Published online Jan 27, 2021. doi: 10.4254/wjh.v13.i1.132
Peer-review started: September 9, 2020
First decision: October 23, 2020
Revised: November 2, 2020
Accepted: December 4, 2020
Article in press: December 4, 2020
Published online: January 27, 2021
Abnormal liver function tests (LFTs) in post-liver transplant (LT) patients pose a challenge in the timing and selection of diagnostic modalities. There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) in diagnosing post-transplant complications.
To evaluate the diagnostic performance of ERCP and LB in patients with non-vascular post-LT complications.
This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017. Diagnostic operating characteristics including accuracy, sensitivity and specificity for various diagnoses were calculated for ERCP and LB. The R factor (ratio of alkaline phosphatase to alanine aminotransferase) was also calculated for each patient.
Of the 1284 patients who underwent LT, 91 patients (74.7% males, mean age of 51) were analyzed. Anastomotic strictures (AS, 24.2%), acute cellular rejection (ACR, 11%) and concurrent AS/ACR (14.3%) were the most common diagnoses. ERCP carried an accuracy of 79.1% (95%CI: 69.3-86.9), LB had an accuracy of 93.4% (95%CI: 86.2-97.5), and the combination of the two had an accuracy of 100% (95%CI: 96-100). There was no difference between patients with AS and ACR in mean R factor (AS: 1.9 vs ACR: 1.1, P = 0.24). Adverse events did not differ between the two tests (ERCP: 3.1% vs LB: 1.1%, P = 0.31).
In patients with abnormal LFTs after LT without vascular complications, the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.
Core Tip: Patients commonly develop unexplained elevations in liver function tests after liver transplantation. After cross sectional imaging and basic lab tests, endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) are both performed in arbitrary fashion since the diagnostic capacity of each test remains unclear. In this study we found that ERCP and LB are both effective diagnostic tests in the setting of the 2 most common diagnoses, anastomotic biliary stricture and acute cellular rejection. Combining these tests increases the overall diagnostic accuracy to 100%, and both tests carried adverse event rates of < 5%. This study justifies combining ERCP and LB when the diagnosis remains elusive.