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

Gor, Niraj; Levy, Ronald M.; Ahn, Joseph; Kogan, Dmitriy; Dodson, S. Forrest; Cohen, Stanley M.

doi:10.1002/lt.21492

Cited by 71 publications

(81 citation statements)

References 21 publications

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“…Physical characteristics and intrahepatic location justify the reportedly higher incidence of endoscopic-percutaneous failure and the greater need for repeated interventions for treatment of casts when compared to stones. A nonsurgical approach to casts is in fact successful in less than 60% of patients, whereas it is therapeutic in over 85% of stone cases, again justifying the differences in the series presented by Gor et al 12 and Spier et al…”

Section: Physical and Metabolic Factorsmentioning

confidence: 64%

“…Such an observation is in line with a series of works showing the impact of prolonged warm ischemic time (WIT) on biliary damage as well as on the "phlogistic pathogenesis" of BCS. 13,14 In the Gor et al 12 study it has been noted that ischemia time dominated other donor and graft characteristics (namely donor risk index), suggesting the prominent role of biliary ischemic damage in BCS pathogenesis.…”

Section: Inflammatory Picturementioning

confidence: 99%

See 1 more Smart Citation

Bile duct stones and casts after liver transplantation: Different entities but similar prevention strategy?

et al. 2008

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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

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Section: Physical and Metabolic Factorsmentioning

confidence: 64%

Section: Inflammatory Picturementioning

confidence: 99%

Bile duct stones and casts after liver transplantation: Different entities but similar prevention strategy?

et al. 2008

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“…16 Although symptoms can be relieved, even reoperation can be avoided in some patients by improving access to organs and minimally invasive methods; [17][18][19][20][21][22][23] 30% to 50% of the diffuse duct stenosis or intrahepatic bile duct stenosis patients require a retransplant or they die of complications. 24,25 The mortality in this group of BCS patients was 13.6%, and the retransplant mortality rate was 44.0%, which demonstrates its seriousness.…”

Section: Clinical Manifestations Of Different Pathotypes Of the Biliamentioning

confidence: 73%

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

Zhu¹,

Shen²,

Chen³

et al. 2013

Exp Clin Transplant

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Objectives: To summarize the pathotyping and clinical manifestations of biliary cast syndrome in patients after an orthotopic liver transplant. Materials and Methods: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. Results: 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. Conclusions:Clinical manifestations and cholangiography presentations mainly depend on pathotyping.

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“…It is characterized by the presence of biliary casts and debris causing biliary obstruction. It occurs in 4 %-18 % of OLT recipients [1]. It can present as cholangitis and graft damage or loss.…”

Section: Introductionmentioning

confidence: 99%

“…It can present as cholangitis and graft damage or loss. Twenty-two percent of patients with BCS require repeat OLT [1]. Symptoms include high fever, jaundice and cholestatic liver enzyme elevation [2].…”

Section: Introductionmentioning

confidence: 99%

Untitled

2017

Endosc Int Open

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IntroductionBile cast syndrome (BCS) is a complication of orthotopic liver transplantation (OLT). It is characterized by the presence of biliary casts and debris causing biliary obstruction. It occurs in 4 %-18 % of OLT recipients [1]. It can present as cholangitis and graft damage or loss. Twenty-two percent of patients with BCS require repeat OLT [1]. Symptoms include high fever, jaundice and cholestatic liver enzyme elevation [2]. We describe 2 patients with BCS who were successfully diagnosed with endoscopic retrograde cholangio pancreatography (ERCP) and one of whom was successfully treated endoscopically. Case Reports Patient 1A 65-year-old female underwent OLT 6 months prior to presentation for chronic hepatitis C and hepatocellular carcinoma. Her intraoperative course during liver transplantation was complicated by a significant amount of blood loss from hepatic veins. She had a complicated postoperative course including hemorrhagic shock, abdominal compartment syndrome and acute renal failure which required hospitalization for 2 months after the transplantation. She developed an anastomotic bile leak which was treated with placement of a 10 Fr stent. At 4 weeks and 8 weeks after initial ERCP, the CBD stents were exchanged and secondary sclerosing cholangitis was suspected based on cholangiographic appearance. Her immunosuppression regimen included tacrolimus 9 mg BID and mycofenolic acid 180 mg BID.Laboratory data showed bilirubin of 1. Fig. 1) revealed near complete resolution of the previously described anastomotic stricture. Balloon sweeps yielded a small amount of debris, but cholangiographic findings persisted that were concerning for filling defects or marked ductal irregularity in the region of the common hepatic duct and bifurcation. Cholangioscopy (▶ Fig. 2) was performed with the SpyGlass TM single operator biliary visualization system (Boston Scientific, Natick, MA, USA). A tubular biliary cast, in the shape of the bile duct, was seen in the donor bile duct extending from the anastomosis into the intrahepatic ducts. Attempts to extract the cast with a snare, basket, mechanical lithotripter, balloon, SpyBite TM (Boston Scientific, Natick, MA, USA) biopsy forceps, and standard EGD forceps were all unsuccessful due to inability to grasp the cast and tethering of the cast to intrahepatic extension. A 10 Fr 12-cm CBD stent was placed. In subsequent months, periodic stent changes with continued attempts of removing the bile cast were unsuccessful. The patient's anastomotic stricture has resolved with endoscopic treatment. Patient 2A 58-year-old male with a history of hepatitis C and cirrhosis presented with fevers, chills, and a headache. He also complained of diffuse itching which was affecting his quality of life. He underwent deceased donor liver and kidney transplan-

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

Cited by 71 publications

References 21 publications

Bile duct stones and casts after liver transplantation: Different entities but similar prevention strategy?

Bile duct stones and casts after liver transplantation: Different entities but similar prevention strategy?

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

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