Biliary Cast Research Articles

Long-term clinical outcomes of biliary cast syndrome in liver transplant recipients

Biliary cast syndrome (BCS) is an uncommon complication of orthotopic liver transplantation (OLT), so the long-term treatment outcomes of BCS are not well characterized. The purpose of this study was to evaluate the long-term treatment outcomes and prognosis of BCS after OLT. The medical records of 1097 patients who underwent OLT from January 2000 to September 2009 were reviewed. Those patients who had BCS were evaluated with respect to the treatment method, overall survival and relapse rates, and relapse-free time. Twenty-three patients (2.1%) were diagnosed with BCS with a mean overall follow-up of 59.9 months. All the patients had benign biliary strictures and repeatedly underwent balloon dilatation by an endoscopic or percutaneous approach. Primary biliary cast removal was tried with the endoscopic method from 11 patients and with the percutaneous methods from 12 patients. Casts were completely removed by repetitive procedures in 22 patients, but BCS relapsed in 12 patients (55%). Persistent biliary strictures were significantly associated with the BCS relapse frequency (0.37 versus 0.05 times per year, P = 0.006). The 5-year overall survival rate for BCS patients after OLT was 87%. The risk factors associated with early relapse were female sex, hepatic artery stenosis, and acute cellular rejection. In a multivariate analysis, acute cellular rejection was the only significant risk factor for early relapse (hazard ratio = 11.1, 95% confidence interval = 1.9-63.2, P = 0.007). In conclusion, patients with BCS frequently relapse, and multiple interventions and the treatment of biliary strictures are needed. Acute cellular rejection after OLT is a significant risk factor for early relapse.

Biliary cast syndrome after orthotopic liver transplantation: risk factors and outcome

Biliary cast syndrome after orthotopic liver transplantation: risk factors and outcome

Clinical Analysis and Significance of Cholangiography for Biliary Cast/Stone After Orthotopic Liver Transplantation

Cholangiography is an important method for the diagnosis of biliary complications after orthotopic liver transplantation. The cholangiography after orthotopic liver transplantation presents special challenges, especially in patients with biliary cast/stone and biliary stenosis. We described the T-tube cholangiography combined therapeutic fibro-choledochoscopy for the diagnosis and treatment of biliary cast following after orthotopic liver transplantation. Fourteen patients who developed biliary cast/stone after liver transplantation were analyzed retrospectively. The complications were divided into three temporal stages, early, medium, and late. Hepatic functions and the characteristics of the bile duct were observed by T-tube cholangiography and endoscopy. The biliary cast after liver transplantation was divided into three categories: Solitary, multiple, and columnar. Three months after liver transplantation, bile ducts appeared fuzzy by T-tube cholangiography, but no evidence of biliary cast was found. The bile duct was feculent with flocculation during the middle stage 3-6 months after liver transplantation. At six months after transplantation, bile ducts (especially intrahepatic bile ducts) were distended; cholangiectasis was obvious with biliary cast. The intrahepatic bile duct stricture was observed on occasion by T-tube cholangiography and the intrahepatic bile duct could be thin and distended, and resembled withered branches or strings of beads. The intrahepatic bile ducts even disappeared at this stage; hepatic functions were usually unacceptable and the icterus gradually aggravated. Four cases were diagnosed earlier according to the categories of stone and stage. Curative therapy was performed promptly and the clinical outcome was acceptable. Biliary tracts of the transplanted livers could be observed by T-tube channels and biliary complications were treated effectively by therapeutic fibro-choledochoscopy. It is necessary to combine T-tube cholangiography with fibro-choledochoscopy for the diagnosis and treatment of biliary complications after orthotopic liver transplantation.

Detection of Cast in Biliary Cast Syndrome

HomeRadiologyVol. 266, No. 1 PreviousNext CommunicationsLetters to the EditorDetection of Cast in Biliary Cast SyndromeLionel ArrivéLionel ArrivéAuthor AffiliationsDepartment of Radiology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris et Faculté de Médecine Pierre et Marie Curie, 184 rue du Faubourg Saint-Antoine, 75012 Paris, Francee-mail: [email protected]Lionel ArrivéPublished Online:Jan 1 2013https://doi.org/10.1148/radiol.12121350MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 Kinner S, Umutlu L, Dechêne Aet al.. Biliary complications after liver transplantation: addition of T1-weighted images to MR cholangiopancreatography facilitates detection of cast in biliary cast syndrome. Radiology 2012;263(2):429–436. Link, Google Scholar2 Kim YK, Kim CS, Lee JMet al.. Value of adding T1-weighted image to MR cholangiopancreatography for detecting intrahepatic biliary stones. AJR Am J Roentgenol 2006;187(3):W267–W274. Crossref, Medline, Google ScholarArticle HistoryPublished online: Jan 2013Published in print: Jan 2013 FiguresReferencesRelatedDetailsCited ByMagnetic resonance cholangiography: Current and future perspectivesLionelArrivé, MarianneHodoul, AntouneArbache, LucieSlavikova-Boucher, YvesMenu, SanaâEl Mouhadi2015 | Clinics and Research in Hepatology and Gastroenterology, Vol. 39, No. 6Recommended Articles Pediatric Liver Transplant: Techniques and ComplicationsRadioGraphics2017Volume: 37Issue: 6pp. 1612-1631Multimodality Imaging after Liver Transplant: Top 10 Important ComplicationsRadioGraphics2022Volume: 42Issue: 3pp. 702-721Body MRI: Imaging Protocols, Techniques, and Lessons LearnedRadioGraphics2022Volume: 42Issue: 7pp. 2054-2074Imaging Features of Primary Sclerosing Cholangitis: From Diagnosis to Liver Transplant Follow-upRadioGraphics2019Volume: 39Issue: 7pp. 1938-1964Material Separation Using Dual-Energy CT: Current and Emerging ApplicationsRadioGraphics2016Volume: 36Issue: 4pp. 1087-1105See More RSNA Education Exhibits Practical Approach to Liver Transplant Complications in the Emergency Department - What a Radiologist Needs to Know!Digital Posters2020Multi-modality Imaging of Liver Transplant: What You Cannot Afford to MissDigital Posters2020Living Liver Transplantation Diagnostic Imaging and IVR Â Digital Posters2020 RSNA Case Collection Intrahepatic bilomaRSNA Case Collection2022Multifocal hepatic steatosis RSNA Case Collection2020Biliary Hamartomas in Cirrhotic LiverRSNA Case Collection2021 Vol. 266, No. 1 Metrics Altmetric Score PDF download

Erratum

Radiology: Volume 266: Number 1—January 2013 n radiology.rsna.org 367 poor with the in-phase 2D T1-weighted images. Retrospectively going through our analysis, we found that we would have missed cast in one of the cases with use of 2D opposed-phase imaging instead of 3D fat-saturated imaging and vice versa in another case. In our experience, artifacts owing to high inflow have not hampered the diagnostic accuracy of the 2D images. In conclusion, we therefore suggest performing both sequences and using both for the detection of biliary cast.

A Case of Biliary Cast Developed in a Patient with Long-Standing Biliary Sludge

Development of biliary casts is very unusual, especially in patients who have not undergone liver transplantation. Variable causes of biliary cast formation in nonliver transplantation patients have been suggested. However, stasis of bile flow and/or gallbladder hypocontractility is known to eventually result in the promotion of biliary sludge and subsequent cast formation. Here we present one case of biliary cast syndrome, which developed in a nonliver transplant patient who had biliary sludge for a long period of time, providing evidence that long-standing biliary sludge may lead to cast formation.

Long-term management of the successful adult liver transplant: 2012 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation

Michael R. Lucey, Norah Terrault, Lolu Ojo, J. Eileen Hay, James Neuberger, Emily Blumberg, and Lewis W. Teperman Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Gastroenterology Division, Department of Medicine, University of California San Francisco, San Francisco, CA; Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI; Mayo Clinic, Rochester, MN; Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom; Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, PA; and Department of Surgery, NYU Transplant Associates, New York, NY

Pathotyping and Clinical Manifestations of Biliary Cast Syndrome in Patients After an Orthotopic Liver Transplant

To summarize the pathotyping and clinical manifestations of biliary cast syndrome in patients after an orthotopic liver transplant. The clinical manifestations, auxiliary examination, therapeutic regimen, and clinical efficacy of 103 biliary cast syndrome patients who underwent an orthotopic liver transplant were retrospectively analyzed. Patients were divided into 6 groups from type 1 to type 6, according to the injury level of the biliary duct epithelium. Many biliary cast syndrome patients showed symptoms including jaundice, dark urine, argillaceous stool, itchy skin, and fever. Serum levels of alanine aminotransferase, γ-glutamyl transpeptidase, alkaline phosphatase, and total bilirubin were increased. In addition, total white cell counts in peripheral blood also were increased. T-tube cholangiography showed filling defects of various amounts. Optical fiber choledochoscope examination revealed that the biliary tract was filled with solid substances, and necrosis of the biliary tract epithelium was observed in some biliary cast syndrome patients. From type 1 to type 6 biliary cast syndrome patients, the probability of clinical symptoms and biliary tract stricture gradually increased, the time needed for supporting gradually prolonged after removal of the biliary cast, and T-tube cholangiography showed that the filling defects gradually expanded. Clinical manifestations and cholangiography presentations mainly depend on pathotyping.

Biliary cast syndrome after liver transplantation

ANZ Journal of SurgeryVolume 82, Issue 11 p. 849-850 IMAGES FOR SURGEONS Biliary cast syndrome after liver transplantation Carlos Apestegui MD, Carlos Apestegui MD Starzl Abdominal Transplant Unit, Department of Abdominal and Transplantation Surgery (Prof. JF. Gigot), University Hospitals Saint-Luc, Université Catholique de Louvain – UCL, Brussels, BelgiumSearch for more papers by this authorOlga Ciccarelli MD, Olga Ciccarelli MD Starzl Abdominal Transplant Unit, Department of Abdominal and Transplantation Surgery (Prof. JF. Gigot), University Hospitals Saint-Luc, Université Catholique de Louvain – UCL, Brussels, BelgiumSearch for more papers by this authorJan Lerut MD, PhD, Jan Lerut MD, PhD Starzl Abdominal Transplant Unit, Department of Abdominal and Transplantation Surgery (Prof. JF. Gigot), University Hospitals Saint-Luc, Université Catholique de Louvain – UCL, Brussels, BelgiumSearch for more papers by this author Carlos Apestegui MD, Carlos Apestegui MD Starzl Abdominal Transplant Unit, Department of Abdominal and Transplantation Surgery (Prof. JF. Gigot), University Hospitals Saint-Luc, Université Catholique de Louvain – UCL, Brussels, BelgiumSearch for more papers by this authorOlga Ciccarelli MD, Olga Ciccarelli MD Starzl Abdominal Transplant Unit, Department of Abdominal and Transplantation Surgery (Prof. JF. Gigot), University Hospitals Saint-Luc, Université Catholique de Louvain – UCL, Brussels, BelgiumSearch for more papers by this authorJan Lerut MD, PhD, Jan Lerut MD, PhD Starzl Abdominal Transplant Unit, Department of Abdominal and Transplantation Surgery (Prof. JF. Gigot), University Hospitals Saint-Luc, Université Catholique de Louvain – UCL, Brussels, BelgiumSearch for more papers by this author First published: 04 November 2012 https://doi.org/10.1111/j.1445-2197.2012.06267.xCitations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume82, Issue11November 2012Pages 849-850 RelatedInformation

Fungal Infections in Cholangitis: Implementation of Diagnostic and Therapeutic Algorithm

Purpose: Infections of the biliary tract with Candida and other fungal species have frequently been reported in the recent years. The aim of this multicenter study was to establish an algorithm for clinical diagnostics and treatment of biliary candidiasis. Methods: Ninety-four patients were included in the study (ClinicalTrials.gov Identifier: NCT01109550). Bile samples for microbiological analysis were obtained by endoscopic retrograde cholangiography (ERC). If appropriate, endoscopic bile duct biopsies were taken for evaluation of invasive fungal infection. Buccal smears and stool samples were collected to identify the individual transient flora. The obtained information was integrated into a diagnostic algorithm (Figure 1).Figure 1: Suggested diagnostic and therapeutic algorithm for biliary candidiasis.Results: In 26 of the 94 patients, we found Candida species in the bile (27.7%). Risk factors for biliary candidiasis were recent long-term antibiotic therapy (>7 days) and age (p<0.05). Forty-two percent of the Candida subspecies were differentiated as complicated with assumed resistance against azole antifungals (C. glabrata, tropicalis, dubliensis). One invasive mycosis was identified histologically without mycological proof in the in bile. Eight patients were treated with antimycotic drugs according to our suggested treatment algorithm; two patients with progressive cancer, two with biliary cast syndrome after cardiopulmonary resuscitation, one with M. Ormond, and three with sepsis of unknown focus. Positive oral (buccal) and enteral (stool) fungal cultures did not correlate with biliary candidiasis (p=0.066 and p=0.158). Furthermore, no significant association of prior endoscopic sphincterotomy (p=0.360) or prior ERCP (p=0.341) and biliary candidiasis were found. No positive fungal blood culture samples were obtained. Conclusion: Candida and its subspecies are frequently seen in the bile of patients with biliary obstruction. Our data indicate that the suggested diagnostic algorithm for biliary candidiasis is feasible in daily clinical routine. The question whether transpapillary biopsies are necessary to diagnose biliary candidiasis is not answered yet. This research was supported by an industry grant from Merck Investigator-initiated Studies Program.

Biliary Complications after Liver Transplantation: Addition of T1-weighted Images to MR Cholangiopancreatography Facilitates Detection of Cast in Biliary Cast Syndrome

To evaluate the diagnostic performance of T2-weighted magnetic resonance (MR) cholangiopancreatography pulse sequences in comparison with MR cholangiopancreatography sequences combined with nonenhanced T1-weighted images in the detection of biliary cast syndrome in liver transplant recipients. This retrospective study was conducted in accordance with the declaration of Helsinki. Institutional review board approval was obtained. MR images in 95 patients who were examined after liver transplantation and who presented with symptoms of biliary obstruction were examined. Two separate sets of images, MR cholangiopancreatograms and MR cholangiopancreatograms plus T1-weighted images, were evaluated independently by three readers. Sensitivities, specificities, and positive and negative predictive values for biliary cast syndrome were calculated, and receiver operating characteristic curves were generated. The results of endoscopic retrograde cholangiopancreatography served as the reference standard. To determine interobserver agreement, κ values were calculated. Cast appeared hyperintense on nonenhanced T1-weighted images. Sensitivities for T2-weighted MR cholangiopancreatography data alone were 0.65, 0.70, and 0.55 for the three readers. Adding unenhanced T1-weighted images resulted in sensitivities of 0.95, 0.90, and 0.90, respectively. Specificities for MR cholangiopancreatography alone and for MR cholangiopancreatography plus T1-weighted images were high on average (0.98, 0.97, and 0.97 vs 1.0 for all readers, respectively). Interobserver agreement was good for T2-weighted MR cholangiopancreatography (κ for readers 1 and 2 = 0.589, κ for readers 2 and 3 = 0.593, κ for readers 1 and 3 = 0.734) and was excellent for MR cholangiopancreatography plus T1-weighted images (κ for readers 1 and 2 = 0.806, κ for readers 2 and 3 = 0.881, κ for readers 1 and 3 = 0.848). The combination of T2-weighted MR cholangiopancreatography and T1-weighted imaging yields higher diagnostic performance than MR cholangiopancreatography alone. Therefore, readers evaluating liver MR images with regard to biliary complications after liver transplantation should also look at the bile ducts on unenhanced T1-weighted images, as biliary cast might be more easily depicted on these images.

Biliary Cast Syndrome in Non-Liver Surgery Patients

Biliary cast describes the presence of casts within the biliary tree. It is resultant sequel of cholangitis and hepatocyte damage secondary to bile stasis and bile duct injury. Biliary cast syndrome was first reported in patient undergone liver transplantation. The pathogenesis of biliary cast is not clearly identified, but proposed etiologic factors include post-transplant bile duct damage, ischemia, biliary infection, or post-operative biliary drainage tube. Although biliary casts are uncommon, most of biliary cast syndrome are reported in the liver transplant or hepatic surgery patients. A few reports have been published about non-transplant or non-liver surgery biliary cast. We report two cases of biliary cast syndrome in non-liver surgery patients.

Biliary Cast Formation with Sclerosing Cholangitis in Critically Ill Patient: Case Report and Literature Review

Sclerosing cholangitis in critically ill patients (SC-CIP) is a rare condition that is not familiar to many radiologists. In addition, the associated imaging findings have not been described in the radiological literature. We report a case of biliary cast formation with SC-CIP and describe the radiological findings of CT, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiography (ERC). A diagnosis of SC-CIP should be considered in intensive care unit (ICU) patients with persistent cholestasis during or after a primary illness. The typical CT, MRCP and ERC findings include new biliary casts in the intrahepatic duct with multiple irregular strictures, dilatations, and relative sparing of the common bile duct.

Establishment of animal model for biliary cast syndrome

Objective To establish an animal model for biliary cast syndrome （BCS） of human and investigate the pathological mechanism for BCS. Methods Forty Japanese large-ear rabbits were divided into two groups at random. Biliary endepidermis was damaged with carbolic acid in experiment group rabbits, then a support tube was placed at the breakpoint of bile common duct in each experimental animal. Only support tube was placed at the breakpoint of bile common duct in control group. After four weeks, rabbits were executed, and the liver was dissected for pathological analysis. Results All experiment animals were operated successfully. Six rabbits died at 3rd week after operation. And all animals appeared as listlessness, poor appetite, changes in stool description and loss of weight. The symptoms of experimental group were obviously severe than in control group. There were adhesions at hepatic hilum and distensions at biliary tracts above intersect of common duct in experimental group, 4 rabbits appeared necrosis on biliary tract paries and bile retention hepatapostema in 6 experimental animals. Biliary cast was found in each experimental rabbit liver. There were mild adhesions at hepatic hilum, distensions at biliary tracts above intersect of common duct in control group. The biliary tract paries was slick, and no biliary cast was found in control animal liver. After the damage by carbolic acid, there were biliary endepidermis necrosis and defluvium defluxion in large bile duct at 24th h after operation. There were plenty of pink materials in liver exterior and interior biliary tract at 72nd h after operation. The biliary tract paries was infiltrated by white blood cells and part of biliary endepidermis was placed by flat epithelium. The biliary endepidermis was placed by fibrous tissue and fiat epithelium in large bile duct at 21st day after operation. Conclusion The animal model for BCS has been established successfully. BCS is contributed to the serious damage of biliary endepidermis. The formation of biliary cast and appearance of correlated symptoms are based on the sequentia inflammatory reaction. Key words: Biliary tract diseases; Biliary cast; Model, animal

The therapeutic value of percutaneous transhepatic cholangioscopy for biliary cast after liver transplantation

Objective To investigate the value of percutaneous transhepatic cholangioscopy （PTCS） for diagnosis and treatment of biliary cast after liver transplantation. Methods Data of 11 patients with biliary cast after liver transplantation, who underwent PTCS from April 2008 to November 2010, were retrospectively analyzed. Results In 11 patients , one had biliary cast in common bile duct, 3 in right in- tra-hepatic bile duct, 4 in left intra-hepatic bile duct, and 3 distributed in intra- and extra-hepatic bile ducts. A total of 68 times of PTCS were performed in 11 patients, achieving significant decrease in levels of serum transaminase and bilirubin in 10. Occasional fever occurred in 1 patient after closure of drainage tube, which was managed by replacement with a thinner one. There were no severe complications such as biliary fistula or uncontrollable bleeding. Partial rupture of fistula occurred in 1 case. All patients were followed up for 10-30 months and were all in good condition except one patient died from other disease during the followup. Conclusion PTCS is a safe, effectiVe and applicable method to treat the biliary cast after liver transplantation. Key words: Liver transplantation; Biliary cast electronic choledochoscope; Percutaneous transhepatic cholangioscopy

Pathogenic analysis and treatment of biliary tract complication following orthotopic liver transplantation

Objective To investigate the pathogenesis of biliary tract complication following orthotopic liver transplantation ( OLT) and explore the methods of countermeasures. Methods Clinical data of 74 cases of biliary tract complication following OLT at our institute from 2004 to 2009 were retrospectively analysed. The patterns and high risk factors of biliary tract complication following OLT were summarized. Furthermore the interventing time and efficacy of any treatment for biliary tract complication following OLT were carefully analyzed. Results Bile leakage,biliary sludge,biliary duct stoma stricture,biliary ischemia stricture and biliary cast syndrome were predominant patterns of biliary tract complication following OLT. The inexperience in organ procurement,organ preservation,operating technique and post-operating treating was major factors for bile leakage and biliary duct stoma stricture. The prolong of warm ischemia time was the major factor for biliary sludge and biliary ischemia stricture ( P 0. 01) . At the same time the T-tube and cholangiojejunostomy could induce high morbility of biliary ischemia stricture( P 0. 01) . The organs to be perfused with UW through abdominal aorta had higher morbilities in biliary sludge,biliary ischemia stricture and biliary cast syndrome than those no use with UW( P 0. 05) . Endoscopic and radiative interventionswere effective methods for bile leakage,biliary sludge and biliary duct stoma stricture but unsatisfactory for treating biliary ischemia stricture and biliary cast syndrome. Retransplantation was a salvage method for invalid cases. Conclusions The biliary tract complication following OLT was directly associated with operation technique, ischemical reperfusion injury, the pattern of biliary duct anastomosis, organ procurement and so on. It was very important to think highly of preventing biliary ischemia stricture and biliary cast syndrome in order to cut down the morbilitis for those severe biliary tract complication following OLT.

Percutaneous Treatment of Biliary Cast Syndrome After Orthotopic Liver Transplantation: Comparison of Mechanical Versus Hydraulic Rheolytic Cast Extraction

Biliary cast syndrome (BCS) is the presence of casts within the intrahepatic or extrahepatic biliary system after orthotopic liver transplantation. Our work compares two percutaneous methods for BCS treatment: the mechanical cast-extraction technique (MCE) versus the hydraulic cast-extraction (HCE) technique using a rheolytic system. A total of 24 patients were included in the study. Six patients were referred for HCE, and 18 patients were treated with MCE. A statistically significant larger number of sessions was required in the MCE group (21.0, range 11 to 72 sessions) (p=0.033). Median therapy duration was shorter in the HCE group at 2.4months (range 2 to 5) compared with 6.7months (range 3 to 39) in the MCE group (p<0.001). Both patient acceptance was better and costs for total therapy were 40% less in the HCE group. No significant differences where found concerning clinical and biochemical improvement or graft and patient survival. The use of the hydraulic rheolytic system decreased total therapy time, thereby decreasing the induced inflammation time of the biliary tree. A significant benefit of HCE has been observed in our patients when we compare our results with those of MCE.

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