Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft

Abstract

We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population.

Significant arterial complications after pancreas transplantation—A single‐center experience and review of literature

“…Arterial fistulas have been reported to be a complication associated with failed pancreas allografts, especially those which have failed secondary to chronic rejection . Our series harmonized with this observation, with 13 of the 23 patients (57%) having failed pancreas allografts at the time of the complication.…”

“…The literature reporting arterial complications associated with a pancreatic allograft is sporadic, spanning 1989‐2017. In all, 7 case series and 34 case reports describe 70 patients with arterial complications. As in our series, the majority of complications were in primary pancreatic transplant recipients with enteric drainage.…”

“…Serious arterial complications are rarely described in the literature but can present with dramatic bleeding and can be both graft and life threatening. The extant literature includes either case reports or small case series from individual centers . The approach to evaluation and management of arterial complications has been variable, spanning from surgical to endovascular.…”

Late recurrent bleeding episodes from duodenojejunostomy after pancreas transplantation

“…Due to the fact that follow‐up visits are not solely performed at a single center, these data likely underestimate the occurrence of late complications. Late bleeding episodes are mainly caused by the herein described late hemorrhage from the enteric graft site, by fistulae (arterioenteric, arterioureteric, arteriocystic, or arteriovenous), pseudoaneurysms, rejection, or invasive infections …”

“…While thrombosis is the most frequent vascular complication in the early period after transplantation, hemorrhage, although less common, may be a life‐threatening condition occurring early as well as late after transplantation. Primary causes for late bleeding episodes are fistulae (arterioenteric, arterioureteric, arteriocystic, or arteriovenous), pseudoaneurysms, invasive infections, as well as severe rejection episodes . In addition to the vascular anastomoses, the enteric anastomoses are a potential source of bleeding in enterically drained pancreas grafts .…”