Abstract
Background This article highlights two cases of massive lower gastrointestinal bleeding in patients on dialysis after rejection of kidney–pancreas transplants. Patient 1 was a 34-year-old female with 27 years of type I diabetes, who had a kidney–pancreas transplant in 1996, which was complicated by rejection of the kidney and pancreas in 2000 and 2002, respectively. Later in 2002, she presented in shock after experiencing cramping abdominal pain and passage of large bloody stools. Patient 2 was a 38-year-old male with 26 years of type I diabetes, who had a pancreas–kidney transplant in 1998, which was complicated by rejection of the kidney and pancreas in early 2003. He presented in late 2003 with a single episode of coffee-ground emesis and two episodes of brisk hematochezia.
Investigation Arterial angiography.
Diagnosis Pseudoaneurysm and small-bowel fistula from the arterial supply to the transplanted pancreas.
Management Angiographic embolization of the aneurysmal vessel and fistula achieved hemostasis. Patient 1 did not have her transplanted organ surgically removed and suffered a recurrent massive lower gastrointestinal bleed that proved fatal. In Patient 2, subsequent surgery and removal of the rejected pancreas was performed and the patient continues to do well.
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Acknowledgements
Peter Higgins is supported by a NIH K12 Award for Clinical Research, RR017607-01.
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Glossary
- NASOGASTRIC LAVAGE
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Lavage of the stomach with 1–4 l of water via a size 12–24 French tube placed through the nose
- HERALD BLEED
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A brisk gastrointestinal bleed that stops spontaneously then recurs hours later; it is associated with aortoenteric fistula or other arterial sources
- MECKEL'S DIVERTICULUM
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A congenital diverticulum in the wall of the small bowel; it can contain gastric tissue that develops ulcers and bleeds
- LOS ANGELES GRADE D ESOPHAGITIS
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Mucosal breaks involving at least 75% of the esophageal circumference as detected by endoscopy
- INTUSSUSCEPTION
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The small intestine is folded into itself in a telescope fashion, causing obstruction; when prolonged it can result in ischemia and bleeding
- DIEULAFOY LESIONS
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Erosions of the mucosa into very superficial small arteries, usually in the stomach, that can cause severe intermittent bleeding
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Higgins, P., Umar, R., Parker, J. et al. Massive lower gastrointestinal bleeding after rejection of pancreatic transplants. Nat Rev Gastroenterol Hepatol 2, 240–244 (2005). https://doi.org/10.1038/ncpgasthep0175
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DOI: https://doi.org/10.1038/ncpgasthep0175
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