Management of Biliary Strictures Following Liver Transplantation

Abstract

Case Presentation and EvolutionA 55-year-old man with end-stage liver disease due to chronic hepatitis C and alcohol abuse underwent orthotopic liver transplantation (OLT). Six weeks later, he developed a sudden rise in liver enzyme level. He underwent a liver biopsy that revealed acute cellular rejection and was treated with anti-thymocyte globulin. Although his aminotransferase levels declined over the following weeks, total bilirubin remained elevated over 5 mg/dl. Hepatic sonography and color Doppler imaging were normal. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture at the biliary anastomosis ( Fig. 1), which was treated with balloon dilation and biliary stent placement.The patient presented four months later with fever, sweats, and enterococcal bacteremia. An abdominal computed tomography (CT) scan with intravenous contrast revealed a 6-cm right hepatic lobe fluid collection communicating with dilated intrahepatic bile ducts, consistent with a biloma. Altered hepatic perfusion was also seen, manifested by heterogeneous attenuation in the right hepatic lobe (Fig. 2a-b). Percutaneous transhepatic cholangiography (PTC) with biliary drainage was performed, followed by internal-external biliary drain placement over the next several weeks. Follow-up hepatic sonography showed interval development of low resistance within the hepatic artery and tardus-parvus waveforms, suggesting proximal occlusion. A CT angiogram demonstrated complete occlusion of the common hepatic artery ( Fig. 3a-b). Over the following weeks, the patient developed multifocal intrahepatic biliary strictures with recurrent bilomas requiring percutaneous drainage. Because of subsequent progressive graft failure, he ultimately underwent a second liver transplantation.

Post–Endoscopic Retrograde Cholangiopancreaticography complications in liver transplanted patients, a single-center experience

“…Perforation is a rare complication. Complications in the biliary tracts occur in 5%-30% of all patients after LTX (15)(16)(17). These complications include anastomotic and non-anastomotic stenosis ( Fig.…”