S4899 Intestinal Transplantation in Crohn’s Disease: A Case of Recurrent Disease and Secondary Allograft Failure

Introduction: We present a case involving the management of recurrent, severe Crohn’s disease (CD) following an isolated intestinal transplant in a patient with short bowel syndrome. Case Description/Methods: A 63-year-old man with intestinal failure secondary to CD presents with failure to thrive. Over 5 decades, he underwent over 40 surgeries with bowel resections and stricturoplasties. He developed short bowel syndrome and has been total parenteral nutrition (TPN) dependent for over 30 years. His course is complicated by catheter-related complications resulting in loss of venous access and intestinal-failure-associated liver dysfunction due to TPN dependence. He underwent an isolated intestinal transplant. Postoperatively, he continues to struggle with poor appetite and requires intermittent TPN. He improves initially, but over the next 5 years he experiences repeated episodes of acute cellular rejection and infections, including cytomegalovirus and Clostridioides difficile colitis. Underlying CD remains refractory to multiple medical therapies, including sulfasalazine, azathioprine, corticosteroids, infliximab, adalimumab, and certolizumab. Two years later, he develops progressively worsening abdominal pain and diarrhea. Imaging and endoscopy reveal a new severe stricture at the ileocolic anastomosis and another proximal stricture in the neo-terminal ileum. Due to progressive and disabling symptoms, he undergoes an elective exploratory laparotomy with lysis of adhesions and resection of 45 centimeters of strictured bowel. Histology reveals extensive ulceration, granulation tissue, submucosal fibrosis, and granulomas, suggesting recurrent CD and chronic rejection. Despite surgery, he continues to experience intractable diarrhea and remains TPN dependent. Vedolizumab is initiated to stabilize his disease and prevent further strictures. Although initially stable, he dies due to acute cerebrovascular disease. Discussion: This case illustrates the complex challenges of managing CD after intestinal transplantation. Significant risks include graft rejection and disease recurrence, even with aggressive immunosuppression. Currently, no definitive method exists to distinguish recurrent CD from other immune-mediated inflammation in the transplanted bowel. Existing diagnostics lack the specificity needed for accurate differentiation. A more precise approach incorporating integrated molecular diagnostics and bioinformatics is necessary to better understand the underlying mechanisms of post-transplant gut inflammation.