Gastrointestinal Dysfunction Following Intestinal or Multivisceral Transplantation

Abstract

Introduction: The risk of rejection and infection following intestinal or multivisceral transplant is well documented[1] however there is little literature on the other causes of gastrointestinal symptoms, which can affect intestine containing grafts. Our aim was to review the incidence of other gastrointestinal conditions identified following transplantations. Methods: A retrospective search of patient notes and radiology reports was carried out in Addenbrookes hospital, in patients who had undergone either an isolated intestine or multivisceral transplant. Small intestinal bacterial overgrowth and bile salt malabsorption were investigated with a glucose hydrogen breath test and 23-seleno-25-homotaurocholic acid (SeHCAT) respectively. Other tests undertaken included whole gut scintigraphy and oesophageal physiology in selected cases. Results: There were 71 transplants in 65 patients between Jan 2006 and September 2016. 8 patients (11 transplants) in this cohort with gastrointestinal symptoms following transplant have undergone investigation for causes of these symptoms. Four patients were diagnosed as having small intestinal bacterial overgrowth (SIBO) as a result of positive breath tests with consistent symptoms. Two patients with otherwise unexplained diarrhoea had bile salt malabsorption (BSM) identified following positive SeHCAT scans. Both of these patients had a colon in continuity. One patient had both SIBO and BSM diagnosed one year apart. There were two cases of gastric dumping syndrome detected (one positive glucose tolerance test and one had rapid gastric emptying on scintigraphy). One of these patients had documented hypoglycaemia after meals, while the other patient presented with diarrhoea. One patient who underwent a full multivisceral transplant suffered recurrent aspiration pneumonia and had demonstrable oesophageal dysmotility. He is awaiting fundoplication. Conclusion: This review identified four different causes of gastrointestinal symptoms in intestine transplant patients. Before the diagnosis was made all patients were screened for rejection and infection. Patients are at risk of SIBO due to distorted intestinal anatomy. Those with an oeosophago-gastric anastomosis are vulnerable to gastro-oesophageal reflux and fundoplication may be considered concurrently with the transplant or at a later date. Five of the eight patients had full multivisceral transplants with denervation of the vagal supply to the entire gastrointestinal tract, which may explain the slighter higher incidence of gastrointestinal dysfunction in these patients. We should have a low threshold for suspecting these intestinal disorders following intestine containing grafts. This would allow prompt treatment of these conditions. Reference: 1. Middleton SJ, Pither C, Gao R, et al. Small intestinal and multivisceral transplantation: lessons through the “Retrospectoscope” at a single UK centre from 1991 to 2013. Transplant Proceedings 2014;46:2114–8.