Intrahepatic bile duct strictures in a liver allograft recipient mimicking recurrent primary sclerosing cholangitis. Follow-up of a case report.

Sir: Reasons for development of large biliary tract complications after orthotopic liver transplantation (OLT) are varied and include: (a) most commonly, surgical complications from reconstruction of the extrahepatic bile duct [2]; (b) occasionally. recurrence of malignant biliary tract disease [1]; and (c) debatably, recurrence of the original benign biliary tract disease [5,6]. Although a higher incidence of biliary tract complications in primary sclerosing cholangitis (PSC) patients versus other indications for liver transplantation has been reported [4], only 1 of our first 55 patients [3] grafted for PSC developed biliary tract abnormalities suggestive of recurrent primary disease. This communication provides a follow-up of our exceptional patient for whom a detailed clinicopathologic history was pre\'iously provided [2.3]. The patient, with PSC and. at the time. 40 years old. underwent uneventful orthotopic li\'er transplantation in August 1984 (male donor. blood type identical): no HLA typing or crossmatch results were available. The biliary reconstruction was with end-to-side choledochojejunostomy reusing a previously constructed Roux -en-Y limb. the length of which was not mentioned in the operative report. Convalescence was uneventful and the patient was discharged after 20 days with normal liver functions. After 5.5 months. he was readmitted because of an" obstructive" liver enzyme profile. and a percutaneous cholangiogram showed the presence of intrahepatic biliary strictures with a patent biliary anastomosis. A liver biopsy showed early changes of bile duct obstruction without evidence of rejection. viral infection. or drug toxicity. At two other admissions in the next 3 months. liver biopsies showed similar changes. but with progressive portal fibrosis. The arterial and venous allograft vasculature were normal with ultrasound. Case reports were written at this time [2] suggesting that there had possibly been a recurrence ofPSC. Thisconclusion appeared to be strengthened in the subsequent 2427 months. during which the total serum bilirubin fluctuated between 2.0 and 2.5 mg/dl. although the patient was clinically stable [3]. Thereafter. he began to have fatigue.