RECURRENT CROHN'S DISEASE AFTER BOWEL TRANSPLANT
Shanique Wilson*, Janelle Cuervo, Nathaniel Ernstoff, Leopoldo Arosemena, Maria T. Abreu
University of Miami/Jackson Memorial Hospital, Miami, FL
Intro:
Crohn's disease (CD) may result in short bowel syndrome (SBS) and need for intestinal transplant. The pathogenesis of IBD is attributed to a combination of genetic risk factors and changes in the microbiome. Thus, the question becomes whether CD can recur following an intestinal transplant. We present a patient with clinically significant CD after receiving intestinal transplantation and compare this presentation with other cases in the literature.
Case:
A 58-year old black woman with a 36-year history of severe fistulizing CD status post multiple resections resulting in TPN dependence which she continued for 1 year until her small bowel transplant. 2 years later she developed bloody stools and worsening abdominal pain. Colonoscopy showed features suggestive of CD in both the colon and small intestine with a simple endoscopic score (SES-CD) of 11 but negative path. She was restarted on infliximab but changed to vedolizumab because of recurrent infections. Repeat colonoscopy at that time showed a SES-CD of 15 and biopsies were consistent with CD - not graft rejection.
Another 2 cases in the literature both had long-standing, aggressive CD requiring multiple surgeries and ultimate TPN dependence. Small bowel transplants were performed. In spite of transplant-related immunosuppression, CD recurred between 7 months and 8 years after transplant. Both patients, required additional immunosuppression.
Discussion:
These cases illustrate the potential for recurrent Crohn's disease in transplanted bowel. There have only been two reported cases of recurrence in transplanted bowel in patients with prior CD. These two cases showed evidence of both microscopic and macroscopic recurrence with patients on tacrolimus. Our patient has been on tacrolimus/everolimus with histological and clinical recurrence of CD. Our patient also had no response to a gut selective T cell and monocyte homing inhibitor, vedolizumab. With little definitive understanding of the cause of CD, these cases of recurrence can offer insight into the pathogenesis of Crohn's and speak to the primed immune response newly attacking the transplanted intestine.
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