Biliary casts after liver transplantation: Morphology and biochemical analysis

Endoscopic Features of Post-COVID-19 Cholangiopathy and Its Management Using ERCP

INTRODUCTION

Despite growing awareness of post-coronavirus disease 2019 (COVID-19) cholangiopathy as one of the most serious long-term gastrointestinal consequences of COVID-19, the endoscopic features of this disease are still poorly characterized. This study aimed to more precisely define its endoscopic features and to outline the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of this entity.

METHODS

In this observational study, 46 patients with confirmed post-COVID-19 cholangiopathy were included.

RESULTS

Based on the endoscopic features observed in 141 ERCP procedures, post-COVID-19 cholangiopathy can be classified as a variant of secondary sclerosing cholangitis in critically ill patients. It appeared early in the course of intensive care treatment of patients with COVID-19 (cholestasis onset 4.5 days after intubation, median). This form of cholangiopathy was more destructive than stricturing in nature and caused irreversible damage to the bile ducts. A centripetal pattern of intrahepatic bile duct destruction, the phenomenon of vanishing bile ducts, the absence of extrahepatic involvement, and the presence of intraductal biliary casts (85% of patients) were typical cholangiographic features of post-COVID-19 cholangiopathy. This cholangiopathy was often complicated by small peribiliary liver abscesses with isolation of Enterococcus faecium and Candida spp. in bile culture. The prognosis was dismal, with a 1-year liver transplantation-free survival rate of 44%. In particular, patients with peribiliary liver abscesses or destruction of the central bile ducts tended to have a poor prognosis (n.s.). As shown by multivariate analysis, bilirubin levels (on intensive care unit day 25-36) negatively correlated with liver transplantation-free survival (hazard ratio 1.08, P < 0.001). Interventional endoscopy with cast removal had a positive effect on cholestasis parameters (gamma-glutamyl transpeptidase, alkaline phosphatase, and bilirubin); approximately 60% of all individual values decreased.

DISCUSSION

Gastrointestinal endoscopy makes an important contribution to the management of post-COVID-19 cholangiopathy. ERCP is not only of great diagnostic and prognostic value but also has therapeutic value and therefore remains indispensable.

Intensive Care Unit-Related Cholangiopathy-Induced Biliary Cast Syndrome Without Liver Transplantation: A Rare Entity

The development of biliary cast syndrome (BCS) is very rare, mostly documented in patients with liver transplantation. The etiology of BCS is unknown; however, risk factors include post-liver transplant bile duct injury, ischemia, infection, fasting, parenteral feeding, and increased bile viscosity and gallbladder dysmotility. We present the case of a 41-year-old man who developed BCS secondary to a prolonged intensive care unit course without a liver transplant. This case highlights the importance of monitoring patients with protracted intensive care unit course and abnormal aminotransferases to recognize and timely manage cholangiopathy and BCS-related complications.

Biliary complications after liver transplantation: A computed tomography and magnetic resonance imaging pictorial review

Biliary complications are the most common complications after liver transplantation. Computed tomography (CT) and magnetic resonance imaging (MRI) are cornerstones for timely diagnosis of biliary complications after liver transplantation. The diagnosis of these complications by CT and MRI requires expertise, mainly with respect to identifying subtle early signs to avoid missed or incorrect diagnoses. For example, biliary strictures may be misdiagnosed on MRI due to size mismatch of the common ducts of the donor and recipient, postoperative edema, pneumobilia, or susceptibility artifacts caused by surgical clips. Proper and prompt diagnosis of biliary complications after transplantation allows the timely initiation of appropriate management. The aim of this pictorial review is to illustrate various CT and MRI findings related to biliary complications after liver transplantation, based on time of presentation after surgery and frequency of occurrence.

Biliary cast syndrome after liver transplantation: A cholangiographic evolution study

BACKGROUND AND AIM

The aim of this study is to describe the cholangiographic features and endoscopic management of biliary cast syndrome (BCS), a rare specific ischemic cholangiopathy following liver transplantation.

METHODS

Patients with biliary complications were identified from prospectively collected database records of patients who underwent liver transplantation at the Erasme Hospital from January 2005 to December 2014. After excluding patients with hepatico-jejunostomy or no suspicion of stricture, cholangiograms obtained during endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging were systematically reviewed. Biliary complications were categorized as anastomotic (AS) and non-AS strictures, and patients with BCS were identified. Clinical, radiological, and endoscopic data were reviewed.

RESULTS

Out of 311 liver transplantations, 14 cases were identified with BCS (4.5%) and treated with ERCP. Intraductal hyperintense signal on T1-weighted magnetic resonance and a "duct-in-a-duct" image were the most frequent features of BCS on magnetic resonance imaging. On initial ERCP, 57% of patients had no stricture. Complete cast extraction was achieved in 12/14, and one of these had cast recurrence. On follow-up, 85% of the patients developed biliary strictures that were treated with multiple plastic stents reaching 60% complete stricture resolution, but 40% of them had recurrence. After a median follow-up of 58 months, BCS patients had lower overall and graft survival (42.9% and 42.9%) compared with non-AS (68.8% and 56.3%) and AS (83.3% and 80.6%), respectively.

CONCLUSIONS

Particular magnetic resonance-cholangiographic and ERCP-cholangiographic features of BCS have been identified. Outcomes for BCS are characterized by high complete cast extraction rates, high incidence of secondary strictures, and poorer prognosis.

Biliary Cast Syndrome: Hepatic Artery Resistance Index, Pathological Changes, Morphology and Endoscopic Therapy

BACKGROUND

Biliary cast syndrome (BCS) was a postoperative complication of orthotopic liver transplantation (OLT), and the reason for BSC was considered to relate with ischemic type biliary lesions. This study aimed to evaluate the relationship between BCS following OLT and the hepatic artery resistance index (HARI), and to observe pathological changes and morphology of biliary casts.

METHODS

Totally, 18 patients were diagnosed with BCS by cholangiography following OLT using choledochoscope or endoscopic retrograde cholangiopancreatography. In addition, 36 patients who did not present with BCS in the corresponding period had detectable postoperative HARI on weeks 1, 2, 3 shown by color Doppler flow imaging. The compositions of biliary casts were analyzed by pathological examination and scanning electron microscopy.

RESULTS

HARI values of the BCS group were significantly decreased as compared with the non-BCS group on postoperative weeks 2 and 3 (P < 0.05). Odds ratio (OR) analysis of HARI 1, HARI 2, HARI 3 following the operation was >1 (OR = 1.300; 1.223; and 1.889, respectively). The OR of HARI 3 was statistically significant (OR = 1.889; 95% confidence interval = 1.166-7.490; P = 0.024). The compositions of biliary casts were different when bile duct stones were present. Furthermore, vascular epithelial cells were found by pathological examination in biliary casts.

CONCLUSIONS

HARI may possibly serve as an independent risk factor and early predictive factor of BCS. Components and formation of biliary casts and bile duct stones are different.

Spectrum of biliary complications following live donor liver transplantation

Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.

Percutaneous yttrium aluminum garnet-laser lithotripsy of intrahepatic stones and casts after liver transplantation

Bile duct stones and casts (BDSs) contribute importantly to morbidity after liver transplantation (LT). The purpose of this study was to estimate the clinical efficacy, safety, and long-term results of percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in transplant recipients and to discuss underlying factors affecting the outcome. A retrospective chart review revealed 18 recipients with BDSs treated by PTCSL laser lithotripsy with a holmium-yttrium aluminum garnet laser probe at 365 to 550 µm. They were analyzed in a median follow-up time of 55 months. In all but 1 patient (17/18 or 94%), it was technically feasible to clear all BDSs with a mean of 1.3 sessions. PTCSL was unsuccessful in 1 patient because of multiple stones impacting the bile ducts bilaterally; 17% had early complications (Clavien II). All biliary casts were successfully cleared; 39% had total remission; 61% needed additional interventions in the form of percutaneous transhepatic cholangiography and dilation (17%), re-PTCSL (11%), self-expandable metallic stents (22%), or hepaticojejunostomy (6%); and 22% eventually underwent retransplantation. The overall liver graft survival rate was 78%. Two patients died during follow-up for reasons not related to their BDS. Nonanastomotic strictures (NASs) were significantly associated with treatment failure. We conclude that PTCSL in LT patients is safe and feasible. NASs significantly increased the risk of relapse. Repeated minimally invasive treatments, however, prevented graft failure in 78% of the cases.