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Strictures after liver transplantation
Last reviewed: 07.07.2025
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Complications of the biliary tract after liver transplantation develop in 10-20% of cases. These include strictures, bile leakage, fistulas and cholangitis. Strictures of anastomoses caused by technical errors, inflammation due to bile leakage and fibrosis, and strictures not associated with anastomoses, formed above the anastomosis in the direction of the porta hepatis, caused in some cases by duct ischemia, may be observed.
The distal part of the bile duct (recipient) receives abundant blood supply from collaterals. The blood supply to the proximal part (donor) is worse and is provided by peribiliary plexuses formed from the reconstructed hepatic artery. After thrombosis of the hepatic artery, bile leakage with necrosis of the duct wall is observed, unrelated to the anastomosis. The development of strictures unrelated to the anastomosis does not seem to depend on the method of bile duct reconstruction (choledochocholedochostomy or anastomosis with a Roux-en-Y loop of intestine). In most cases, strictures in the porta hepatis region develop within 3 months after transplantation.
In addition to ischemia, the development of strictures not related to anastomosis may be promoted by delayed healing due to the use of high doses of corticosteroids, infection, chronic rejection reaction with ductopenia and arteriopathy.
Bile leakage may be associated with T-tubes and occurs when they become displaced or removed. T-tube drainage has been used to prevent biliary complications but has not been shown to affect their incidence, which does not increase in the absence of drainage.
[ Symptoms of strictures after liver transplant
Liver function parameters deteriorate; signs of sepsis may be observed. Other causes of liver function deterioration should be excluded by liver biopsy and serological testing for viral markers. Differential diagnostics include rejection reaction, sepsis of any etiology, cytomegalovirus infection, relapse of the underlying disease, and drug-induced damage.
Diagnosis of strictures after liver transplantation
Signs of bile duct damage may include intermittent increases and decreases in serum bilirubin levels and significant fluctuations in transaminase activity that are independent of immunosuppressive therapy.
Ultrasound reveals dilation of the ducts or bile leaks. Doppler ultrasound is performed to assess blood flow through the hepatic artery. If ultrasound does not reveal pathological changes, a liver biopsy or cholangiography is performed. ERCP reveals bile leaks or strictures.
Treatment of strictures after liver transplantation
Post-transplant strictures (both anastomotic and non-anastomotic) often require revision or reconstruction of the anastomosis; balloon dilation and stent placement are also used. Factors that contribute to successful stricture management using X-ray and endoscopic surgery require further study.