Biliary Cast Syndrome Research Articles

A novel combination regimen for the treatment of refractory bacteremia due to multidrug-resistant Pseudomonas aeruginosa in a liver transplant recipient

Both bacteremia and biliary cast syndrome are serious post-transplant complications in liver transplant recipients. In the setting of increasing drug resistance in the current era, management of infections caused by multidrug-resistant (MDR) bacteria has proven challenging. We present a case of a liver transplant recipient who developed biliary cast syndrome and intractable MDR Pseudomonas bacteremia that failed to resolve with conventional antimicrobial therapy and which was finally controlled by a novel combination regimen of colistimethate, doripenem, and tobramycin. Future studies validating the clinical efficacy of this combination strategy are warranted.

Biliary cast syndrome and benign biliary stricture as complications of allogeneic hematopoietic stem cell transplantation

Biliary cast syndrome and benign biliary stricture as complications of allogeneic hematopoietic stem cell transplantation

Biliary cast syndrome in sclerosing cholangitis

Biliary cast syndrome in sclerosing cholangitis

Imaging findings of biliary cast syndrome in a non-transplant patient

患者女,60岁,受凉后畏寒、发热伴咳嗽、咳白痰3 d于2009年2月14日入院.1个月前曾患急性胰腺炎,既往有糖尿病、肾功能不全、胆囊及胆管结石、胆囊炎、胆管炎病史.体检:体温40℃,皮肤巩膜中度黄染,腹肌紧张,无压痛及反跳痛.实验室检查提示肝功能异常、梗阻性黄疸,血淀粉酶正常。

Successful endoscopic treatment of biliary cast syndrome in an orthotopic liver transplant patient with a Roux-en-Y anastomosis via balloon enteroscopy

The endoscopic treatment of biliary cast syndrome after liver transplantation (LT) has been described; it has been performed only in patients with a duct-to-duct anastomosis. We describe the successful endoscopic removal of a biliary cast via balloon enteroscopy–guided endoscopic retrograde cholangiopancreatography in an orthotopic liver transplantation (OLT) patient with Roux-en-Y reconstruction. A 51-year-old man had undergone OLT 1 month previously for primary sclerosing cholangitis and cholangiocarcinoma. He was clinically well post-transplantation but was noted to have a progressive rise in his alkaline phosphatase level up to 984 U/L. Abdominal ultrasound showed prominent bile ducts in the left lobe. The endoscopic evaluation was undertaken to evaluate him for suspected stenosis of the biliary enteric anastomosis. LT, liver transplantation; OLT, orthotopic liver transplantation. In the endoscopy suite, with the patient supine and under monitored anesthesia care, a single balloon enteroscope (SIFQ180, Olympus Corp., Center Valley, PA) was passed into the enteroenterostomy and eventually up the afferent limb (Fig. 1). The choledochojejunostomy was identified as a pinpoint opening. An angled 0.035-inch hydrophilic wire, preloaded into a long-length stone retrieval balloon, was used to cannulate the biliary tree. Scout radiograph demonstrating the configuration of the balloon enteroscope when it reached the choledochojejunal anastomosis. A cholangiogram revealed a filling defect in both the right and left intrahepatic systems extending down to the level of the choledochojejunostomy, and it was consistent with a biliary cast (Fig. 2). The choledochojejunostomy was balloon-dilated to 8 mm. A stone retrieval balloon was passed into the peripheral right and left intrahepatic ducts, inflated, and withdrawn distally with removal of the cast (Figs. 3 and 4). A follow-up cholangiogram revealed no residual filling defects, and the biliary tree was without obvious ischemic changes (Fig. 5). The patient tolerated the procedure well without complications. Two and 5 months later, the patient underwent additional endoscopic procedures for cholangitis because of the subsequent development of ischemic strictures. Balloon dilation was performed during both sessions without the need for stent placement. Over the last 10 months after the initial removal of the cast, the patient has remained asymptomatic. Cholangiogram demonstrating intrahepatic and extrahepatic filling defects. Endoscopic image taken during the withdrawal of the cast from the bile duct into the jejunal lumen. Biliary cast after its removal from the patient. Follow-up cholangiogram after cast removal. No filling defects can be seen, and the biliary tree appears normal. To our knowledge, this is the first case of successful endoscopic treatment of biliary cast syndrome in an LT patient with a Roux-en-Y biliary anastomosis. In patients with a duct-to-duct anastomosis, endoscopic access to the biliary tree is straightforward, and biliary cast syndrome has been successfully managed endoscopically in such patients.1, 2 The failure of endoscopic treatment may necessitate percutaneous or surgical revision of the anastomosis and possibly retransplantation.1, 2 The endoscopic management of post-LT biliary disorders in patients with a biliary enteric anastomosis is technically difficult because reaching the anastomosis requires negotiating the relatively long-length Roux-en-Y anastomosis. Chahal et al.3 described successful endoscopic management of a variety of biliary disorders in transplant patients with Roux-en-Y anatomy. This study was published prior to the utilization of balloon enteroscopes. Since that time, a number of authors have described successful biliary interventions using balloon enteroscopy in patients with postsurgical anatomy.4-6 However, none of these cases have been performed for the treatment of cast syndrome. In conclusion, successful endoscopic biliary interventions in LT patients with a Roux-en-Y anastomosis are increasingly feasible, especially with the use of balloon endoscopes.

Fatal case of biliary cast syndrome in nontransplant patient

Fatal case of biliary cast syndrome in nontransplant patient

Clinical significance of HLA antibody detection in patients with biliary cast syndrome after liver transplantation

Objective To investigate the association of situation of HLA antibody with biliary cast syndrorne(BCS)in patients after liver transplantation and explore the role of HLA antibody in predicting BCS caused by immunization.Methods A total of 416 serum samples were collected at 8 time phases before and after liver transplantation from 52 patients.The 52 patients were divided into the BCS group(n=32)and NBCS group(n=20).The HLA-Ⅰ and HLA-Ⅱ antibodies in the serum samples were detected with ELISA.Meanwhile,ALT,AST,ALP,GGT,TB and DB were determined,Results The positive rate of HLA was significantly higher in the BCS group than in NBCS group (P<0.05).The recovery time of biliary complications were negatively correlated to the appearance time of HLA-Ⅱ antibody.Conclusion HLA-Ⅱ antibody can be dynamically monitored to help predict the biliary complications in liver transplantation recipients. Key words: Liver transplantation; HLA antibody; Biliary cast syndrome(BCS)

High levels of soluble Major Histocompatibility Complex class I related chain A (MICA) are associated with biliary cast syndrome after liver transplantation

Background The biliary cast syndrome (BCS) is a frequent problem following liver transplantation. The pathogenesis of this complication is not well understood. Previous research has demonstrated that the soluble form of MICA (sMICA) is significantly higher in patients with chronic liver disease and hepatocellular carcinoma (HCC) than in healthy volunteers. The aim of this study is to investigate the possible involvement of sMICA in the formation of BCS after liver transplantation. Methods Serum soluble MICA was retrospectively evaluated in pre- and post-transplant sera from 133 consecutive primary liver transplant patients and in sera from 88 healthy volunteers using sandwich ELISA. Normal distribution of serum sMICA was described by the data obtained from healthy population and sMICA concentration that was greater than the upper bound 95% normal range was considered as high levels of sMICA. Patient records were reviewed to identify patients who developed BCS. Results The results demonstrated that 37.6% of patients with end-stage liver diseases had significantly higher pre-transplant serum sMICA than in healthy population. 34.4% of recipients with post-transplant high levels of sMICA developed BCS. In contrast, 17.3% of patients with post-transplant normal levels of sMICA developed BCS. The risk of BCS development is significantly associated with the presence of post-transplant high levels of sMICA ( P = 0.0365). Further analysis disclosed that patients with decreased post-transplant sMICA following liver transplantation had a lower incidence rate of BCS than those with remained high levels of sMICA after transplantation (10.5% vs. 38.7%, P = 0.0302). Furthermore, log-rank test showed that BCS occurrence was significantly associated with dynamic changes of sMICA among different groups ( P = 0.0188). Conclusions Biliary cast syndrome is more likely to develop in recipients who have post-transplant high levels of sMICA. The data suggested that sMICA might have some immunologic effect on BCS development following liver transplant. Monitoring of serum sMICA could have a prognostic value in assessment of patients with liver transplantation.

Biliary cast syndrome following liver transplantation: Predictive factors and clinical outcomes

Biliary cast syndrome (BCS), the presence of biliary casts and debris causing biliary obstruction, occurs in 4%-18% of orthotopic liver transplant (OLT) recipients. Potential consequences include cholangitis and graft damage or loss. Limited data exist regarding the etiology and outcomes of BCS. The purpose of this study was to evaluate donor and recipient risk factors and determine the impact of BCS. A retrospective review of 355 OLT cases identified 9 BCS patients (2.5%) diagnosed by cholangiography. Twenty-six matched controls were also identified. The warm ischemic time was significantly longer in BCS patients. Other recipient and donor preoperative and intraoperative characteristics, including the donor risk index, revealed no significant differences. Overall patient survival showed a trend toward worse outcomes at 6, 12, and 18 months and end of follow-up in the BCS group. Overall graft survival was also worse in the BCS group at all time periods, with statistical significance demonstrated at 18 months and end of follow-up. The number of therapeutic biliary procedures and hospital readmissions was significantly higher in the BCS group. Twenty-two percent of the BCS patients required repeat OLT versus none of the control patients. In conclusion, BCS is an uncommon complication of OLT. Except for a longer warm ischemic time, recipient and donor factors did not predict the occurrence of BCS. BCS patients showed a significantly worse graft survival, as well as a trend toward worse patient survival. Given the negative impact of BCS on liver transplant outcomes, further studies appear justified.

Successful Diagnosis and Management of Biliary Cast Syndrome in a Liver Transplant Patient Using Single Operator Cholangioscopy

Purpose: Biliary cast syndrome is an unusual complication of orthotopic liver transplantation (OLT) with serious clinical implications. Biliary cast formation is usually associated with biliary strictures and/or hepatic ischemia. Surgical management is the mainstay of treatment. Endoscopic techniques have been recently described in the successful removal of biliary casts. We report a post OLT patient who underwent successful endoscopic removal of biliary cast using single operator cholangioscopy. Our patient is a 68 year-old male with history of OLT seven months before for hepatitis C induced cirrhosis who came for a follow up visit. He had no complaints and physical exam was normal. He had cholestatic liver enzyme elevation (Alkaline phosphatase 580 IU/L, Total bilirubin 2.3 mg/dl) with normal aminotransferases. Hepatitis C RNA was undetectable. Ultrasound demonstrated normal common bile duct (CBD) diameter with normal Doppler flow. Liver biopsy showed no rejection with suggestion of cholestasis. Endoscopic retrograde cholangiopancreatoscopy (ERCP) was performed and cholangiogram showed multiple linear filling defects in the common hepatic duct (CHD) proximal to the anastomosis with extension into the intrahepatic system. After failure of the balloon to remove the filling defect, a single-operator choledochoscope was passed into the CHD for diagnostic and possible therapeutic purposes. A dark brown tubular structure was seen resembling a cast of the bile duct. Using a basket, the distal aspect of the cast was secured and a 6 cm long cast was successfully removed in a single piece. (Image) Cholangiogram showed improvement with excellent biliary drainage both fluoroscopically and endoscopically. Liver function tests have subsequently normalized and the patient remains normal with a follow period of 10 months without recurrence. In conclusion, Biliary cast syndrome is a rare complication of OLT which should be thought of when patients present with cholestatic liver enzyme elevation usually within the first year of transplant. Single operator cholangioscopy provides a safe means of diagnosing and treating patients with Biliary cast syndrome particularly in cases with intrahepatic duct casts where surgery or percutaneous techniques are often required. Methods: N/A Results: N/A Conclusion: N/A

Successful Endoscopic Management of Biliary Cast Syndrome in Nonliver Transplant Patients

Biliary cast syndrome is an uncommon condition, almost always associated with liver transplantation. We describe 2 patients with biliary cast syndrome in a nonliver transplant setting. The casts were managed endoscopically.

Clinical manifestation and patho-typing of biliary cast syndrome in patients after orthotopic liver transplantation

To summarize the Patho-typing and the clinical manifestation of biliary cast syndrome (BCS) in patients after orthotopic liver transplantation. The clinical manifestation, findings,therapeutic means and efficacy of 103 patients with biliary cast syndrome after orthotopic liver transplantation were retrospectively analyzed. According to the injury level of biliary duct epithelium, patients were divided into different groups. All cases were followed up for twelve months. The place, degree and time after operation would be recorded when non-anastomotic biliary stricture was found. There were 59 BCS cases in the general hospital of armed police force of China. The incidence rate of BCS was 9.1%. Many BCS patients showed symptoms such as jaundice, deep urine color, gray stools, itch of skin and fever. Some were asymptomatic. In laboratory test, the liver functional enzyme in serum were increased, the total white cell count in peripheral blood was increased either. Cholangiography via T tube of biliary tract might show filling defect. According to the change degree of the biliary tract tree, there were four types filling defect concluded from all the presentation in BCS patients. Solid obturation of biliary tract were found by the check with optical fiber choledochoscope in all BCS patients, necrosis of biliary tract epithelium were observed in partial BCS patients. According to the injury level of biliary duct epithelium (gradually aggravated), BCS patients were divided into six groups (type I, type II, type III, type IV, type V and type VI). Fourteen cases were found in type I and 18 in type II. No clinical symptom was found in these two groups, a few indicators in serum (alanine aminotransferase ALT, total bilirubin TBIL, direct bilirubin DBIL) were in normal range, and others (gamma-glutamyl transferase GGT, alkaline phosphatase ALP) were heightened in 5 patients. There was no biliary cast (BC) found anymore in the period of follow-up in two groups. No stricture was found in both group. Twenty-seven cases in type III and 23 cases in type IV, it was found there were about 33.4% patients accompanied with fever and 25.9% accompanied with jaundice in type III. Paralleled,there were about 30.4% and 34.8% patients in type IV. The liver functional enzyme in serum were found increased in both type. After supporting treatment for 3-6 months,there were 5 and 3 patients present as mild non-anastomotic biliary stricture in type III and type IV group. In the group type V, there were 13 patients. The detected liver functional indicators in serum were increased. After supporting treatment for 6-12 months,there were 4 patients present as moderate non-anastomotic biliary stricture in this group. There were 18 patients in type VI group, all indicators of the liver functional enzyme in serum before the treatment were elevated conspicuously. All patients in this group were found serious stricture up to three places that have not been sustained in the period of follow-up. Nine died of MOSF, 1 died of AOSC, 8 had undergone retransplantation. In the retransplantation patients, 4 died of post operation MOSF, 3 recovered to normal, 1 patient was found BCS once more 15 d after the retransplantation and the third-transplantation was performed 7 months after the second transplantation, no BCS was found again. The deaths total rate was 13.6%, death rate of retransplantation was 44.0%, total cure rate was 54.0%, total improvement rate was 71.0% and total stenosis rate was 29.0%. (1) According to the check with optical fiber choledochoscope, there are 6 types of patho-typing in BCS patients. The clinical manifestation includes jaundice and fever. The filling defect of the biliary tract tree might showed 4 appearances. (2)The patho-typing contributes to the clinical manifestation and the filling defect of the biliary tract tree.

Heterogeneity of endoscopy negative heartburn: Epidemiology and natural history

A 76-year-old diabetic man underwent cholecystectomy for gangrenous calculous cholecystitis. His postoperative course was complicated by the development of Candida albicans esophagitis necessitating antifungal therapy, and total parenteral nutrition (TPN) for 15 d. Seven weeks after cholecystectomy, he presented with cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated extrahepatic filling defects. Despite endoscopic extraction of a biliary cast, cholestasis remained unchanged. Oral administration of ursodeoxycholic acid (UDCA), 750 mg/d, resulted in normalization of liver function tests. We, therefore, propose for the first time, combined endoscopic plus UDCA treatment for the management of biliary cast syndrome.

Experience in treatment of biliary cast syndrome in 103 patients after liver transplantation

目的 总结治疗肝移植术后胆道铸型综合征(ECS)的经验.方法 回顾性分析103例肝移植术后BCS病人的治疗方法及转归.术后＜3个月病人出现较重梗阻症状或合并有胆道感染时,以PTBD外引流管置换T型管.术后≥3个月病人,行纤维胆道镜治疗.BC取出后,对有吻合口以上胆道上皮坏死者,以支撑管支撑3～6个月.病人按照病变程度分成单纯BC组、中度坏死(累及肝门部及以下胆道上皮)BC组、重度坏死(累及肝内外各级胆管)BC组,统计各组在治疗前后1周的肝功酶指标(GPT、GGT、ALP、TB、DB),用SPSS11.5软件行统计学分析.结果 经过治疗后,单纯BC组32例,在随访过程中,未发现再有BC出现,各项肝功酶均在正常范围.中度坏死BC组53例,经支撑管支撑3～6个月后,治疗前后各项肝功指标有显著性差异(P＜0.05).重度坏死BC组18例,9例因经济原因未能再次移植死于多脏器衰竭,1例死于急性梗阻性化脓性胆管炎.8例接受了再次肝移植.其中4例围手术期死于多脏器衰竭,3例行再次肝移植后恢复正常未再有BCS存在,1例出现再次肝移植后BCS,行三次肝移植未再发现BCS存在.结论 BCS大多可通过纤维胆道镜取BC和后续的支撑管支撑治疗而解除梗阻症状,明显改善BCS病人的生活质量,降低BCS的再次移植率.BC合并肝内外胆管弥漫坏死者应尽早再次移植。

Hepatobiliary and pancreatic: Biliary cast syndrome

Hepatobiliary and pancreatic: Biliary cast syndrome

Biliary complications in liver transplant recipients

Despite numerous advancements in the management of patients who have undergone cadaveric liver transplantation, biliary complications continue to challenge clinicians. Biliary leaks in the early postoperative period and strictures in the late postoperative period represent the two major posttransplant biliary complications. Intrahepatic and hilar strictures are particularly difficult to manage and frequently require retransplantation, which should not be delayed. Choledocholithiasis and the biliary cast syndrome are frequently associated with underlying biliary strictures, and endoscopic attempts at removal should precede surgical interventions. Sphincter of Oddi dysfunction is increasingly recognized despite unclear pathophysiology. Hemobilia is most commonly iatrogenic and requires a high suspicion and prompt intervention. Although the number of diagnostic and therapeutic options have increased, there is no consensus as to which is superior. In recent years there has been a trend toward nonsurgical interventions, in particular endoscopic approaches.

Resurgence of biliary cast syndrome

Resurgence of biliary cast syndrome

Biliary cast syndrome: Successful endoscopic treatment

Biliary cast syndrome: Successful endoscopic treatment