Persistent duodenal ulcers bleeding in postkidney transplant patient treated by infliximab

A 50-year-old woman with end-stage kidney disease was admitted for a living-donor kidney transplantation. On post-transplantation day 6, she developed antibody-mediated rejection and was treated with plasmapheresis, rituximab and intravenous immunoglobulin. 1 week later, she developed severe upper gastrointestinal bleeding from multiple duodenal ulcers along the bulb and the third part of the duodenum. She underwent 11 sessions of endoscopic and interventional therapies comprised with the combination of various techniques including bipolar coaptation, hemoclipping, band ligation and angiogram with coil embolisation of duodenal branch of gastroduodenal artery. Histopathology showed neither any organism nor any feature of graft-versus-host disease. However, empiric treatments with intravenous proton pump inhibitor and broad-spectrum antibiotics/antifungal were given but failed to heal the ulcer, and bleeding recurred from the new developed ulcers. Finally, a single dose of intravenous infliximab was administered to stop bleeding. The patient responded dramatically with rapid ulcers healing and there was no recurrent bleeding during a 3-month follow-up.