Biliary complications following orthotopic liver transplantation: May contrast-enhanced MR Cholangiography provide additional information?

Imaging features of COVID-19-associated secondary sclerosing cholangitis on magnetic resonance cholangiopancreatography: a retrospective analysis

Background

Despite emerging reports of secondary sclerosing cholangitis (SSC) in critically ill COVID-19 patients little is known about its imaging findings. It presents as delayed progressive cholestatic liver injury with risk of progression to cirrhosis. Diagnosis cannot be made based on clinical presentation and laboratory markers alone. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) can aid in the diagnosis. The aim of this study was to describe MRI/MRCP imaging features of COVID-19-associated SSC.

Results

Seventeen patients (mean age 60.5 years, 15 male) who underwent MRI/MRCP were included. All had been admitted to intensive care unit (ICU) (median duration of ICU stay 10 weeks, range, 2–28 weeks) and developed acute respiratory distress syndrome requiring mechanical ventilation. On imaging, all patients had intrahepatic bile duct strictures and 10 (58.8%) had associated upstream dilatation. Intrahepatic bile duct beading was seen in 14 cases (82.3%). Only one patient (5.9%) had extrahepatic bile duct stricturing. Patchy arterial phase hyperenhancement and high signal on T2- and diffusion-weighted images were seen in 7 cases (53.8%) and 9 cases (52.9%), respectively. Biliary casts were seen in 2 cases (11.8%). Periportal lymphadenopathy and vascular complications were not seen.

Conclusion

On MRI/MRCP, COVID-19-associated SSC presents with multiple intrahepatic bile duct strictures with or without upstream dilatation and intrahepatic bile duct beading. Surrounding hepatic parenchymal changes including alterations in enhancement and T2 signal are common. The extrahepatic biliary tree was typically spared and periportal lymphadenopathy was missing in all patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-022-01266-9.

Clinical usefulness of T1-weighted MR cholangiography with Gd-EOB-DTPA for the evaluation of biliary complication after liver transplantation

Backgrounds/Aims

Biliary complications continue to be the major morbidity and mortality causes following living donor liver transplantation (LT). Endoscopic retrograde cholangiopancreatography (ERCP) has been performed to identify the biliary leakage source. However, this can lead to retrograde cholangitis and pancreatitis, and is not sufficient to diagnose bile leakage from cuts' surface. This study aimed to describe the use of T1-Weighted Magnetic Resonance (MR) Cholangiography with Gd-EOB-DTPA (Primovist) examination for evaluating the bile duct complication following LT.

Methods

From March 2012 to December 2018, 869 adult LT were performed at the Seoul National University Hospital. Forty-three recipients had undergone MR Cholangiography with Gd-EOB-DTPA. We reviewed these cases with their clinical outcomes and described the utility of the MR cholangiography with Gd-EOB-DTPA.

Results

In radiologic examinations performed in the patients suspected of bile duct complication, 95% had bile leakage and stricture. Cut surface leakage was diagnosed in two cases, and biliary leakage from the anastomosis site was diagnosed in the others. Most patients with leakage had undergone percutaneous drainage and ERCP, which was performed to evaluate the bile secretion function of the hepatocytes. There was no contrast-enhanced bile duct image in one case with severe rejection, and it might have been related to hepatocyte secretary dysfunction.

Conclusions

T1-Weighted MR Cholangiography with Gd-EOB-DTPA 40-minute delay examination is a feasible and safe non-invasive procedure for identifying biliary leakage sites.

Biliary complications after liver transplantation: current perspectives and future strategies

Importance

Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation.

Objective

The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT.

Evidence Review

a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment.

Findings

Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks.

Conclusions and Relevance

BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.

Can ultrasonography differentiate anastomotic and non-anastomotic biliary strictures after orthotopic liver transplantation- a single-center experience

PURPOSE

To evaluate the role of ultrasonography (US) in differentiating anastomotic biliary strictures (AS) and non-anastomotic biliary strictures (NAS) after orthotopic liver transplantation (OLT).

METHOD

This retrospective study included 1259 OLT recipients between 2005-2018. Seventy-six with anastomotic strictures (AS) and 103 with non-anastomotic strictures (NAS) were analyzed. The reference standard was cholangiography. The sensitivity, specificity, accuracy of US was evaluated.

RESULTS

There were significant differences between AS and NAS groups (p < 0.001) for skipped and irregular dilatation of intrahepatic bile duct and visualization of hilar biliary lumen. The better US imaging feature for NAS was poorly visualized and non- visible hilar bile duct luminal contour. The sensitivity, specificity and accuracy were 94.2 %, 84.2 % and 88.9 % respectively. Combined two predictors greatly increased the specificity to 93.4 % while diminished its sensitivity and accuracy.

CONCLUSION

US is useful and efficient to differentiate AS and NAS after OLT.

Gadoxetate Disodium-Enhanced MR Cholangiography for Evaluation of Biliary-Enteric Anastomoses: Added Value Beyond Conventional T2-Weighted Images

OBJECTIVE. The objective of our study was to evaluate image quality and reader confidence in MR cholangiography of bile ducts using conventional T2-weighted MR cholangiography alone in comparison with T2-weighted MR cholangiography and gadoxetate disodium-enhanced MR cholangiography in a series of patients with biliary-enteric anastomosis (BEA). SUBJECTS AND METHODS. Fifty patients with BEA and clinically and sonographically suspected complications underwent 1.5-T MRI. After acquisition of T1- and T2-weighted images, conventional MR cholangiography was performed using 3D fast relaxation fast spin-echo (FRFSE) and single-shot fast spin-echo (SSFSE) T2-weighted sequences (image set 1). In each patient, a 3D fat-suppressed Liver Acquisition with Volume Acceleration (LAVA) sequence was performed before and 15, 20, 25, 30, and 40 minutes after IV administration of 0.1 mL/kg of gadoxetate disodium (Primovist) (image set 2). Two radiologists in consensus evaluated image quality in the anatomic segments of the biliary tract and recorded diagnostic confidence scores for image set 1 alone and image sets 1 and 2 together. MRI findings were compared with postsurgical specimen if surgery was performed, conventional cholangiography, or 12 months of imaging follow-up. RESULTS. A significant improvement in image quality for visualization of all biliary segments was found using gadoxetate disodium-enhanced MR cholangiography in comparison with T2-weighted MR cholangiography alone. Readers judged diagnostic confidence of image set 1 alone and image sets 1 and 2 together as very confident in three and 37 cases, confident in 30 and 11, not confident in 14 and one, and not confident at all in three and 1, respectively. Concordance between image set 1 alone and image sets 1 and 2 together and the reference standard results was present in 23 of 50 cases (46%) and 47 of 50 cases (94%), respectively (p < 0.0001). CONCLUSION. Gadoxetate disodium-enhanced MR cholangiography can improve image quality for visualization of the biliary tract and further enhanced the diagnostic performance of conventional T2-weighted MR cholangiography in the evaluation of patients with BEA.

Biliary complications after liver transplantation: Assessment with MR cholangiopancreatography and MR imaging at 3T device

PURPOSE

Our study was aimed to assess the diagnostic value of MR cholangiopancreatography (MRCP) and MR imaging at 3 T device when evaluating biliary adverse events after liver transplantation.

MATERIALS AND METHODS

A series of 384 MR examinations in 232 liver transplant subjects with suspected biliary complications (impaired liver function tests and/or biliary abnormalities on ultrasound) were performed at 3 T device (GE-DISCOVERY MR750; GE Healthcare). After the acquisition of axial 3D dual-echo T1-weighted images and T2-weighted sequences (propeller and SS-FSE), MRCP was performed through coronal thin-slab 3D-FRFSE and coronal oblique thick-slab SSFSE T2w sequences. DW-MRI of the liver was performed using an axial spin-echo echo-planar sequence with multiple b values (150, 500, 1000, 1500 s/mm²) in all diffusion directions. Contrast-enhanced MRCP was performed in 25/232 patients. All MR images were blindly evaluated by two experienced abdominal radiologists in consensus to determine the presence of biliary complications, whose final diagnosis was based on direct cholangiography, surgery and integrating clinical follow-up with ultrasound and/or MRI findings.

RESULTS

In 113 patients no biliary abnormality was observed. The remaining 119 subjects were affected by one or more of the following complications: non-anastomotic strictures including typical ischemic-type biliary lesions (n = 67), anastomotic strictures (n = 34), ampullary dysfunction (n = 4), anastomotic leakage (n = 4), stones, sludge and casts (n = 65), vanishing bile duct (n = 1). The sensitivity, specificity, PPV, NPV and diagnostic accuracy of the reviewers for the detection of all types of biliary complications were 99%, 96%, 95%, 99% and 97%, respectively.

CONCLUSION

MR cholangiopancreatography and MR imaging at 3 T device are extremely reliable for detecting biliary complications after liver transplantation.