Liver transplant bile duct suture leading to acute cholangitis. Endoscopic removal via cholangioscopy. Primary author, Emil Thussen. Co-authors, Parsia Vaghafi, Arjman Mufti, and Thomas Tillman. These are our disclosures. A 52-year-old female with a history of cirrhosis secondary to primary biliary cholangitis, status post orthotopic liver transplantation with duct-to-duct biliary anastomosis, presented four years after transplantation with acute right upper quadrant abdominal pain, nausea, and vomiting. They were found to have obstructive jaundice and sepsis consistent with acute cholangitis. CT scan revealed intrahepatic biliary dilation and a 2.7-centimeter filling defect in the mid-to-upper common bile duct, as shown here. ERCP revealed pus emerging from the major papilla and a 27-millimeter stone at the level of the bile duct anastomosis. Electrohydraulic lithotripsy was deferred given active cholangitis. Biliary stents were placed for biliary decompression. Following initial ERCP for source control in the setting of cholangitis, the patient was brought back for repeat ERCP one month later for stent removal and bile duct reevaluation. Cholangiogram again revealed one large stone at the level of the bile duct anastomosis. Therefore, the decision was made to proceed with cholangioscopy with electrohydraulic lithotripsy. As the stone was progressively broken it became evident that there was a suture at the core of the stone as shown here. This raised suspicion that the suture from the prior liver transplant bile duct anastomosis was acting as a nidus for stone formation. As the stone continued to be broken with EHL, a conglomeration of suture was noted at the core of the stone. The suture appeared to still be attached to the wall of the bile duct. A cholangioscope forceps was used to grasp the suture and gently remove it from the bile duct to reduce the risk of future stone formation. The suture was easily removed without any damage to the bile duct noted and no further suture remaining. The final cholangiogram revealed a normal intra and extrahepatic biliary duct system with a mild change in bile duct caliber at the anastomotic site. The patient has not had recurrence of abnormal liver function tests or evidence of choledocal athiasis in one year of follow-up. Clinical Implications. This patient was noted to have cholangitis from a large stone at the level of their biliary anastomosis from a prior liver transplantation. Electrohydraulic lithotripsy revealed residual bile duct suture at the core of the stone which was acting as a nidus for stone formation. The suture was able to be easily removed with cholangioscopy forceps thus removing the nidus for future stone formation and lowering the risk of future complications. Conclusions. Introductal suture from prior biliary surgeries can act as a nidus for bile duct stone formation and result in complications such as biliary obstruction and cholangitis. Suture from remote biliary surgeries can be removed with a cholangioscopy forceps to reduce the risk of future bile duct stone formation and the resulting complications of choledocal athiasis.

liver transplant

acute cholangitis

bile duct stone

endoscopic removal

cholangioscopy