Although frequently subtle in presentation, a syndrome of acute rejection includes fever, liver tenderness, lymphocytosis, eosinophilia, liver enzyme elevation, and a change in bile color or production. In the perioperative period, the differential diagnosis must include infection, acute biliary obstruction, or vascular insufficiency. Diagnosis can be made with certainty only by hepatic ultrasound and biopsy, which usually requires referral back to the transplant center for management and follow up.
Two possible surgical complications in liver transplant patients are biliary obstruction or leakage and hepatic artery thrombosis. Biliary obstruction follows 3 typical presentations. The most common is intermittent episodes of fever and fluctuating liver function tests. The second is a gradual worsening of liver function tests without symptoms. Third, obstruction may present as acute bacterial cholangitis with fever, chills, abdominal pain, jaundice, and bacteremia. It can be difficult to distinguish clinically from rejection, hepatic artery thrombosis, CMV infection, or a recurrence of a preexisting disease, especially hepatitis.
If a biliary complication is suspected, all patients should have a complete blood count; serum chemistry levels; liver function tests; basic coagulation studies; and lipase levels; cultures of blood, urine, bile, and ascites, if present; chest radiograph; and abdominal ultrasound. Ultrasound looks for the presence of fluid collections, screens for the presence of thrombosis of the hepatic artery or portal vein, and identifies any dilatation of the biliary tree. Alternatively, abdominal computed tomography can be used.
Biliary leakage is associated with 50% mortality. It occurs most frequently in the third or fourth postoperative week. The high mortality may be related to a high incidence of concomitant hepatic artery thrombosis, infection of leaked bile, or difficult bile repair when the tissue is inflamed. Patients most often have peritoneal signs and fever, but these signs may be masked by concomitant use of steroids and immunosuppressive agents. Presentation is signaled by elevated prothrombin time and transaminase levels and little or no bile production, but this complication also may present as acute graft failure, liver abscess, unexplained sepsis, or a biliary tract problem (leak, obstruction, abscess, or breakdown of the anastomosis).