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Bowel Complications Seen on CT After Pancreas Transplantation with Enteric Drainage

Chandana G. Lall1, Kumaresan Sandrasegaran1, Dean T. Maglinte1 and Jonathan A. Fridell2

1 Department of Radiology, UH 0279, Indiana University School of Medicine, 550 N University Blvd., Indianapolis, IN 46202.
2 Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.


Figure 1
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  		Fig. 1 —llustration of systemic-enteric pancreatic transplantation procedure where exocrine secretions drain into small intestine. Donor Y graft is anastomosed to recipient right common iliac artery. Donor portal vein is anastomosed to recipient common iliac vein. Enteric anastomosis for exocrine pancreatic drainage is between donor duodenum and recipient jejunum. Renal artery and vein from donor kidney are anastomosed to recipient external iliac artery and vein, respectively. Inset shows construction of Y graft (using donor vessels) by end-to-end attachment of splenic to internal iliac arteries and superior mesenteric to external iliac arteries. Used with permission from the Office of Visual Media, Indiana University.

 

Figure 2
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  		Fig. 2A —52-year-old man with donor duodenum simulating abscess. Axial unenhanced CT image shows "fluid collection" (arrowhead) that did not opacify with addition of oral contrast agent, contained gas bubbles, and was incorrectly interpreted as perigraft abscess. Drains (arrows) are noted adjacent to this structure.

 

Figure 3
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  		Fig. 2B —52-year-old man with donor duodenum simulating abscess. Subsequent contrast-enhanced CT scan at similar level shows orally administered contrast agent within structure surrounded by ring of staples (arrowhead), confirming normal donor duodenum.

 

Figure 4
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  		Fig. 3 —36-year-old man 5 days after kidney-pancreas transplantation. Axial CT shows moderate amount of fluid (black arrowheads) around pancreas allograft (white arrow). Allograft shows enhancement. Note peritoneal gas bubble (white arrowhead) in keeping with recent surgery and renal transplant (black arrow). Such fluid collections are commonly seen in first few weeks after transplantation and do not correlate with graft survival.

 

Figure 5
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  		Fig. 4 —Sagittal-view line drawing shows internal hernia. Drawing shows potential for internal hernia between donor duodenum/pancreatic allograft and posterior peritoneum. Hernia occurs through mesenteric defect used to attach donor duodenum to recipient jejunum. Used with permission from the Office of Visual Media Indiana University)

 

Figure 6
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  		Fig. 5A —29-year-old woman with internal hernia 8 months after pancreas transplantation. Fluoroscopic part of CT enteroclysis shows beaked end at site of small-bowel obstruction (arrowhead). Donor duodenum (arrow) is attached to jejunum just proximal to obstruction.

 

Figure 7
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  		Fig. 5B —29-year-old woman with internal hernia 8 months after pancreas transplantation. Reformats in coronal (B) and sagittal (C) planes of isotropically acquired CT enteroclysis show contrast-filled distended proximal jejunum (white arrows). More distal distended bowel loops (white arrowhead, C) lie posterior to donor duodenum (black arrows). Pelvic small-bowel loops (curved arrows) are nondistended. Internal hernia, through mesenteric defect, was noted during surgery on same day images were obtained.

 

Figure 8
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  		Fig. 5C —29-year-old woman with internal hernia 8 months after pancreas transplantation. Reformats in coronal (B) and sagittal (C) planes of isotropically acquired CT enteroclysis show contrast-filled distended proximal jejunum (white arrows). More distal distended bowel loops (white arrowhead, C) lie posterior to donor duodenum (black arrows). Pelvic small-bowel loops (curved arrows) are nondistended. Internal hernia, through mesenteric defect, was noted during surgery on same day images were obtained.

 

Figure 9
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  		Fig. 6A —20-year-old man with adhesive small-bowel obstruction 8 months after pancreas transplantation. Axial CT images show dilated small-bowel loops (white arrow, B) with nondistended loops in anterior abdomen (black arrows) adherent to parietal peritoneum. Note absence of distended small-bowel loops between donor duodenum (black arrowhead, A) and iliac vessels (white arrowhead, A).

 

Figure 10
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  		Fig. 6B —20-year-old man with adhesive small-bowel obstruction 8 months after pancreas transplantation. Axial CT images show dilated small-bowel loops (white arrow, B) with nondistended loops in anterior abdomen (black arrows) adherent to parietal peritoneum. Note absence of distended small-bowel loops between donor duodenum (black arrowhead, A) and iliac vessels (white arrowhead, A).

 

Figure 11
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  		Fig. 6C —20-year-old man with adhesive small-bowel obstruction 8 months after pancreas transplantation. CT enteroclysis performed next day with positive enteral contrast enhancement shows long segment narrowing of anterior loop of small bowel (black arrow) closely applied to anterior peritoneum. Proximal bowel (white arrow) is distended. Appearances were of adhesive obstruction confirmed during surgery on same day image was obtained.

 

Figure 12
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  		Fig. 7A —28-year-old man with adhesive small-bowel obstruction 3 weeks after pancreas transplantation. Axial CT images show distended small-bowel loops (solid white arrows) and nondistended anterior loop (white arrowhead, B). On image A, no bowel is seen between donor duodenum (straight black arrow) and iliac vessels (curved black arrow), confirming absence of internal hernia. On image B, pancreas allograft (dashed white arrow) is edematous, which is consistent with pancreatitis. Patient subsequently underwent adhesionolysis. Incidental note of thrombosed vessel (black arrowhead, B) is seen adjacent to transplant. This is common postoperative finding, caused by thrombosis of distal donor superior mesenteric artery, and is of no clinical significance.

 

Figure 13
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  		Fig. 7B —28-year-old man with adhesive small-bowel obstruction 3 weeks after pancreas transplantation. Axial CT images show distended small-bowel loops (solid white arrows) and nondistended anterior loop (white arrowhead, B). On image A, no bowel is seen between donor duodenum (straight black arrow) and iliac vessels (curved black arrow), confirming absence of internal hernia. On image B, pancreas allograft (dashed white arrow) is edematous, which is consistent with pancreatitis. Patient subsequently underwent adhesionolysis. Incidental note of thrombosed vessel (black arrowhead, B) is seen adjacent to transplant. This is common postoperative finding, caused by thrombosis of distal donor superior mesenteric artery, and is of no clinical significance.

 

Figure 14
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  		Fig. 8 —52-year-old man with nonobstructive bowel adhesions 9 weeks after pancreas transplantation. Contrast-enhanced axial CT, with orally administered contrast agent, shows multiple loops of small bowel closely applied to anterior abdominal wall. Parietal peritoneum is thickened in parts (black arrowhead). Asymmetric thickening of small-bowel loops (white arrowhead) is shown.

 

Figure 15
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  		Fig. 9 —34-year-old woman with peritonitis 6 weeks after pancreas transplantation. Patient had stormy postoperative course characterized by anastomotic leak, drainage of fluid collections, repeat laparotomy, and continued fever. Contrast-enhanced axial CT image, with IV-administered contrast agent, shows fluid collection (arrows) surrounded by enhancing peritoneum. Abdominal wound was left open after prior surgery, to prevent abdominal compartment syndrome. Note donor duodenum surrounded by staples (arrowhead). Peritonitis was diagnosed and confirmed during surgery on same day image was obtained.

 

Figure 16
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  		Fig. 10A —36-year-old man with enterocutaneous fistula 6 weeks after pancreas transplantation. Contrast-enhanced axial CT image, with orally and IV-administered contrast media, shows possible track (arrow) through abdominal wall extending into open wound. Edema is seen in head of allograft (arrowhead), which is consistent with pancreatitis.

 

Figure 17
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  		Fig. 10B —36-year-old man with enterocutaneous fistula 6 weeks after pancreas transplantation. Axial image from CT enteroclysis performed next day, at same level as in A, shows enterally introduced contrast material has extravasated into subcutaneous tissue (arrow) indicating enterocutaneous fistula. Note pancreatic allograft (white arrowhead) and surgical drain (black arrowhead).

 

Figure 18
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  		Fig. 11 —36-year-old man with pseudomembranous colitis 4 weeks after pancreas transplantation. Patient had diarrhea and right colon (arrowhead) is considerably thickened. Stool cultures were positive for Clostridium difficile. Incidentally, small-bowel loops are closely applied to anterior abdominal wall (black arrow) and thickening of normally invisible anterior parietal peritoneum (white arrow) is seen, which indicates nonobstructive adhesions.

 

Figure 19
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  		Fig. 12A —49-year-old woman with bowel necrosis 5 weeks after pancreas transplantation. Contrast-enhanced axial CT image, with IV-administered contrast agent, shows diffuse small-bowel mural thickening (solid black arrow) and ascites (arrowhead). Bubble of free peritoneal (white arrow) gas is noted, which may have been caused by focal bowel perforation, but was clinically thought to be introduced via surgical drain. CT features, although nonspecific, raise suspicion of early bowel ischemia. Patient also had necrotic pancreatic allograft. Note donor duodenum (dashed arrow) anterior to iliac vessels.

 

Figure 20
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  		Fig. 12B —49-year-old woman with bowel necrosis 5 weeks after pancreas transplantation. Unenhanced axial CT obtained 2 weeks later, after further surgical intervention, shows diffuse pneumatosis (arrowheads) and high-density hemorrhagic ascites (arrows). Patient died 1 day later, and postmortem examination showed extensive small-bowel infarction.

 

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