Ileocolonic anastomotic ulcers: a case series and review of the literature

Although gastric anastomotic ulcers have been well described, there are only a few reports in the literature, mostly in the pediatric population, of ulcers occurring at colonic anastomotic sites. Our aim was to determine the clinical profile of postoperative colonic anastomotic ulcers in adult patients undergoing colonoscopy at our institution.

We performed a retrospective review of colonoscopies done at our institution between 1993 and 1997.

Six patients with colonic anastomotic ulcers were identified; all had ileocolonic anastomoses. All patients presented with iron deficiency anemia with evidence of gastrointestinal (GI) blood loss and this was the indication for colonoscopy. The age at the time of ileocolonic anastomoses ranged from birth to 74 yr and age at the time of colonoscopy ranged from 24 to 76 yr. The interval between surgery and detection of anastomotic ulcer ranged from 15 months to 28 yr. Only two patients had a possible etiology: one with previous small bowel Crohn's disease, and the other with significant nonsteroidal antiinflammatory drugs (NSAID) use and evidence of small-bowel ulcers in the adjacent ileum as well. Three of the patients had previously undergone surgical resection and revision of the anastomosis without benefit; the ulcers recurred at the new anastomosis and continued to bleed.

Ulcers can develop at sites of ileocolonic anastomoses. The commonest presentation is with iron deficiency anemia due to occult blood loss. The etiology of the ulcer, in most patients, remains speculative. The therapeutic approach to these ulcers is to discontinue all NSAIDs, treat underlying inflammatory bowel disease, if present, and supplement with oral iron. Surgery should be reserved for life-threatening bleeds or for anemia refractory to oral iron therapy.