Bile duct complications

Bile is a digestive fluid made in the liver to break down fats. Bile ducts carry bile from the liver to the gall bladder and then to the small intestine. You can think of them as drainage pipes.

Around 15-20 in 100 patients develop bile duct complications after a liver transplant.

You have many bile ducts running throughout your liver. During a liver transplant, the main bile duct coming out of the donated liver is joined with your main bile duct. Sometimes, it is not possible to use your main bile duct, for example, if this is the cause of your liver disease. In these cases, a loop of small intestine is joined to the main donor bile duct (hepaticojejunostomy) to allow bile to drain.

Less serious bile duct complications

Sometimes a leak or narrowing (stenosis) of your bile ducts occurs. This happens either within your transplanted liver or at the join between your main bile duct and a donor main bile duct.

More serious bile duct complications

Complications to the bile ducts can also occur due to a lack of blood supply to the ducts. This might be due to a blood clot. This is called ischaemic cholangiopathy.

Ischaemic cholangiopathy can cause jaundice and infection within the liver. You might notice that your eyes or skin have become yellow or that your skin is itchy. Your urine may be very dark. Infections can cause fevers, chills, and pain over the liver.

A leak of bile is usually found in the first days or weeks after a liver transplant when most patients are still in hospital. Sometimes bile can be seen coming out of the tubes (drains) placed around the liver at the end of the transplant. Or a scan done to check on the health of the liver may find fluid around the liver.

Bile duct complications are often picked up on blood tests done after the liver transplant. Special scans of the liver may be needed to see if the bile ducts are diseased or if there are problems with the blood supply to the liver. A liver biopsy may also be needed to check the health of the small bile ducts.

For leaks, a special tube, called a stent (tube) may need to be placed (usually at endoscopy) in the bile duct to allow the leak to dry up. The leak may require placement of a percutaneous drain (passed through the skin in radiology) or a return to theatre to wash out the bile and place drains. 

If there is a narrowing of the bile ducts, this can be fixed with stretching or a stent tube. Biliary stents are usually placed endoscopically (using a small flexible tube with a camera) but if a hepaticojejunostomy was made the stent may need to be inserted through the liver in the radiology department. Stents placed endoscopically have potential complications, including bleeding, pancreatitis or perforation.

Sometimes a return to theatre for more surgery is required for bile duct reconstruction.

Ischaemic cholangiopathy may require a second transplant (re-transplantation).

Some bile duct complications are more common if the liver is from a donation after circulatory death (DCD) donor or if there has been a problem with the blood supply to the liver (hepatic artery narrowing or blockage).

There is a way to lower the risk of ischaemic cholangiopathy in transplants where the liver is from a donation after circulatory death (DCD) donor. This is usually the most severe bile duct complication and is caused by a lack of oxygenated blood in the bile ducts, often as a result of a blood clot. 

The risk is reduced by using new machine perfusion technology to optimise the organ for transplant. These techniques are called Normothermic Machine Perfusion (NMP) and Normothermic Regional Perfusion (NRP).

What is machine perfusion?

In certain situations, the transplant team may feel that it is beneficial to place the liver on a machine before you receive it. The machine circulates blood or fluid into the liver allowing it to survive for longer. This also helps the transplant team to check its condition before it is transplanted into you. This is a new technology which we are learning more about through ongoing research. It may enable us to use more organs in the future, particularly from DCD donors. Machine perfusion is now available in most liver transplant units in the UK and you may be offered a liver following this treatment. If this is thought necessary for the particular liver you have been offered, it will be discussed with you.

Rejection is when your immune system attacks your transplanted liver. It is most common in the first 6 months after a liver transplant, which is why you need immunosuppressants to reduce this risk. 

Chronic rejection refers to long-standing dysfunction of the transplanted liver that is cause by the recipient’s immune system reaction. It occurs in only a small number of liver transplant recipients (around 2 in100). Chronic rejection can lead to destruction of the liver’s bile ducts (ductopenia).

It is important to take immune suppression as prescribed and have regular monitoring of graft function and immune suppression levels.

If identified early, it may be possible to treat chronic rejection. Sometimes the only way to treat this condition is to have another liver transplant. Some patients are not suitable for another liver transplant. 

Learn more about rejection