Pediatric Gastrointestinal Posttransplant Lymphoproliferative Disorder: Incidence, Clinical Characteristics, and Impact of Major Surgical Interventions Upon Overall Survival

Post-Transplant Lymphoproliferative Disorder Presenting as a Gastrointestinal Fistulous Tract in a Heart Transplant Recipient: Case Report and Literature Review

We present a challenging case of Epstein-Barr virus-related isolated small bowel post-transplant lymphoproliferative disorder (PTLD) in a pediatric heart transplant recipient presenting as recurrent gastrointestinal (GI) bleeding and subsequently a GI fistulous tract with associated intra-abdominal abscess. Diagnosis was not confirmed until exploratory laparoscopy was performed, with excision of the fistulous tract revealing evidence of PTLD on pathology. Early diagnosis of GI-PTLD remains a challenge, especially if isolated in the small intestine. Diagnosis may rely on positron emission tomography/ computed tomography scan (PET/CT) or invasive intervention to obtain appropriate tissue samples for pathology diagnosis.

Gastrointestinal symptoms and endoscopy findings after pediatric solid organ transplantation: A case series

BACKGROUND

Gastrointestinal symptoms are common among solid organ transplant (SOT) recipients. Information about colonoscopy findings after pediatric SOT is limited. This retrospective study reports endoscopy findings in a nationwide pediatric transplant recipient cohort.

METHODS

All pediatric recipients (kidney, liver, or heart) transplanted between 2010 and 2020 at our institution (n = 193) who had undergone ileocolonoscopy and upper gastrointestinal endoscopy after SOT were enrolled. Sixteen patients were identified. A meticulous search on clinical data including transplantation, gastrointestinal symptoms, endoscopy findings, and follow-up data was performed.

RESULTS

Endoscopy was performed at a median of 2.6 years (0.4-13.3) after the first transplantation (median age at SOT 1.2 years). Gastrointestinal symptoms leading to endoscopy did not differ between the different transplant groups. The leading endoscopy indications were prolonged diarrhea and anemia. PTLD was found in 8 (50%) patients. Five were histologically early PTLD lesions and three were monomorphic large B-cell PTLDs (two EBV-positive and one EBV-negative), one having previously been diagnosed with autoimmune enteropathy. One patient had EBV enteritis. De novo inflammatory bowel disease was found in one patient, eosinophilic gastroenteritis in another, and in one patient with several episodes of watery diarrhea, the histological finding was mild non-specific colitis. In four patients, the endoscopy finding remained unclear and the symptoms were suspected to be caused by infectious agents or mycophenolate.

CONCLUSIONS

PTDL with various stages is a common finding after pediatric SOT in patients with gastrointestinal symptoms. Endoscopy should be considered in transplant recipients with prolonged diarrhea, anemia, and/or abdominal pain.

Pitfalls in gastrointestinal tract haematopoietic lesions

Specimens from the gastrointestinal (GI) tract are among the most commonly encountered in routine pathology practice worldwide. It is well known that the luminal GI tract is home to various areas rich in mucosa-associated lymphoid tissue (MALT), whether native or acquired. The latter may be particularly problematic due to its well-known predisposing factors such as Helicobacter pylori infection and autoimmune conditions. Nevertheless, native GI structures are often the subject of query, particularly in conditions that may mimic lymphoproliferative conditions, including infectious and inflammatory diseases. Herein, we describe and share common clinicopathological findings in our daily practice that are challenging to distinguish from subtle low-grade neoplastic lymphoproliferative disorders.

Pediatric hematolymphoid pathology in the gastrointestinal tract

Hematolymphoid processes involving the gastrointestinal tract in the pediatric and adolescent young adult (AYA) populations include processes occurring primarily within the gastrointestinal tract as well as systemic diseases with predilection for gastrointestinal involvement. Here, we present a focused review of reactive and neoplastic entities occurring in the pediatric and AYA age groups.

Diarrhea in the pediatric solid organ transplantation recipient: A multidisciplinary approach to diagnosis and management

Diarrhea in the pediatric solid organ transplantation (SOT) recipient is a frequent complaint that is associated with significant morbidity and impaired quality of life. There are limited published data regarding the specific epidemiology, diagnostic evaluation, and treatment of diarrhea after SOT in children. Pediatric SOT recipients have an increased risk of developing diarrhea because of a generalized immunosuppressed state, epidemiologic exposures, and polypharmacy. There is a need to standardize the diagnostic evaluation of diarrhea in children after SOT to facilitate an accurate diagnosis and timely treatment. Herein, we review the available published data and propose a systematic, stepwise approach to the evaluation of diarrhea in this high-risk population, focusing on timely diagnosis of both infectious and non-infectious causes, in order to provide focused management. Prospective studies are needed to better assess the true prevalence, risk factors for, etiologies, and complications of diarrhea in pediatric SOT patients that will guide optimal management. Development of effective vaccines and antiviral therapies for enteric viruses may also contribute to improved outcomes.

Hematologic malignancies of the gastrointestinal luminal tract

Hematologic malignancies include several lymphoproliferative and myeloproliferative disorders, many of which are frequently encountered in current health care settings. These malignancies frequently affect the gastrointestinal (GI) tract, either by secondary extranodal or extramedullary extension to the GI tract, or as a primary process arising in the GI tract. In fact, the GI tract may represent the most common extranodal site of involvement in many of them, such as lymphoma. Furthermore, in the current era of improved cancer treatment and advanced transplant procedures with increased survival, it has been quite common to encounter GI involvement by these malignancies through the disease course. Post-transplant lymphoproliferative disorder following kidney transplantation, for example, very commonly involves the GI tract. Other conditions that can involve the GI tract include multiple myeloma, plasmacytoma, myeloid sarcoma, mastocytosis, and Castleman disease. Imaging diagnosis of these malignancies can be challenging, since they are much less common than primary GI cancers and both share many common imaging features as well. However, certain imaging features, particularly in combination with a matching clinical scenario, play a pivotal role in diagnosing these conditions and directing further evaluation. In this article, we review common and rare hematologic malignancies of the GI tract and discuss their pathophysiologic, clinical, and imaging features.

Embolization for acute gastrointestinal hemorrhage secondary to post-transplant lymphoproliferative disorder

Gastrointestinal manifestations of post-transplant lymphoproliferative disorder (GI-PTLD) encompasses a spectrum of mucosal inflammation and ulceration that can present as severe acute gastrointestinal bleed. This case report describes a case of GI-PTLD in a 19-year-old female status postcardiac transplant. This patient presented with extensive gastrointestinal hemorrhage secondary to PTLD involving the duodenum. The patient was treated with extensive embolization of the gastroduodenal artery and the pancreaticoduodenal arcades. Embolization was used to mitigate gastrointestinal bleeding, thus preventing the need for surgical resection and extensive reconstruction. This case report demonstrates the utility of embolization as potential therapeutic option in the setting of GI-PTLD in addition to medical and endoscopic therapy.

Posttransplant Lymphoproliferative Disorder in Children: A 360-degree Perspective

An earlier incorrect version of this article appeared online. This article was corrected on December 17, 2019.