Delayed Gastrointestinal Bleeding in a Case of Failed Graft Pancreatic and Kidney Transplant: Presidential Poster

Abstract

Introduction: Arterioenteric fistulae and pseudoaneuryms, although rare, are potentially lifethreatening complications of simultaneous kidney and pancreatic transplants (SPAK). We describe a case of a 53-year-old white man, a recipient of SPAK transplant in 2003, who presented to the emergency department with near syncope following 2 episodes of maroon-colored stools. The kidney and pancreas grafts failed, and he was being treated with insulin and hemodialysis, respectively. The transplanted kidney was resected in 2009, following an infection. A screening colonoscopy done in 2010 was unremarkable. Upon presentation, he was resuscitated with intravenous fluids and multiple blood transfusions for hypovolemic shock from acute blood loss. (Hemoglobin had decreased from 11 gm/dL 1 month ago to 6.9 gm/dL on admission.) Abdominal exam was unremarkable. Gastric lavage revealed bilious fluid, but no blood. Rectal exam revealed maroon stool. An emergent CT angiography showed a 12 mm x 20 mm pseudoaneurysm arising from the right external iliac artery. An emergent stent-assisted coil embolization was performed by interventional radiology; hemostasis and hemodynamic stability were achieved. Three days after the index embolization, he had further episodes of hematochezia,warranting an emergent pelvic angiogram, which demonstrated continued patency of the pseudoaneurysm. Occlusion of the right external iliac artery with a covered stent was subsequently performed. A colonoscopy on day 4 revealed only a few scattered sigmoid diverticula and ulcerated mucosa of the ileocecal valve without active bleeding. An elective exploratory laparotomy revealed the site of the fistula. The renal graft remnant was found to be anastamosed to the iliac artery. Bowel was dissected from the underlying graft, and a 5-cm resection of the bowel was performed. The patient had no further episodes of bleeding and was stable at the time of discharge. Arterial pseudoanerysms and areterio-enteric fistuale are known complications of SPAK transplants. Most of these occur early in the post-operative period. Fistulae are seen in the setting of pancreatic graft failure. This can occur because of anatomic apposition of the arterial and enteric anastomoses or a result of proteolytic enzymes released from the pancreatic graft. Lower gastrointestinal bleeding in patients with failed SPAK transplants should raise a high suspicion for arterioenteric fistulae, and early diagnosis with angiography can be life-saving. Multimodality treatment with percutaneous stenting, coil embolization, and operative correction usually achieve satisfactory results.