P1.04: Anastomotic Ulcers in Children with Short Bowel Syndrome: A Single Intestinal Rehabilitation Center Experience

Anastomotic ulcers can present as a significant problem in children with short bowel syndrome (SBS). They are typically a late complication occurring years after creation of an ileocolonic anastomosis. As the mucosa becomes inflamed and ulcers form complications of GI blood loss (gross or occult), iron deficiency anemia, chronic diarrhea, and feeding intolerance may occur. The purpose for this study is to identify a most common etiology of anastomotic ulcers and best treatment options in patients with SBS. A retrospective chart review of intestinal rehabilitation patients was completed, and was limited to pediatric patients (<19 yo) with diagnoses of SBS, gastrointestinal bleeding, and endoscopic evidence of ulcers during a 10 year period of time (2006–2016). We collected basic data, including the age, sex, diagnoses, past medical and surgical history, post surgical anatomy, endoscopic findings, small bowel aspiration culture results, laboratory findings, and GI bleeding management and response. Data were analyzed using descriptive statistics and processed to find trends for clinical interpretation. 14 patients met inclusion criteria. The average intestinal length was 40 cm (11/14 ≤70 cm), and remaining colon median was 50% (9/14 ≤50%). Serial Transverse Enteroplasty (STEP) procedures performed on 9/14. Average age of anastomosis at first step was 2.9 yrs. Of the patients that had a STEP procedure, the median number of procedures was 1 (range 1–5). The median age of surgical anastomosis where ulcer was detected was approximately 3 years. On reviewed laboratory data, 11/14 patients required transfusions. Of the 11 that required a transfusion, the median number of transfusions was 3. The median number of procedures was 6 (range of 1–19). When treated for SBBO 3/7 showed improvement of ulcers with antibiotics alone. Stopping enteral iron therapy was successful in 2 cases. Surgical intervention was required in 6/14 cases. Anastomotic ulcers are viewed as multifactorial problem. Factors that seemed to contribute include; past medical and surgical history, ischemic changes, medication exposure (ferrous sulfate), exposure to colonic bacteria and bile acids malabsorption. The one universal factor was the absence of an ileocecal valve. A systematic approach started with antibiotics, cholestyramine and/or steroids should be utilized and consider avoidance of enteral iron therapy. Early consideration of surgical intervention may be necessary.