Biliary complications are significant causes of morbidity and mortality after orthotopic liver transplantation (OLT). The estimated incidence of biliary complications after OLT ranges between 10%-25%, however, these numbers continue to decline due to improvement in surgical techniques. The most common biliary complications are strictures (both anastomotic and non-anastomotic) and bile leaks. Most of these problems can be appropriately managed with endoscopic retrograde cholangiography (ERC). Other complications such as bile duct stones, bile casts, sphincter of Oddi dysfunction, and hemobilia, are less frequent and also can be managed with ERC. This article will review the risk factors, diagnosis, and endoscopic management of the most common biliary complications after OLT.

Complications of the biliary tract after orthotopic liver transplantation (OLT) are an important cause of morbidity and mortality in liver transplant recipients. The most frequent biliary complications following LT are biliary tract strictures, bile leaks, and bile duct stones. Biliary complications arising after a liver transplantation occur in 10% to 25% of cases, with biliary strictures, bile leaks, and bile duct stones accounting for the majority of the complications[1–6].

These complications can be successfully managed with endoscopic retrograde cholangiography (ERC) in most cases. This article will review the different types of biliary complications after OLT and their endoscopic management.

Risk factors for the development of biliary complications after OLT are shown in Table 1. A major risk factor is the type of biliary reconstruction (duct-to-duct choledochocholedochostomy vs Roux-en-Y choledochojejunostomy). The risk of biliary complications with the Roux en Y reconstruction is similar or only slightly higher compared with the duct-to-duct anastomosis[27–10]. Duct-to-duct anastomosis of the common bile duct has the advantage of including easy access to the biliary system after OLT and preservation of the sphincter of Oddi[11]. The use of T-tubes has also been implicated as a risk factor after OLT, although this issue is controversial. Some centers prefer the routine use of T-tubes for bridging of the biliary anastomosis as it allows the assessment of the quality and quantity of bile, biliary tract anatomy, and reduces the incidence of strictures. Despite these benefits, comparative studies indicate that routine T-tube placement is associated with higher incidence of bile leaks and cholangitis[12–15].

Acute hepatic artery thrombosis, which may lead to ischemic strictures unless vascular flow is immediately reconstituted, is one of the major risk factors for the development of complications after OLT[12]. Other risk factors for the development of biliary complications include technical factors during surgery (excess dissection of periductal tissue during procurement and tension of the duct anastomosis), ischemia/reperfusion injury, cytomegalovirus infection, non-heart beating donors, ABO incompatibility and primary sclerosing cholangitis[1216–22].

Patients may present with asymptomatic elevations of serum transaminases, serum bilirubin, alkaline phosphatase and/or γ-glutamyl transferase levels. In some cases patients may have non-specific symptoms, such as fever and anorexia[101116]. In the initial evaluation of these patients, an abdominal/liver ultrasound (US) should be performed to evaluate the biliary tree and the hepatic vessels. If hepatic artery stenosis is suspected, a hepatic angiography is usually indicated. Liver biopsy is useful in order to exclude rejection, but histological features of biliary obstruction can sometimes be misleading and confused with rejection or hepatitis C recurrence[23]. In cases where there is biliary dilation on the abdominal US, liver biopsy is not initially performed due to the risk of causing a bile leak. The yield of abdominal US in detecting biliary complications is sometimes limited by a lack of good sensitivity and accuracy to detect common bile duct obstruction or stones. Hence, the absence of bile duct dilation on US should not preclude further evaluation with other sensitive techniques (see below) in patients in whom there is suspicion of biliary tract complications.

If there is a strong clinical suspicion of bile duct obstruction or bile leak, a cholangiogram, by means of endoscopy or radiology, should always be performed. In recent years, the role of magnetic resonance cholangiopancreatography (MRCP) as a tool to evaluate the biliary tract of post-OLT patients has significantly improved. Recent studies demonstrate that MRCP has high sensitivity and specificity in detecting biliary complications after OLT (93%-100% and 92%-98%, respectively). MRCP is particularly useful in patients with a low suspicion of biliary complications or when there is a low probability of ERC or percutaneous transhepatic cholangiography (PTC)[2425] (Figure 1). In patients with an indwelling T-tube, a T-tube cholangiography is the method of choice to evaluate the biliary tract. The best diagnostic approach (ERC vs PTC) depends on the type of biliary reconstruction, the likelihood of therapeutic intervention, and the center’s expertise. ERC is probably the best diagnostic intervention in patients with duct-to-duct anastomosis, while PTC should be performed in cases of failed ERC or in patients with a Roux-en-Y anastomosis. In high volume centers with experienced endoscopists, ERC can be successfully performed with a variable stiffness pediatric colonoscope. In one report from the Mayo Clinic, 22 out of 31 patients post-OLT with Roux-en-Y anastomosis referred for ERC were successfully treated with endoscopy[26].

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Figure 1 Magnetic resonance cholagiopancreatography (MRCP) image of the biliary tract of a patient that developed abnormal liver enzymes 8 mo after liver transplantation. The MRCP showed a severe biliary stricture at the anastomotic site (arrow).

Biliary complications arising after OLT occur in approximately 10%-25% of cases. Biliary strictures, bile leaks and bile duct stones account for the majority of these complications. The diagnostic approach of biliary complications after OLT should begin with a liver US and Doppler examination of the hepatic artery. In cases with a strong clinical and radiological suspicion of biliary pathology, the patient should proceed directly to ERC. MRCP is an excellent diagnostic tool for the evaluation of the biliary tree after OLT and should be performed in cases where there is a lower suspicion for biliary pathology. Patients with AS and NAS should undergo repeated ERC sessions with biliary balloon dilatation and placement of plastic stents to achieve maximal diameter with routine stent changes every 3 mo. In most cases, patients require between 3 and 5 sessions. In patients with bile leaks, ERC with or without sphincterotomy with placement of a plastic stent, which should be left in place for 2-3 mo, is recommended. Other complications such as common bile duct stones, casts, mucocele or sphincter of Oddi dysfunction can be managed successfully with ERC and standard techniques for removal of stones and sphincterotomy.