A Unique Case of Biliary Necrosis and Arterial Complications Following Two Orthotopic Liver Transplants

Document Type

Conference Proceeding

Publication Date

10-25-2023

Publication Title

Am J Gastroenterol

Abstract

Introduction: We present a rare case of hepatic artery thrombosis leading to biliary necrosis complicating two different orthotopic liver transplants (OLT) in a single patient. Case Description/Methods: A 69-year-old man with a history of 2 separate OLTs presents with decompensation. He underwent initial liver transplantation with Roux-en-Y hepaticojejunostomy 25 years ago due to hepatitis C, cirrhosis, and hepatocellular carcinoma. Two years later, after complications in the biliary system, a second liver transplant was performed. Approximately 24 years later, an endoscopic retrograde cholangiopancreatography was performed, and the patient was diagnosed with choledocholithiasis. He was admitted to the hospital 5 months ago due to weakness and fever from sepsis. Blood culture revealed bacteremia and fungemia, including Klebsiella, Enterobacter, and Candida, which progressed for months. A CT of the liver demonstrated that the hepatic artery graft was almost entirely occluded, except for the proximal short segment portion. The CT showed diffuse branching hypoattenuating structures that followed the bile ducts. When compared to other CT scans taken a few weeks prior, these structures continuously increased, reflecting worsening biliary necrosis. A percutaneous biliary drain was placed by Interventional Radiology to relieve symptoms from cholangitis. A few weeks later, an MRI of the liver demonstrated decreased vascularity in the inferior right hepatic lobe at segment 6. No evidence of steatosis was found. The MRI also showed branching heterogenous hyperintense T2 signals along the portal triad, showing further signs of extensive peribiliary necrosis. Three months ago, the patient underwent a procedure to add a second internal/external biliary drain. A month later, the patient was re-admitted to the hospital due to fever and decreased output from one of the drains. Subsequently, he underwent a bilateral biliary tube replacement. He was evaluated for a possible third OLT, but due to infections and debility, he was not listed. After overwhelming complications and infections, the patient passed away. Discussion: Hepatic artery thrombosis is a rare complication of OLTs. If chronic occlusion occurs, a serious possible result that can occur is biliary necrosis. This is responsible for approximately 50% of the mortality from hepatic artery thrombosis. Studying how this complication manifests is crucial to finding treatments that will ultimately reduce mortality.

Volume

118

Issue

10

First Page

S2270

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