Iron deficiency anaemia and perianastomotic ulceration as a late complication of ileal resection in infancy

I was interested to read the “editor's quiz: GI snapshot” of iron deficiency anaemia in an adult who had been operated on for ileal atresia as a newborn infant (Gut 2007;56:43). While the heading for this item was “iron deficiency anaemia 10 years after small bowel resection in infancy”, in fact the patient presented with anaemia at the age of 13 years, and from then it took 10 years to make the diagnosis (by video capsule endoscopy) of a circular ulcer at the site of ileo–ileal anastomosis. This is a well described but probably underrecognised late complication of bowel surgery in early childhood.¹ Although an ischaemic aetiology has been mooted, pathological features have been poorly characterised, and the ulceration may be some distance from the site of anastomosis. Changes reported at the margins of some ulcers suggest the possibility that a vascular malformation produced ischaemic ulceration; pyloric metaplasia has also been found.² Response to medical treatment is poor and surgical excision often required to control chronic blood loss. It is important to bear in mind, however, that even after such surgery, ulceration and anaemia may recur months or even years later,²,³ making long term follow up essential.