is associated with systemic inflammation. The influence of VAT on pediatric inflammatory bowel disease (IBD) has not been studied. The objective of this study was to investigate the differences in VAT between pediatric patients with IBD and age-matched controls and identify associations between VAT and Crohn's disease (CD) outcomes.Single-center retrospective cohort study of 114 pediatric patients with IBD (101 CD and 13 ulcerative colitis) who had abdominal computed tomography at diagnosis. VAT volumes were measured from computed tomography images. A control group of 78 age-matched patients without IBD who had abdominal computed tomography was selected for comparison.Median VAT was 634 cm3 (interquartile range, 411–1041) in the IBD group and 659 cm3 (interquartile range, 394–1015) in the controls. IBD group had 33% higher VAT than controls (95% confidence interval [CI], 11–58) P = 0.002 after adjusting for body mass index and age. In patients with CD, higher VAT was associated with fistulizing or fibrostenotic disease (odds ratio [OR], 1.7; 95% CI, 1.1–2.9; P = 0.03), CD hospitalizations (OR, 1.9; 95% CI, 1.2–3.4; P = 0.01), moderate or severe disease activity scores (OR, 1.8; 95% CI, 1.1–3.1; P = 0.02), and shorter intervals from diagnosis to surgery (hazard ratio, 1.4; 95% CI, 1.0–2.0; P = 0.05) after adjusting for body mass index and age.At diagnosis, pediatric patients with IBD have higher adjusted VAT volumes than age- and body mass index–matched controls. Higher VAT volumes in pediatric patients with CD predicted more hospitalizations, increased likelihood of complicated disease, shorter interval from diagnosis to surgery, and higher disease activity scores at diagnosis.