Biliary necrosis (liver transplant)

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

This patient has had four orthotopic liver transplants (OLT) for fulminant hepatitis A. The last OLT was two years ago. She also had a renal transplant twelve months ago. She presented with abdominal pain and vomiting. Liver enzymes were abnormally high.

Patient Data

Age: 30 years
Gender: Female

PFA in the emergency department

Modality: X-ray

There is an ill-defiend lucency projected over the liver. The appearances are not typical for either pneumobilia or portal venous gas. There is no evicence of Chilaiditi syndrome.

Relevant liver transplant anatomy in this case: 

  • Graft hepatic arteries are of conventional anatomy, and anastomosed to an aortic conduit
  • Hepaticojejunostomy

Ultrasound ("Ducts and Dopplers")

Modality: Ultrasound

as a screening test

Definite but faint Doppler signal is detected in the extrahepatic artery. No Doppler signal is detected in the intrahepatic arteries. The portal and hepatic veins are patent. There is pneumobilia - a common finding after hepaticojejunostomy. In addition, in the right lobe of the liver, there is a rounded area of dirty acoustic shadowing as seen due to gas, but not typical for pneumobilia.

CT liver

Modality: CT

Performed a a result of abnormal intrahepatic arteries, and the unusual gas in the right lobe at ultrasound.

Overall findings are in keeping with biliary necrosis and abscess formation, secondary to hepatic artery compromise due to anastomotic stenosis and subsequent occlusion of the aortic conduit.

CT liver 2 years earlier (for comparison of the aortic conduit)

Modality: CT

(on the same graft)

2 years earlier, the aortic conduit was widely patent, and there was good intrahepatic arterial contrast opacification. The liver parenchyma appeared normal on art. phase. There was pneumobilia, as expected after hepaticojejunostomy.

Note that an aortic conduit (from a prior transplant), located inferior to the current one, is thrombosed.

Case Discussion

While the liver parenchyma has a dual blood supply from portal vein and hepatic artery, the biliary tree is exclusively supplied arterially. In addition, biliary epithelium is more prone to ischaemia compared to hepatocytes.

In this case, due to thrombosis of the aortic conduit, hepatic arterial supply was shut off, bare some minor collateral arteries via the GDA. Biliary avascular necrosis with abscess formation occurred.

The management of this patient consists of:

  1. Placement on the urgent liver transplant list
  2. Radiological catheter drainage of the right lobe of liver collection

Related articles: Hepatic artery resistive index, Liver abscess

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Case Information

rID: 21876
Case created: 23rd Feb 2013
Last edited: 4th Jul 2016
Inclusion in quiz mode: Included

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