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
Elevated liver function tests (LFTs) are commonly encountered in the post-liver transplant (LT) setting. When a diagnosis is not made by history, labs, and cross-sectional imaging, endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) are commonly performed. However, the diagnostic performance of each of these tests individually and in combination remains unknown.
We first hoped to determine what are the most common diagnoses in the population of patients with elevated LFTs after LT. At the same time, we want to assess the diagnostic performance of both ERCP and LB in these patients so that we can decide which of these tests is safer and more effective at clinching the diagnosis.
We aimed to assess the diagnostic accuracy and safety of ERCP and LB together and in isolation for a final diagnosis in patients with unexplained LFT elevations after LT.
In this single-center, retrospective study we evaluated patients undergoing both ERCP and LB for the evaluation of elevated LFTs within 6 mo of LT based on review of existing medical records. Diagnostic accuracy, sensitivity and specificity for the various final diagnoses were calculated for each test.
Anastomotic strictures (AS), acute cellular rejection (ACR) and concurrent AS and ACR were the most common diagnoses. ERCP carried an accuracy of 79.1%, LB had an accuracy of 93.4%, and the combination of the 2 had an accuracy of 100% (95%CI: 96-100). The pattern of liver chemistries (R Factor) did not diagnostic accuracy of either test. Adverse event rates did not differ between the 2 tests.
While LB had a higher accuracy than ERCP, the combination of the 2 tests had an accuracy of 100% and a low adverse event rate, suggesting that physicians can have a low threshold in utilizing both modalities for the evaluation of elevated LFTs.
In patients with elevated LFTs after LT without a diagnosis, neither LB nor ERCP is clearly superior. Both tests can be used and the decision to use one over the other will depend on the clinical context and physician preference. However, when necessary both tests can be used safely together to reach a final diagnosis in nearly all patients.