Role of ERCP in Evaluation of Post-stem Cell Transplantation Patients with Hepatobiliary Disease

Abstract

Purpose: Patients with hematopoietic stem cell transplantation (HSCT) may develop hepatobiliary disease. The role of ERCP in evaluating this group of patients is being defined. The aim was to review our experience with ERCP in HSCT patients. Methods: All patients who had ERCP following HSCT from 2002-2009 were identified. Clinical data were extracted from the electronic medical record. Results: During the study period 8,010 HSCTs were performed (53% allogeneic). Thirty patients (13 male) who had 37 ERCPs were identified. Average age was 50 years and 24 patients were white. There were 19 allogeneic HSCT. Indications for HSCT were: lymphoma (9), acute leukemia (9), breast cancer (3), MDS (2), CLL (2), ovarian cancer (2) and other malignancies (3). Nine patients had biopsy proven graft-versus-host disease (GVHD), 7 with GI tract involvement. Mean and time to ERCP was 640 (S.D. 808) days post transplant with a range of 20 to 3805 days. Indications for initial ERCP were: obstructive jaundice (12), suspected choledocholithiasis (CBD stones) (11), dilated bile ducts (3), stent removal/revision (3), and bile leak (1). Findings on ERCP were: stricture (14), CBD stones (10), resolved stricture/normal (3), leak (1), sludge (1), and dilated duct without stricture or stone (1). The stricture group had 10 females and the mean age was 50.6 (SD 13.2) years. Eight patients had autologous and 6 had allogeneic HSCT with two having GI GHVD. ERCP occurred at a mean of 1088 days after HSCT (SD 980). Etiologies of the strictures were: recurrent malignancy (11), pancreatic cancer (1), gallbladder compressing bile duct (1) and unclear etiology (1). This latter patient had mild duodenal GVHD, negative biliary brushings and sludge on EUS. The stent was removed after 2 wks and 4 wks later CT scan showed resolution of ductal dilation. None of the stricture patients with recurrent disease had GI GVHD. The CBD stone group had a mean age of 45.9 (SD 9.0) years and 6 were female. All patients had allogeneic HSCT and two had GI GVHD. ERCP occurred at a mean of 362 days after HSCT (SD 310). Overall there were 20 deaths, 16 from recurrent disease. Other deaths were from pneumonia (2), pancreatic cancer (1), and GVHD induced liver failure (1). All 14 patients with strictures died in a mean time of 139 days after ERCP. Three of 10 with CBD stones died at a mean of 164 days post ERCP. The seven survivors in the stone group have been followed a mean of 951 days without recurrence of biliary disease. Conclusion: ERCP is uncommonly performed in the post HSCT patient. The most common indication is obstructive jaundice from either recurrent disease or CBD stones. Inflammatory strictures possibly related to GHVD are rare in our experience.