Biliary necrosis - liver transplant

Case contributed by Jan Frank Gerstenmaier


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


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")


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


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

Arterial phase: the aortic conduit is occluded approximately 2cm from its origin. There is very little, if any contrast opacification of the intrahepatic arteries. (There may be some collateralisation via the GDA). There is pneumobilia and a gas-containing collection in the right lobe of the liver.

Portal venous phase: There is heterogeneous enhancement of the graft with peripheral wedge-shaped low attenuation adjacent to the gas-containing collection in the right lobe. This collection is connected to the biliary tree via the right posterior sectoral duct which is abnormally dilated and contains the same material as the collection. The portal vein is patent. There is periportal edema. Bilateral atrophic kidneys with cysts - a sign of chronic renal failure - and a partially imaged unremarkable renal graft in the right iliac fossa are incidentally noted.

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)


(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 the portal vein and hepatic artery, the biliary tree is exclusively supplied arterially. Also, the biliary epithelium is more prone to ischemia 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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