89: Therapeutic challenges of intestinal ulceration in pediatric intestinal failure: a unique case
Bibliographic record
Abstract
Introduction: Intestinal ulcers contribute to chronic anemia in children with short bowel syndrome (SBS). The potential etiologies, including small intestinal bacterial growth (SIBO), anastomotic ulcers and non-specific intestinal inflammation present therapeutic challenges. Herein we present a case of with multifactorial persistent perianastomotic ulceration in the context of chronic SBS-related SIBO preceding the onset of Crohn’s disease. Case: A boy with SBS type II secondary to necrotizing enterocolitis who had achieved intestinal autonomy at 7 months of age, presented at 3 years of age with chronic bloody diarrhea, iron deficiency, hypoalbuminemia, elevated CRP and poor growth. Endoscopy demonstrated a deep anastomotic ulcer as well as ulcers in the jejunum and colon distal to the anastomosis. Histology was consistent with SIBO. After initial clinical, biochemical, radiologic, and endoscopic improvement with cycling antibiotics for SIBO, persistent and progressive ulceration prompted a change in management. In the ensuing 4 years, treatment trials included prokinetics, prebiotics, exclusive enteral nutrition, bowel rest and oral 5-ASA; repeated prolonged courses of oral budesonide had a predictable biochemical response. Serial endoscopies revealed a persistent gross appearance and histologic changes compatible with SIBO. Poor growth necessitated re-initiation of parenteral nutrition at 6 years of age. At 7 years of age, he was diagnosed with Crohn’s Disease (CD) of the jejunum and rectum; with the most severe disease being perianastomotic. Treatment with vedolizumab resulted in clinical and biochemical remission, including a normalization of fecal calprotectin (117.5 mg/Kg). PN dependence decreased from 82 kcal/Kg/day (135% dependence) to 61 kcal/kg/day (122% dependence) in the first year on vedolizumab and further decreased to 42 kcal/kg/day (104% dependence) at 3 years. Over that time, height for age z-score improved from -2.1 to -0.92. While annual endoscopy for 3 years revealed resolution of jejunal and rectal ulcerations, deep, serpiginous circumferential anastomotic ulcers persisted despite dose optimization and the addition of budesonide. Conclusion: This case of Crohn’s disease in the context of SBS-related altered anatomy and chronic SIBO demonstrated a significant clinical, nutritional, and biochemical response, and relative endoscopic response to vedolizumab. However, there was treatment failure at the anastomotic site where vascular changes may make healing challenging. This case highlights the varied underlying etiologies and therapeutic challenges of intestinal ulcers in children with short bowel syndrome. Multicenter collaboration is needed to improve our understanding and develop an evaluation and management algorithm for intestinal ulcers in pediatric intestinal failure.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.004 | 0.003 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".