EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: The overall incidence, causes, and treatment of posttransplant gastrointestinal bleeding, have been previously described. In this study, we examined the causes and treatment of postoperative gastrointestinal bleeding after orthotopic liver transplant.

Materials and Methods: Clinical data of 335 patients who underwent an orthotopic liver transplant at our institution between September 2001 and December 2012 were analyzed retrospectively. The diagnosis and treatment of postoperative gastrointestinal bleeding after an orthotopic liver transplant were reviewed.

Results: Gastrointestinal bleeding occurred in 13 patients (3.8%) after an orthotopic liver transplant. Five patients (38.4%) were adult and 8 patients (61.6%) were pediatric. The sites of the bleeding were Roux-en-Y anastomosis bleeding in 5 cases, peptic ulcer in 3 cases, erosive gastritis in 3 cases, gastric and esophageal varices in 1 case, and hemobilia in 1 case. These 13 patients with gastrointestinal bleeding were managed with conservative treatment, endoscopic treatment, radiologic interventional embolism, or exploratory laparotomy. No patients died because of gastrointestinal bleeding. During follow-up, 4 patients died because of sepsis and 1 patient died of recurrence of hepatocellular carcinoma.

Conclusions: Gastrointestinal bleeding after liver transplant and its incidence, causes, and treatment are not well-described in the literature. Diagnosis and management of gastrointestinal bleeding requires a multidisciplinary approach involving surgeons, hepatologists, advanced and experienced endoscopists, and interventional radiologists.

Key words : Posttransplant complications, Roux-en-Y anastomosis bleeding, Morbidity of transplant

Liver transplant is the only curative treatment for end-stage liver disease.¹ After a liver transplant, many factors affect morbidity and mortality. Bleeding is a postoperative complications reported after liver transplant and a leading cause of morbidity and mortality. Although postoperative bleeding has been described in several clinical situations, the importance of gastrointestinal bleeding has not been precisely determined.^2-5

The causes, incidence, and treatment of post-transplant gastrointestinal bleeding, have been described in a few publications. They are rare but life-threatening.^2,6 Therefore, this study sought to indicate the incidence, causes, and treatment of postoperative gastrointestinal bleeding after an orthotopic liver transplant.

Materials and Methods

Clinical data of 335 patients (162 patients were children or adolescents and 173 patients were adults) who underwent an orthotopic liver transplant at the University of Baskent Hospital between September 2001 and December 2012 were analyzed retrospectively. Demographic data was collected, including sex, age, cause of liver disease, and the number and type of transplant. The experiences in diagnosis and treatment of postoperative gastro intestinal bleeding after an orthotopic liver transplant were reviewed. The diagnosis of gastrointestinal bleeding was confirmed with endoscopic or radiologic tests.

Tacrolimus and methylprednisolone were used as baseline immunosuppression, and all patients were treated with the same immunosuppressive protocols. Heparin infusion was administered intravenously for 7 days after the operation, since confirming there was no postoperative bleeding. Patients were monitored with partial thromboplastin time levels taken 4 times a day, as we wanted to keep the level at 60 to 80 IU/mL. On the sixth day, patients were given acetylsalicylic acid 100 mg once daily and dipyridamole 75 mg 3 times a day.

Among patients, gastrointestinal bleeding occurred in 13 (3.8%) after an orthotopic liver transplant. Five patients (38.4%) were adult and 8 patients (61.6%) were pediatric. There were 7 male patients (53.7%) and 6 female patients (46.1%). The mean age was 18 ± 4 years (6 mo-54 y). The cause of liver failure in these patients included neonatal hepatitis (n=3; 23%), hepatitis B infection (n=2; 15%), hepatocellular carcinoma (n=2; 15%), α1 antitrypsin deficiency (n=1; 7.7%), Wilson disease (n=1; 7.7%), autoimmune hepatitis (n=1;7.7%), and progressive familial intrahepatic cholestasis (n=1;7.7%). Two patients (15, 3%) received an organ from deceased donor, and 11 (84.7%) received an organ from living donor. The bleeding sites were a Roux-en-Y anastomosis bleeding in 5 cases, peptic ulcer in 3 cases, erosive gastritis in 3 cases, gastric and esophageal varices in 1 case, and hemobilia in 1 case (Table 1).

These 13 patients with gastrointestinal bleeding were controlled by different methods. Four patients were managed with blood products. In 2 cases, the source of bleeding was visualized endoscopically, and they were given band ligation therapy. Two patients were treated with radiologic intervention, but in 1, the bleeding could not be controlled and a laparotomy was performed.

In this series of patients, bleeding from Roux-en-Y anastomosis was indicated surgically, and 5 patients performed laparotomy. All Roux-en-Y bleeding appeared during first 15 days after a liver transplant, hemobilia was detected in 5 days; 1 case of erosive gastritis was detected on the tenth day, and the other was after 1 year. Variceal bleeding appeared after 10 years, and a peptic ulcer appeared after 1 year. No patients died because of gastrointestinal bleeding. During follow-up, 4 patients died because of sepsis, and 1 died of recurrent hepatocellular carcinoma.

Although improvements in postoperative care have resulted in a significant reduction of gastrointestinal bleeding, it is associated with increased morbidity and is the leading cause of graft loss (53%) and mortality.⁷ The occurrence of bleeding has long been recognized as a complication after a liver transplant.³ Sources of blood loss in recipients of liver transplants are vascular anastomotic leaks,^3,4 persistent coagulopathy,^3,4 hemobilia,^3,8 viral (cytomegalovirus and Epstein-Barr virus) gastroduodenitis,^4,9 Roux-en-Y anastomotic bleeds,^4,10 esophageal perforations,^3,9 and portal hypertension due to splenic^11,12 or portal vein thrombosis,^3,13 and various other vascular complications.⁴

In most studies, the most common cause of gastrointestinal bleeding after liver transplant was ulcers. In our study, Roux-en-Y anastomosis was the most common cause of bleeding, followed by peptic ulcer, erosive gastritis, esophageal varices, and hemobilia. We believe that bleeding involved an anastomosis, such as Roux-n-Y, and the low level of platelets, elongation of international normalized ratio, heparin administration by intravenously, and peptic ulcer, and erosive gastritis. Small grafts may cause transient PHT, which increases the risk of gastrointestinal bleeding^14,15; however, in our study, we did not have small grafts. Bleeding from a Roux-en-Y anastomosis during the first 2 weeks has been attributed to incomplete hemostasis of the mucosa at the site of the Roux-en-Y anastomosis, facilitated by the reabsorption of the sutures, poor nutritional status, presence of PHT, and use of immuno-suppressants.⁴

There have been several studies that examine the incidence of gastrointestinal bleeding after a liver transplant. One of them described an 8.9% cumulative risk of gastrointestinal bleeding in the postliver transplant setting, primarily resulting from ulcers, but also from enteritis, portal hypertensive lesions, and Roux-en-Y bleeding. That was found to be an indicator of decreased graft and patient survival.² In another study examining gastro-intestinal bleeding after living-related liver transplant, the incidence of posttransplant bleeding was 4% in pediatric recipients. Portal vein thrombosis and variceal bleeding were the main reasons for gastrointestinal bleeding.¹⁴ Aydin and associates describe a 16% rate of gastrointestinal bleeding in pediatric patients after a liver transplant. In this study similar to ours, the most common cause of gastrointestinal bleeding was Roux-en-Y anastomotic bleeding and less frequently, peptic ulcer, and esophageal varices.¹⁶ Although patients with gastrointestinal bleeding had been reported as having an increased morbidity,^2,3,6,7 in our study, no decrease in the survival duration of patients with orthotopic liver transplant complicated by gastrointestinal bleeding has been seen.

In conclusion, gastrointestinal bleeding may occur in different sites after an orthotopic liver transplant. Because of difficulties in diagnosing and managing gastrointestinal bleeding, successful management requires a multidisciplinary approach involving hepatologists, advanced and experienced endoscopists, interventional radiologists, and surgeons. Despite this, it is difficult to recommend general guidelines for managing bleeding after a liver transplant, and each case should be treated by considering the site and severity of bleeding.

Volume: 12 Issue: 1 March 2014 - Supplement - 1

FULL TEXT