Late Gastrointestinal Bleeding and Protein Loss after Distal Small-Bowel Resection in Infancy

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Abstract
Four children who underwent extensive smallbowel resection in infancy developed recurrent iron deficiency anemia due to gastrointestinal bleeding between 4 and 12 years later. The initial resections were required for multiple ileal astresia (n = 2) and gastroschisis (n = 2). Three patients have had melena and one had presistently guaiac-positive stools. Three patients had protein-losing enteropathy, and in one there was persistent hypoalbuminemia. Colonoscopy identified circumferential ulcerative lesions at the surgical anastomosis (n = 2) and at laprotomy another patient had well-defined linear ulcers close to the surgical anatomosis. Histology demonstrated focal ulceration with chronic inflammation, but did not show granulomata, crypt abcesses, or malignancy. Multiple imaging procedures and gastroduodenoscopy failed to identify an alternative bleeding source. Medical therapy including iron, antacids, sucralfate, H2 antagonists, and cholestyramine was ineffective. Two patients have undergone anastomotic resection. One experienced symptomatic recurrence 4 months after surgery. Repeat colonoscopy found ulceration at the new anatomosis with similar histology. The other patient remains asymptomatic 7 months postsurgery. Recurrent gastrointestinal hemorrhage due to anastomotic ulceration, of unknown etiology, appears to be a late complication of small-bowel resection in infancy.