2808 Gastrointestinal Bleeding After Pancreatic Transplant, Beyond the Usual Suspects: A Systematic Review

Abstract

INTRODUCTION: Pancreatic transplant represents the ultimate treatment for certain patients with diabetes mellitus & end-stage renal disease. Despite good outcomes, it carries a high rate of vascular complications, & with increased numbers of enterically-drained grafts, obscure gastrointestinal bleeding (GIB) can be the initial presentation. Delayed diagnosis & treatment of life-threatening hemorrhage can ensue if clinicians are not aware of this association. Therefore, we aimed to perform a systematic review of the literature, evaluating the presentation, diagnosis & treatment of patients with GIB caused by complications from enterically-drained pancreatic transplants. METHODS: We performed a systematic search of published data, regarding GIB due to complications from pancreatic transplant. Specific keywords including pancreatic transplant & gastrointestinal bleeding, with all possible permutations & associated MeSH terms were used, from inception of PubMed database to 04/30/2019. 107 results matched initial search criteria. After assessment to determine appropriateness, 26 publications with complications resulting in GIB at presentation were included. A recursive search was performed from bibliographies, yielding the remaining results. RESULTS: 36 publications met final inclusion criteria (25 case reports & 11 case series) dating from 1989 to 2019, for a total of 69 patients, (47.8% men, mean age 41.4 years). Of these, 67 (97%) presented with overt bleeding, with lower GIB as the most common presentation (59.4%), followed by cases of both upper & lower GIB (8.7%), & occult GIB the least common (2.9%). Sentinel GIB was reported in 49.3% of cases. GIB etiologies included formation of fistulas (52.2%), anastomotic ulcer & donor duodenal bleed (11.6% each) & pseudoaneurysms (8.7%), with other rare causes (mucosal rejection, cytomegalovirus-related ulcers) also identified. Diagnosis was made by angiography in 31.9% & by surgery in 21.7% of cases, respectively. Endoscopic diagnosis was only successful in 7 patients. Surgery (n = 42) & interventional radiology procedures (n = 19) were the mainstays for treatment. Overall, 50.7% of patients had pancreatic graft loss prior to GIB. CONCLUSION: GIB after pancreatic transplant can be devastating. In our review, failed grafts were found in half the cases, with lower GIB due to arterial-enteric fistulas being the most common presentation. Angiography & surgery were the most common diagnostic & therapeutic modalities.