Gastrointestinal Bleeding in a Pancreas Transplant Recipient: A Case to Remember

Abstract

Patient: Male, 51-year-old Final Diagnosis: Ectopic varix Symptoms: Bleeding • portal hypertension Medication:— Clinical Procedure: — Specialty: Transplantology Objective: Unusual clinical course Background: Pancreas transplantation has proven to be the most effective therapeutic option for insulin-dependent diabetes mellitus. However, despite advances in surgical technique and continuously improving outcomes, pancreas transplantation has the highest complication rate among all solid-organ transplants. Vascular complications in particular can be catastrophic, with graft- and life-threatening potential. Ectopic variceal bleeding is less common and is rarely reported in the literature. Case Report: A 51-year-old man presented with recurrent intermittent gastrointestinal bleeding (GIB) associated with hepatic dysfunction and portal hypertension 4 years after a successful pancreas-after-kidney transplant. Apart from positive serology for hepatitis E virus, all the other liver disease screening results were negative. He was extensively investigated with 6 computed tomography (CT) scans, 3 esophago-gastro-duodenoscopies (EGD), 3 colonoscopies, and 1 visceral arteriogram before the plausible diagnosis of ectopic trans-anastomotic variceal bleeding involving the pancreas transplant was established. Selective variceal catheterization and embolization were done with 3% sodium tetradecyl sulphate (STD). He remained free of bleeding after embolization. Conclusions: This case report adds to the scanty literature on the management of ectopic variceal bleeding in a pancreas transplant recipient. Diagnosis of ectopic varix is usually challenging and frequently requires a visceral arteriogram. We describe a novel minimally-interventional technique to obtain source control and also discuss the complexity involved in the management, along with future implications.

A Case of Successfully Treated Varices at the Anastomosis Between the Native Jejunum and the Duodenal Graft After Pancreas Transplantation

“…The complication of varices of anastomosis between the native jejunum and the duodenal graft after the PTx is rare and has been reported in only 3 case studies summarized in Table 1. [1][2][3] The onset times in these studies were 1, 4, 5, and 14 years (our case) after the PTx, which suggested that this complication developed relatively slowly after the PTx. In addition, in 3 of the 4 cases, embolization was successful, which suggested that embolization might be a clinically effective treatment for varices after a PTx.…”

Management of ectopic intestinal variceal bleeding following pancreatic transplant: Two cases

“…Four case reports detail patients with variceal bleeding in the setting of prior pancreas transplant 4–6,10 . Two of the four patients underwent embolization with sodium tetradecyl sulfate, one of whom died of myocardial infarction shortly after 6 and the other required additional embolization procedures for ongoing bleeding, ultimately requiring bowel resection, and also experienced non‐occlusive portal vein thrombosis 5 . In one case, the patient underwent coil embolization with durable effect and no reported bowel ischemia 4 .…”

“…4,9 To our knowledge, there are only four reported cases in the literature of ectopic varices causing gastrointestinal hemorrhage following pancreatic transplant. [4][5][6]10 We present two patients with remote history of SPK who presented with anemia and melena found to be secondary to bleeding ectopic varices.…”

“…They represent dilated splanchnic varicosities and intestinal portosystemic collaterals that develop in the setting of either portal hypertension or focal splanchnic venous occlusion following hepatopancreatobiliary or intestinal surgery, 1,2 and can cause life-threatening gastrointestinal hemorrhage. [3][4][5][6] GI bleed due to ectopic varices occurs in an estimated 1%-5% of cirrhotic patients, 27%-40% of patients with extrahepatic portal hypertension, and 64% of patients with coexisting portal venous occlusion and history of hepatobiliary surgery. 7 In the non-transplant population, diagnosis of bleeding ectopic varices has been accomplished by arteriography, endoscopy, and transhepatic portography.…”

“…Ectopic gastrointestinal varices, defined as non‐gastric, non‐esophageal, and non‐rectal intestinal varices, are rare. They represent dilated splanchnic varicosities and intestinal portosystemic collaterals that develop in the setting of either portal hypertension or focal splanchnic venous occlusion following hepatopancreatobiliary or intestinal surgery, 1,2 and can cause life‐threatening gastrointestinal hemorrhage 3–6 . GI bleed due to ectopic varices occurs in an estimated 1%–5% of cirrhotic patients, 27%–40% of patients with extrahepatic portal hypertension, and 64% of patients with coexisting portal venous occlusion and history of hepatobiliary surgery 7 .…”