Diagnostic Accuracy of Laboratory Tests and Diagnostic Imaging in Detecting Biliary Strictures After Liver Transplantation.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is often required to diagnose post-liver transplant (LT) biliary strictures. We evaluated the diagnostic accuracy of noninvasive laboratory and imaging tests in detecting post-LT biliary strictures. METHODS: Adult LT recipients who underwent ERCP between 2008 and 2015 were evaluated. Biliary strictures were diagnosed after blinded review of cholangiograms by three interventional endoscopists. The accuracy of liver enzymes, ultrasound, and MRI was determined using cholangiography as the reference standard. To evaluate the accuracy of change in liver enzymes, the difference between baseline and liver enzymes prior to ERCP (Δlab) was utilized. RESULTS: Biliary strictures were present on cholangiogram in 48 (58%) of 82 LT recipients meeting inclusion criteria. Baseline liver enzyme values did not differ significantly between patients with and without strictures. The optimal cutoffs for ΔALT, ΔAST, Δbilirubin, and Δalkaline phosphatase (AP) were determined to be 174 IU/L, 75 IU/L, 3.1 mg/dL, and 225 IU/L, respectively. ΔALT had a sensitivity of 100%, specificity 43%, and negative predictive value 100%. ΔAP had the highest specificity (53%) but modest sensitivity (69%) with a positive predictive value of 67%. Ultrasound had sensitivity of 29% and specificity of 69%, while MRI had sensitivity of 78% and specificity of 56%. DISCUSSION: The diagnostic accuracy of liver enzymes and imaging modalities is modest in detecting post-LT biliary strictures and cannot be used solely to identify patients needing further workup.

Delayed, recurrent bile leak from isolated right posterior sectoral duct injury after laparoscopic cholecystectomy: An unusual presentation.

Bile leak after cholecystectomy is associated with significant comorbidity. Biliary duct variant anatomy can complicate identification and management. We report a very rare presentation of recurrent delayed bile leaks years after laparoscopic cholecystectomy secondary to missed right posterior sectoral bile duct injury. Surgical intervention was required after the failure of conservative management.

Significant infections in liver transplant recipients undergoing endoscopic retrograde cholangiography are few and unaffected by prophylactic antibiotics.

INTRODUCTION: Current practice guidelines recommend prophylactic antibiotics prior to endoscopic retrograde cholangiopancreatography (ERCP) in liver transplant recipients (LTR). This study evaluated the risk of clinically significant infections after ERCP in LTR who received antibiotic prophylaxis compared to those who did not. METHODS: This retrospective case-cohort study evaluated all LTR who underwent elective, outpatient ERCP from 2008 to 2015. Hospitalized patients, pediatric allograft recipients and patients with cholangitis or incomplete biliary drainage were excluded. The primary outcome was unanticipated hospitalization from procedure-related clinically significant infection occurring within 3 days of ERCP. RESULTS: Sixty-nine patients (48 males; mean age 60.5 ±â€¯7.4 years) underwent 191 ERCPs after liver transplantation. Prophylactic antibiotics were administered during 82 ERCPs and not administered for 109 ERCPs. Unscheduled admissions for fever within 3 days occurred in 4 patients. Only 2 patients had documented bacteremia, of which only 1 patient received prophylactic antibiotics and also met primary outcome. Interventions during ERCP, patient demographics, and time from transplantation were not associated with increased risk of hospitalization from infections or bacteremia. CONCLUSIONS: The risk of infectious complications after ERCP in LTR is low and not affected by administration of prophylactic antibiotics. A tailored approach to antibiotic prophylaxis may be more appropriate than universal prophylaxis in selected LTR at low risk of infections.

Recurrent flares of pancreatitis predict development of exocrine insufficiency in chronic pancreatitis.

BACKGROUND & AIMS: The natural history of specific morphologic stages of chronic pancreatitis (CP) is not well defined. The aim of this study was to determine if worsening morphologic stages of CP are associated with poorer clinical outcomes. METHODS: A retrospective analysis of 159 subjects with CP was performed. The baseline stage of CP was categorized according to the Cambridge classification. Pain was categorized as type A (intermittent acute), B (continuous), or combined. Exocrine failure was defined by steatorrhea; endocrine failure was characterized as diabetes mellitus. Complications were defined clinically. RESULTS: Pancreatic duct (PD) morphology was equivocal in 37.1%, minimal in 12.6%, moderate in 7.5%, and severe in 42.8% of the patients. Over a median follow-up period of 3.7 years, the risk of developing exocrine insufficiency and diabetes was 28% and 19%, respectively. Recurrent acute flares of pancreatitis predicted the development of exocrine insufficiency (P = .004). Severe PD morphology predicted the likelihood of having persistent pain (P = .008). Patients with concurrent type A and B pain and older age at diagnosis had a greater likelihood of having persistent pain (P = .021). The risk of developing bile duct stricture was higher in the advanced morphologic stages of CP (P = .005). CONCLUSIONS: Recurrent flares of pancreatitis predispose to the development of exocrine insufficiency in CP. Patients with complex-type pain, older age at diagnosis, and advanced morphologic stage are more likely to have persistent pain. PD morphology does not correlate with the risk of developing exocrine failure and/or diabetes. Pain does not necessarily decrease or disappear with the onset of exocrine insufficiency and diabetes.