Pancreas rejection with graft necrosis presenting with episodic massive intestinal bleeding

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Purpose: This study is to present our unusual experience of episodic massive intestinal bleeding due to pancreas rejection with graft necrosis. Materials and methods: A case of NIDDM with uremia underwent simultaneous pancreas and kidney transplant in 2005. With 3 times of acute rejection on the kidney and pancreas grafts, he eventually went back to hemodialysis 7 years later. Results: The pancreas graft failed due to acute rejection on the pancreas graft 9 years after SPK transplant. Therefore, all immunosuppressants were discontinused. Unfortunately, the pancreas graft became necrotic, and thereafter, intermittent gastrointestinal (GI) bleeding occurred. The angiography detected bleeding from arterial Y-graft, and the extravasated blood flew through the graft duodenojeunostomy anastomosis into the bowels and presented with GI bleeding. The bleeder was controlled by coil embolization. Hemorrhagic shock due to massive re-bleeding happened 1.5 months after coil embolization. The emergent angiography showed coil migration into the necrotic pancreas graft and active re-bleeding again from the same arterial Y-graft. The bleeder was temporarily controlled by a covered-stent in recipient common iliac artery, and emergency explant of the failed and necrotic pancreas graft was performed and the arterial Y-graft was ligated securely to prevent re-bleeding. Conclusion: Bleeding from arterial Y-graft could occur after rejection and necrosis of pancreas graft due to sudden withdrawal of immunosuppressants, which might present with intermittent massive GJ bleeding. The coil embolization might fail due to coil migration into the necrotic pancreas graft.