Meckel’s Diverticulum Masquerading as an Arterio-Enteric Fistula in an Adult Patient With Simultaneous Pancreas-Kidney Transplantation

Abstract

Introduction: Simultaneous pancreas-kidney (SPK) transplantation is a treatment for patients with type1 diabetes (DM) and end-stage renal disease (ESRD). Complications of SPK transplantation include peripancreatic abscess, enterocutaneous fistula, and rarely, gastrointestinal bleeding (GIB). We report a case of an adult patient with SPK transplantation who presented with massive GIB caused by Meckel’s diverticulum. Case Report: A 40-year-old male presented 3 years after SPK transplantation to an outside hospital with maroon-colored stool and dizziness. His co-morbidities included DM, ESRD, coronary artery disease, hepatitis C, nonalcoholic steatohepatitis, and cirrhosis. He was hypotensive (94/43), but otherwise, vitals were within reference range. His exam was significant for a soft abdomen with normoactive bowel sounds and mild confusion without any focal deficits or asterixis. Labs were notable for a hemoglobin of 5.9 g/dL, creatinine 1.73 mg/dL (baseline 1.1 mg/dL), BUN 64 mg/dL, and liver function tests within reference range. An esophagogastroduodenoscopy (EGD) revealed presumed Dieulafoy’s lesion, which was cauterized and clipped. Colonoscopy showed mild inflammation, but no obvious source of bleeding. Biopsies were negative for infection or inflammatory bowel disease. The patient was transferred to our center for management of persistent GIB (requiring 26 units of blood total) and worsening renal function. At our center, EGD, colonoscopy, push enteroscopy, tagged RBC scan, and provocative angiography were negative for the source of bleeding. Video capsule endoscopy showed a large amount of red blood in the small bowel without adequate identification of the source lesion. Exploratory laparotomy with intraoperative small bowel endoscopy was performed, which demonstrated a healthy appearing anastomosis with a more distal Meckel’s diverticulum full of clotted blood. The diverticulum was excised without recurrent bleeding. Discussion: The differential for lower GIB is vast, but in adult patients, Meckel’s diverticulum is a rare cause. Patients status-post SPK transplantation have additional considerations for GIB, including anastomotic site ulcer, pseudoaneurysm, arterioenteric fistula, severe graft rejection, and cytomegalovirus infection. This is a rare case of GIB secondary to Meckel’s diverticulum in patients with SPK transplantation. Clinicians should be aware of Meckel’s diverticulum as a cause of massive GIB in SPK transplant patients. A high index of suspicion and timely evaluation can improve morbidity and mortality.