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Zong W, Salich J, Kastl A, Kirsch J, Albenberg L, Bales C. Whole Foods Introduction Associated With Symptomatic Anastomotic Ulceration in Children With Short Bowel Syndrome. J Pediatr Gastroenterol Nutr 2023; 77:788-795. [PMID: 37705420 DOI: 10.1097/mpg.0000000000003942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
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 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 gastrointestinal 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 1 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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Affiliation(s)
- Wenjing Zong
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Arthur Kastl
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jacqueline Kirsch
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lindsey Albenberg
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina Bales
- From the Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
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2
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Xi D, Hakar M, Davis J, Lin H. Resolution of Anastomotic Ulceration and Profound Bleeding by Endoscopic Cauterization and Oral Budesonide. JPGN REPORTS 2023; 4:e328. [PMID: 37600605 PMCID: PMC10435016 DOI: 10.1097/pg9.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 03/10/2023] [Indexed: 08/22/2023]
Abstract
Anastomotic ulceration is a known complication of short gut syndrome, which can be complicated by concurrent iron deficiency and chronic bleeding. Diagnosis is confirmed through endoscopy, typically performed for the investigation of severe anemia. Inflammatory colitis in short gut syndrome has been previously reported; therefore, it is important to treat both ulceration and inflammation. Currently, no effective therapies are available. Herein, we describe the case of a child with short gut syndrome who subsequently developed anastomotic ulcers with recurrent severe bleeding and was successfully treated with endoscopic argon plasma cauterization for circumferential ulcerations, followed by a prolonged course of oral enteric budesonide. This intervention could be a potential and beneficial nonsurgical treatment for anastomotic ulceration.
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Affiliation(s)
- Dong Xi
- From the Pediatric Gastroenterology, University of Tennessee Health Science Center, Memphis, TN
| | - Melanie Hakar
- Pathology and Laboratory Medicine, Oregon Health & Science University, Portland, OR
| | - Jessica Davis
- Pathology and Laboratory Medicine, Oregon Health & Science University, Portland, OR
| | - Henry Lin
- Pediatric Gastroenterology, Oregon Health & Science University, Portland, OR
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3
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Norsa L, Goulet O, Alberti D, DeKooning B, Domellöf M, Haiden N, Hill S, Indrio F, Kӧglmeier J, Lapillonne A, Luque V, Moltu SJ, Saenz De Pipaon M, Savino F, Verduci E, Bronsky J. Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2023; 77:298-314. [PMID: 37256821 DOI: 10.1097/mpg.0000000000003850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.
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Affiliation(s)
- Lorenzo Norsa
- From the Department of Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Olivier Goulet
- the Department of Pediatric Gastroenterology-Hepatology-Nutrition, APHP Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Daniele Alberti
- the Department of Pediatric Surgery, ASST Spedali Civili, Brescia, Italy
- the Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Barbara DeKooning
- From the Department of Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Magnus Domellöf
- the Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Nadja Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Susan Hill
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Flavia Indrio
- the Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Jutta Kӧglmeier
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alexandre Lapillonne
- the Neonatal Intensive Care Unit, APHP Necker-Enfants Malades Hospital, Paris Cité University, Paris, France
- the CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Veronica Luque
- Serra Hunter, Universitat Rovira I Virgili, IISPV, Tarragona, Spain
| | - Sissel J Moltu
- the Department of Neonatology, Oslo University Hospital, Oslo, Norway
| | - Miguel Saenz De Pipaon
- the Department of Neonatology, Instituto de Investigación Sanitaria del Hospital Universitario La Paz - IdiPAZ, Hospital Universitario La Paz - Universidad Autónoma de Madrid, Madrid, Spain
| | - Francesco Savino
- the Dipartimento di Patologia e cura del bambino "Regina Margherita", A.U.O. Città delle Salute e della Scienza di Torino, Torino, Italy
| | - Elvira Verduci
- the Department of Pediatrics, Ospedale dei Bambini Vittore Buzzi University of Milan, Milan, Italy
| | - Jiri Bronsky
- the Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
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4
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Zhang W, Tou J. Digestive perianastomotic ulcerations after intestinal resection in children. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000533. [PMID: 37564926 PMCID: PMC10410847 DOI: 10.1136/wjps-2022-000533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 06/07/2023] [Indexed: 08/12/2023] Open
Abstract
Digestive perianastomotic ulceration (DPAU) is a rare complication after intestinal resection and anastomosis occurring at or near the anastomosis site. The purpose of this review is to summarize the characteristics of DPAU, including the etiology, diagnosis and differential diagnosis, clinical manifestations, treatment, and future research. All recent literature on DPAU was searched in PubMed, Embase, and Cochrane and then reviewed. The clinical manifestations of DPAU are mainly gastrointestinal symptoms such as bloody stool and chronic anemia. The diagnosis of DPAU is difficult. Specific diseases, such as Crohn's disease, must be ruled out before a diagnosis can be made. In addition, there are no clear treatment guidelines due to the high degree of heterogeneity in response to drugs and surgery. It is recommended to adjust medication in time and combine various treatment methods. In addition, the mechanism that causes DPAU is not well understood; however, several possible mechanisms have been proposed, such as scar tissue ischemia and underlying diseases. Moreover, there is a high risk of relapses, and a long-term follow-up is necessary. Numerous issues remain to be solved in this area; therefore, more randomized controlled trials and studies should be carried out to further understand this disease.
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Affiliation(s)
- Weicheng Zhang
- Department of Neonatal Surgery, Zhejiang University School of Medicine Children's Hospital, Hangzhou, Zhejiang, China
| | - Jinfa Tou
- Department of Neonatal Surgery, Zhejiang University School of Medicine Children's Hospital, Hangzhou, Zhejiang, China
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McKay S, Cohran V, Bass LM. Anastomotic Ulcers: Current Understanding of the Pathogenesis and Management. Curr Gastroenterol Rep 2023:10.1007/s11894-023-00873-w. [PMID: 37303027 DOI: 10.1007/s11894-023-00873-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE OF REVIEW Anastomotic ulceration following intestinal resection is an under- recognized problem in pediatrics. We discuss the relevant literature regarding this condition. RECENT FINDINGS Anastomotic Ulceration following intestinal resection is a potentially life threatening cause of refractory anemia. Evaluation should include correction of micronutrient deficiencies and endoscopic evaluation by upper and lower endoscopy and small intestinal endoscopy if necessary. Initial treatment by medical therapy may consist of anti-inflammatory agents as well as antibiotics to treat small intestinal bacterial overgrowth. Surgical resection should be considered if refractory to treatment. Anastomotic ulcers in pediatric patients with small bowel resection should be considered as a cause of refractory iron deficiency anemia. Endoscopic evaluation should be undertaken to look for evidence of anastomotic ulcers. Surgical resection should be considered if medical therapy fails.
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Affiliation(s)
- Shaunte McKay
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave Box #65, Chicago, IL, 60611, USA
| | - Valeria Cohran
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave Box #65, Chicago, IL, 60611, USA
| | - Lee M Bass
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave Box #65, Chicago, IL, 60611, USA.
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Teduglutide in pediatric intestinal failure: A position statement of the Italian society of pediatric gastroenterology, hepatology and nutrition (SIGENP). Dig Liver Dis 2022; 54:1320-1327. [PMID: 35654733 DOI: 10.1016/j.dld.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/05/2022] [Accepted: 04/29/2022] [Indexed: 12/29/2022]
Abstract
In recent years, the spectrum of possible treatments for Intestinal Failure (IF)-Short Bowel Syndrome (SBS) has been enriched by the implementation of GLP-2 analogues. In Italy, teduglutide (Ted), an analogue of GLP-2, was approved in January 2021 by the Italian Regulatory Agency for Drugs (AIFA) for IF-SBS patients ≥1 year old. According to the Agency indications, Ted can now be prescribed by regional reference centers, with costs fully charged to the National Health Service. Following pediatric-use approval in our country and in light of scarce evidence in childhood, the pediatric network for IF of the Italian Society for Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) planned to share management methods of Ted in pediatric IF. The main purpose was to identify the best candidates from a cost-effective perspective. Thus, focusing on available literature and on expert opinions, the present position statement provides consensus-based recommendations on the use of Ted for pediatric gastroenterologists and nutritionists treating children with SBS.
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7
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Chi-Lun Leung Y, Man-Yee Tang P, Shih-Yin Chao N, Wai-Yip Leung M. Perianastomotic ulceration in children with short bowel syndrome. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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8
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Udina C, Galimberti AMC, Bramuzzo M, Di Leo G, Barbi E. Enteral bleeding in a former preterm girl with short bowel syndrome: Do not miss the diagnosis. J Paediatr Child Health 2022; 58:697-698. [PMID: 34047422 PMCID: PMC9291955 DOI: 10.1111/jpc.15593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/25/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Matteo Bramuzzo
- Institute for Maternal and Child Health – IRCCS ‘Burlo Garofolo’TriesteItaly
| | - Grazia Di Leo
- Institute for Maternal and Child Health – IRCCS ‘Burlo Garofolo’TriesteItaly
| | - Egidio Barbi
- University of TriesteTriesteItaly,Institute for Maternal and Child Health – IRCCS ‘Burlo Garofolo’TriesteItaly
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9
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Koivusalo A, Karila K, Pakarinen M. Late Abdominal Reoperations after Surgery for Necrotizing Enterocolitis and Spontaneous Intestinal Perforation. Eur J Pediatr Surg 2021; 31:535-540. [PMID: 33440455 DOI: 10.1055/s-0040-1722616] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The aim of this study was retrospective assessment of late major reoperations after surgery for necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) in neonates. MATERIALS AND METHODS Appropriate ethical consent was obtained. Data collection was by review of hospital records of 165 successive prematures who underwent surgery for NEC (n = 99) or SIP (n = 66) from 1986 to 2019. Outcome measures were late major abdominal surgeries or endoscopies that occurred after the primary surgical treatment, closure of enterostomies, and weaning from parenteral nutrition (PN). We assessed also risk factors for late abdominal surgeries. RESULTS Hundred and twenty-six (76%) patients (NEC, n = 70, 71% and in SIP, n = 56, 85%) survived. Median follow-up was 13 (interquartile range: 5.9-23) years. Nineteen (15%) patients underwent late abdominal surgery with 0% mortality. Most common was surgery for small bowel obstruction (SBO) in 12(9.5%) patients (NEC, n = 5; 7.0%, SIP, n = 7; 13%, p = 0.36) with 10-year cumulative risk of 8.7 (95% confidence interval [CI]: 3.5-14). Long duration of PN and development of intestinal failure associated cholestasis (IFAC) increased the risk of SBO surgery, relative risk: 1.0-3.2 (95% CI: 1.0-9.1), p = 0.02-0.03. Other surgeries included serial transverse enteroplasty (NEC, n = 2), incisional hernia repair (n = 3), cholecystectomy (n = 1), and ovarian torsion (n = 1). Twenty (29%) NEC and four (7%) SIP patients required endoscopic assessment of postoperative symptoms (p = 0.003). CONCLUSION Late abdominal reoperations occurred in 15% of patients with NEC and SIP with nil mortality. SBO was the main indication. Risk of SBO was similar between NEC and SIP. Long PN and IFAC increased the risk of SBO.
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Affiliation(s)
- Antti Koivusalo
- New Childreńs Hospital, University of Helsinki, Pediatric Surgery, Helsinki, Finland
| | - Kristiina Karila
- New Childreńs Hospital, University of Helsinki, Pediatric Surgery, Helsinki, Finland
| | - Mikko Pakarinen
- New Childreńs Hospital, University of Helsinki, Pediatric Surgery, Helsinki, Finland
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Iwamoto M, Koshinaga T, Fujita E, Hanada M, Uehara S, Moriyama M. Ileal Dieulafoy lesion arose 15 years after partial small bowel resection for meconium obstruction of the neonate: a case report. BMC Pediatr 2021; 21:437. [PMID: 34620131 PMCID: PMC8494758 DOI: 10.1186/s12887-021-02914-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background Anastomotic or perianastomotic ulcers present with symptoms such as chronic anaemia and occult bleeding as long-term complications of bowel resection performed in infancy. Case presentation Herein, we describe a 15-year-old girl with a history of surgery for meconium obstruction without mucoviscidosis in infancy who was hospitalized with chief complaints of presyncope and convulsions. Seven hours after admission, she developed melena and went into shock. An emergency laparotomy was performed, and a Dieulafoy lesion was detected near the site of ileal anastomosis from the surgery that had been performed during infancy. Conclusions Although overt massive lower gastrointestinal bleeding necessitating emergency care is rare in the long term after infant bowel resection, Dieulafoy lesions can cause serious bleeding, requiring rapid life-saving haemostatic procedures. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02914-7.
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Affiliation(s)
- Maho Iwamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Tsugumichi Koshinaga
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Eri Fujita
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Manabu Hanada
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shuichiro Uehara
- Department of Pediatric Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Mitsuhiko Moriyama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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Abstract
Improvements in neonatal care and surgical advances, has led to an increased prevalence of children with small and large bowel anastomoses. Ulceration at the site of anastomosis is a rare, but well-recognised phenomenon, with no clearly understood pathogenesis. Paediatric case series have been reported but there remains no clear effective treatment strategy and there is limited experience with endoscopic techniques in their management. We report our tertiary centre experience of managing nine anastomotic ulcer patients, including endoscopic treatment with argon plasma coagulation and clips.Two patients with inflammatory bowel disease (IBD) responded to optimisation of medical therapy. In our non-IBD patients, those requiring a blood transfusion (n = 2) ultimately required surgery and those who did not require a blood transfusion responded to aminosalicylate treatment (n = 1) or endoscopic therapeutic techniques (n = 3).We conclude that endoscopic interventions can be an effective management strategy for anastomotic ulcers when a blood transfusion isn't required.
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12
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A European Survey on Digestive Perianastomotic Ulcerations, a Rare Crohn-like Disorder Occurring in Children and Young Adults. J Pediatr Gastroenterol Nutr 2021; 73:333-337. [PMID: 34117192 DOI: 10.1097/mpg.0000000000003200] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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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Wendel D, Ho BE, Kaenkumchorn T, Horslen SP. Advances in non-surgical treatment for pediatric patients with short bowel syndrome. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1770079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Beatrice E. Ho
- Department of Pharmacy, Seattle Children’s Hospital, Seattle, WA, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Tanyaporn Kaenkumchorn
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Simon P. Horslen
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Mezoff EA, Cole CR, Cohran VC. Etiology and Medical Management of Pediatric Intestinal Failure. Gastroenterol Clin North Am 2019; 48:483-498. [PMID: 31668178 DOI: 10.1016/j.gtc.2019.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pediatric intestinal failure occurs when gut function is insufficient to meet the growing child's hydration and nutrition needs. After massive bowel resection, the remnant bowel adapts to lost absorptive and digestive capacity through incompletely defined mechanisms newly targeted for pharmacologic augmentation. Management seeks to achieve enteral autonomy and mitigate the development of comorbid disease. Care has improved, most notably related to reductions in blood stream infection and liver disease. The future likely holds expansion of pharmacologic adaptation augmentation, refinement of intestinal tissue engineering techniques, and the development of a learning health network for efficient multicenter study and care improvement.
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Affiliation(s)
- Ethan A Mezoff
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University College of Medicine, Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Valeria C Cohran
- Division of Gastroenterology, Hepatology and Nutrition, Feinberg School of Medicine, Northwestern University, The Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Box 65, Chicago, IL 60611, USA
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15
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Fusaro F, Tambucci R, Romeo E, Bagolan P, Dall'Oglio L, Ceccarelli S, Francalanci P, Hermans D, Pietrobattista A, Diamanti A, Torroni F, De Angelis P. Anastomotic ulcers in short bowel syndrome: New suggestions from a multidisciplinary approach. J Pediatr Surg 2018; 53:483-488. [PMID: 28610705 DOI: 10.1016/j.jpedsurg.2017.05.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Anastomotic ulceration (AU) is a rare potential life-threatening complication that may occur after intestinal resection. The diagnosis is often delayed after a long-lasting history of refractory anemia. The pathogenesis remains unknown and there are no established therapies. The aim of the study was to analyze the medical history of children with short bowel syndrome (SBS) who were experiencing AU. METHODS Records of SBS children were retrospectively reviewed. Demographics, baseline characteristics, presentation, diagnosis and treatment of AU cases were analyzed. RESULTS Eight out of 114 children with SBS were identified as having AU. Mean gestational age was 32.5weeks. Underlying diseases were: 5 necrotising enterocolitis, 2 gastroschisis and 1 multiple intestinal atresia. The mean age at AU diagnosis was 6.5years (diagnosis delay of 35months). All but 2 patients had AU persistency after medical treatment. Endoscopic treatment (2 argon plasma coagulation; 1 platelet-rich fibrin instillation; 2 endoscopic hydrostatic dilations) was effective in 3 out of 5 children. Surgery was required in 3 patients. CONCLUSIONS Severe bowel ischemic injury, especially in preterm infant, could predispose to AU development. Medical treatment showed discouraging results. We firstly described that different endoscopic treatment could be attempted before resorting to further surgery. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Fabio Fusaro
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Renato Tambucci
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy; Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Erminia Romeo
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
| | - Pietro Bagolan
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
| | - Luigi Dall'Oglio
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
| | - Stefano Ceccarelli
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
| | - Paola Francalanci
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
| | - Dominique Hermans
- Department of Pediatrics, Saint Luc Hospital - Université Catholique De Louvain, Brussels, Belgium
| | - Andrea Pietrobattista
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
| | - Antonella Diamanti
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
| | - Filippo Torroni
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
| | - Paola De Angelis
- Intestinal Failure Rehabilitation Group, Bambino Gesù Children's Hospital, Rome, Italy
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Cohran VC, Prozialeck JD, Cole CR. Redefining short bowel syndrome in the 21st century. Pediatr Res 2017; 81:540-549. [PMID: 27997531 DOI: 10.1038/pr.2016.265] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 10/30/2016] [Indexed: 12/12/2022]
Abstract
In 1968, Wilmore and Dudrick reported an infant sustained by parenteral nutrition (PN) providing a potential for survival for children with significant intestinal resections. Increasing usage of TPN over time led to some patients developing Intestinal Failure Associated Liver Disease (IFALD), a leading cause of death and indication for liver/intestinal transplant. Over time, multidisciplinary teams called Intestinal Rehabilitation Programs (IRPs) began providing meticulous and innovative management. Usage of alternative lipid emulsions and lipid minimization strategies have resulted in the decline of IFALD and an increase in long-term and transplant-free survival, even in the setting of ultrashort bowel (< 20 cm). Autologous bowel reconstructive surgeries, such as the serial tapering enteroplasty procedure, have increased the likelihood of achieving enteral autonomy. Since 2007, the number of pediatric intestinal transplants performed has sharply declined and likely attributed to the newer innovations healthcare. Recent data support the need for changes in the listing criteria for intestinal transplantation given the overall improvement in outcomes. Over the last 50 y, the diagnosis of short bowel syndrome has changed from a death sentence to one of hope with a vast improvement of quality of life and survival.
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Affiliation(s)
- Valeria C Cohran
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joshua D Prozialeck
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Conrad R Cole
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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17
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Bass LM, Kim S, Superina R, Mohammad S. Jejunal varices diagnosed by capsule endoscopy in patients with post-liver transplant portal hypertension. Pediatr Transplant 2017; 21. [PMID: 27762481 DOI: 10.1111/petr.12818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 12/11/2022]
Abstract
Portal hypertension secondary to portal vein obstruction following liver transplant occurs in 5%-10% of children. Jejunal varices are uncommon in this group. We present a case series of children with significant GI blood loss, negative upper endoscopy, and jejunal varices detected by CE. Case series of patients who had CE for chronic GI blood loss following liver transplantation. Three patients who had their initial transplants at a median age of 7 months were identified at our institution presenting at a median age of 8 years (range 7-16 years) with a median Hgb of 2.8 g/dL (range 1.8-6.8 g/dL). Upper endoscopy was negative for significant esophageal varices, gastric varices, and bleeding portal gastropathy in all three children. All three patients had significant jejunal varices noted on CE in mid-jejunum. Jejunal varices were described as large prominent bluish vessels underneath visualized mucosa, one with evidence of recent bleeding. The results led to venoplasty of the portal vein in two patients and a decompressive shunt in one patient with resolution of GI bleed and anemia. CE is useful to diagnose intestinal varices in children with portal hypertension and GI bleeding following liver transplant.
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Affiliation(s)
- Lee M Bass
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stanley Kim
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Riccardo Superina
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Saeed Mohammad
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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18
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Hubertus J, von Schweinitz D. Nekrotisierende Enterokolitis und Kurzdarmsyndrom. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0153-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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