S4707 Hark the Herald Bleed

Introduction: “Hark” in Shakespearean language means to “pay attention” – a relevant term when referring to minor, intermittent “herald” gastrointestinal (GI) bleeds that often precede more major bleeding events. One example is an iliac-artery enteric fistula (IEF), or an abnormal connection between the iliac artery and the GI tract, which can result in massive bleeding. Case Description/Methods: A 48-year-old man with dual pancreatic and kidney transplants presented to the emergency department with hematochezia. His hemoglobin was 9.4, and computed tomography imaging revealed mild fat stranding in the pancreas and rectosigmoid colon. He was previously hospitalized 5 years prior for similar symptoms and had an unremarkable endoscopic evaluation. Given all of this, the emergency department decided to transfuse 1 unit of red blood cells before discharging home with close outpatient follow up. Only 2 weeks later, he presented to the emergency department again for similar complaints, but this time his hemoglobin was significantly decreased to 5.4. The patient underwent repeat computed tomography imaging which was unrevealing. He was scheduled for a colonoscopy the following day; however, upon starting his bowel prep, he developed hematochezia and eventually hemorrhagic shock. Massive transfusion protocol was activated, and interventional radiology was consulted for emergent angiography which revealed an IEF originating from the proximal right internal iliac artery at the failed pancreatic graft site. An arterial stent was placed successfully with no further evidence of contrast extravasation. Despite this, the patient developed ventricular fibrillation and cardiac arrest secondary to transfusion associated circulatory overload, and his family ultimately decided to transition to comfort measures. Discussion: IEFs are thought to arise from pressure against the bowel wall by a graft or pseudoaneurysm in conjunction with some degree of infection leading to necrosis and then perforation or fistulization. They occur, albeit rarely, in patients with failed pancreatic transplants. This case highlights the difficulty in identifying arterial-enteric fistulas specifically in dual pancreatic and kidney transplants. While esophagogastroduodenoscopy and colonoscopy are the gold standards for evaluating GI bleeds, these procedures often only detect up to 25% of secondary IEFs. We feel this case to be clinically important as it is an example of one of the rarer types of GI bleeds. Let this serve as a poignant reminder to hark the herald GI bleed in patients with pancreatic transplants.