Endoscopic retrograde cholangiopancreatography and liver biopsy in the evaluation of elevated liver function tests after liver transplantation

Abstract

Background: Abnormal liver function tests (LFTs) in post-liver transplant (LT) patients pose a challenge in the timing and selection of diagnostic modalities. There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) in diagnosing post-transplant complications.

Aim: To evaluate the diagnostic performance of ERCP and LB in patients with non-vascular post-LT complications.

Methods: This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017. Diagnostic operating characteristics including accuracy, sensitivity and specificity for various diagnoses were calculated for ERCP and LB. The R factor (ratio of alkaline phosphatase to alanine aminotransferase) was also calculated for each patient.

Results: Of the 1284 patients who underwent LT, 91 patients (74.7% males, mean age of 51) were analyzed. Anastomotic strictures (AS, 24.2%), acute cellular rejection (ACR, 11%) and concurrent AS/ACR (14.3%) were the most common diagnoses. ERCP carried an accuracy of 79.1% (95%CI: 69.3-86.9), LB had an accuracy of 93.4% (95%CI: 86.2-97.5), and the combination of the two had an accuracy of 100% (95%CI: 96-100). There was no difference between patients with AS and ACR in mean R factor (AS: 1.9 vs ACR: 1.1, P = 0.24). Adverse events did not differ between the two tests (ERCP: 3.1% vs LB: 1.1%, P = 0.31).

Conclusion: In patients with abnormal LFTs after LT without vascular complications, the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.

Keywords: Abnormal liver tests; Acute cellular rejection; Anastomotic biliary stricture; Endoscopic retrograde cholangiopancreatography; Liver biopsy; Liver transplantation.

Figure 1

Photomicrograph of representative portal tract in acute cellular rejection. Mixed, lymphocyte predominant portal-based inflammation, bile duct inflammation characterized by lymphocyte infiltration (circle), and a large portal venule with subendothelial lymphocyte infiltration and intraluminal lymphocyte tethering[24] (hematoxylin and eosin stain, 40 ×).

Figure 2

Cholangiogram during endoscopic retrograde cholangiopancreatography demonstrating an anastomotic stricture (arrow).

Figure 3

Flow diagram of patients. ERCP: Endoscopic retrograde cholangiopancreatography.

Figure 4

Causes of liver test abnormalities after liver transplantation. Legend: Used with permission from Lucey et al[2], 2013. HBV: Hepatitis B virus; HCV: Hepatitis C virus; PBC: Primary biliary cholangitis; PSC: Pulmonary scar cancer.