Tintinalli Tuesday: The Liver Transplant Patient.

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August 21, 2012 by EmerJencyWEBB

Busy week last week, but I got the chance to outline this chapter from Tintinalli’s 6th edition.  I don’t see a lot of these patients as our center is not a big liver transplant place, but with increased rates of survival, we are sure to stumble across a few of these patients in our career.  As always, this outline is not all inclusive, only the highlights are presented here.   I have re-organized some content for flow, and have also added a few additional references to supplement your reading.

THE LIVER TRANSPLANT PATIENT

Primary Indication: End Stage Liver Disease that fails more conservative therapy

This is the incision you’ll see on patients’ abdomens:

Typically orthotopic:  placed in the same position as the native organ.

Some patients may present with a percutaneous biliary drain as seen below:

Note: Not all patients attach their biliary drain to water guns.  This is a little gross.

At the time of surgery, if they cannot adequately anastamose the biliary drainage via a choledochocholecochostomy, they have the option of performing a Roux-En Y Choledochojejunostomy, seen below:

COMPLICATIONS SEEN BY EM DOCS (5 B’S)

BLEEDING

Typically an early complication, and GI in origin.  If upper GI bleed, think about varices in these patients which can bleed if the portal vein becomes thrombosed (increasing portal venous pressures).  Also get coagulation profiles on these patients, as a coagulopathy may indicate graft failure.  Treat as you would typically.

BILIARY

These are pipes like any other, and suffer from same complications.  Primarily from leak (anastamosis site or hepatic artery thrombosis) or obstruction (from blockage or stricture).

Biliary Leak Presentation: Fever, Abdominal Pain, Peritonitis, GI sx.

Biliary Obstruction Presentation:  Intermittent Fever, Waxing/Waning LFTs, signs of acute cholangitis.

BLOOD VESSELS

Hepatic Artery Thrombosis:  early complication, signs of hepatic failure, intra-abdominal sepsis.  Require re-transplantation.  Sometimes, surgical thrombectomy may be performed if an early diagnosis can be made.

Portal Venous Thrombosis: as discussed above, upper GI bleed from variceal origin, signs of portal hypertension (ascites, caput medusa, edema, etc)

BUGS

Huge topic.  A better summary of infection in solid organ transplant can be found in this NEJM Review Article.  Click the picture below to be re-directed to article.

BUM LIVER: REJECTION

May occur early as an acute allograft rejection or late as chronic allograft rejection.  Nonspecific symptoms of each including liver tenderness, abnormal LFTs, eosinophilia, fever, etc.  You have to r/o other causes of transplant malfunction/complication.  Gold standard diagnosis is made with a liver biopsy. Treatment left to specialty team, but typically consists of high dose glucocorticoid therapy.

Work Up and Disposition

Initial w/u of most complications should include complete blood counts, electrolytes, LFTs, lipase, coagulation profile, cultures of blood, bile drainage, or ascites.  Ammonia if enephalopathic.  CT abdomen with contrast if available, and RUQ US may be helpful. May require specialized biliary radiography with cholangiography or ERCP in hospital.

Broad spectrum antibiotics if fever, concern for intra-abdominal sepsis given immunocompromised state.  Refer to transplant center where procedure was performed.

ADDITIONAL RESOURCES

Moreno R, Berenguer M.  Post-liver Transplant Medical Complications. Annals of Hepatology.  2006. 5(2): April – June: 77-85.

Ayoub WS, et al.  Biliary Complications Following Liver Transplantation.  Dig Dis Sci.  2010: 55: 1540-1546

Saad W, et al.  Noninvasive Imaging of Liver Transplant Complications.  Tech Vasc Interv Radiol. 2007 Sep;10(3):191-206.

(This outline is only a reference, and is not all-inclusive of ideas presented in the published chapter.  Nor should this be used to guide patient care. Please refer to the definitive text for details beyond the big ideas above.  All credit to the written material above goes to Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 6th Edition)

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