A Rare Case of Gastroparesis in Renal Transplant Patient

Abstract

Introduction: VACTERL association is a congenital mesoderm anomaly, characterized by Vertebral anomalies, Anal atresia, Cardiovascular anomalies, Tracheoesophageal fistula, Esophageal atresia, Renal anomalies, Limb defects. VACTERL association has not been reported to cause functional gastric obstruction. We report a case of uncommon cause of gastroparesis in a patient with VACTERL association with recent kidney transplant. Case Report: A 32-year-old African American female with VACTERL association diagnosed since childhood who received kidney transplant 2 month ago due to renal agenesis, history of imperforated anus status post anoplasty, and history of subtotal colectomy with ileorectal anastomosis due to severe disabling constipation requiring multiple endoscopic/surgical dis-impaction presented with a 3-day history of worsening nausea, vomiting and prolonged diarrhea. On admission, her vital signs were stable and physical exam revealed mild right-sided tenderness without signs of peritonitis. Her blood work revealed leukopenia and acute kidney injury. Tacrolimus level was 19.8 μg/L. CT scan of abdomen showed distention of the stomach and distal small bowel proximal to the ileocolic anastomosis with concern for possible anastomotic stricture. Conservative management with hydration and electrolyte replacement was started and discontinuation of Mycophenolate mofetil resulted in unsatisfactory improvement. Her workup revealed negative tests for CMV DNA, EBV DNA, Rotavirus Ag, and Clostridium difficile. Of note, Norovirus RNA PCR from rectal swab was detected. She underwent upper endoscopy and found to have a significant amount of retained fluid in stomach and a patent pylorus. Colonoscopy showed normal terminal ileum and patent ileorectal anastomosis. Post-infectious gastroparesis was then diagnosed and she was started on metoclopramide with significant improvement. Conclusion: Common causes of gastroparesis are diabetic gastroparesis, post-surgical gastroparesis, post-infectious gastroparesis, and idiopathic gastroparesis. In general, exhaustive workup in post-infectious gastroparesis would be of low yield. However, we report a case of confirmed post-infectious gastroparesis from Norovirus infection in immunosuppressive patient. Of note, Norovirus infection can result in prolonged diarrhea, gastroparesis, and pneumatosis intestinalis. However, given the prior significant GI dysmotility disorder in VACTERL association, further study would be warranted to elucidate that inherent motility disorder plays a role in gastroparesis in this case.