An Atypical Case of Fatal Gastrointestinal Bleeding

Abstract

Introduction: A 48-year-old male with a history of type I diabetes mellitus, diabetic nephropathy status post deceased donor renal transplant in 2011, pancreatic transplant in 2012 complicated by rejection, and coronary artery disease with stent placement 2 weeks prior to admission presented to Robert Wood Johnson University Hospital with multiple syncopal episodes and hematemesis. He denied melena and hematochezia. Vitals were notable for a blood pressure of 82/43 mm Hg and pulse of 95 bpm. The hemoglobin level was 8.1g/dL from an unknown baseline. He was resuscitated with intravenous fluids and 1 unit of red blood cells. An esophagogastroduodenoscopy showed a normal esophagus, stomach, and duodenum without evidence of bleeding. Later that night, the patient had maroon-colored stools and became acutely hypotensive and tachycardic. Repeat hemoglobin was 5.2 g/dL despite being transfused 1 unit of red blood cells earlier that day. The patient then suffered a pulseless electrical activity arrest and died. An autopsy was performed, which showed a massive gastrointestinal bleed with blood clots present throughout the stomach, small intestine, and large intestine. The transplanted pancreas was necrotic and hemorrhagic. It also revealed a fistula through the duodenal cuff into the jejunal anastomosis containing clotted blood, which was deemed to be the culprit of the bleeding. Cases of gastrointestinal bleeding related to failed pancreatic transplants are rare, but should be considered in patients with a history of a pancreatic transplant given the potential for massive bleeding. It is known that a reduction of the blood flow at the duodenal graft can lead to anastomotic leakage and hemorrhage in the immediate postoperative period. One study indicated that 11% of the patients studied experienced anastomotic hemorrhage between the jejunum and duodenal stump. Outside of the immediate post-operative period, causes of massive gastrointestinal bleeding after rejection of the transplant include donor artery pseudoaneurysm formation and rupture with subsequent extravasation of blood through the small-bowel fistula. This diagnosis is made with arterial angiography as opposed to endoscopy. Two case reports highlight the timely use of angiography to successfully localize the pseudoaneurysm with subsequent embolization and/or transplant pancreatectomy. Therefore, in patients status post pancreatic transplants who present with gastrointestinal bleeding, physicians should consider the pancreatic transplant as the cause of the bleeding and have a low threshold for obtaining arterial angiography.