Identification of an Enteroarterial Fistula at a Pancreas Transplant Site on Retrograde Double Balloon Enteroscopy

Iliac artery pseudoaneurysm is a rare complication after pancreas transplantation that can present as obscure gastrointestinal bleeding. A 56-year-old gentleman with failed pancreas transplant developed hematochezia and anemia with bidirectional endoscopy and computed tomography angiography being inconclusive. Video capsule endoscopy suggested distal small bowel bleeding, and retrograde double-balloon enteroscopy identified a solitary ulcer with a protruding pulsatile vessel. A right external iliac pseudoaneurysm was confirmed and treated with endovascular stenting that was complicated by limb ischemia and subsequently by surgical resection of the fistula. This case highlights retrograde double-balloon enteroscopy utility in identifying vascular-enteric fistulas when imaging fails.