Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jan 27, 2021; 13(1): 132-143
Published online Jan 27, 2021. doi: 10.4254/wjh.v13.i1.132
Endoscopic retrograde cholangiopancreatography and liver biopsy in the evaluation of elevated liver function tests after liver transplantation
Augustin Attwell, Samuel Han, Michael Kriss
Augustin Attwell, Department of Medicine, University of Colorado-Denver, Denver, CO 80203, United States
Samuel Han, Department of Medicine, Ohio State University Wexler Medical School, Columbus, OH 43210, United States
Michael Kriss, Department of Medicine, University of Colorado Medical School, Aurora, CO 80045, United States
Author contributions: Han S designed and performed and research and wrote the manuscript; Kriss M designed the research and contributed to the analysis and revised the manuscript; Attwell A supervised the study and organized and edited the manuscript.
Institutional review board statement: This study was reviewed and approved by the Colorado Multiple Institutional Review Board.
Informed consent statement: As this was a retrospective study, informed consent was not required from patients.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: Certain additional data from the study results are available from the corresponding author at augustin.attwell@cuanschutz.edu. Otherwise no additional data is available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Augustin Attwell, AGAF, FASGE, Associate Professor, Department of Medicine, University of Colorado-Denver, 601 Broadway MC 4000 Denver, Denver, CO 80203, United States. augustin.attwell@cuanschutz.edu
Received: September 9, 2020
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
Research background

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.

Research motivation

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.

Research objectives

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.

Research methods

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.

Research results

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.

Research conclusions

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.

Research perspectives

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.