University of Texas Medical Branch Galveston, TX, United States
Christopher Nguyen, DO1, Michelle Baliss, MD2, Kevin Brown, MD2, Milee M. Patel, DO2, Ronak Gandhi, DO2, Frank Ventura, BS2, Rupak Kulkarni, MD1, Michael J. Antony, MD1, Robinder P. Abrol, DO2, Kevin Kline, MD1, Shehzad Merwat, MD1 1University of Texas Medical Branch, Galveston, TX; 2University of Texas Medical Branch at Galveston, Galveston, TX
Introduction: Bile cast syndrome (BCS) is an uncommon complication in 4-18% of orthotopic liver transplantations (OLT). BCS is characterized by biliary obstruction from biliary casts and debris that can present as cholangitis or graft failure. Management is challenging and can require re-transplantation. We describe two cases of post-OLT BCS managed at our institution.
Case Description/Methods: Case 1:
A 55-year-old male with a history of OLT due to alcoholic cirrhosis from donor after cardiac death (DCD) presented one month after transplantation with confusion for two days. Vitals were within normal limits, and physical exam was unremarkable. Labs revealed AST 130 U/L, ALT 198 U/L, ALP 578 U/L, direct bilirubin 2.3 mg/dL. Hepatobiliary scintigraphy showed evidence of common bile duct obstruction and a biliary stent was placed with endoscopic retrograde cholangiopancreatography (ERCP). He developed multiple episodes of cholangitis secondary to biliary casts requiring a percutaneous cholecystostomy and five ERCP to remove bile casts (Figure A-B). He underwent repeat OLT 1.5 years after his initial OLT without further complication.
Case 2:
A 56-year-old female with a history of OLT due to non-alcoholic steatohepatitis from DCD presented four months after OLT with fatigue and nausea for three days. She was febrile and physical exam was unremarkable. Labs revealed AST 89 U/L, ALT 187 U/L, ALP 219 U/L. Computed tomography revealed intrahepatic biliary ductal dilatation. She developed recurrent cholangitis requiring six ERCP to remove biliary casts (Figure C) and one percutaneous cholecystostomy. She underwent hepaticojejunostomy one year after OLT without further complications.
Discussion: While the majority of BCS cases occur within weeks after OLT, BCS can also present several years later and can significantly impact a patient’s quality of life in cases of recurrence. The pathogenesis of BCS is poorly understood but is postulated to be related to ischemic factors or anastomotic biliary stricture formation. Clearance of casts is typically attempted with ERCP, percutaneous approaches or open surgical exploration. The management of BCS can be challenging, particularly with cases involving the intrahepatic biliary ducts which often require multiple procedures due to recurrent cholangitis. Re-transplantation can be indicated when complete cast removal is unsuccessful or in cases of rapid clinical decline. It is crucial to report these cases given the negative impact BCS can have on OLT outcomes.
Disclosures: Christopher Nguyen indicated no relevant financial relationships. Michelle Baliss indicated no relevant financial relationships. Kevin Brown indicated no relevant financial relationships. Milee Patel indicated no relevant financial relationships. Ronak Gandhi indicated no relevant financial relationships. Frank Ventura indicated no relevant financial relationships. Rupak Kulkarni indicated no relevant financial relationships. Michael Antony indicated no relevant financial relationships. Robinder Abrol indicated no relevant financial relationships. Kevin Kline indicated no relevant financial relationships. Shehzad Merwat indicated no relevant financial relationships.
Christopher Nguyen, DO1, Michelle Baliss, MD2, Kevin Brown, MD2, Milee M. Patel, DO2, Ronak Gandhi, DO2, Frank Ventura, BS2, Rupak Kulkarni, MD1, Michael J. Antony, MD1, Robinder P. Abrol, DO2, Kevin Kline, MD1, Shehzad Merwat, MD1. P0849 - Bile Cast Syndrome: A Case Series in Post-Orthotopic Liver Transplant Patients, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
