KEY FACTS
Imaging
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Ultrasound
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Initial imaging modality for evaluation of biliary system
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Dilated biliary duct proximal to site of anastomosis
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Focal area of narrowing may be seen in mid common hepatic duct or near hepatic hilum (latter in patients with hepaticojejunostomy)
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Magnetic resonance cholangiopancreatography
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Heavily T2-weighted image of common hepatic duct shows upstream ductal dilatation and focal narrowing at anastomosis
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Cholangiogram
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Performed in patients with hepaticojejunostomy in which access to anastomosis difficult with endoscopic retrograde cholangiopancreatography (ERCP)
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ERCP
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May be diagnostic as well as therapeutic with balloon dilation and plastic stent placement
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Top Differential Diagnoses
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Obstruction from other causes
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Choledocholithiasis
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Malignancy
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Recurrent primary sclerosing cholangitis (PSC) (in patients with prior history of PSC)
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Pathology
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Biliary stricture is most common type of complication after liver transplant, occurring in up to 60%
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In late stricture, > 1 month post transplant, usually related to ischemic injury of bile duct anastomosis
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Site of stricture depends on type of biliary anastomosis created
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Clinical Issues
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Early stricture
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Usually responds well to single endoscopic therapy
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Late stricture
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Often requires longer treatment regimens
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