Biliary Cast Research Articles

S3189 Cholangioscopic Balloon Dilation and Lithotripsy-Assisted Snare Extraction of a Large Biliary Cast After Liver Transplantation

S3189 Cholangioscopic Balloon Dilation and Lithotripsy-Assisted Snare Extraction of a Large Biliary Cast After Liver Transplantation

S2421 Duct and Cover: A Case of Post-COVID-19 Cholangiopathy Requiring Biliary Cast Removal

S2421 Duct and Cover: A Case of Post-COVID-19 Cholangiopathy Requiring Biliary Cast Removal

Biodegradable internal biliary stenting in orthotopic liver transplantation – A feasibility study

IntroductionBiliary complications remain a common cause of morbidity after liver transplantation and often require invasive interventions to manage. We aimed to assess the technical feasibility and safety of placement of a biodegradable stent across the biliary anastomosis at the time of liver transplantation in patients having a duct to duct biliary reconstruction. MethodsFor this prospective, single-arm, descriptive study, 10 consecutive patients undergoing whole graft, deceased donor, liver transplantation and duct-to-duct biliary tract reconstruction were enrolled and a biodegradable biliary stent was sutured into the bile duct across the anastomosis. ResultsIn all 10 patients it was technically feasible to place and secure the stent safely during the operation. After >6 months (median of 212 days) follow up, no patients had developed biliary anastomotic stricture. One patient had transient bile leak immediately post-operative that was managed conservatively. One patient required endoscopic intervention for non-anastomotic stricture development and biliary cast material that had resulted in stent dysfunction. DiscussionThe results of this study suggest surgical feasibility of placement of an absorbable biliary stent across the biliary anastomosis at the time of liver transplantation, as well as an acceptable safety profile. Further studies are required to confirm these safety and feasibility findings and to assess efficacy in reducing rates of biliary complications and the need for endoscopic intervention in the early post-transplant period.

Biliary cast syndrome in Roux-en-Y hepaticojejunostomy anatomy

Biliary cast syndrome in Roux-en-Y hepaticojejunostomy anatomy

Expression of concern: “High levels of soluble Major Histocompatibility Complex class I related chain A (MICA) are associated with biliary cast syndrome after liver transplantation” [Transplant Immunology 2009, volume 21, pages 210–214]

Expression of concern: “High levels of soluble Major Histocompatibility Complex class I related chain A (MICA) are associated with biliary cast syndrome after liver transplantation” [Transplant Immunology 2009, volume 21, pages 210–214]

Biliary Complications After Liver Transplantation

Liver transplantation continues to be an optimal treatment choice for end-stage liver disease, acute liver failure, and primary liver cancer. An understanding and anticipation of potential complications of liver transplantation is integral to the medical and interventional management of these postoperative patients. Complications related to the biliary system are the most common posttransplant complications. Potential complications include biliary strictures, leakage, intraductal stone/sludge, and biliary cast syndrome. Multiple diagnostic imaging modalities are available including ultrasound, CT angiography, and hepatobiliary iminodiacetic acid scanning for evaluation of the biliary system and associated complications. The approach of interventional access to the biliary system after surgery is tailored based on surgical transplantation techniques. Endoscopic retrograde cholangiopancreatography remains the imaging modality of choice for evaluation and potential therapeutic intervention. If the biliary tree is not accessible by endoscopy due to postsurgical anatomy changes, interventional radiology may play a vital role in complication management and can provide percutaneous transhepatic cholangiography as a less invasive alternative to surgical intervention.

Biliary cast syndrome developed after treatment for acute cholangitis: progression to secondary sclerosing cholangitis

Biliary cast syndrome developed after treatment for acute cholangitis: progression to secondary sclerosing cholangitis

COVID-Associated Cast-Forming Cholangiopathy: A Commentary on Disease Mechanism, Treatment, and Prognosis.

The complete impact of COVID-19 infection continues to develop since the onset of the COVID-19 pandemic. COVID-19 cholangiopathy has been recently described in a subset of patients who recovered from severe COVID-19 infection. The most common phenotype of patients suffering from COVID-19 cholangiopathy had severe infection requiring a stay in the intensive care unit, mechanical ventilation and vasopressor medications. Patients with COVID-cholangiopathy present with severe and prolonged cholestatic liver injury. In cases where biliary cast formation is identified, we defined the entity as "COVID-19 cast-forming cholangiopathy". This subset of COVID-19 cholangiopathy is not well understood and there are no standardized diagnosis or management to this date. The reported clinical outcomes are variable, from resolution of symptoms and liver test abnormalities to liver transplant and death. In this commentary, we discuss the proposed pathophysiology, diagnosis, management, and prognosis of this disease.

Endoscopic Removal and Typical Presentation of Biliary Cast Formation

Endoscopic Removal and Typical Presentation of Biliary Cast Formation

S1870 A Case of Biliary Cast Syndrome After Liver Transplantation

S1870 A Case of Biliary Cast Syndrome After Liver Transplantation

S1704 Casting a Wider Net: Rare Presentation of Biliary Cast Syndrome in a Non-Liver Transplant Patient

S1704 Casting a Wider Net: Rare Presentation of Biliary Cast Syndrome in a Non-Liver Transplant Patient

Multimodality Imaging after Liver Transplant: Top 10 Important Complications.

Patients who have undergone liver transplant are now regularly seen in day-to-day radiology practice. All surgical techniques for liver transplant require arterial, portal venous, hepatic venous and caval, and biliary anastomoses. This review is focused on the 10 "not to be missed" complications of liver transplant that affect the health and life of the graft and graft recipient. Arterial complications are the most common and devastating. Early hepatic artery thrombosis may be catastrophic because the biliary tree is solely dependent on the hepatic artery after transplant and collateral vessels have not yet formed. In contrast, delayed hepatic artery thrombosis may be more insidious as collateral arteries develop. US findings of delayed hepatic artery thrombosis may be similar to those of hepatic artery stenosis and celiac artery stenosis. Splenic artery steal syndrome is an increasingly recognized cause of graft ischemia. Venous complications are much less common. Hepatic venous and caval complications are notable for their increased incidence in living-donor and pediatric transplants. Biliary complications often result from arterial ischemia. Biliary cast syndrome is a notable example in which ischemic biliary mucosa sloughs into and obstructs the duct lumens. Neoplasms also may occur within the hepatic graft and may be due to recurrent malignancy, posttransplant lymphoproliferative disorder, or metastases. US is the initial imaging modality of choice, particularly in the acute postoperative setting. Further evaluation with contrast-enhanced US, CT, or MRI; catheter angiography; endoscopic retrograde cholangiopancreatography; and/or nuclear medicine studies is performed as needed. An invited commentary by Bhargava is available online. Online supplemental material is available for this article. ©RSNA, 2022.

An Unusual Case of COVID-19: What Is This 3D Printed Model of the Biliary Tree?

An Unusual Case of COVID-19: What Is This 3D Printed Model of the Biliary Tree?

Critical Illness Cholangiopathy in COVID-19 Long-haulers

Critical Illness Cholangiopathy in COVID-19 Long-haulers

S1464 COVID Bile Duct: Biliary Cast Syndrome as a Complication of SARS-CoV-2 Infection

Introduction: The hypothesis involving the pathophysiology of liver damage in COVID-19 infected patients involves the binding of the virus to angiotensin converting enzyme 2 (ACE2) receptors which are found in hepatocytes and hepatic cholangiocytes and increase in interleukin-6 (IL-6) levels resulting in cholestasis. We present a case of cholestatic hepatitis as a result of biliary cast syndrome after acute COVID-19 infection Case Description/Methods: 42-year-old female with a history of orthotopic heart transplant (2014) on chronic immunosuppression presented with chief complaints of nausea, vomiting and pruritus. Patient had an admission six weeks prior for acute respiratory distress syndrome secondary to COVID-19 infection and was treated with convalescent plasma and Tocilizumab. Liver enzymes during that admission peaked at AST 196, ALT 236, ALP 344, and total bilirubin 1.3, however, they all returned to normal by discharge. These abnormalities were attributed to severe sepsis from COVID-19 infection. Computed Tomography (CT) of the abdomen during that admission revealed normal hepatobiliary anatomy. On this admission, laboratory work up was significant for AST 94, ALT 83, ALP 1003 and total bilirubin of 4.6. Magnetic resonance cholangiopancreatography (MRCP) revealed mild intrahepatic biliary ductal dilation with subtle central biliary enhancement concerning for cholangitis along with hypodense material in extrahepatic biliary system. Endoscopic retrograde cholangiopancreatography (ERCP) with liberal sphincterotomy revealed filling defects on cholangiogram. The biliary tree was swept using a 12-15 mm balloon and patient was found to have multiple large biliary casts, the largest measuring 7 cm. LFTs trended down and she was eventually discharged home in stable condition. She had two more subsequent ERCPs with balloon extraction of multiple small biliary casts from the intrahepatic ducts. Discussion: Biliary cast syndrome is a well-recognized complication of orthotopic liver transplantation; however, to the best of our knowledge, this is the first case report of biliary cast syndrome secondary to severe COVID-19 infection. As the pathogenesis of COVID-19 becomes better understood, cholestasis with possible biliary cast syndrome should be considered as a potential complication of the COVID-19 virus in a patient with abnormal LFTs, especially after a severe infection.Figure 1.: Biliary cast

S2763 Post COVID-19 Biliary Cast Syndrome: A Novel Disease

S2763 Post COVID-19 Biliary Cast Syndrome: A Novel Disease

Cholesterol crystals in biliary cast syndrome related to sclerosing cholangitis in critically ill patients

Cholesterol crystals in biliary cast syndrome related to sclerosing cholangitis in critically ill patients

Percutaneous Transhepatic Cholangioscopy Utilizing Different Endoscopes to Optimize Treatment Success in Biliary Cast Syndrome, how a Paediatric Bronchoscope can Help: A Case Report

Percutaneous Transhepatic Cholangioscopy Utilizing Different Endoscopes to Optimize Treatment Success in Biliary Cast Syndrome, how a Paediatric Bronchoscope can Help: A Case Report

Biliary cast syndrome after liver transplantation: A cholangiographic evolution study.

The aim of this study is to describe the cholangiographic features and endoscopic management of biliary cast syndrome (BCS), a rare specific ischemic cholangiopathy following liver transplantation. Patients with biliary complications were identified from prospectively collected database records of patients who underwent liver transplantation at the Erasme Hospital from January 2005 to December 2014. After excluding patients with hepatico-jejunostomy or no suspicion of stricture, cholangiograms obtained during endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging were systematically reviewed. Biliary complications were categorized as anastomotic (AS) and non-AS strictures, and patients with BCS were identified. Clinical, radiological, and endoscopic data were reviewed. Out of 311 liver transplantations, 14 cases were identified with BCS (4.5%) and treated with ERCP. Intraductal hyperintense signal on T1-weighted magnetic resonance and a "duct-in-a-duct" image were the most frequent features of BCS on magnetic resonance imaging. On initial ERCP, 57% of patients had no stricture. Complete cast extraction was achieved in 12/14, and one of these had cast recurrence. On follow-up, 85% of the patients developed biliary strictures that were treated with multiple plastic stents reaching 60% complete stricture resolution, but 40% of them had recurrence. After a median follow-up of 58months, BCS patients had lower overall and graft survival (42.9% and 42.9%) compared with non-AS (68.8% and 56.3%) and AS (83.3% and 80.6%), respectively. Particular magnetic resonance-cholangiographic and ERCP-cholangiographic features of BCS have been identified. Outcomes for BCS are characterized by high complete cast extraction rates, high incidence of secondary strictures, and poorer prognosis.

COVID-19 Infection Causing Liver Infarction, Severe Cholangiopathy, and Biliary Cast Syndrome

We present a patient with COVID-19 pneumonia with severe multi-organ failure who developed a liver infarction in the setting of acute illness and following recovery, had persistent cholestatic liver injury. On further evaluation, he was found to have a severe destruction of the intrahepatic bile ducts and biliary cast syndrome and ultimately, was felt to have severe ischemic cholangiopathy in the setting of recent COVID-19 infection. Because of the extent of destruction and persistent cholestasis, he is at risk of secondary biliary cirrhosis and is therefore undergoing a liver transplant evaluation. This case highlights a rare entity of liver infarction and severe cholangiopathy with biliary cast syndrome in the setting of COVID-19 infection. It is the first case of this reported to date, and its recognition in the presence of the COVID-19 pandemic is important. Keywords: Biliary cast, Cirrhosis, Cholangiopathy , COVID-19, Liver infarction.