This 50 year old patient had undergone a living donor liver transplant seven months ago. His latest liver enzymes showed a raised alkaline phosphatase and gamma glutamyl transferase. A liver biopsy showed mild rejection. His MRCP films showed an anastomotic stricture (A: white arrow). On ERCP, we kept going into the pancreatic duct (B: white arrows). We thus decided to leave our guidewire there and go for the CBD with the second wire. This was successful (C: white arrows show the second guidewire in the CBD while black arrows show the first wire in the pancreatic duct). Contrast injection showed a sharp cutoff at the level of anastomosis (D: white arrow). Our standard 0.035 inch guidewire just couldn't negotiate this stricture and we decided to use a thinner 0.025 inch glide wire. This wire was maneuvered across successfully (E: white arrow). Repeat contrast injection showed a picture very similar to the MRCP film (F: white arrow marks the site of anastomotic narrowing and black arrows show the dilated intrahepatic channels). We dilated the stricture with a 9 French graduated dilatation catheter (G: black arrow) and placed a 12 cm long plastic stent of 8.5 French diameter. He will be followed up with serial ultrasounds and LFTs with a second ERCP due in a few months.
No comments:
Post a Comment