Diagnostic Ultrasound - Abdomen and Pelvis

Liver Transplant Biliary Stricture
IMAGING
• Ultrasound
○ Initial imaging modality for evaluation of biliary system
○ Dilated biliary duct proximal to site of anastomosis
○ Focal area of narrowing may be seen in mid common
hepatic duct or near hepatic hilum (latter in patients with
hepaticojejunostomy)
• Magnetic resonance cholangiopancreatography (MRCP)
○ Heavily T2-weighted image of common hepatic duct
shows upstream ductal dilatation and focal narrowing at
anastomosis
• Cholangiogram
○ Performed in patients with hepaticojejunostomy in
which access to anastomosis difficult with ERCP
• ERCP
○ May be diagnostic as well as therapeutic with balloon
dilation and plastic stent placement
KEY FACTS
TOP DIFFERENTIAL DIAGNOSES
• Obstruction from other causes
○ Choledocholithiasis
○ Malignancy
○ Recurrent primary sclerosing cholangitis (PSC) (in
patients with prior history of PSC)
PATHOLOGY
• Biliary stricture is most common type of complication after
liver transplant, occurring in up to 60%
• In late stricture, > 1 month post-transplant, usually related
to ischemic injury of bile duct anastomosis
CLINICAL ISSUES
• Early stricture
○ Usually responds well to a single endoscopic therapy
• Late stricture
○ Often require longer treatment regimens
Diagnoses: Liver
(Left) Graphic depicts a liver
transplant with focal stricture
in the common bile duct
anastomosis ſt. Notice the
mild upstream dilatation st,
which may be seen with a
biliary duct stenosis. (Right)
Transverse grayscale
ultrasound of the common bile
duct in a patient status post
liver transplant shows a
moderately dilated common
bile duct ſt, which was
related to a biliary duct
stricture at the anastomosis.
(Left) Percutaneous
transhepatic cholangiogram in
a patient with liver transplant
and hepaticojejunostomy
shows a severe stenosis of the
right hepatic duct, at the
junction of the right and
common hepatic duct, near
the hepaticojejunostomy site.
(Right) ERCP in a patient after
liver transplant shows a focal
stenosis in the common bile
duct at the level of the
anastomosis.
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