Bron, KM

Campbell, WL

Iwatsuki, S

Skolnick, ML

Starzl, TE

Zajko, AB

Zemel, G

English

Sholnick, ML

Name not available

Percutaneous transhepatic cholangiography rather than ultrasound as a screening test for postoperative biliary complications in liver transplant patients

D-Scholarship@Pitt

I' Percutaneous Transhepatic Cholangiography Rather Than Ultrasound as a Screening Test for Postoperative Biliary Complications in Liver Transplant Patients A.B. Zajko, G. Zemel, M.L. Skolnick, K.M. Bran, W.L. Campbell, S. Iwatsuki, and T.E. Starzl DIAGNOSTIC IMAGING of the biliary tract is often required in liver transplant patients with suspected biliary com plica-tions.u Direct cholangiography. either percu-taneous transhepatic (PTC) or endoscopic retrograde. is the definitive radiological exam-ination for the detection of biliary abnormali-ties.) Ultrasound (US) is noninvasive and accurate in detecting dilatation of the biliary tree. On the basis of experience in non trans-plant patients. US has traditionally been con-sidered the screening examination of choice for detecting bile duct obstruction.4•5 Because liver allograft recipients undergo close postoperative laboratory monitoring, elevation of liver enzyme levels is often the first manifestation of a biliary complication. Because transplant patients typically undergo imaging evaluation early and because certain allograft biliary complications are not neces-sarily accompanied by ductal enlargement, bile duct dilatation is often not seen. In this study, we review the results of US examina-tions performed in 50 transplant patients with biliary complications diagnosed by PTe. Data are presented that show that US is insensitive as a screening test in the early detection of biliary complications in liver allograft recip-ients. SUBJECTS AND METHODS During the 75-month period ending March 31, 1987, 800 patients received 1.045 orthotopic liver transplants. From the Departments of Radiology and Surgery, University of Pittsburgh School of Medicine. Address reprint requests to A.B. Zajko. MD. Depart-ment of Radiology. Presbyterian University Hospital. DeSoto at O'Hara Sts. Pittsburgh. PA 15213. © 1988 by Grune & Stratton. Inc. 0041-1345/88/2001-1249$03.00/0 Biliary complications were diagnosed by PTe in 71 patients. US examinations were available in 50 of the 71 patients. PTe followed the US examination within three days in 35 patients, four to seven days in six patients. and eight to 15 days in nine patients. PTe was performed from a right lateral intercostal approach with a 22-gauge needle. Real-time sonographlc evaluation was performed on Advanced Technology Laboratories' MK 300 (Bothwell, W A) and Acuson 128 scanners (Mountain View. CAl. The presence of intrahe-patic bile duct dilatation. a common duct diameter greater than 7 mm. an intrahepatic or subhepatic fluid collection. or an intraductal stone constituted an abnor-mal. or positive, US study. RESULTS Biliary complications were diagnosed by PTC in 50 patients. Complications included anastomotic and nonanastomotic strictures. bile leaks. stones, bile duct redundancy. cystic duct abscess, and obstructed internal biliar' stents (Table 1). The results of US exam were abnormal (Table 1) in 23 of the 50 patients (sensitivity, 46%). In 20 of the 23 cases, US findings were abnormal because of bile duct dilatation. In 27 patients with abnor-mal PTC results (Figs 1 and 2), no abnormal-ity was demonstrated on US. Table 1. Results of US-Examinations in Liver Transplants With Bilisry Complications Diagnosed by PTC Biliary Complication (n) US-POSitive Strictures (32) 17-Bile leak (4) Stones (2) Common duct redundancy 1· (4) Cystic duct abscess ( 1 ) Occluded Internal stent (7) 2-Total (50) 23t • US-positive because of bile duct dilatation. tSensitivity of ultrasound. 46%. US-Negative 15 3 1 3 0 5 27 678 Transplantation Proceedings, Vol XX, No 1, Suppl 1 (February), 1988: pp 678-681 rhan lary arzl C in 71 <)f the 71 hin three lents. and nercosL. Io~rPrD chnolo~D uson 1O~ f intra he-diameter -3tic fluid 10 abnor-)sed by ncluded -ictures. y.C\Sl1C ! bi Ii: ; ':X:l, the ~ , the 23 cause of h abnor-lnormal-liver )5 ;-Negatlve -15 3 o 5 27 -Jp 678-681 PTe IN LIVER TRANSPLANT PATIENTS Fig 1. Transhepatic chol-angiogram performed because of elevated liver enzyme levels demonstrates an irregular stricture of the allograft com-mon hepatic duct (arrowsl with a nondilated biliary tree. A US study was normal; the hepatic artery was patent by pulsed Doppler examination. The eti-ology of the stricture was unknown. DISCUSSION ., Biliary tract evaluation is often required in * liver transplant patients with an abnormal f> postoperative course. Clinical manifestations ~: of biliary complications in these patients may tj ,\! be nonspecific and include acute cholangitis, ~ fever, septicemia, and elevation of liver enzyme levels.6 In the nontransplant patient, earlier studies have shown that US is sensitive in detecting bile duct dilatation and therefore is a useful screening test for biliary obstruc-tion.4.5 However, US may fail to demonstrate dilated ducts because of biliary sludge, obscu-ration by bowel gas, and technically inade-quat;;: scans.3 Also, in 9% of nontransplants with obstructive jaundice, bile duct dilatation is absent.7 We have demonstrated that in liver transplant patients US has a much higher false-negative rate for detecting biliary com-plications, especially obstruction. In screening liver transplants for biliary 679 complications, there are several reasons for the low sensitivity of US. Early detection of elevated liver enzyme levels permits the cholangiographic diagnosis of biliary stric-tures that have not been present for sufficient time to cause bile duct dilatation (Fig I). This finding has been reported in nontransplant pa tients as well. 7.8 Partial biliary obstruction, as seen with occluded internal biliary stents and some bile duct strictures, may not result in bile duct dilatation, thus leading to a negative US result. Sludge and bile encrustation that can narrow or occlude internal biliary stents can-not be seen with US. On US, internal biliary stents also cause acoustic shadowing, which does not permit evaluation of the stent lumen or common duct caliber. To diagnose stent occlusion, a common cause of biliary obstruc-tion after Roux-en-Y choledochojejunosto-my,6 PTC is therefore required. 680 Direct contrast opacification of the com-mon duct is also usually necessary to demon-strate extrahepatic duct redundancy because bile duct dilatation may be absent. In addi-tion, not only may it be impossible for US to demonstrate the common duct along its entire course, but the more distal duct can also be obscured by an overlying gas-filled bowel. At our institution, if direct opacification of the biliary tree is required, PTC rather than endoscopic retrograde cholangiography is the preferred method for two reasons. First, many transplant patients undergo biliary recon-ZAJKO ET :. Fig 2. Transhepatic cholangiogram per-formed because of fever demonstrates con-trast extravasation from the distal common duct into the peritoneal cavity (arrows). The biliary tree is normal in size. On US, such bile leaks may mimic postoperative ascites. struction by choledochojejunostomy in Roux-en-Y. In these patients, the only access to evaluate the biliary tree is a percutaneous transhepatic one. Second, if biliary obstruc-tion is diagnosed by PTC, the preferred initial method of treatment is transhepatic cathett" drainage. This procedure is a direct extensi,· of transhepatic cholangiography. Bile leaks after liver transplantation can result in a contained biloma that may be detectable by US. However, a biloma cannot be distinguished from other fluid collections such as loculated ascites, which occurs fre-ler-an-nan The bile JX-to :~I 'US UC- ~ 1:1: ", .<if K~ f 'jJ:' :an be not llns :'re-PTe IN LIVER TRANSPLANT PATIENTS quently, seromas. or abscesses, In addition. small confined bile leaks may be obscured on US by adjacent bowel gas or acoustic shadow-ing from internal biliary stents, Free bile extravasation into the peritoneal cavity may lead to the US appearance of postoperative ascites, PTe readily demonstrates both locu-lated contrast extravasation into bilomas and free leakage into the peritoneal cavity (Fig 2). In the immunosuppressed transplant pa-681 tient. serious biliary complications are asso-ciated with a high mortality if they are not recognized and corrected promptly.9 US is insensitive as a screening test for the early detection of biliary complications in liver allo-grafts, We conclude that in liver transplant patients with suspected biliary complicI~tions PTe is the screening procedure of choice, PTe permits the diagnosis of a variety of posttransplant complications that frequently require early intervention, REFERENCES I. Zajko AB, Campbell Wl. Bron KM. et al: AJR 144:127,1985 2. Zajko AB, Bron KM, Campbell Wl. et al: Gastro-intest Radiol 12:137, 1987 3. Gold RP, Casarella WJ, Stern G, et al: Radiology 133:39. 1979 4. Neiman HL. Mintzer RA: AJR 129:979, 1977 5. Koenigsberg M. Wiener SN. Walzer A: Radiology 133:157.1979 6. lerut J. Gordon RD. Iwatsuki S, et al: Transplanta-tion 43:47. 1987 7. Beinart C. Efremidis S, Cohen B. et al: JAMA 245:353. 1981 8. Ferrucci JT Jr. Adson MA. Mueller PR, et al: AJR 141:1. 1983 9. Starzl TE. Putnam CW, Hansbrough JF, et al: Surgery 81 :212. 1977 

Percutaneous transhepatic cholangiography rather than ultrasound as a screening test for postoperative biliary complications in liver transplant patients.

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Percutaneous transhepatic cholangiography rather than ultrasound as a screening test for postoperative biliary complications in liver transplant patients.

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