The most common complications in liver transplant arise from the gastrointestinal tract. These complications may range from mild to moderate disease, such as diarrhea or nausea, to more severe, life-threatening ones, such as colon perforation, digestive bleeding, or others. They can be related to medications, infections, or exacerbations of preexistent pathology. Risk factors include previous operation, steroid therapy, prolonged portal venous cross-clamp time, poor nutritional status, and iatrogenic injury.
Peptic ulcer disease (Fig. 90-1) is the most frequent etiology of gastrointestinal bleeding in these patients due to prolonged steroid therapy and nonsteroidal anti-inflammatory drug (NSAID) use. Hemoperitoneum (Fig. 90-2) in the first days after transplant can occur with secondary coagulation disorders.
Bleeding peptic ulcer (black arrow) in a 22-month-old girl, 6 months after a related living-donor liver transplant.
A CT scan showed a hemoperitoneum after liver transplant (white arrows).
Sometimes patients with biliodigestive anastomosis can present bleeding either in the anastomosis or enteroenterostomy of the Roux-en-Y. Varices may persist following hepatic transplantation, but they rarely bleed in the absence of portal vein thrombosis (Fig. 90-3). Colonic ulcers are rare. They are often related to infections with opportunistic microorganisms.
Variceal banding in a 22-year-old patient 4 years after liver transplant secondary to hepatitis C virus. The white arrow shows the varice and the black arrow the banding.
Steroid administration can induce gut perforation (Fig. 90-4). Steroids stimulate the secretion of gastric acid and pepsin, inhibit the secretion of gastric mucus, and reduce the resistance of the gastric mucosal barrier, which can induce ulcers and perforate vulnerable sites in the gut (Fig. 90-5). Segments of the bowel can be inadvertently injured during the hepatectomy.
A CT scan showed pneumoperitoneum (white arrow) secondary to gut perforation of unknown etiology, 15 days after transplant.
Hartman procedure due to colon perforation, 15 days after liver transplant. The black arrow shows the terminal ostomy.
It is important to note that a choledochocholedochostomy obviates the need for entry into the gastrointestinal tract and thus eliminates the possibility of gut fistula. Enteric leaks, because of immunosuppression, can sometimes be subtle. In this type of patient early diagnosis of gut perforation may be difficult, and if the diagnosis is delayed, the condition may be life-threatening. Patients often have fever, increased leukocytes, abdominal pain, and tenderness.