A Clinical Algorithm to Guide the Need for ERCP for Evaluation of Early Post Liver Transplant Cholestasis.

Abstract

Introduction: Severe cholestasis after liver transplant can be due to delayed graft dysfunction, reperfusion injury or biliary complications. ERCP in the immediate post-transplant period has significant risks and limitations. Our aim was to develop a criteria using a combination of HIDA and clinical information to further guide biliary intervention in these patients. Methods: Among 806 liver transplants, 62 patients required further evaluation of biliary complications within 30 days of transplant by HIDA scan. 57 patients (5 excluded as they had bile leak), were included in the study. Serum total bilirubin levels within 48 hours of ERCP were used to determine the success of ERCP intervention. If there was a > 50% reduction in bilirubin levels within 48 hours of ERCP intervention, biliary duct obstruction was established and ERCP was considered successful. Results: 25 patients had normal HIDA, 32 patients had delayed uptake suggesting hepatocellular dysfunction. Among the 25 patients with normal HIDA, 12 had ERCP, 6 required stent. Among the 6 patients with stent only 2 had >50% decrease in serum bilirubin within 48 hours (true biliary duct obstruction =8%). Out of 32 patients with delayed uptake on HIDA scan, 22 had ERCP, and 14 required stents. 4 patients had >50% decrease in bilirubin within 48 hours ( true biliary obstruction =12.5%). 3 patients had >50% decrease in bilirubin 48 hours after ERCP even when no stent was placed. Hence, among the 57 patients with severe hyperbilirubinemia in the immediate post-operative period, only 11% had large duct obstruction as the etiology of the hyperbilirubinemia. More importantly, of the 34 ERCPs performed only 17% had biliary obstruction. The peak AST among patients with biliary obstruction was lower at 1005±364 IU/L (vs. 2522±3177 IU/L p value 0.035) and the peak bilirubin among patients with biliary obstruction was 24±11mg/ (vs. 18±10 mg/dl p value 0.02). On multivariate analysis, we found that patients having both AST < 1500 IU/L, a bilirubin >15 mg/dl have an odds ratio of 25.1 (p value 0.002, 95% CI 6-37) in predicting biliary obstruction and benefiting from ERCP. Conclusion: Normal HIDA scan along with combination of peak AST and peak bilirubin levels offer a valuable tool in identifying patients who will NOT benefit from ERCP. By using these parameters large number of ERCPs could be avoided in the immediate post-transplant period.