title: Clinical algorithm to guide the need for endoscopic retrograde cholangiopancreatography to evaluate early postliver transplant cholestasis.
abstract: OBJECTIVE
  Severe cholestasis after liver transplant is common. In this study, our aim was to develop an algorithm to guide biliary intervention in these patients.
  
  
  METHODS
  A retrospective review was performed on patients who had undergone a hepatobiliary scan, with or without subsequent endoscopic retrograde cholangiogram, during the immediate postoperative period. These findings were evaluated along with laboratory values to determine the benefit for this evaluative process. Biliary duct obstruction was defined as > than a 50% reduction in serum bilirubin within 48 hours of endoscopic retrograde cholangiogram intervention.
  
  
  RESULTS
  Twelve patients had endoscopic retrograde cholangiogram with 6 stents in 25 patients with normal a hepatobiliary scan, and 2 patients met criteria for biliary duct obstruction. Twenty-two patients had endoscopic retrograde cholangiogram with 14 stents in 32 patients with delayed uptake, suggesting hepatocellular dysfunction on a hepatobiliary scan, and 4 patients met criteria for biliary duct obstruction. In the 57 patients with severe hyperbilirubinemia, 6 patients (11%) had biliary duct obstruction as a cause. Among the 34 endoscopic retrograde cholangiograms performed, 17% had biliary obstruction. On multivariate analysis, patients having both serum aspartate transaminase concentrations < 1500 IU/L and serum total bilirubin levels > 257 μmol/L had an odds ratio of 25.1 for predicting biliary obstruction (95% CI: 6-37; P = .002).
  
  
  CONCLUSIONS
  A hepatobiliary scan with a combination peak serum aspartate transaminase and peak serum total bilirubin levels offer a valuable tool to identify patients with hepatocellular dysfunction and can avoid endoscopic retrograde cholangiogram in the immediate posttransplant period.
authors.affiliation: From the University of Tennessee Health Sciences Center, Methodist University Transplant Institute, Memphis, TN, 38104 USA.
authors.forename: Satheesh
authors.initials: S
authors.lastname: Nair
authors.forename: Shilpa
authors.initials: S
authors.lastname: Lingala
authors.forename: Sanjaya K
authors.initials: SK
authors.lastname: Satapathy
authors.forename: James D
authors.initials: JD
authors.lastname: Eason
authors.forename: Jason M
authors.initials: JM
authors.lastname: Vanatta
mesh_terms: D000328:Adult; D000465:Algorithms; D001219:Aspartate Aminotransferases / Q000097:blood; D001663:Bilirubin / Q000097:blood; D015415:Biomarkers / Q000097:blood; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002779:Cholestasis / Q000097:blood / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy; D004796:Clinical Enzyme Tests; D019091:Critical Pathways; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007098:Imino Acids; D008111:Liver Function Tests; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D015609:Organotechnetium Compounds; D018579:Patient Selection; D011237:Predictive Value of Tests; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D016896:Treatment Outcome; D019564:Unnecessary Procedures
chemical_list: D015415:Biomarkers; D007098:Imino Acids; D015609:Organotechnetium Compounds; D019275:Radiopharmaceuticals; C046767:technetium Tc 99m iminodiacetic acid; D001219:Aspartate Aminotransferases; D001663:Bilirubin