Successful treatment of ileal ulcers caused by immunosuppressants in two organ transplant recipients

Abstract

Although gastroduodenal ulcers are common in solid organ transplant patients, there are few reports on multiple giant ulcers in the distal ileum and ileocecal valve caused by immunosuppressants Herein, we report on a liver transplant recipient and a renal transplant recipient with multiple large ulcers in the distal ileum and ileocecal valve who rapidly achieved ulcer healing upon withdrawal of sirolimus or tacrolimus and administration of thalidomide. In case 1, a 56-year-old man with primary hepatocellular carcinoma had received a liver transplantation. Tacrolimus combined with sirolimus and prednisolone was used as the anti-rejection regimen. Colonoscopy was performed because of severe abdominal pain and diarrhea at post-operative month 10. Multiple giant ulcers were found at the ileocecal valve and distal ileum. The ulcers healed rapidly with withdrawal of sirolimus and treatment with thalidomide. There was no recurrence during 2 years of follow-up. In case 2, a 34-year-old man with end-stage kidney disease received kidney transplantation and was put on tacrolimus combined with mycophenolate mofetil and prednisolone as the anti-rejection regimen. Twelve weeks after the operation, the patient presented with hematochezia and severe anemia. Colonoscopy revealed multiple large ulcers in the ileocecal valve and distal ileum, with massive accumulation of fresh blood. The bleeding ceased after treatment with intravenous somatostatin and oral thalidomide. Tacrolimus was withdrawn at the same time. Colonoscopy at week 4 of follow-up revealed remarkable healing of the ulcers, and there was no recurrence of bleeding during 1 year of follow-up. No lymphoma, tuberculosis, or infection of cytomegalovirus, Epstein-Barr virus, or fungus was found in either patient. In post-transplantation cases with ulcers in the distal ileum and ileocecal valve, sirolimus or tacrolimus should be considered a possible risk factor, and withdrawing them or switching to another immunosuppressant might be effective to treat these ulcers.

Keywords: Ileal ulcers; Kidney transplantation; Liver transplantation; Sirolimus; Tacrolimus.

Figure 1

Colonoscopic images of case one. A-C: Multiple giant and deep ulcers in the ileocecal valve and distal ileum, with polypoid hyperplasia; D-F: Rapid healing of the ulcers in the ileocecal valve and distal ileum and only two healing 2 stage ulcers left.

Figure 2

Photomicrograph of biopsy specimens. A and B: Biopsy specimens of ulcers from case one; C and D: Biopsy specimens of ulcers from case two. Hematoxylin-eosin staining, magnification × 200.

Figure 3

Multiple ulcers in ileocecal valve and distal ileum, with massive fresh blood accumulation (A-C); rapid healing of the ulcers with scar tissue in ileocecal valve and distal ileum (D-F).