Complications of liver biopsy in liver transplant patients: increased sepsis associated with choledochojejunostomy

The nature of complications following liver biopsy in transplant patients with Roux-en-Y choledochojejunostomy

Liver biopsy is an important diagnostic tool in the management of patients following orthotopic liver transplant. We evaluated complications following percutaneous liver biopsy in a group of liver transplant patients who had Roux-en-Y choledochojejunostomies fashioned as part of their biliary reconstruction during liver transplantation. Complications were divided into two major groups: septic complications (including fever, symptomatic bacteremia, cholangitis, infected hematoma and hypotension related to sepsis) and bleeding (defined as hypotension requiring volume expansion greater than 500 cm3 or blood transfusion, hemothorax, intrahepatic or peritoneal hemorrhage and hemobilia occurring within 1 wk of liver biopsy). One hundred ninety-two biopsies were performed in 46 patients with choledochojejunostomies, and 118 biopsies were carried out in an age- and sex-matched control group of patients with choledochocholedochostomy biliary anastomosis. There were no septic complications in the choledochojejunostomy patients and one (0.32%) septic complication in the choledochocholedochostomy patients (NS). Eight bleeding complications occurred (2.6%) in eight patients (8.3%). Five (2.6%) occurred in five (10.8%) of the choledochojejunostomy patients, vs. three (2.5%) in three (6.5%) choledochocholedochostomy patients (NS). None of the bleeding complications required surgical intervention or was fatal. We conclude that liver biopsy in posttransplant patients with Roux-en-Y choledochojejunostomies is a safe procedure and that the incidences of complications were similar in our two groups. The negligible incidence of septic complications in the choledochojejunostomy patients does not appear to warrant the administration of prophylactic antibiotics, as has been previously suggested.

Neutrophil cytoplasmic autoantibodies after liver transplantation in patients with primary sclerosing cholangitis

The immunopathogenic importance of neutrophil cytoplasmic autoantibodies in ulcerative colitis and primary sclerosing cholangitis is unknown. These autoantibodies were investigated before and after liver transplantation in 9 patients with primary sclerosing cholangitis. Sera from 10 patients transplanted for metabolic disorders or hemangioma served as controls. Before liver transplantation neutrophil cytoplasmic autoantibodies, producing a perinuclear pattern by indirect immunofluorescence on ethanol fixed neutrophils, were present in all patients with primary sclerosing cholangitis. A decline in titer was noted in the first months after liver transplantation. During long-term follow up, the autoantibodies remained present and most often the titer did not differ from before transplantation. They were not directed against proteinase 3, myeloperoxidase, elastase or lactoferrin. All but one of the control patients were negative for the autoantibody. No relation was seen, before or after transplantation, with ulcerative colitis or proctocolectomy. There was no recurrence of primary sclerosing cholangitis in any of the patients as judged by liver histology. We conclude that neutrophil cytoplasmic autoantibodies remain present after liver transplantation for primary sclerosing cholangitis and that its synthesis is not related to the presence of the diseased organ(s). The primary disease process in primary sclerosing cholangitis and ulcerative colitis may well be a disturbance of the immune system.

Antibiotics may predispose to lactobacillemia in liver transplant patients

Lactobacilli are ubiquitous inhabitants of the human oral cavity, vagina, and gastrointestinal tract, that are generally considered non-pathogenic. We retrospectively reviewed all positive blood cultures for Lactobacillus species (sp.) from liver transplant recipients at our institution. Eight cases of lactobacillus bacteremia were identified. Selective bowel decontamination with non-absorbable oral antibiotics was administered to all patients. Additionally, all patients received intravenous vancomycin; most isolates exhibited either in vitro or in vivo vancomycin resistance. The biliary anastomosis in each patient was a Roux-Y choledochojejunostomy. The underlying clinical conditions included perihepatic abscesses in two patients, biliary strictures with either hepatic abscesses or infected bile in four, and heaptic infarctions with necrosis and infection of the liver in two. The use of selective bowel deontamination, intravenous vancomycin and Roux-Y choledochojejunostomy in liver transplantation patients may predispose to lactobacillemia.