Intestinal transplantation
Relapsing encephalopathy following small bowel transplantation

https://doi.org/10.1016/S0041-1345(03)00461-5Get rights and content

Abstract

We report a case of a 40-year-old man presenting with relapsing encephalopathy 4 years post-intestinal transplantation. Each episode was preceded by symptoms suggestive of subacute intestinal obstruction, marked dehydration, and, on one occasion, grade 4 encephalopathy. Physical examination revealed hypertonia, clonus, and hyperreflexia. Biochemistry was consistent with renal impairment, metabolic alkalosis, hyperammonaemia, and normal liver function. Plain radiographs and abdominal computed tomography revealed dilated proximal small bowel loops, and barium radiography demonstrated a strictured distal anastomosis. Hydrogen breath testing indicated bacterial overgrowth. Following rehydration and antibiotic therapy, the patient recovered fully between episodes. Further episodes of encephalopathy did not recur following resection of the distal anastomotic stricture and resolution of bacterial overgrowth. Unfortunately, one year later the patient died of pneumonia. To the best of our knowledge, encephalopathy secondary to intestinal transplant related porto-caval shunt and bacterial overgrowth in strictured bowel has not been previously reported but might have implications for the management of future patients.

Section snippets

Patient and history

A 40-year-old Caucasian male presented with recurrent encephalopathic episodes 4 years after cadaveric small bowel transplantation because of a large mesenteric desmoid tumour. The small bowel graft terminated as a stoma, and the mesenteric vessels had been anastomosed directly to the infra-renal aorta and the inferior vena cava. Maintenance immunosuppressive therapy consisted of low dose prednisolone (5 mg/day) and tacrolimus. He remained independent of parenteral nutrition, maintaining his

Results and discussion

In a review of 31 patients following intestinal transplantation, bacterial overgrowth was found in 27, although hepatic encephalopathy has not been reported.1 The much higher fluctuating serum ammonia levels noted in our patient could be explained by two major factors. First, the graft venous drainage was directly into the inferior vena cava, creating an iatrogenic porto-caval shunt.2, 3, 4

Second, partial small bowel obstruction cuased by stricture formation in the setting of chronic small

References (5)

  • W.A. Koltun et al.

    J Surg Res

    (1987)
  • D.W. Seldin et al.

    Kidney Int

    (1972)
There are more references available in the full text version of this article.

Cited by (0)

View full text