Complications are very common after an intestinal or multivisceral transplant. The positive thing is that your transplant team will be vigilant in monitoring you for all complications and will be on top of treating you if any complications do arise.

This section contains a sampling of the potential of complications. This is not an all-inclusive list, nor does the explanation for each complication contain every possible symptom, treatment, or scenario. If you are concerned that you are experiencing a complication after your transplant, or are concerned about the possibility of complications, it is always best to contact your transplant team directly.

This occurs when your body detects the new intestine as foreign and, as a result, attacks the organ. Most patients will experience some form of rejection in the first 3-6 months post- transplant. This type of rejection can be classified as indeterminate, mild, moderate, or severe based on the histologic findings on your endoscopic biopsy.

Signs and Symptoms:

• Fever

• Abdominal pain

• Abdominal distention or swelling

• Nausea/ vomiting

• Increase in stoma output

• Changes in the appearance of stool

• Blood in stoma output

• Change in the appearance or color of stoma

• Loss of appetite/ weight loss

• Often causes no physical symptoms

Diagnosis: Diagnosis is made by taking a biopsy of your intestine through your ileostomy with an endoscope. If you are experiencing symptoms, this may prompt your transplant team to order an ileoscopy. On the other hand, since rejection often times does not cause symptoms, acute cellular rejection may be found on your surveillance biopsies. The transplant team will rely on the pathology of the biopsy to confirm the diagnosis and severity of the rejection.

Treatment: Treatment ultimately depends on the severity of the rejection. Mild rejection may just require adjustment of your immunosuppression medications and high doses of corticosteroids. Moderate to severe rejection may require heavier immunosuppression agents such as Thymoglobulin or Campath. Your transplant team will determine the best course of treatment for you based upon your immune status and biopsy results.

For intestinal transplants, unlike other solid organ transplants, antibody mediated rejection is poorly defined and the frequency and clinical significance remains uncertain.

This type of rejection develops months to years after the transplant has been completed and after acute rejection episodes have subsided. It appears to be a combination of both antibody and cell mediated rejection. Overall, there is fibrosis and scarring of the transplanted organs.

The only way to definitively diagnose chronic rejection is through a full thickness biopsy of the graft to look at the histology. A full thickness biopsy means that an entire portion of the intestine must be removed for full examination, unlike the pin-point biopsies that can be taken during a scope procedure. This is completed in the operating room.

Risks for chronic rejection include:

• Acute rejection within the first month of transplant.

• Isolated small bowel graft (in many reports it has been shown that including the liver in the graft has an immunoprotective effect in preventing rejection).

• Greater number of acute rejection episodes.

• Older recipient age.

Symptoms of chronic rejection include:

• Abdominal pain and/or distention.

• Increased output from ostomy.

• Poor oral intake and/or decreased appetite.

GVHD occurs in all types of transplant, however, it is of major concern to intestinal transplant due to the large amount of immune tissue that the intestine contains. GVHD results when the donor’s cells (the graft) view the patient’s healthy cells (the host) as foreign and begin to attack and damage them.

Signs and symptoms can vary based on if the disease is local on the skin or effecting a particular organ:

• Skin reactions: itching; red rash on the upper trunk, neck and feet; blisters on the palm, soles, and abdominal skin.

• Mouth or tongue lesions.

• GI manifestations: Diarrhea, nausea, or vomiting.

• Hepatitis or liver inflammation: May not have symptoms, but may lead to jaundice or yellowing of the skin.

Diagnosis: Usually a tissue biopsy of the affected skin will be used to diagnose GVHD along with clinical picture and patient history. Blood tests will often be taken to help manage the condition and to check liver function. If gastrointestinal symptoms are present, an endoscopy may be ordered.

Treatment: In self-limited, mild skin cases of GVHD no treatment may be necessary. In disseminated disease, steroid therapy is the treatment of choice along with adjustments in immunosuppression.

This is a complication that results when the lymphatic system of the donor graft does not grow together properly with the recipient's lymphatic system after transplant, resulting in lipid rich lymph fluid to leak into the abdominal cavity.

Signs and Symptoms:

• Abdominal distention

• Early satiety

• Abdominal pain

• Nausea/ vomiting

Diagnosis: Diagnosis is based on the clinical picture, observation of a milky fluid coming from JP drains, and/or from imaging studies such as an abdominal CT scan.

Treatment: Treatment is mainly supportive with NPO (nothing by mouth), fat-free diet, and bowel rest. In refractory cases, surgical intervention may be necessary.

• A blood clot is a clump of blood that has changed from a liquid to a gel-like or semi-solid state.

  • Clotting is a necessary process that your body undertakes in certain circumstances to prevent yourself from losing too much blood, however, there are times when your body forms clots in your veins when they are not needed and these can be dangerous.

  • If the clot in your vein accidentally breaks free from your vein and travels to your lungs or heart, it can get stuck and prevent blood flow, prompting a medical emergency.

• Blood clots are common after surgery, especially after a big operation like an intestinal transplant.

• Clots can form anywhere in your body, including your arms, legs, and/or abdominal vessels.

• It is important to keep yourself up and moving as much as possible after transplant to try and avoid getting any blood clots, but if you do notice any of the following symptoms, you must contact your transplant team immediately.

Signs and Symptoms:

• Cramping/ pain.

• Swelling, usually of one area.

• Reddish or bluish skin discoloration.

• Area warm to touch.

Diagnosis: Diagnosis of a blood will be based on clinical picture, Doppler ultrasound, venography, MRI, angiogram, and/or blood tests.

Treatment: Treatment of blood clots is a very tricky balance. Your transplant team will most likely start you on some form of anti-coagulation ‘blood thinning’ medication to treat your blood clots. Usually you first will start with heparin, an IV anti-coagulation medication, and then often will switch to warfarin (Coumadin) the pill form of the anti-coagulation.