Digestive perianastomotic ulcerations and Crohn's disease

Frémond, Marie-Louise; Viala, Jérôme; Roy, Maryline; Berrebi, Dominique; Gottrand, Frédéric; Bonnard, Arnaud; Martinez-Vinson, Christine; Hugot, Jean‐Pierre

doi:10.1016/j.crohns.2014.06.011

Cited by 18 publications

(27 citation statements)

References 22 publications

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“…Indeed, the presence of scattered ulcerations on the SB is reminiscent to CD lesions, especially in case of recurrence after ileocecal resection. The association between DPAU and NOD2 mutations (like for CD) further supported the idea that DPAU could be an “experimental CD” situation (9). Of note, we failed to confirm this association in a subgroup of 10 patients genotyped for the 3 main CD-associated NOD2 mutations (data not shown).…”

Section: Discussionsupporting

confidence: 69%

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A European Survey on Digestive Perianastomotic Ulcerations, a Rare Crohn-like Disorder Occurring in Children and Young Adults

Madre

Mašić

Prlenda-Touilleux

et al. 2021

Journal of Pediatric Gastroenterology &Amp; Nutrition

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Objectives:Digestive perianastomotic ulcerations (DPAU) resembling Crohn disease lesions are long-term complications of intestinal resections, occurring in children and young adults. They are known to be uncommon, severe and difficult to treat.Methods:In the absence of recommendations, we performed a large European survey among the members of the ESPGHAN working group on inflammatory bowel disease (IBD) in order to collect the experience of expert pediatric gastroenterologists on DPAU.Results:Fifty-one patients (29 boys and 22 girls) were identified from 19 centers in 8 countries. Most patients were followed after necrotizing enterocolitis (n = 20) or Hirschsprung disease (n = 11). The anastomosis was performed at a median age (interquartile range) of 6 [1–23] months, and first symptoms occurred 39 [22–106] months after surgery. Anemia was the most prevalent symptom followed by diarrhea, abdominal pain, bloating, and failure to thrive. Hypoalbuminemia, elevated CRP, and fecal calprotectin were common. Deep ulcerations were found in 59% of patients usually proximally to the anastomosis (68%). During a median follow-up of 40 [19–67] months, treatments reported to be the most effective included exclusive enteral nutrition (31/35, 88%), redo anastomosis (18/22, 82%), and alternate antibiotic treatment (37/64, 58%).Conclusions:Unfortunately, persistence of symptoms, failure to thrive, and abnormal laboratory tests at last follow-up in most of patients show the burden of DPAU lacking optimal therapy and incomplete understanding of the pathophysiology.

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Section: Discussionsupporting

confidence: 69%

“…Patients were identified from 19 centers in 8 countries. The cohort consisted of 29 boys and 22 girls (sex ratio 1.32) with a median age at inclusion of 13 [9][10][11][12][13][14][15][16][17] years. The anastomosis had been performed at median age of 6 months.…”

Section: Resultsmentioning

confidence: 99%

A European Survey on Digestive Perianastomotic Ulcerations, a Rare Crohn-like Disorder Occurring in Children and Young Adults

Madre

Mašić

Prlenda-Touilleux

et al. 2021

Journal of Pediatric Gastroenterology &Amp; Nutrition

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“…Children with SBS are at risk for developing AU that can lead to hemodynamically significant GI bleeding and anemia. The etiology for ulcer development is unclear, though various mechanisms have been proposed, including ischemia, inflammatory bowel disease-like process, SIBO, hypersecretion of acid, bile acid toxicity, among others (5,9). Additionally, the diagnosis and treatment of AUs remain challenging.…”

Section: Discussionmentioning

confidence: 99%

Whole Foods Introduction Associated With Symptomatic Anastomotic Ulceration in Children With Short Bowel Syndrome

Zong,

Salich,

Kastl

et al. 2023

Journal of Pediatric Gastroenterology &Amp; Nutrition

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Objectives: Anastomotic ulceration (AU) is a rare but life-threatening complication of pediatric short bowel syndrome (SBS). AUs may be challenging to detect and refractory to treatment. This study aimed to identify features associated with symptomatic bleeding AUs in children with SBS and factors that may impact resolution of bleeding. The relationship between dietary changes and symptomatic anastomotic hemorrhage was also explored. Methods: We conducted a retrospective chart review of 381 patients cared for in the Intestinal Rehabilitation Program (IRP) at our center from 2013 to 2022. Patients with symptomatic AUs were identified based on at least 1 endoscopic procedure showing AUs and evidence of clinically significant GI bleeding. We collected patient demographics, clinical characteristics, dietary history, radiologic imaging, and histopathology. We used descriptive statistics to identify patterns of presentation. Results: AUs were identified in 22 patients who were followed for a median duration of 2.9 years after anastomotic ulcer identification. AUs uniformly evolved years after the initial anastomosis (median 3.2 years). Characteristics included bowel stricture (4/22), small bowel-colon anastomosis (19/22), partial colectomy (17/22), and an increase in whole foods fraction (12/18). Bleeding resolved with operative intervention in the majority with anastomotic stricture (3/4). Recurrent bleeding was common in those without stricture (13/18). In a subset of patients without stricture, whole food reduction was associated with improvement or resolution of bleeding (5/6). Conclusions: We observed a higher proportion of patients with AUs who responded to surgical intervention in the subset of children with definitive anastomotic strictures versus those without, suggesting that careful characterization of intestinal anatomy may be critical to predicting response to therapy. We also observed that bleeding from AU typically first manifested within one year of a shift from elemental or hydrolyzed enteral formula to a whole food-based diet (including commercial blenderized feeds), which may indicate that components of the enteral diet play a role in the pathogenesis of AU. Further studies are needed to validate these hypotheses.

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“…PAU is a rare but severe complication after intestinal resection and anastomosis. It is described mostly in children [9091]. The main symptom is bleeding, leading to iron-deficiency anemia, which is life threatening.…”

Section: Management Of Sbs-ifmentioning

confidence: 99%

“…The mechanism leading to PAU remains unknown but it is likely that intestinal microbiota dysbiosis might play an important role. Another recent series reported 14 cases revealed by severe anemia, diarrhea, abdominal pain and growth failure in average 11.5 years after surgery [91]. Ulcerations were most often multiple (n=11), located on the upper part of ileocolonic anastomoses (n=12) and difficult to treat.…”

Section: Management Of Sbs-ifmentioning

confidence: 99%

Short Bowel Syndrome as the Leading Cause of Intestinal Failure in Early Life: Some Insights into the Management

Goulet

Nader

Pigneur

et al. 2019

Pediatr Gastroenterol Hepatol Nutr

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Intestinal failure (IF) is the critical reduction of the gut mass or its function below the minimum needed to absorb nutrients and fluids required for adequate growth in children. Severe IF requires parenteral nutrition (PN). Pediatric IF is most commonly due to congenital or neonatal intestinal diseases or malformations divided into 3 groups: 1) reduced intestinal length and consequently reduced absorptive surface, such as in short bowel syndrome (SBS) or extensive aganglionosis; 2) abnormal development of the intestinal mucosa such as congenital diseases of enterocyte development; 3) extensive motility dysfunction such as chronic intestinal pseudo-obstruction syndromes. The leading cause of IF in childhood is the SBS. In clinical practice the degree of IF may be indirectly measured by the level of PN required for normal or catch up growth. Other indicators such as serum citrulline have not proven to be highly reliable prognostic factors in children. The last decades have allowed the development of highly sophisticated nutrient solutions consisting of optimal combinations of macronutrients and micronutrients as well as guidelines, promoting PN as a safe and efficient feeding technique. However, IF that requires long-term PN may be associated with various complications including infections, growth failure, metabolic disorders, and bone disease. IF Associated Liver Disease may be a limiting factor. However, changes in the global management of IF pediatric patients, especially since the setup of intestinal rehabilitation centres did change the prognosis thus limiting “nutritional failure” which is considered as a major indication for intestinal transplantation (ITx) or combined liver-ITx.

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Digestive perianastomotic ulcerations and Crohn's disease

Abstract: Altogether, these findings argue for common physiopathological features between DPAU and Crohn's disease and for a prospective follow-up of selected operated children to explore the early events involved in gut inflammatory lesions.

Cited by 18 publications

References 22 publications

A European Survey on Digestive Perianastomotic Ulcerations, a Rare Crohn-like Disorder Occurring in Children and Young Adults

A European Survey on Digestive Perianastomotic Ulcerations, a Rare Crohn-like Disorder Occurring in Children and Young Adults

Whole Foods Introduction Associated With Symptomatic Anastomotic Ulceration in Children With Short Bowel Syndrome

Short Bowel Syndrome as the Leading Cause of Intestinal Failure in Early Life: Some Insights into the Management

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