P3884 - Recurrent Ascending Cholangitis and Polymicrobial Hepatic Abscesses in a Patient With Porto-Biliary Fistula After Liver Transplantation

Brenda Amuchi, MD, MPH¹, Joseph Cappuccio, DO¹, Mohammad Almeqdadi, MD^2
1Lahey Hospital and Medical Center, Burlington, MA; ²Lahey Hospital, Burlington, MA

Introduction: Liver transplant recipients with primary sclerosing cholangitis (PSC) can develop recurrent PSC, anastomotic strictures and ascending cholangitis. We present a unique case of a liver transplant (LT) recipient with PSC who developed a porto-biliary communication resulting in polymicrobial hepatic abscesses.

Case Description/Methods: A 52-year-old man with a medical history of Crohn's disease (on high dose steroids), type 2 diabetes, PSC cirrhosis who underwent a living donor LT in 2012. His post-transplant complications included nonanastomotic and anastomotic strictures requiring multiple percutaneous transhepatic cholangiograms (PTCs), and recurrent ascending cholangitis. In March 2023, a PTC revealed biliary venous communication, which was stented (Figure 1A). In April 2023, he presented with a one-week history of fever, jaundice, abdominal pain, and worsening liver function tests. CT abdomen showed multiple ill-defined hypodense areas within the allograft. Biopsies grew Candida albicans and Lactobacillus species. The patient was treated with fluconazole and penicillin. Worsened symptoms prompted repeat CT imaging which showed a new liver abscess, not previously seen on prior imaging along with sequelae of portal hypertension (Figure 1B). Liver biopsy confirmed recurrent cirrhosis. Abscess cultured Methicillin Resistant Staph Aureus. He was subsequently treated with imipenem and micafungin and evaluated for a repeat LT given his MELD Na of 30 with good outcomes.


Discussion: This case highlights the cascade of complications that can occur following LT in patients with PSC necessitating vigilant monitoring and early intervention. Ascending cholangitis and anastomotic strictures requiring frequent instrumentation may have predisposed the development of a port-biliary fistula resulting in hepatic abscesses. His other risk factors included PSC, colonic Crohn's disease with long-term prednisone management and poorly controlled diabetes. Prompt identification and management of complicated cholangitis can significantly improve patient outcomes.



Disclosures:


Brenda Amuchi, MD, MPH¹, Joseph Cappuccio, DO¹, Mohammad Almeqdadi, MD². P3884 - Recurrent Ascending Cholangitis and Polymicrobial Hepatic Abscesses in a Patient With Porto-Biliary Fistula After Liver Transplantation, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.