Risk Factors and Treatment Strategies for Anastomotic Ulcers in Pediatric Intestinal Failure.

Purpose: Anastomotic ulcers (AUs) are a rare cause of morbidity in intestinal failure (IF). Prior studies of AUs have been small, descriptive reports. We evaluated a large cohort of IF patients to identify risk factors and describe treatment strategies for AUs.

Methods: This was a retrospective, case-control study of IF patients within an interdisciplinary pediatric intestinal rehabilitation program from 2013 to 2023. Each case was a child who had a bowel resection, with intestinal failure (IF) meeting the American Society for Parenteral and Enteral Nutrition (ASPEN) definition of IF, with localized, peri-anastomotic ulceration on GI endoscopy. Each case was matched with 2 controls (children with IF but without an AU diagnosis), based on sex and time since intestinal failure diagnosis. Cases and controls were compared using conditional logistic regression on clinically relevant risk factors.

Results: Of 588 patients followed in our program and screened, 31 (5.3 %) cases were identified. Median duration from initial surgery to AU diagnosis was 6 years, and ulcers were noted to be close to the entero-colonic anastomosis in 23 (77.4 %). The ulcers were noted to be <50 % of circumference in 9 (29 %), ≥50 % circumference in 7 (22.6 %) and multiple in 15 (48.4 %). Median follow up after AU diagnosis was 2.17 years. On multivariable analysis, AU was associated with increased bowel length (OR 1.65 for each 10 % increase in percent expected bowel length, CI 1.01, 2.7) and longer duration of parenteral nutrition (PN) in years (OR 1.68, CI 1.09, 2.6). Of the 31 cases, 10 (32.3 %) required at least one red blood cell transfusion. Initial medical management with antibiotics, anti-inflammatory medications, and/or enteral steroids was utilized in 29 (93.5 %). Of these, 8 ultimately failed medical management, as defined by the clinical team, and underwent surgery (7) or endoscopic coagulation (1). Initial procedural intervention was performed with endoscopic coagulation in 1 case and surgery in 1 case, of which the patient required repeat surgery.

Conclusions: In this large cohort of IF patients, AU occurred in 5.3 % of patients. Most patients can be managed medically but surgery may be ultimately required in select patients. The odds of AU increased with greater percent expected bowel length and longer PN duration.