Late presentation of a biliary tract complication after right hepatic donation resulting in secondary biliary cirrhosis

Endoscopic management of biliary strictures after liver transplantation

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classified as anastomotic or non-anastomotic strictures according to location and are defined by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Non-anastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is significant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.

Biliary complications in liver transplantation

Biliary complications of living donor liver transplantation remain common. The complications of biliary leakage and stricture result in substantial recipient morbidity. A major focus of liver transplantation research is the prevention and reduction of these complications through identification of the multiple factors that are conducive to them. Such factors include the donor bile duct anatomy and quality, and the techniques of donor hepatectomy, recipient hepatectomy, and ductal reconstruction. A low threshold for re-exploration for possible bile leakage prevents development of uncontrolled sepsis. Return of good graft function can usually be expected after successful early endoscopic treatment. Contingent measures of percutaneous transhepatic dilatation and stenting, and revision hepaticojejunostomy have to be exercised with utmost care to avoid hepatic artery injury which may results in graft loss.

Relevant histopathologic findings that distinguish acute cellular rejection from cholangitis in hepatic allograft biopsy specimens

BACKGROUND AND AIM

Histopathologic differential diagnosis of acute cellular rejection (ACR) and cholangitis continue to pose important problems following liver transplantation. The purpose of the present study was to evaluate the histopathologic features of ACR versus cholangitis.

METHODS

The following variables were evaluated among 36 hepatic allograft biopsy specimens, consisting of 21 with ACR (group 1) and 15 with cholangitis (group 2) for ductal neutrophilic infiltration, presence/density of portal eosinophilia, centrilobular necrosis, central/portal vein endothelialitis, pericentral inflammation, hepatocyte ballooning, hepatocanalicular/ductular cholestasis, hepatocyte apoptosis, lobular inflammation, ductular proliferation, periductal fibrosis/edema, ductular epithelial damage, and portal inflammation. Only the first biopsy samples of the ACR group were included in this study.

RESULTS

The incidences of ductal neutrophilic infiltration (93.3% vs 19%), hepatocanalicular cholestasis (86.7% vs 47.6%), ductular cholestasis (60% vs 0%), ductular proliferation (93.3% vs 4.8%), and periductal fibrosis/edema (93.3% vs 19%) were significantly greater in group 2 than group 1 (P < .05). In contrasts the incidences of portal eosinophilia (mean +/- SD, 3.37 +/- 3.9 vs 0.73 +/- 0.8), dense portal eosinophilia (mean +/- SD, 0.33 +/- 0.31 vs 0.11 +/- 0.16), central vein endothelialitis (0% vs 57.1%), portal vein endothelialitis (20% vs 95.2%), apoptosis (40% vs 71.4%), and necroinflammation (0% vs 90.5%) were significantly higher in group 1 (P < .05). The other parenchymal histopathologic changes and features of portal inflammation were similar in the 2 groups.

CONCLUSION

In the differential diagnosis, ductal changes (cholestasis, neutrophilic infiltration, proliferation, and periductal fibrosis/edema) favor cholangitis, whereas the presence and density of portal eosinophilia favor ACR. Portal inflammation is not a distinctive morphological finding.