Complication Of Orthotopic Liver Transplantation Research Articles

Clinical case of staged treatment of combined complications of orthotopic liver transplantation

Hepatic artery thrombosis (HAT) following liver transplantation (LT) is a severe life-threatening complication that can lead to graft loss and mortality after LT. According to different reports, HAT incidence ranges from 2% to 9%. Modern endovascular and radiosurgical techniques allow for minimally invasive liver graft revascularization. Nonetheless, a major consequence of even a successful revascularization is ischemic cholangiopathy, which can lead to ischemic biliary strictures and anastomotic leak. The paper presents a clinical case of long-term complex treatment of combined complications of LT using minimally invasive endovascular and endoscopic techniques.

Surgical site infections in liver transplantation in the era of multidrug-resistant bacteria.

Surgical site infection (SSI) is the major complication in orthotopic liver transplantation (LT). It is of prime importance to assess the incidence of infections in liver transplants and to analyze the risk factors associated with morbidity and mortality. Between 2014 and 2019, we performed a retrospective cohort study at the Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy. The liver transplant procedure and its related infections were examined in 4 timepoints, both prior and post-surgery. Multiple random-intercept Poisson regression models with robust variance were fitted to calculate the adjusted risk ratios (RR) and the 95% confidence intervals (CI) according to selected recipient and donor variables. We included in the analysis 249 transplants (in 241 patients). The SSIs (mostly due to S. aureus, E. faecium, and K. pneumoniae) were 7 (2.8%) in the days following LT, increasing to 61 (24.5%) within the first month after LT, and declining to 35 (14.1%) between 31 and 60 days, and to 19 (7.6%) afterwards. The factors associated with increased risk of infection were age (RR=1.17 per 10 years, CI: 0.99-1.38), BMI (RR=1.04 per BMI Unit, CI: 0.99-1.08), donor age (RR=0.88 per 10 years, CI: 0.78-0.98), re-interventions (30 infections, RR=2.02, CI: 1.21-3.38) and the Roux-en-Y approach (25 infections, RR=2.75, CI: 1.47-5.15). The risk of infection occurred mainly in the first two months after LT. Important determinants were age and BMI, donor age, reinterventions, and Roux-en-Y procedure. Our study suggests that these factors should be assessed when performing LT.

Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients.

BACKGROUNDIn orthotopic liver transplantation (OLT) recipients, median arcuate ligament syndrome (MALS) is considered a risk factor for hepatic arterial thrombosis (HAT), which is dreadful for OLT recipients. Different alternative surgical procedures have been proposed to overcome the impact of MALS on transplantation, but clinical evidence is still scarce. AIMTo evaluate the feasible surgical management of MALS to reduce complications in OLT patients.METHODSData for 288 consecutive patients who underwent OLT at The First Hospital of Jilin University between January 2017 and July 2020 were retrospectively reviewed. The surgical management of median arcuate ligament (MAL) and modifications to the arterial anastomosis were recorded. The perioperative and long-term prognosis of MALS recipients were noted. Detailed preoperative and postoperative data of patients were analyzed in a descriptive manner.RESULTSEight patients with MALS were included in this study. The first patient with MALS received no intervention during the primary surgery and developed postoperative HAT. Salvage liver transplantation with MAL division was successfully performed. Gastroduodenal artery (GDA) preservation with splenic artery ligation was performed on three patients, only GDA preservation was performed on two patients, and no intervention was performed on two patients. No patient developed HAT after surgery and postoperative recovery was satisfactory. CONCLUSIONThe preservation of collateral circulation between the superior mesenteric artery and celiac trunk via the GDA with or without splenic artery ligation is a safe and feasible alternative to MAL division.

Postoperative Trapped Lung After Orthotopic Liver Transplantation is a Predictor of Increased Mortality.

Pleural effusions are a common complication of orthotopic liver transplantation (OLT), and chronic post-OLT pleural effusions have been associated with worse outcomes. Furthermore, “trapped lung” (TL), defined as a restrictive fibrous visceral pleural peel preventing lung re-expansion, may have prognostic significance. We performed a retrospective analysis of adult OLT recipients over a 9-year period at UCLA Medical Center. Post-OLT patients with persistent pleural effusions, defined by the presence of pleural fluid requiring drainage one to 12 months after OLT, were included for analysis. Outcomes for patients with and without TL were compared using univariate and multivariate analysis. Of the 1722 patients who underwent OLT, 117 (7%) patients met our criteria for persistent postoperative pleural effusion, and the incidence of TL was 21.4% (25/117). Compared to patients without TL, those with TL required more surgical pleural procedures (OR 59.8, 95%CI 19.7–181.4, p < 0.001), spent more days in the hospital (IRR 1.56, 95%CI 1.09–2.23, p = 0.015), and had a higher risk of mortality (HR 2.47, 95%CI 1.59–3.82, p < 0.001) following transplant. In sum, we found that post-OLT TL was associated with higher morbidity, mortality, and healthcare utilization. Future prospective investigation is warranted to further clarify the risk factors for developing postoperative pleural effusions and TL.

S3374 Plastic vs Metal Stents for Anastomotic Biliary Strictures After Orthotopic Liver Transplant (OLT)

Introduction: Biliary anastomotic stricture is the most common complication of orthotopic liver transplantation (OLT) occurring in about 20% of cases. Endoscopic stent placement across the stricture with plastic or metal stents is the first-line treatment strategy. The aim of this study is to investigate the difference between plastic and metal stents in terms of anastomotic biliary stricture resolution and adverse events. Methods: This is a retrospective study of post OLT patients who underwent ERCP over a 3-year period between 2018-2020. Out of 178 post OLT patients who underwent ERCP, 108 were excluded because of only one ERCP performed and repeat ERCP was not indicated or because ERCP was performed for indications other than anastomotic biliary strictures. Data was collected up to 3 consecutive ERCP procedures during the studied period. Results: A total of 70 patients with anastomotic biliary strictures were included in the study. ERCP was performed on a native papilla in 32 (45.7%), advanced cannulation techniques were performed in 5 (7.1%), and prophylactic pancreatic stents were placed in 6 (8.6%) cases. Plastic stents (PS) were used in 53 (75.7%) of which multiple plastic stents were used in 27 cases, whereas 17 (24.3%) cases were treated with fully covered self-expanding metal stents (FCSEMS). Average follow up duration was 2.2 (1-3) months for PS and 3.7 (2-5) months for FCSEMS (P < 0.01). Biliary strictures resolved in 21 (30.0%) patients on repeat ERCP most of which from the FCSEMS group (58.8% vs 20.8%) (P = 0.009). Plastic stents were exchanged to FCSEMS in 11 (20.8%) patients during the second ERCP follow-up. On the third ERCP during the studied period, biliary strictures resolved in 71.4% of the FCSEMS group vs 33.3% of the PS group (P = 0.03). Using multiple plastic stents instead of a single plastic stent didn’t seem to improve biliary stricture resolution rate. Two patients (2.4%) developed post-ERCP pancreatitis, both patients had a native papilla and underwent FCSEMS placement with sphincterotomy and without pancreatic duct manipulation (P = 0.06). There was no difference between the stents used in terms of post-procedural cholangitis or stent migration rates. Conclusion: FCSEMS outperformed PS with respect to the anastomotic biliary stricture resolution rate over 3 endo-therapy sessions. Post-ERCP pancreatitis, although uncommon, occurred exclusively in the FCSEMS group.

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

Abstract No. 69 Bifurcated hepatocaval stent reconstruction for treatment of hepatic venous outflow obstruction in orthotopic liver transplantation

Hepatic venous outflow obstruction (HVOO) is a complication of orthotopic liver transplantation (OLT). This study reported efficacy and safety of bifurcated hepatocaval stent reconstruction for treatment of anastomotic stenoses in OLT.

Preoperative platelet count predicts posttransplant portal vein complications in orthotopic liver transplantation: a propensity score analysis

BackgroundThe role of platelets on the prognosis of patients with liver transplantation remains unclear. Thus, we aimed to evaluate the influence of preoperative platelet count on postoperative morbidity after liver transplantation.MethodsClinical data of the patients who received liver transplantation from January 2015 to September 2018 were evaluated.ResultsOf the 329 patients included, the average age was 46.71 ± 0.55 years, and 243 were men (75.2%). The incidence of posttransplant portal vein complication was significantly higher in the high platelet count group (> 49.5 × 109/L; n = 167) than in the low platelet count group (≤ 49.5 × 109/L, n = 162, 12.6% vs. 1.9%). After multivariable regression analysis, high platelet count was independently associated with postoperative portal vein complication (odds ratio [OR]: 8.821, 95% confidence interval [CI]: 2.260 to 34.437). After the inverse probability of treatment weighting analysis, patients in the high platelet count group had significantly higher risk of portal vein complication (OR: 9.210, 95%CI: 1.907 to 44.498, p = 0.006) and early allograft dysfunction (OR: 2.087, 95%CI: 1.131 to 3.853, p = 0.019).ConclusionsPreoperative platelet count > 49.5 × 109/L was an independent risk factor for posttransplant portal vein complication and early allograft dysfunction. High preoperative platelet count could be an adverse prognostic predictor for liver transplantation recipients.

Association of overweight with postoperative acute kidney injury among patients receiving orthotopic liver transplantation: an observational cohort study

BackgroundAcute kidney injury (AKI) is a common postoperative complication of orthotopic liver transplantation (OLT). So far, little attention has been paid on the association between overweight and AKI after OLT, and animal models or clinical studies have drawn conflicting conclusions. The objective of our study was to determine whether overweight (BMI [Body Mass Index] ≥ 25 kg/m2) is associated with an increased risk of AKI after OLT.MethodsThis retrospective cohort study included 244 patients receiving OLT in the Affiliated Hospital of Qingdao University between January 1, 2017, and August 29, 2019. Preoperative, intraoperative, and postoperative data were collected retrospectively. The primary outcome was the development of AKI as defined by Kidney Disease, Improving Global Outcome (KIDGO) staging system. Logistic regression analysis was used to determine the relationship between overweight and the occurrence of postoperative AKI. Data analysis was conducted from September to October 2019, revision in April 2020.ResultsAmong 244 patients receiving OLT (mean [standard deviation] age, 54.1 [9.6] years; 84.0% male) identified, 163 patients (66.8%) developed postoperative AKI. Overweight (BMI ≥ 25 kg/m2) was associated with a higher rate of postoperative severe AKI (stage 2/3) compared with normal weight (18.5 ≤ BMI < 25 kg/m2) (41 [47.7%] vs 39 [28.7%]; adjusted odds ratio [OR], 2.539; 95% confidence interval [CI], 1.389–4.642; P = 0.002). Furthermore, patients with obese were at even higher risk of postoperative severe AKI after controlling for confounding factors (adjusted OR: 3.705; 95% CI: 1.108–12.388; P = 0.033).ConclusionsOverweight is independently associated with an increased risk of postoperative severe AKI among patients receiving OLT. The association of BMI with severe AKI after OLT is J-shaped.

Incisional Hernia After Orthotopic Liver Transplantation: A Systematic Review and Meta-analysis

BackgroundIncisional hernia (IH) is a well-known complication of orthotopic liver transplantation. Despite wide recognition of the impact of this problem, the incidence remains imprecisely known. MethodsThe MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials and Cochrane Database of Systematic Reviews databases were searched from their inception to November 2017 for abstracts documenting IH after orthotropic liver transplantation (OLT). The primary endpoint of this study was incidence of IH, secondary endpoints were time to hernia and recurrence. Three reviewers independently graded abstracts for inclusion in this review. Heterogeneity in combining data was assumed prior to pooling. Random-effects meta-analyses were performed to estimate percentages and 95% CIs. ResultsAfter a review of 77 abstracts, 18 studies were graded as relevant. The methodological quality of studies was assessed with a minimum Oxford Centre for Evidence-Based Medicine level of 2B. These represent a cohort of 981 patients with IH after OLT reported in the literature. A meta-analysis of studies meeting inclusion criteria shows mean incidence of 15.1% (CI 12.1%-18.2%). Aggregate recurrence rate reported in the literature is 12.4% (CI 4.3%-20.5%). Overall reported time to IH after OLT was 42.9 months. ConclusionsAlthough reported incidences of IH after OLT vary widely across studies, an overall incidence of 15.1% is reported. This is a relatively late complication after transplantation. Recurrence of hernia after initial repair is 12.4% within this patient population.

Urinary and Serum Biomarkers for Prediction of Acute Kidney Injury in Patients Undergoing Liver Transplantation.

Acute kidney injury (AKI) is a frequent and serious complication of orthotopic liver transplantation (OLT), with a significant impact on mortality, graft survival, and chronic kidney disease. Currently, the diagnosis of AKI is based on changes in serum creatinine, which is a late marker, usually rising when there is already significant damage to the renal parenchyma. During the last 2 decades, various biomarkers have been studied in many clinical situations, mostly after cardiac surgery, in drug-induced AKI, or in sepsis. The present article summarizes the data on those biomarkers that have been evaluated for the prediction of AKI in patients undergoing OLT.

Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study.

Median arcuate ligament compression (MALC) potentially causes arterial complications in orthotopic liver transplantation (OLT). Here we aimed to investigate the incidence of MALC and its impact on clinical outcome after OLT. In addition, we performed an international survey among 52 European liver transplant centers to explore local protocols on the management of these patients. Data of 286 consecutive OLT recipients from a prospective database were analyzed retrospectively (05/2010-07/2017). Preoperative computed-tomography images were evaluated. Celiac axis stenosis due to MALC was found in 34 patients (12%). Intrinsic stenosis was present in 16 (6%) patients. Twenty-six patients (77%) with MALC underwent standard arterial revascularization with median arcuate ligament (MAL)-division. Patients treated for MALC had comparable baseline data and no difference was found in early- and long-term outcome compared to the rest of our cohort. Our survey found heterogeneous strategies regarding diagnosis and treatment of MALC. Only 29% of the centers reported the division of MAL in these patients as routine procedure. Even though there is no consensus on diagnosis and management of MALC among European centers, a surgical division of MAL is feasible and safe and should be considered in OLT recipients with MALC.

A systematic review and meta-analysis of rescue revascularization with arterial conduits in liver transplantation.

Although aortohepatic conduits (AHCs) provide an effective technique for arterialization in liver transplantation (LT) when the native recipient artery is unusable, various publications report higher occlusion rates and impaired outcome compared to conventional anastomoses. This systematic review and meta-analysis investigates the published evidence of outcome and risk of AHCs in LT using bibliographic databases and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Primary and secondary outcome were artery occlusion as well as graft and patient survival. Twenty-three retrospective studies were identified with a total of 22113 patients with LT, of whom 1900 patients (9%) received an AHC. An AHC was used in 33% of retransplantations. Early artery occlusion occurred in 7% (3%-16%) of patients with AHCs, compared to 2% (1%-3%) without conduit (OR 3.70; 1.63-8.38; P=.001). The retransplantation rate after occlusion was not significantly different in both groups (OR 1.46; 0.67-3.18; P=.35). Graft (HR 1.38; 1.17-1.63; P<.001) and patient (HR 1.57; 1.12-2.20; P=.009) survival was significantly lower in the AHC compared to the nonconduit group. In contrast, graft survival in retransplantations was comparable (HR 1.00; 0.82-1.22; P=.986). Although AHCs provide an important rescue option, when regular revascularization is not feasible during LT, transplant surgeons should be alert of the potential risk of inferior outcome.

Transfusion of Older Red Blood Cells Increases the Risk of Acute Kidney Injury After Orthotopic Liver Transplantation: A Propensity Score Analysis.

Acute kidney injury (AKI) is a common and serious complication of orthotopic liver transplantation (OLT). Transfusion of older red blood cells (RBCs) has been implicated in poor outcomes in trauma, cardiac surgery, and critically ill patients. However, whether transfusion of older RBCs plays any role in post-OLT AKI remained unknown. The aim of this study was to investigate the effect of the age of transfused RBCs on post-OLT AKI. The clinical data of consecutive adult patients who received donation after cardiac death and underwent OLT from December 2011 to December 2015 were analyzed. These patients were divided into 2 groups: the newer blood group, who received exclusively RBCs that had been stored for <14 days; and the older blood group, who received RBCs that had been stored for 14 days or more. The incidence of post-OLT AKI, severe AKI, lengths of intensive care unit and hospital stay, and in-hospital mortality after OLT were analyzed. Postoperative AKI occurred in 65.1% of patients in the older blood group and 40.5% of patients in the newer blood group (P < .01). The incidence of severe AKI after OLT was significantly higher, and the duration of intensive care unit stay was significantly longer, in the older blood group. After adjustment by the multivariable regression logistic analysis, transfusion of older blood was independently associated with post-OLT AKI (odds ratio [OR] = 2.47 [95% confidence interval {CI}, 1.13-5.41]; P = .024) and severe AKI (OR = 5.88 [95% CI, 2.06-16.80]; P = .001). After adjustment by the inverse probability of treatment weighting analysis, patients in the older blood group still had significantly higher incidences of postoperative AKI (OR = 2.13 [95% CI, 1.07-4.22]; P = .030) and severe AKI (OR = 3.34 [95% CI, 1.47-7.60]; P = .003) than those in the newer blood group. Transfusion of older RBCs significantly increased the risk of postoperative AKI in liver transplant recipients.

Ischemic Cholangiopathy 11 Years after Liver Transplantation from Asymptomatic Chronic Hepatic Artery Thrombosis

Hepatic artery thrombosis is a concerning complication of orthotopic liver transplantation, and it most often occurs early in the posttransplant period. However, on rare occasions it can occur at a time remote from transplant. We present a case of ischemic cholangiopathy complicated by stricture and anastomotic bile leak from chronic hepatic artery thrombosis that occurred 11 years after the transplant. The initial biliary stenting helped with the resolution of the leak but she was found to have stones, sludge and copious pus at the time of stent exchange. Hepatic arteriography demonstrated complete occlusion of the transplant hepatic artery with periportal collaterals reconstituting intrahepatic hepatic arterial branches. The patient was subsequently referred for repeat liver transplantation.

Ischemic Cholangiopathy 11 Years after Liver Transplantation from Asymptomatic Chronic Hepatic Artery Thrombosis

Hepatic artery thrombosis is a concerning complication of orthotopic liver transplantation, and it most often occurs early in the posttransplant period. However, on rare occasions it can occur at a time remote from transplant. We present a case of ischemic cholangiopathy complicated by stricture and anastomotic bile leak from chronic hepatic artery thrombosis that occurred 11 years after the transplant. The initial biliary stenting helped with the resolution of the leak but she was found to have stones, sludge and copious pus at the time of stent exchange. Hepatic arteriography demonstrated complete occlusion of the transplant hepatic artery with periportal collaterals reconstituting intrahepatic hepatic arterial branches. The patient was subsequently referred for repeat liver transplantation.

Ischemic Cholangiopathy 11 Years after Liver Transplantation from Asymptomatic Chronic Hepatic Artery Thrombosis

Hepatic artery thrombosis is a concerning complication of orthotopic liver transplantation, and it most often occurs early in the posttransplant period. However, on rare occasions it can occur at a time remote from transplant. We present a case of ischemic cholangiopathy complicated by stricture and anastomotic bile leak from chronic hepatic artery thrombosis that occurred 11 years after the transplant. The initial biliary stenting helped with the resolution of the leak but she was found to have stones, sludge and copious pus at the time of stent exchange. Hepatic arteriography demonstrated complete occlusion of the transplant hepatic artery with periportal collaterals reconstituting intrahepatic hepatic arterial branches. The patient was subsequently referred for repeat liver transplantation.

Operative Techniques, Treatment, and Precaution of Common Complications of Orthotopic Rat Liver Transplantation

<b>Objective</b> This study investigates operative techniques, treatment, and precaution for common complications of orthotopic liver transplantation (OLT) in rats. <b>Methods</b> OLT was performed in 110 rats through modified two-cuff method. Operative techniques were concluded, and causes, treatment, and precaution of common complications were analyzed. <b>Results </b>In operation phase, main causes for rat death included anesthesia, airway obstruction, pneumothorax, hemorrhagic shock, long anhepatic time, and air embolism. After surgery, main causes for rat death were as follows: stoma bleeding, infection, obstruction, and necrosis of biliary tract and poor hepatic function restoration. <b>Conclusion </b>Improving operative techniques, modifying operative methods, and familiarizing with common complications can reduce occurrence of complications, heighten operative successful rate, and establish more stable models of OLT in rats.

Acute Graft-vs-Host Disease After Liver Transplantation: Experience at a High-volume Liver Transplantation Center in Korea

BackgroundAcute graft-vs-host disease (GVHD) is a rare but life-threatening complication of orthotopic liver transplantation (OLT). We present 6 cases of GVHD after OLT. MethodsAmong our 4294 OLT recipients, we identified 6 patients (0.14%) who were diagnosed with GVHD. Their medical records were reviewed retrospectively. ResultsLiver graft types included deceased donor whole liver graft (n = 3) and right liver graft from son (n = 3). Mean recipient and donor ages were 57.2 ± 6.6 years and 32.7 ± 10.8 years, respectively. Onset of GVHD symptoms occurred 14 to 32 days after OLT, and initial symptoms were skin rash (n = 5) and fever (n = 1). GVHD was pathologically confirmed by skin or rectal biopsy. Chimerism of donor lymphocytes was identified in all 3 patients who underwent the short tandem repeat polymerase chain reaction assay. Attempts were made to treat the GVHD in all 6 patients by corticosteroids with or without low-dose calcineurin inhibitor, but we had to stop early or reduce these agents due to aggravation of pancytopenia and septic complications. Ultimately, 5 patients died 6 to 106 days after the onset of GVHD, and only 1 patient recovered. This surviving patient was diagnosed earlier and had been administered the recommended dosage of corticosteroid for a longer period with aggressive infection prophylaxis compared to the other cases. ConclusionsBecause of very poor outcomes of GVHD after OLT, early diagnosis and vigorous treatment should be emphasized, although no effective treatment modality has been established yet. We strongly suggest performing aggressive infection prophylaxis during GVHD treatment.

An Unusual Case of Upper Gastrointestinal Bleeding in a Patient with an Orthotopic Liver Transplant

Introduction: Neo-hepatic artery pseudoaneurysm is a rare case of upper gastrointestinal bleeding. An esophagogastroduodenoscopy is often performed to investigate and treat cases of upper gastrointestinal bleeding. It is important to be aware of this complication of orthotopic liver transplantation in the setting of an upper gastrointestinal bleed in a patient with previous hepatic artery thrombosis. We present a rare case of neo-hepatic artery pseuodoaneurysm in a patient with orthotopic liver transplant. Case Presentation: A 60 year old male with past medical history of chronic hepatitis B and cholangiocarcinoma status post liver transplantation in 2008 presented with melena and hematemesis. The patient reported history of small esophageal varices on last EGD completed in 2009. He was admitted to the Medical ICU with an initial hemoglobin of 11.5. His hemoglobin subsequently dropped to 9.0 within 2 hours of admission to ICU, and the patient was taken for esophagogastroduodenoscopy. During endoscopy, no evidence of mucosal disease of variceal disease was found. However, there was evidence of extrinsic compression of the antrum. Following EGD, the patient was taken for CT Scan of Abdomen/Pelvis. This showed a vascular mass measuring 7.4cm x 5.4cm posterior to the gastric body. Repeat upper endoscopy again demonstrated extrinsic compression of the antrum along the lesser curvature. As the endoscope was passed a 1-cm dark pigmented lesion was noted. This was concerning for re-implanted hepatic artery pseudoaneurysm which was concerning for erosion into the extrahepatic artery.Figure 1Figure 2At this point, the patient was taken for angiogram with the inability to emobilize lesion. Subsequently, the patient was taken to operating room by the transplant surgery team and underwent exploratory laparotomy with ligation of the hepatic artery. Discussion: Gastrointestinal bleeding after liver transplantation occurs in 8.9& of patients. Less than 1% are due to hepatic artery pseudoaneurysm. This is caused by visceral inflammation adjacent to the arterial wall leading to weakening of the wall. The three primary predisposing factors include hepatic arterial wall digestion due to bile from anastomotic leakage, arterial irritation due to localized abscess in inferior hepatic space, and mechanical injury from surgery. Conclusion: Hepatic artery pseudoaneurysm is a rare, and often morbid complication of transplant. Physicians should be aware of this as a rare cause of GI Bleeding.Figure 3