Abdominal pain and abnormal liver tests after orthotopic liver transplantation.

A 53-year-old man is seen in clinic 4 months after receiving an orthotopic liver transplant (OLT) for two small (<3 cm in diameter) hepatomas which were discovered incidentally. The patient had a history of heavy alcohol use in his twenties and thirties, but has not used alcohol for over 10 years. Liver histology on the resected organ revealed early micronodular cirrhosis with the two tumor nodules localized to the right lobe. He has been well since leaving the hospital. His T-tube was removed 2 weeks prior to the clinic visit and subsequent endoscopic retrograde cholangiopancreatography (ERCP) (Figure 1). The patient experienced immediate severe discomfort when the tube was withdrawn and he was admitted to hospital for over-night observation and narcotic analgesia. The pain improved by the next day, when an abdominal ultrasound examination was performed; this showed no obvious fluid collection(s) that might suggest a bile leak. His pain persisted for about 1 week, and was managed with oral analgesia. Liver function tests (LFTs) carried out during the overnight hospitalization revealed mildly elevated serum bilirubin at 1.7 mg/dl (normal <1 mg/dl) with aspartate and alanine aminotransferases (AST and ALT) of 180 IU/l and 220IU/l, respectively (both mildly elevated). Alkaline phosphatase was also elevated, at 310 IU/l. Cytomegalo-virus (CMV) serology was positive (a conversion from negative before the transplant).