Endoscopies in pediatric intestinal transplantation: Five year experience

Introduction: Following intestinal transplantation, endoscopies with biopsies are necessary for monitoring of rejection and infections Little has been written about endoscopic findings in pediatric intestinal transplant recipients. Method and patients: We reviewed our histologic and endoscopic data from all children receiving intestinal transplants from 1990 to Oct 1995 at Children's Hosp of Pittsburgh. Forty one children, ages 5 months to 18 years, received 44 transplants which included isolated small bowel (n=10), liver and small bowel (n=27). multi visceral (n=7) allografts. In most children, we performed endoscopies through the ileostomy twice weekly for the first month then once weekly for the next 4-8 weeks. If clinicilly indicated by diarrhea, bleeding from GI tract, fever or bacteremia, additional endoscopies were performed. Depending on the clinical situation, these could be upper (EGDJ) or lower (ileo or colon) endoscopies. Results: A total of 1273 endoscopies in 975 endoscopic sessions were performed in 39 children. Two children did not survive to undergo endoscopy. Seven hundred sixty ileoscopies, 273 upper endoscopies and 240 colonoscopies were performed. A total of 104 rejection episodes were documented in 32 children occuring six days to four years after transplant. Severity of rejection was mild to moderate in most children, but nine patients had severe exfoliative rejection with loss of epithelium. On 248 occasions, endoscopy was performed on proximal and distal portions of the graft simultaneously; on 168 occasions no rejection was present, on 42 occasions both sites were involved, but on 38 occasions rejection was present in one site while sparing the other Eight children were found to have CMV enteritis. In six, only the native bowel was involved, and in two, both native bowel and allograft. Eleven children were found to have the characteristic raised, ulcerated nodules of post-transplant lymphoproliferative disease (PTLD) in the GI tract. Ten of these had lesions in the allograft, but native colon was involved in three children and native stomach in two children. Complications were rare with only one perforation, three episodes of bleeding controlled without surgical intervention, and three episodes of transient respiratory compromise related to sedation. Conclusion: We conclude that endoscopy is a safe and valuable tool in the care of intestinal transplant recipients. If patients are clinically deteriorating with unexplained fever, bacteremia, diarrhea or GI bleeding, endoscopy can help in differentiating rejection from enteritis or PTLD.