Lower Gastrointestinal Bleeding in a Post Kidney Pancreas Transplant Patient
Comments: We would like to start by presenting a rare case of gastrointestinal bleeding post combined kidney-pancreas transplantation.
This is a 43 y/o male with a history of kidney-pancreas transplantation in 2002 and failed graft functioning over time. He was seen several weeks prior to presentation at our institution with hematochezia. He had an upper endoscopy and colonoscopy which were significant for esophagitis and small non-bleeding internal hemorrhoids.
Bleeding subsided and patient was discharged home from there. Several weeks later our patient had recurrent one day history of massive hematochezia. He was subsequently transferred to out institution for further evaluation. Endoscopy was repeated here the following day after the bowel preparation and appropriate resuscitation. Upper endoscopy was normal. We proceeded with colonoscopy.
During our endoscopy, there was blood noted throughout the colon but no bleeding source identified. Here, a standard adult long colonoscope is being passed through the ascending colon. There was a large pool of blood in the cecum. On careful examination, blood was seen exiting the ileocecal valve. The valve was intubated for further endoscopic evaluation.
With standard maneuvers the valve was intubated and the terminal ileum was insufflated. Fresh blood is seen in the ileum. No bleeding source was identified on the initial exam suggesting a more proximal source. The colonoscope was maneuvered further into the ileum. We have positioned our colonoscope at approximately 10 cm proximal to the ileocecal valve. With water lavage, the terminal ileum was carefully insufflated and examined. There is the unexpected appearance of two lumens. These are both indicated by the arrows.
We hypothesized that the altered anatomy was likely related to the prior history of kidney-pancreas transplantation. As we pause to examine both lumens, a large clot was seen ejected from one limb. This was followed by a gush of blood. When we look again, the clot and stream of blood are clearly from a single limb. At this point we still had not located the bleeding source. The colonoscope was slowly passed into the limb with observed bleeding. Once inside there was a large pool of blood. Frequent suctioning and lavage did not clear the large pool. Despite great effort, the endoscope could not be passed any further. For completeness, the second nonbleeding limb was examined to the furthest possible extent. This limb was clear of blood and did not reveal a source for bleeding. Since active bleeding was suspected from the first limb, we consulted interventional radiology for angiographic evaluation.
Angiographic images under fluoroscopy are seen here. There is a small area of dye extravasation which is indicated by the circle. This defect is noted to be a right external iliac artery aneurysm. This was the suspected source for bleeding in this patient. A fluoroscopic guided endovascular stent was placed. This is indicated by the yellow highlight. The aorta and iliac arterial system is represented by the red highlight.
After stent placement there was no further leakage of dye noted on fluoroscopy or CT angiography. CT angiography revealed that the stent was adjacent to the failed pancreatic graft. This diagram illustrated the post-transplant bowel anatomy in relation to the stented right external iliac artery. The pseudoaneurysm was suspected to be leaking into the transplanted duodenal stump as indicated by the top arrow. Blood subsequently flowed out of the donor bowel, through the native distal ileum and subsequently through the colon. This image compares the actual post transplanted anastomosis with the diagram. The native distal ileum is indicated by the green arrows. The transplanted duodenal stump is indicated by the white arrows.
In conclusion, this case illustrates the importance to recognize rare causes of gastrointestinal bleeding in patients post kidney-pancreas transplantation. Angiography may be a useful method of localizing sources of bleeding in the complex anatomy of post kidney-pancreas transplant patients. Endovascular stent placement may be a successful method for effective hemostasis from a communicating enteric to external iliac artery pseudoaneurysm.
| Contributed by: |
Srikrishna Vemana, MD University Hospitals Case Medical Center |
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Citation: Vemana, S. (Jun 01 2009). Lower Gastrointestinal Bleeding in a Post Kidney Pancreas Transplant Patient. The DAVE Project. Retrieved Feb, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=853 Times viewed since Feb 2006: 2415 |
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