Balloon enteroscopy for diagnosis and treatment of cytomegalovirus-induced small bowel gastrointestinal bleeding after whole-organ pancreas transplantation

Letters to the Editor
Balloon Enteroscopy for
Diagnosis and Treatment
of Cytomegalovirus-
Induced Small Bowel
Gastrointestinal Bleeding
After Whole-Organ
Pancreas Transplantation
Adriana Costa Genzini , MD 1 ,2 , Ricardo Dib , MD 1 , Wagner Takahashi , MD 2 , Patr í cia Souza de Almeida , MD 3 , Marcelo Perosa de Miranda , MD 1 ,3 , T é rcio Genzini , MD 1 ,3 and Luiz Estevan Ianhez , MD 1 To the Editor: Whole-organ pancreas
transplantation is being increasingly per-
formed worldwide in selected patients
with type I diabetes mellitus
donor duodenum and pancreas are anas-tomosed to the jejunum to allow exocrine Figure 1. Illustration of the anatomy after duodenopancreatic transplantation with excluded Roux-en-Y.
drainage using either loop in transit or by creation of a Roux-en-Y jejunal loop (2) . In the latter situation, the donor duode-num and pancreas are relatively inac-cessible using standard endoscopes. To our knowledge, we report the fi rst case in which balloon enteroscopy was used to diagnose and treat small intestinal bleeding in a pancreas transplant patient with a Roux-en-Y anastomosis, in which the source of bleeding was located in the Roux limb in and around the duodeno-jejunal anastomosis. Figure 2. Endoscopic photographs in the excluded afferent jejunal limb. (a) Ulcers and bleeding near
the duodenojejunal anastomosis. (b) Major (large arrow) and minor papillae (small arrow) with
surrounding ulcers as seen from inside the Roux limb.
denopancreatic anastomosis was per-formed with exocrine drainage achieved through an excluded Roux-en-Y loop standard upper endoscopy, colonoscopy, ( Figure 1 ). Th
of CMV were identifi ed ( Figure 2a ). Th
cm beyond mal. Cytomegalovirus (CMV) serologic e duodenal studies were also negative. Th also identifi ed ( Figure 2b ). Endoscopic
e patient initially was discharged home. However, bleed- was achieved using argon – plasma coag- did well but then developed melena ing recurred and she was again hospi- ulation at 30 W and a fl ow rate of 1.5 l. fusion of 5 Units of packed red blood Tokyo, Japan) under general anesthesia. e enteroscope was passed into the obtained and confi rmed CMV antigen- site of gastrointestinal bleeding included graft ed duodenum, where serpiginous emia 2 days later. Ganciclovir therapy 2010 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY
Letters to the Editor
was initiated. Five days later, she devel- 1 Hospital Alem ã o Oswaldo Cruz S ã o Paulo , S ã o Paulo , Brazil ; 2 Centro Avan ç ado Endoscopia and fever (38.5 ° C) lasting a week. Years Diagn ó stica e Terap ê utica (CAEDT) — S ã o Paulo , oscopy confi rmed the previous source of S ã o Paulo , Brazil ; 3 HEPATO, Transplants S ã o before, his sister had died at the age of 32 Paulo , S ã o Paulo , Brazil . Correspondence: Adriana Costa Genzini , MD, Hospital Alem ã o Oswaldo Cruz S ã o Paulo, Rua Romilda Margarida Gabriel n. 99 hemostasis was again achieved using Ap. 81, Itaim Bibi , Sao Paulo , SP 04530-090 , diac diseases was negative in all siblings, Brazil . E-mail: [email protected] days to assist in the control of bleeding, as has been described to control massive Lymphocytic
Myopericarditis in a
discharged aft er 14 days of ganciclovir Patient With Previously
therapy. She remains well 60 days later. CMV infection is estimated to occur Undiagnosed Crohn ’ s
in ~ 10 % of patients who have undergone enteric anastomosis (4) . However, isolated gastrointestinal bleeding in the Roux limb E.C.M. Sikkens , MD 1 , T.C.M.A. Schreuder , due to CMV has not been reported. In this MD 1 , J. Fronczek , MD 2 , C.J.J. Mulder , case, standard endoscopic methods did not tive treatment and was discharged within allow access to bowel lumen, in which the bleeding was located. We believe this area would also have been inaccessible using a similar laboratory tests. Medication given colonoscope passed transorally because To the Editor: Infl ammatory bowel
of the distance from the mouth. As major disease (IBD) is associated with the and ondansetron. Repeated esophagogas- and minor papillae were identifi ed, balloon enteroscopy could be used for pancreatog- . ties. While preparing for colonoscopy, he is case Cardiac involvement, however, is rare developed cardiac arrest because of ven- demonstrates the utility of balloon enteros- tricular fi brillation. Subsequent cardiop- copy for the evaluation of obscure gastroin- case reports (2 – 5) . When undiagnosed, ulmonary resuscitation was unsuccessful. testinal bleeding in Roux-en-Y limbs aft er vomiting as the fi rst presenting symptom normal cardiomyocytes ( Figure 1 ).
CONFLICT OF INTEREST
Histologically, the wall of the descend- tis resulting in a lethal cardiac arrest. An otherwise healthy 46-year-old tion with lymphocytes, crypt abscesses, and granulomata consistent with Crohn ’s tent nausea, vomiting, tachypnea, weight disease ( Figure 2 ).
REFERENCES
1 . Gruessner AC , Sutherland DE . Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of June 2004 . Clin Transplant 2005 ; 19 : 433 – 55 . 2 . Boggi U , Vistoli F , Signori S et al. Outcome of 118 pancreas transplants with retroperito-neal portal-enteric drainage . Transplant Proc 2005 ; 37 : 2648 – 50 . treatment of massive hemorrhage due to cytomegalovirus colitis . Can J Gastroenterol 2003 ; 17 : 722 – 5 . 4 . Berger N , Wirmsberger R , Kafk a R et al. Infec- tious complications following 72 consecutive enteric-drained pancreas transplants . Transpl Figure 1. CD45-stained slide (original magnifi cation ×100) showing the presence of lymphocytes
The American Journal of GASTROENTEROLOGY
VOLUME 105 | JANUARY 2010 www.amjgastro.com

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