2017 - CIRTA

10- Intestinal Transplantation

52.12 - Gastrointestinal bleeding in the pediatric post-intestinal transplant patient.

Presenter: Joanne, Lai, New York, United States
Authors: Joanne Lai, Alyssa Burnham, Jang Moon, Kishore Iyer

Gastrointestinal bleeding in the pediatric post-intestinal transplant patient.

Joanne Lai1, Alyssa Burnham2, Jang Moon2, Kishore Iyer2.

1Department of Pediatrics, Mount Sinai Medical Center, New York, NY, United States; 2Intestinal Rehabilitation and Transplantation Program, Mount Sinai Medical Center, New York, NY, United States

Introduction: Gastrointestinal bleeding (GIbleed) in the intestinal transplant (ITx) patient is a common indication for endoscopic evaluation. The aim of the study was to elucidate the causes of GIbleed in pediatric ITx recipients. 

Methods: We performed a retrospective chart review of all ITx recipients <18 years of age, in a single center, who underwent endoscopy for a primary indication of GIbleed during a 10-year period to December 2016. All endoscopic and histologic findings were reviewed.

Results: During the 10-year period, 57 endoscopic procedures were performed for 34 episodes of GIbleed in 12 pediatric ITx patients. The procedures performed were: upper endoscopy (27), colonoscopy (20), ileoscopy (6), capsule endoscopy (3) and push enteroscopy (1). The causes of bleeding are shown in Table 1.The median time from transplant to bleeding episode was 1231 days, with a range of 2 days to 17.5 years. The median number of procedures per patient was 3. In 8 episodes of GIbleed, the source of bleeding was not identified. Two patients had recurrent GIbleed refractory to medical management and required repeated procedures. Endoscopic intervention to treat active bleeding occurred during 4 procedures: injection of esophageal varices (2 episodes in 1 patient) and thermal bipolar cautery of anastomotic ulcerations (2 patients).

Nonspecific enteritis was the most common finding as the source of bleeding found on 17 endoscopies in 6 patients. Gross endoscopic findings in these patients labelled as nonspecific enteritis were erythema, ulceration and friability present in both native bowel (Fig 1A) and graft bowel (Fig 1B).Mucosal biopsies of this inflamed bowel showed active and chronic inflammatory infiltration, often with erosions, villous blunting and acute cryptitis, without viral inclusions or apoptotic bodies. This nonspecific enteritis is a poorly defined and poorly understood entity which contributed significantly to bleeding episodes in this population. 

Conclusion: Gastrointestinal bleeding may be seen at any point following ITx and causes include acute cellular rejection, anastomotic ulcerations, viral enteritis, gastroesophageal varices and nonspecific enteritis. The majority of endoscopies were performed for diagnostic purposes though endoscopic interventions to treat active bleeding were also performed. Nonspecific inflammation of the graft and native intestine was a common cause of recurrent bleeding following ITx. 

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