Liver & intrahepatic bile ducts
Liver transplantation
Early onset graft injury
Transplantation - surgical / vascular complications
Editorial Board Member: Monika Vyas, M.D.
Last staff update: 20 February 2023 (update in progress)
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PubMed Search: Liver transplantation complications
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Radiology description | Radiology images | Prognostic factors | Case reports | Treatment | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Positive stains | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Oliveira RC. Transplantation - surgical / vascular complications. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/livertransplantcomplications.html. Accessed April 2nd, 2023.
Definition / general
- Complications after liver transplantation
- Biliary and vascular complications are common
- Important cause of posttransplant morbidity
Essential features
- Biliary and vascular complications are common events after liver transplantation
- These events have implication on overall survival and quality of life of patients
- Retransplantation may be necessary
Terminology
- Post liver transplantation biliary complications include:
- Anastomotic strictures
- Nonanastomotic strictures
- Bile leaks
- Bile duct stones
- Bilomas
- Sphincter of Oddi dysfunction
- Ischemic cholangiopathy
- Thrombosis
ICD coding
- ICD-10: T86.4 - complications of liver transplant
Epidemiology
- A major complication in patients submitted to liver transplantation (GE Port J Gastroenterol 2018;25:1)
- Biliary complications arise in 10 to 15% of patients (BMJ Open Gastroenterol 2022;9:e000778)
- Risk of biliary complications is higher in living donor transplantation, up to 30% (Clin Liver Dis (Hoboken) 2017;10:63)
- Biliary complications are associated with 13% of retransplantation and 19% of mortality (Clin Transplant 2004;18:647)
- Number of arterial anastomoses, low donor weight and previous history of abdominal surgeries are risk factors for hepatic artery thrombosis (Liver Transpl 2014;20:713)
Sites
- Liver
- Bile ducts
- Hepatic artery
- Portal vein
Pathophysiology
- Bile injury is the result of a multifactorial process involving the bile duct
- Cold / warm ischemia, perfusion injury, bile salt toxicity and immune mediated lesions have been described as causative (Virchows Arch 2012;461:41)
- Lesions of the peribiliary vascular plexus and deep biliary glands are thought to be the main cause of nonanastomotic strictures (J Hepatol 2014;60:1172)
- Graft injury, with prolonged cold (> 12 hours) and warm (> 90 minutes) ischemia time (Clin Liver Dis (Hoboken) 2016;7:73)
- Donor quality (affected by donor age, steatosis > 30%, hypotension, small for size allograft) (Clin Liver Dis (Hoboken) 2016;7:73)
Etiology
- Ischemia
- Inflammation
- Infection
- Surgery complications
- Rejection
Clinical features
- Abdominal pain
- Fatigue
- Fever (if infection)
- Jaundice
Diagnosis
- Usually by a combination of clinical, laboratory and radiologic findings
Laboratory
- Liver enzyme increase, namely aspartate aminotransferase (AST)
- International normalized ratio (INR) increase
- Acidosis
- Alkaline phosphatase, gamma glutamyl transferase, total bilirubin and conjugated bilirubin, especially in biliary complication (Ann Hepatobiliary Pancreat Surg 2022;26:76)
Radiology description
- Extravasation of contrast material in the region of the anastomosis on endoscopic retrograde cholangiopancreatography (Clin Liver Dis (Hoboken) 2016;7:73)
- Cholangiography is able to detect strictures in the bile ducts (Clin Liver Dis (Hoboken) 2016;7:73)
Radiology images
Contributed by Ricardo Martins, M.D.
Portal vein thrombosis
Hepatic artery thrombosis
Acute portal vein thrombosis
Nonanastomotic strictures
Prognostic factors
- Early elevation of laboratory values after liver transplantation is associated with biliary stenosis (Ann Hepatobiliary Pancreat Surg 2022;26:76)
- Severe liver injury is defined by AST > 3,000 and INR ≥ 2.5, or acidosis (arterial pH ≤ 7.3 or venous pH ≤ 7.25 or lactate ≥ 4 mmol/L) (Clin Liver Dis (Hoboken) 2016;7:73)
- Encephalopathy is a factor of worse prognosis
Case reports
- 30 year old woman with acute portal vein thrombosis after liver transplant (World J Hepatol 2019;11:234)
- 51 year old man with recurrent hepatic artery thrombosis following living donor liver transplant (SN Compr Clin Med 2021;3:2629)
- 60 year old man with an accidentally ligated and subsequently completely unflushed common bile duct (Int J Surg Case Rep 2017;41:200)
Treatment
- Endoscopic retrograde cholangiopancreatography (ERCP) with balloon dilation or stenting
- ERCP with sphincterotomy
- Endoscopic ultrasound drainage
- Thrombolysis
- Retransplant
- References: World J Hepatol 2016;8:36, World J Hepatol 2021;13:66, World J Hepatol 2015;7:2890
Gross description
- Biliary complications
- Liver explant with biliary obstruction / fibrosis of the bile duct; on cut section, it shows a mild to moderate fibrous tissue with bile casts and green tone
- Vascular complications
- Liver explant with hepatic artery / portal vein thrombosis, with complete / partial occlusion; on cut section, the liver is hemorrhagic and congestive
Gross images
Contributed by Rui Caetano Oliveira, M.D., Ph.D.
Bile casts in cholangiopathy
Liver necrosis
Liver necrosis cut section
Liver necrosis cut section
Liver thrombosis
Microscopic (histologic) description
- Biliary cirrhosis is common after cholangiopathies or at least moderate to severe fibrosis
- Ductular reaction in cases of bile duct obstruction, associated with portal tract edema
- Copper stains may be positive in cases of chronic cholestasis as well as hepatocyte biliary metaplasia
- Sinusoidal dilation and congestion are common in venous drainage complications
- Ischemic necrosis is common in thrombosis
- Reference: Diagn Histopathol 2018;24:508
Microscopic (histologic) images
Contributed by Rui Caetano Oliveira, M.D., Ph.D. and @RaulSGonzalezMD on Twitter
Ischemic cholangiopathy
Sinusoidal dilation
Hemorrhage
Foci of necrosis
Severe necrosis
Extensive necrosis
Extensive liver necrosis
Venous portal tract thrombosis
Major portal branch thrombosis
Bile duct ulceration
Extensive ulceration
Bile duct necrosis
Lipopeliosis following liver transplantation
Biliary cirrhosis
Ductular reaction and biliary metaplasia
Copper accumulation
Positive stains
- CK7 may be useful in demonstrating ductular reaction and hepatocyte biliary metaplasia in cases of biliary obstruction
- Rhodanine stain usually demonstrates copper deposits in periportal hepatocyte in cases of biliary obstruction
Sample pathology report
- Liver, retransplant:
- Biliary cirrhosis due to ischemic cholangiopathy (see comment)
- Comment: There is ulceration of the right biliary duct, with severe inflammation consisting of neutrophils and foamy histiocytes round bile pigment. Hepatic parenchyma exhibits architectural changes, with bridge forming cirrhosis in a jigsaw pattern. CK7 demonstrates a ductular reaction and there is copper accumulation in the periseptal hepatocytes.
Differential diagnosis
- Biliary obstruction:
- Rejection is the major differential diagnosis, with inflammation in portal tracts; in biliary complications, there is edema and ductular reaction (Transpl Int 2010;23:971)
- Ischemic necrosis:
- Paracetamol overload (Vet World 2019;12:1682)
- Sepsis (World J Gastroenterol 2008;14:1389)
Board review style question #1
Liver retransplantation is performed and the image above shows the gross examination. Which of the following is the probable cause?
- Acute rejection
- Biliary complications
- Portal thrombosis
- Primary no function
Board review style answer #1
B. Biliary complications
Comment Here
Reference: Transplantation - surgical / vascular complications
Comment Here
Reference: Transplantation - surgical / vascular complications
Board review style question #2
Which of the following is thought to be the main cause of nonanastomotic strictures?
- Cytomegalovirus infection
- Lesions of the peribiliary vascular plexus and deep biliary glands
- Liver size
- Rejection
Board review style answer #2
B. Lesions of the peribiliary vascular plexus and deep biliary glands
Comment Here
Reference: Transplantation - surgical / vascular complications
Comment Here
Reference: Transplantation - surgical / vascular complications
