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GE-Portuguese Journal of Gastroenterology

Print version ISSN 2341-4545

GE Port J Gastroenterol vol.31 no.2 Lisboa Apr. 2024  Epub Apr 15, 2024

https://doi.org/10.1159/000533162 

Images in Gastroenterology and Hepatology

Bowel Obstruction after Liver Transplant: A Rare Cause

Obstrução Intestinal Após Transplante Hepático: Uma Causa Rara

Tiago Ribeiro1  2 

Miguel Mascarenhas1  2  3 

Hélder Cardoso1  2  3 

Guilherme Macedo1  2  3 

1Department of Gastroenterology, Centro Hospitalar Universitário de São João, Porto, Portugal;

2World Gastroenterology Organization Gastroenterology and Hepatology Training Center, Porto, Portugal;

3Faculty of Medicine of the University of Porto, Porto, Portugal


We present the case of a 67-year-old man with a medical history significant for orthotopic liver transplant 20 years earlier due to alcohol-related liver cirrhosis. The posttransplant period was complicated with posttransplant lymphoprolifer-ative disease, treated with adjustment of immunosuppressive therapy and systemic chemotherapy, and is currently on remission. This patient developed a biliary stenosis at the level of the biliary anastomosis (choledococholedocostomy), leading to secondary graft cirrhosis. Cross-sectional magnetic resonance cholangiopancreatography demonstrated the anastomotic stricture with a concomitant dilation of the distal common bile duct (native bile duct segment), with recurrent identification of large biliary stones in this dilated section. During the post-transplant follow-up period, he had multiple hospital admissions due to acute cholangitis (last episode in 2018), requiring multiple endoscopic retrograde cholangiopancreatographies for stone extraction. The patient presented to the emergency department with right upper quadrant pain, jaundice, and fever. Laboratory workup revealed elevated total bilirubin (10 mg/dL) and C-reactive protein (77 mg/L). An abdominal ultrasound was performed and revealed a discrete dilation of intrahepatic bile ducts. The patient was hospitalized under antibiotic therapy for acute cholangitis. Given the prior episodes of acute cholangitis and lithiasis and the current clinical presentation, the patient underwent an endoscopic retrograde cholangiopancreatography which showed no evidence of dilated intrahepatic bile ducts or biliary calculi but reported abundant gastric and duodenal stasis content. Over the following days, the patient developed recurrent biliary vomiting and abdominal distension, complicating with prerenal acute kidney injury and portosystemic hepatic encephalopathy. A contrast-enhanced abdominal computed tomography revealed dilation of the jejunal loops, with a maximum diameter of 40 mm, and the presence of obstructing endoluminal content (Fig. 1). Distal to this point, no dilation was evident. Due to his poor physical condition and underlying comorbidities, surgery was considered to carry an unacceptably high risk. A double-balloon enteroscopy (DBE) was performed revealing an impacted biliary stone with approximately 25 mm in the distal jejunum (Fig. 2). The stone was mobilized to the stomach using a polypectomy snare and ultimately removed using a retrieving basket (RothNet®,STERIS,Dublin,Ireland) (Fig.3).Thepatient had resolution of obstructive symptoms and resumed oral feeding with tolerance.

Fig. 1 Axial abdominal CT scan image showing endoluminal content within a jejunal loop (arrow) with upstream small bowel dilation. CT, computed tomography. 

Fig. 2 Gallstone and alimentary debris impacted in the distal jejunum. 

Fig. 3 a Gallstone from the stomach before being removed with a retrieving basket. b Subsequent measurement of the gallstone confirmed its estimated size of 25 mm (photo taken after the specimen had been several hours in a refrigerator for preservation). 

Bowel obstruction is a rare late complication after liver transplantation, occurring in approximately in 1-2% of cases [1]. The most common etiologies include intra-abdominal adhesions and internal hernias [2]. Gallstone ileus is an uncommon etiology of mechanical small bowel obstruction, accounting for up to 4% of all cases, being more frequent in women [3]. Contrast-enhanced computed tomography is the gold standard for the diagnosis of this entity and can be of value for decision-making regarding the therapeutic strategy. To date, cases of gallstone ileus have scarcely been described in orthotopic liver transplant patients. Recently, 2 cases of gallstone ileus have been reported after liver transplantation [4, 5]. In both cases, the patients had been submitted to liver transplantation due to biliary atresia and had a bilioenteric anastomosis, favoring stone migration, and an altered gastrointestinal anatomy (Y-en-Roux jejunojejunostomy). Both cases were managed with enterotomy for stone extraction. Opposite to these reports, in this case, the patient did not have a bilioenteric anastomosis and was managed using an endoscopic technique. Indeed, the location of stone impaction combined with the accessibility to DBE allowed a safe and efficient stone extraction in a patient with a poor surgical condition.

The resolution of gallstone ileus most often requires aggressive fluid and electrolyte followed by early intervention to relieve bowel obstruction [3]. Surgical enterotomy remains the standard of care for stone extraction and resolution of bowel obstruction. Moreover, when the presence of a bilioenteric fistula is responsible for the passage of a large stone to the small bowel, surgery allows the closure of the defect [3]. The use of DBE for resolution of bowel obstruction has scarcely been reported. Nevertheless, DBE can be a valid alternative to the standard surgical approach in patients with a poor preoperative condition. Endoscopic treatment options include electrohydraulic and mechanical lithotripsy, as well as retrieving baskets [6, 7].

References

1. Porrett PM, Hsu J, Shaked A. Late surgical complications following liver transplantation. Liver Transpl. 2009;15(Suppl 2):S12-8. [ Links ]

2. Blachar A, Federle MP. Bowel obstruction following liver transplantation: clinical and ct findings in 48 cases with emphasis on internal hernia. Radiology. 2001;218(2):384-8. [ Links ]

3. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg. 2007;31(6):1292-7. [ Links ]

4. Vanerio P, Morgade P, Rodriguez F, San Martin G, Abelleira M. Gallstone ileus after hepaticojejunostomy in liver transplant recipient: case report. HPB. 2021;23: S581. [ Links ]

5. Komine R, Sakamoto S, Uchida H, Nakao T, Kodama T, Okada N, et al. Gallstone ileus at 17 years after living donor liver transplantation: a case report. Pediatr Transplant. 2023; 27(4):e14517. [ Links ]

6. Heinzow HS,Meister T, Wessling J, Domschke W, Ullerich H. Ileal gallstone obstruction: single-balloon enteroscopic removal. World J Gastrointest Endosc. 2010;2(9):321-4. [ Links ]

7. Bourke MJ, Schneider DM, Haber GB. Electrohydraulic lithotripsy of a gallstone causing gallstone ileus. Gastrointest Endosc. 1997; 45(6):521-3. [ Links ]

1Statement of Ethics All rules of the Local Ethics Committee (“Comissão de Ética para a Saúde do Centro Hospitalar de São João/Faculdade de Medicina da Universidade do Porto, Portugal”) were followed, preserving patient identity and confidentiality. Informed consent was obtained from the patient for the publication of his case. Written informed consent to share the medical case and images was obtained from the patient.

2Conflict of Interest Statement The authors declare that there was no source of funding.

3Funding Sources The authors have no funding sources to declare.

4Author Contributions Tiago Ribeiro: clinical management of the patient, collection of clinical and endoscopic data, bibliographic review, and drafting and critical revision of the manuscript. Miguel Mascarenhas: collection of clinical data, bibliographic review, drafting of the manuscript, and critical revision of the manuscript. Hélder Cardoso: performance of the endoscopic procedure and critical revision of the manuscript. Guilherme Macedo: critical revision of the manuscript and final approval of the manuscript. All authors agree to be accountable for all aspects of the manuscript.

5Data Availability Statement Data are stored in the hospital’s electronic patient database and will be provided upon reasonable request.

Received: March 24, 2023; Accepted: June 21, 2023

Correspondence to: Tiago Ribeiro, tiagofcribeiro@outlook.com

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License