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Inicio Gastroenterología y Hepatología (English Edition) Microcytic anemia due to ileocolic anastomotic ulcer
Información de la revista
Vol. 42. Núm. 2.
Páginas 111-112 (febrero 2019)
Vol. 42. Núm. 2.
Páginas 111-112 (febrero 2019)
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Microcytic anemia due to ileocolic anastomotic ulcer
Anemia microcítica secundaria a úlcera anastomótica ileocólica
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2903
Jesús Manuel Rivera Estebana,
Autor para correspondencia
jrivera@vhebron.net

Corresponding author.
, Eloy Espín Basanyb, Javier Santos Vicentea,c, Carmen Alonso-Cotonera,c
a Servicio de Aparato Digestivo, Laboratorio de Fisiología y Fisiopatología Digestiva, Institut de Recerca (VHIR), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
b Servicio de Cirugía General, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
c Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Ileocolic perianastomotic ulcers are a late-onset, uncommon, and probably underdiagnosed complication of ileocaecal resections. They tend to present with diarrhoea, malabsorptive syndrome and occult gastrointestinal bleeding which can lead to chronic iron deficiency anemia.

We present the case of a 22-year-old male, who had been a preterm baby, with a history of right hemicolectomy and ileal resection of 23cm in the first months of life due to necrotising enterocolitis, referred to the outpatient clinic at the age of 19 for severe iron deficiency anemia refractory to oral iron therapy. Initial analysis showed haemoglobin 10g/dl, mean corpuscular volume 78.7fl, cholesterol 76mg/dl, triglycerides 49mg/dl, albumin 4.12g/dl and low ferritin levels of 11ng/ml. Fibre optic gastroscopy with gastric and duodenal biopsies ruled out coeliac disease and Helicobacter pylori infection. After confirming the presence of faecal occult blood, fibre optic colonoscopy was performed, showing ileocolic anastomosis ulceration around the entire circumference. Biopsies were compatible with chronic ischaemia. An abdominal CT scan showed multiple gallstones and postoperative changes at the ileocolic anastomosis level.

Treatment was started with mesalazine, diosmin and glutamine. However, since there was no improvement, with the anemia persisting despite oral and parenteral iron replacement, it was decided to resect the ileocolic anastomosis and perform reanastomosis. The histology findings were compatible with chronic ischaemic ulcer (Fig. 1).

Figure 1.

Resection segment from the ileocolic anastomosis showing circumferential ulceration.

(0.06MB).

After 18 months of follow-up, the patient remains asymptomatic, with no anemia or iron deficiency.

In childhood, ileocolic anastomosis is mainly performed in cases of necrotising enterocolitis, intussusception or congenital intestinal abnormalities.

None of the proposed aetiological mechanisms (non-steroidal anti-inflammatories, bacterial overgrowth or perianastomotic relative ischaemia processes) have been able to demonstrate a clear relationship with ulcer formation, so the pathogenesis remains uncertain.1,2

Perianastomotic ulcers are a rare and late-onset complication of gastrointestinal surgery (often >10 years after surgery) and should be suspected in the presence of persistent iron deficiency anemia due to occult blood loss in faeces.1–5

The most common signs and symptoms of complicated ileocolic anastomoses include intestinal obstruction, iron deficiency anemia, abdominal pain, malabsorption and malnutrition, particularly if an extensive ileal resection including the ileocaecal valve or a partial colectomy is performed. In such cases, it may affect the patient's development in terms of weight gain and growth.2

Definitive diagnosis can take months or even years due to the latent expression of symptoms. Endoscopic examinations, particularly colonoscopy, are the most useful diagnostic method.

These lesions do not respond well to drug treatment; neither antibiotics nor corticosteroids have been shown to have any effect either in the prevention or treatment of occult blood loss or in epithelial regeneration. Surgical treatment, i.e. resection and reanastomosis is probably the best therapeutic option, although whether or not this is effective in preventing recurrences is unclear. Permanent ileostomy should be restricted to selected cases as it involves a high risk of dehydration and electrolyte imbalance if the remnant is jejunum.5 Due to the lack of effective treatment, minimally invasive techniques have been developed in recent years, such as the endoscopic injection of immunomodulatory biological compounds. However, experience with these techniques is limited.

In short, although anastomotic ulcers are a rare complication of ileocolic anastomoses, in view of the impact on quality of life and the lack of response to medical treatment, which often means surgical treatment is the only option, it is important that we identify the aetiopathogenic mechanisms involved in order to promote the development of new, less aggressive therapies. We also need to carry out long-term follow-up with the aim of preventing recurrences, as this occurs in over half of all cases.

References
[1]
Z. Péter, G. Bodoky, Z. Szabó, E. Sonfalvi, Z. Varga, I. Szilvási.
Ileocolic anastomotic ulcer after surgery in adulthood: case report and review of the literature.
Z Gastroenterol, 42 (2004), pp. 605-608
[2]
S.T. Chari, R.F. Keate.
Ileocolonic anastomotic ulcers: a case series and review of the literature.
Am J Gastroenterol, 95 (2000), pp. 1239-1243
[3]
P. Abdulhannan, J.W. Puntis.
Iron deficiency anemia and perianastomotic ulceration as a late complication of ileal resection in infancy.
Gut, 56 (2007), pp. 1478-1479
[4]
K. Parashar, S. Kyawhla, I.W. Booth, R.G. Buick, J.J. Corkery.
Ileocolic ulceration: a long-term complication following ileocolic anastomosis.
Can J Surg, 36 (1993), pp. 162-164
[5]
A.H. Hamilton, J.M. Beck, G.M. Wilson, H.J. Heggarty, J.W.L. Puntis.
Severe anemia and ileocolic anastomotic ulceration.
Arch Dis Child, 67 (1992), pp. 1385-1386

Please cite this article as: Rivera Esteban JM, Espín Basany E, Santos Vicente J, Alonso-Cotoner C. Anemia microcítica secundaria a úlcera anastomótica ileocólica. Gastroenterol Hepatol. 2019;42:111–112.

Copyright © 2018. Elsevier España, S.L.U.. All rights reserved
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