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Small Bowel Transplant and the Efficacy of Surveillance Ileoscopy to Evaluate for Graft Rejection


... defined by malabsorption, diarrhea, steatorrhea, fluid and electrolyte ... symptoms (bloating, cramping, diarrhea, increased stomal output) are often present. ... – PowerPoint PPT presentation

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Title: Small Bowel Transplant and the Efficacy of Surveillance Ileoscopy to Evaluate for Graft Rejection

Small Bowel Transplant and the Efficacy of
Surveillance Ileoscopy to Evaluate for Graft
  • Dalia Ibrahim
  • PGY1
  • Department of Internal Medicine
  • Department of Gastroenterology
  • 30 April 2009

Short-Bowel Syndrome
  • The average length of the adult human small
    intestine is approximately 600 cm, as calculated
    from studies performed on cadavers, ranging from
    260-800 cm.
  • Any disease, traumatic injury, vascular accident,
    or other pathology that leaves less than 200 cm
    of viable small bowel or results in a loss of 50
    or more of the small intestine places the patient
    at risk for developing short-bowel syndrome.
  • Short-bowel syndrome is a disorder clinically
    defined by malabsorption, diarrhea, steatorrhea,
    fluid and electrolyte disturbances, and
  • The final common etiologic factor in all causes
    of short-bowel syndrome is the functional or
    anatomic loss of extensive segments of small
    intestine so that absorptive capacity is severely

Causes of Short-Bowel Syndrome
  • Adults
  • Crohns disease
  • Radiation enteritis
  • Mesenteric vascular accidents
  • Trauma
  • Recurrent intestinal obstruction
  • Desmoid tumors
  • Pediatrics
  • Necrotizing enterocolitis
  • Intestinal atresias
  • Intestinal volvulus
  • Congenital short small bowel
  • Gastroschisis
  • Meconium peritonitis

Indications for Small Bowel Transplant (AGA
  • Thus far, intestinal transplants have been
    performed only in patients who have developed
    life-threatening complications attributable to
    their intestinal failure and/or long-term TPN
  • Medicare has approved payment for intestinal
    transplants in patients who fail TPN therapy for
    one of the following reasons
  • Impending or overt liver failure (increased serum
    bilirubin and/or liver enzyme levels,
    splenomegaly, thrombocytopenia, gastroesophageal
    varices, coagulopathy, stomal bleeding, hepatic
    fibrosis, or cirrhosis).
  • Thrombosis of major central venous channels (2
    thromboses in subclavian, jugular, or femoral
    veins). Evidence supporting this indication is
  • Frequent central line-related sepsis (2 episodes
    of systemic sepsis secondary to line infection
    per year, 1 episode of line-related fungemia,
    septic shock, or acute respiratory distress
    syndrome). Evidence supporting this indication is
  • Frequent severe dehydration.

Post Transplant Allograft Rejection
  • Rejection is the most common cause of graft loss
    in intestinal transplant recipients.
  • While clinical signs are frequently unreliable,
    fever and gastrointestinal symptoms (bloating,
    cramping, diarrhea, increased stomal output) are
    often present.
  • There are no reliable biochemical markers of
  • According to the American Gastroenterological
    Association recommendations in April 2003
    multiple biopsies (6 total biopsies) initially
    should be performed biweekly
  • Because early rejection may not be endoscopically
    apparent, biopsy specimens should be obtained
    even from normal appearing mucosa.

Our Study
  • Retrospective design we reviewed the medical
    records, histology reports, and endoscopy reports
    of all patients (78 total) who underwent small
    bowel transplant at Georgetown University
    Hospital from 2003-2008
  • Demographic data of the patients has not yet been
  • During transplantation an ileostomy is created in
    all patients to facilitate postoperative
    surveillance endoscopy.
  • Surveillance endoscopy was performed initially
    biweekly and with clinical indication by fever,
    bacteremia, increased stomal output, diarrhea, or
    gastrointestinal bleeding.
  • Patients also underwent other procedures such as
    colonoscopy, EGD, enteroscopy, or ERCP if
    clinically indicated.

Our Study
  • We are currently compiling a database with the
    following data points
  • Name
  • MR
  • Date of procedure
  • Procedure
  • Indication for procedure
  • Anesthesia
  • Findings
  • Complications
  • Pathology
  • Difficulty
  • Use of glucagon
  • Location of biopsies
  • Type of forceps

Study Question
  • The efficacy of biweekly surveillance ileoscopy
    for evaluation of post transplant rejection.
  • We believe that this approach is too aggressive
    and transplant patients may not need to undergo
    this many endoscopies post-transplantation
    without clinical signs or symptoms of rejection.
  • We hope to prove that the number of surveillance
    ileoscopies need not be so frequent decreasing
    the large financial and social burden on both the
    patient and the health care system.

Transplant Centers
  • There are only 7 Medicare approved Centers for
    small bowel transplantation in the United States
  • Georgetown University Hospital
  • UCLA
  • University of Pittsburg Medical Center
  • Mount Sinai Hospital (New York)
  • Nebraska Health System
  • Clarion Health Methodist-IU-Riley (Indiana)
  • University of Miami, Jackson Memorial Hospital
  • This means that patients must relocate their
    entire lives for an indefinite period of time for
    small bowel transplantation.

Our Study
  • If we are able to prove that such frequent
    surveillance ileoscopies are not necessary we
    could possibly change the current standard of
    care post-transplantation.

Similar Study
  • A retrospective review of endoscopic and
    histologic reports in 41 children who received an
    intestinal transplant between 1990-1995 at
    Childrens Hospital of Pittsburgh.
  • Results
  • A total of 1273 endoscopies was performed of
    which 760 were ileoscopies via allograft
    ileostomy, 273 were upper endoscopies, and 240
    were colonoscopies.
  • One hundred four rejection episodes were
    documented histologically in 32 patients, 6 days
    to gt4yrs after transplantation.
  • Most episodes were mild and easily treated with
    increased immunosuppression however, severe
    rejection with mucosal exfoliation was seen in
    nine patients.
  • Rejection sometimes involved only part of the
  • Endoscopic appearance alone without biopsies was
    sensitive enough to diagnose only 63 of the
    rejection episodes.
  • Epstein-Barr and cytomegalovirus infections
    occurred in 11 and eight patients, repectively,
    and involved both native bowel and allograft in
  • Complicatons of endoscopy were few one
    perforation, three episodes of bleeding, and
    three episodes of transient respiratory
  • .

Similar Study
  • Conclusions
  • Frequent surveillance ileoscopies with biopsies
    should be performed after transplantation.
  • If patients clinically deteriorate with fever,
    diarrhea, bacteremia, or GI bleeding and a clear
    cause is not elucidated by ileoscopy, an upper
    endoscopy with biopsies is indicated

  • American Gastroenterological Association Medical
    Position Statement Short Bowel Syndrome and
    Intestinal Transplantation. Gastroenterology.
  • Scolapio JS, Fleming CR. Short bowel
    syndrome. Gastroenterol Clin North
    Am. Jun 199827(2)467-79, viii. 
  • Wilmore DW, Robinson MK. Short bowel
    syndrome. World J Surg. Dec 200024(12)1486-92. 
  • Sigurdsson L, Reyes J, Putnam PE, et al.
    Endoscopies in Pediatric Small Intestinal
    Transplant Recipients Five Years Experience. The
    Am J Gastroenterol. 199893(2)207-211.