This 40 year old gentleman had undergone a living donor transplant at a foreign centre 7 months ago. He had been compounded with issues including acute cellular rejection and CMV infection. About three months ago he developed cholelithiasis. He underwent ERCP and stone extraction followed by placement of a 7 French 15 cm stent (A1: black arrow shows the stricture site. This may well be a case of sharp angulation of a main graft duct. A2: black arrows indicate the stent). He presented to us with ascites, a right pleural effusion, rising bilirubin levels. His biopsy showed only cholestasis. MRCP indicated a narrowed anastomotic site (B: white arrows shows the site of anastomosis. Red and blue arrows show a sub hepatic collection and a prominent cystic duct stump, respectively). On ERCP contrast injection initially showed a cutoff area (C: black arrow). Further contrast outlined the whole biliary tree (D: red arrows shows the anastomotic site with obvious sharp angle of the main graft duct with the native duct). A 12 cm long stent of 7 French diameter was placed (E: white arrows mark the stent).
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