Demetris, AJ

Gordon, R

Hartman, GG

Lerut, J

Starzl, TE

English

Hartmann, GG

Name not available

Intrahepatic bile duct strictures in a liver allograft recipient mimicking recurrent primary sclerosing cholangitis. Follow-up of a case report letter

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Letter to the editor lill TRANSPLANT I Intemational © Springer-Verlag 1991 Transplant Int (1991) 4: 191-192 Intrahepatic bile duct strictures in a liver allograft recipient mimicking recurrent primary sclerosing cholangitis Follow-up of a case report G. G. Hartman, R. Gordon, J. Lerut, T. E. Starzl, and A. J. Demetris PreSb)1erian University Hospital of Pittsburgh, DeSoto at O'Hara Streets, Pittsburgh, PA 15213-2582, USA Received March 5. 1991/Accepted April 5. 1991 Sir: Reasons for development of large biliary tract compli-cations after orthotopic liver transplantation (OLT) are varied and include: (a) most commonly, surgical compli-cations from reconstruction of the extrahepatic bile duct [2]; (b) occasionally. recurrence of malignant biliary tract disease [1]; and (c) debatably, recurrence of the original benign biliary tract disease [5,6]. Although a higher in-cidence of biliary tract complications in primary scleros-ing cholangitis (PSC) patients versus other indications for liver transplantation has been reported [4], only 1 of our first 55 patients [3] grafted for PSC developed biliary tract abnormalities suggestive of recurrent primary disease. This communication provides a follow-up of our ex-ceptional patient for whom a detailed clinicopathologic history was pre\'iously provided [2.3]. The patient, with PSC and. at the time. 40 years old. underwent uneventful orthotopic li\'er transplantation in August 1984 (male donor. blood type identical): no HLA typing or cross-match results were available. The biliary reconstruction was with end-to-side choledochojejunostomy reusing a previously constructed Roux -en-Y limb. the length of which was not mentioned in the operative report. Convalescence was uneventful and the patient was dis-charged after 20 days with normal liver functions. After 5.5 months. he was readmitted because of an" obstructive" liver enzyme profile. and a percutaneous cholangiogram showed the presence of intrahepatic biliary strictures with a patent biliary anastomosis. A liver biopsy showed early changes of bile duct obstruction without evidence of rejec-tion. viral infection. or drug toxicity. At two other admis-sions in the next 3 months. liver biopsies showed similar changes. but with progressive portal fibrosis. The arterial and venous allograft vasculature were normal with ultra-sound. Case reports were written at this time [2] suggesting that there had possibly been a recurrence ofPSC. Thiscon-clusion appeared to be strengthened in the subsequent 24-27 months. during which the total serum bilirubin fluctu-ated between 2.0 and 2.5 mg/dl. although the patient was clinically stable [3]. Thereafter. he began to have fatigue. Offprint requests (0: G. G. Hartman deepening jaundice. and pruritus. Liver biopsy still had fea-tures of duct obstruction but now with focal small bile duct loss. Repeat percutaneous transhepatic cholangiography showed multiple intra- and extrahepatic biliary strictures. Total bilirubin had increased to 10.0 mg/dl, alkaline phos-phatase was 1300 JUn. and gamma glut amyl transpepti-dase was 836 JUn. On 18 August 1989, an uneventful hepatic retransplantation from a blood group and sex-identical donor was performed. There was a two-antigen HLA match and the cytotoxic crossmatch was negative. During the retransplantation. the ascending limb of the Roux-en-Y loop was noted to be less than 20 cm Estandardis4~R cm). The failed graft weighed 1780 grams and was bile-stained. The vascular supply was intact. Histologically. the irregularly dilated large ducts had severe acute ascending cholangitis and focal small bile duct loss. Partially digested vegetable matter was seen embedded in a severely in-flamed intrahepatic bile duct (Fig. 1 ). On the basis of this finding and a short Roux-en-Y limb. we believe that we were incorrect in our earlier conclusion that sclerosing Fig.L Large bile duct with intraluminally embedded vegetable ma-terial with extensive acute inflammatory reaction surrounded by fibrosis I : .. ~ I I 192 cholangitis had possibly recurred. Instead. regurgitation of food into the intrahepatic biliary tree appeared to have been responsible for the clinicopathologic events. We can-not. however, completely exclude an antibody-related in-jury since crossmatch results for the first transplant were not available. The patient has been well since retransplantation. at which time a Raux limb of conventional length was con-structed for the new choledochojejunostomy. If the pa-thogenesis of the problem had been realized early after the first grafting, retransplantation could possibly have been avoided. References 1. Iwatsuki S. Starzl TE. Gordon RD. Esquivel CO. Todo S. Tzakis A, Makowka L. Marsh Jw. Miller CM (1987) Late mortality and morbidity after liver transplantation. Transplant Proc 19: 2373--2378 2. Lerut 1. Gordon RD. Iwatsuki S, Shaw BW Jr. Esquivel CO, Tzakis A. Starzl TE (1987) Biliary tract complications in 393 human liver transplantations. Transplantation 43: 47-51 3. Lerut J. Demetris AJ. Stieber AC. Marsh Jw. Gordon RD. Esqui-vel CO. Iwatsuki S. Starzl TE (1988) Intrahepatic bile duct stric-tures after human orthotopic liver transplantation. Transplant Int 1: 127-130 4. Letourneau JG. Day DL. Hunter OW, Ascher NL. Najarian JS, Thompson WM. Castaneda-Zuniga WR (1988) Biliary complica-tions after liver transplantation in patients with preexisting scle-rosing cholangitis. Radiology 167: 349-351 5. Marsh Jw. Iwatsuki S. Makowka L, Esquivel CO. Gordon RD, Todo S. Tzakis A. Thiel 0 van. Starzl TE (1988) Orthotopic liver transplantation for primary sclerosing cholangitis. Ann Surg 207: 21-25 6. Neuberger 1. Portmann B, MacDougall B. Caine RY, Williams R (1982) Recurrence of primary biliary cirrhosis after liver trans-plantation. N Engl 1 Med 306: 1-4 

Intrahepatic bile duct strictures in a liver allograft recipient mimicking recurrent primary sclerosing cholangitis - Follow-up of a case report

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Intrahepatic bile duct strictures in a liver allograft recipient mimicking recurrent primary sclerosing cholangitis - Follow-up of a case report

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