What To Do with Perianastomotic Ulcerations

C Madre et al. JPGN 2021; 73: 333-337. A European Survey on Digestive Perianastomotic Ulcerations, a Rare Crohn-like Disorder Occurring in Children and Young Adults

This survey study with 51 children described the etiology and treatment of perianastomic ulcerations (PAU).

Key findings:

  • Most common initial etiologies: necrotizing enterocolitis (n = 20) or Hirschsprung disease (n = 11)
  • Median onset of symptoms: 39 [22–106] months after surgery
  • Clinical features: 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%)
  • Treatments:  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%). The authors note that despite similarity to Crohn’s disease, there was a lack of response to immunosuppressors and anti-TNF therapies
From JPGN twitter feed. Figure 2 in article showing examples of ileocolonic ulcerations

Related article: H Barraclough et al. JPGN 2021; 73: 329-332. Anastomotic Ulcers: A Tertiary Centre Experience of Endoscopic Management Techniques This study summarized a tertiary care center experience with 9 patients (2 with IBD). Frequent treatment included aminosalicylates, and endoscopic treatments (APC, endoclips).

Related blog posts:

Crohn’s Disease Anastomotic Ulcerations

A recent retrospective study (RP Hirten et al. Inflamm Bowel Dis 2020; 26: 1050-1058Anastomotic Ulcers After Ileocolic Resection for Crohn’s Disease Are Common and Predict Recurrence) showed that anastomotic ulcers occur in over half of Crohn’s disease patients after ileocolic resection and are associated with Crohn’s disease recurrence and are persistent.

Key findings:

  • Anastomotic ulcers were present in 95 (52.2%) subjects. No factors were associated with anastomotic ulcer development.
  • Anastomotic ulcers were associated with disease recurrence (adjusted hazard ratio [aHR] 3.64)

The associated editorial by Philllip Fleshner (pg 1059) identifies are a number of methodologic flaws, noting that less than 20% of all ileocolonic resections were included and marked variability in postoperative assessment (from 29 days to 2897 days).

My take: (borrowed from the editorial) the “findings should convince us that anastomotic ulcers do not represent ischemic changes but are rather a reflection of disease progression.”  Prospective studies with standardized surveillance would be helpful.