2196 A Case of Successful Endoscopic Management of Choledocholithiasis Complicated by Post-Transplant Biliary Stricture

Abstract

INTRODUCTION: Post Liver transplant (LT) biliary stones, sludge and casts are a challenge to both advanced endoscopists and patients in the setting of complex anatomy, variable pathologies and multiple co-morbidities. The incidence rate of biliary stones is widely variable from 3.8%-18% and are associated with biliary strictures in roughly 90% of cases, increasing the complexity of the procedure. Here we are presenting a case of elevated liver enzymes and normal bilirubin in a LT patient with a history of post-LT biliary stricture. CASE DESCRIPTION/METHODS: 70 year old male with past medical history of fulminant hepatic failure status post orthotopic LT complicated by biliary anastomotic stricture, presented for management of new onset elevated liver enzymes ten years post LT. At the time of presentation he denied any complains of abdominal pain, nausea, vomiting, fevers, or chills. He denied any new medications or herbal supplements. Afebrile and hemodynamically stable at presentation. Labs showed WBC- 6.3, AST-202, ALT-133, GGT-1368, ALP-439 Total Bilirubin – 0.8 (Normal), INR-1.06 and Tacrolimus level -2.4. Liver biopsy showed bile ductular reaction and sparse to mild portal inflammation with minor ductulitis and endothelialitis. Abdomen ultrasound showed common bile duct with biliary ductal dilatation which may represent stones or sludge. Patient underwent ERCP revealing a large 3 × 2 cm stone in the common hepatic duct proximal to the anastomotic stenosis with marked upstream biliary dilation. The stone was partially crushed with electrohydraulic lithotripsy (EHL) via Spyglass cholangioscopy. The stone fragments were removed using an extraction balloon. Two 10 Fr x 12 cm long angled plastic stents were placed in the right and left biliary systems. A repeat ERCP was performed 8 weeks later and EHL under spyglass was performed. The ducts were subsequently cleared and stenosis resolved. DISCUSSION: Biliary stones and sludge can occur at any time after LT, with a reported incidence of 5%–10%. Our patient presented 10 years post-LT with transaminitis and normal bilirubin. Yu et al reported biliary strictures and cold ischemia time were significantly associated with bile duct stone formation after liver transplantation in a case-control study. Hence we conclude that in following patients post LT who are on immunosuppressants, the physician needs to be vigilant as patients can have a late presentation which can lead to graft loss and increased morbidity and mortality.