The enormous antigen load makes an intestinal transplant more prone to rejection than other solid organs. In addition, rejection may impair the absorptive capacity of the graft leading to further under-immunosuppression and aggravation of the rejection process. Therefore, timely diagnosis of any pathology of the graft is essential. For graft monitoring, routine endoscopies and biopsies are performed frequently in the early phase after transplantation. Starting at three times a week immediately following surgery, the frequency is continuously reduced over the following weeks. After restoration of the gastrointestinal continuity, biopsies can be obtained from above with the help of an endoscope and from below via a colonoscopic approach. It has to be emphasized, however, that these patients require lifelong monitoring and attention. Therefore, a close relationship between the physician following the patient, the patient himself and the transplant center is essential. Although most rejection episodes are observed during the first year, they may occur any time after transplantation. Rejection is clinically recognized by the development of diarrhea, but other gastrointestinal symptoms such as ileus, emesis, or general malaise may also occur. These symptoms should always prompt endoscopic evaluation of the graft which usually looks grossly normal unless rejection is severe. Therefore, multiple random biopsies should be taken and evaluated by a pathologist experienced with intestinal transplants. It should be recognized that no serum marker accurately diagnoses bowel rejection at present. Even concomitantly transplanted organs such as the liver or a pancreas are not reliable indicators for rejection of the intestinal component of the graft.
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