Four children who underwent ABO-compatible combined liver and small bowel transplantation developed severe immunemediated hemolytic anemia. The main management strategies were early and aggressive treatment with steroids, the introduction of rituximab (an anti-CD20 monoclonal antibody), and the use of plasma exchange together with compatible but minimal blood transfusions. Three of the 4 children developed thrombi in the major vessels. In small bowel transplant patients, the early recognition of hemolytic anemia and intensified management with anticoagulation are necessary for the prevention of this complication. Liver Transpl 17:921-924,
An 80-year-old lady was referred for management of metastatic colorectal cancer (CRC) causing biliary stricture. She underwent a right hemicolectomy in 2004 for Dukes B adenocarcinoma of colorectal origin. In 2007, she had a subtotal colectomy for a second CRC. Two years later, carcinoembryonic antigen (CEA) rose from 3.6 mcg/L in March to 7.2 mcg/L in September 2009, with positron emission tomography demonstrating hepatic and pulmonary disease. A right pulmonary lobectomy was performed in 2009 for the lesion initially thought to be a primary, however, found to be CRC metastasis on histopathology. A liver resection was not undertaken as disease was not resectable on re-evaluation.The patient was referred in July 2010 for management of jaundice. She had an obstructive pattern of liver function, and a bilirubin 99 μmol/L at presentation. The CEA had risen to 17.4 mcg/L. Computed tomography demonstrated obstruction of left and right hepatic ducts by a hilar mass involving segment 4 and encasement of the portal structures (Fig. 1).As our patient was an avid Bridge player, active within her community, management at this time was palliation at home with effective biliary drainage. Our patient had bilateral percutaneous cholangiography with insertion of bilateral external biliary drains metal stents. After repeat cholangiogram, external drains were removed and she was discharged after a 5-day admission. Follow-up bilirubin was 40 μmol/L. She returned 1 month later in October, jaundiced (bilirubin 223 μmol/L), with right upper quadrant pain, unwell with pyrexia Liam Quinn, MBBS
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