Crohn's disease-like perianastomotic ulcerations after neonatal necrotizing enterocolitis surgery: a case of successful anti-TNF therapy.

Abstract

Background: Digestive perianastomotic ulcerations (DPAU) are rare Crohn's disease (CD)-like lesions that develop following intestinal surgery. Although enteral nutrition and anti-inflammatory agents constitute first-line therapies, 59% of refractory cases require advanced interventions. Emerging evidence implicates tumor necrosis factor (TNF)-α-driven inflammation as a key pathogenic mechanism, yet optimal therapeutic strategies remain undefined. A 12-year-old girl with a surgery history of neonatal necrotizing enterocolitis (NEC) presented with severe anemia (hemoglobin: 51 g/L) and chronic abdominal pain. Endoscopy revealed circumferential ulcers at the ileocolonic anastomosis, histologically confirmed as active inflammation without granulomas or evidence of infections. Initial therapy with 3 months enteral nutrition and mesalamine failed. Subcutaneous adalimumab induced endoscopic ulcer healing and hemoglobin normalization (111 g/L) within 3 months. At the 12-month follow-up, sustained clinical remission was observed (hemoglobin: 120 g/L, fecal calprotectin: 45 µg/g), with complete mucosal healing and no adverse events.

Conclusions: Early anti-TNF therapy induced rapid and sustained remission in a pediatric patient with DPAU, reinforcing the mechanism that TNF-α-driven inflammation underlies disease pathogenesis. While promising, these findings require validation in larger cohorts. Individualized therapeutic decisions should weigh the risks of recurrence, cost, and long-term biologic safety.