Imaging Liver transplantation post operative dr ahmed esawy include different cases for oral radiodiagnosis examination all over the world CT /MRI ultrasound DUPLEX Plain X ray images 1- Vascular complications : I- Arterial complications (i) Hepatic artery thrombosis. (ii) Hepatic artery stenosis. (iii) Hepatic artery pseudoaneurysm and (iv) arteriovenous (HA and PV) (v) arteriobiliary (HA and biliary tree) fistulae. II- Venous complications: involve the inferior vena cava or the PV and consist of thrombosis or stenosis) 2- Biliary complications : (i) Biliary duct obstruction (due to stricture anastomotic or nonanastomotic. (ii) Bile leak. (iii) other rare biliary complications). 3-Parenchymal complications -Rejection Acute or Chronic rejection. -Hepatic infarction Hepatic abscess Biloma Recurrence of malignancy Fatty liver Complication of biopsy 4- Post-transplant lymphoproliferative disorders 5- Post-transplant malignancies. 6- Postoperative abdominal complications. Hemorrhage Bowel obstruction 7- Chest complications. Pulmonary calcinosis Edema Pneumonia Pulmonary infarction 8- Neurological complications. Hemorrhage Ischemia Abscess and PTLD 10- Infection and fever. 11- Recurrent liver disease. 12- Other long-term complications. a-Arterial hypertension. b-Diabetes mellitus EARLY POSTOPERATIVE EVALUATION Normal postoperative findings Ascites Perihepatic fluid Rt pleural effusion Small lymph nodes Periportal collar Regeneration(LRLT)

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
Dr Ahmed Esawy

2. Postoperative Complications
of Transplanted Liver
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr Ahmed Esawy

3. Postoperative Complications
Vascular Others
Biliary Parenchymal
Dr Ahmed Esawy

4. POSTOPERATIVE COMPLICATIONS OF
LIVER TRANSPLANTATION
1- Vascular complications :
I- Arterial complications
(i) Hepatic artery thrombosis.
(ii) Hepatic artery stenosis.
(iii) Hepatic artery pseudoaneurysm and
(iv) arteriovenous (HA and PV)
(v) arteriobiliary (HA and biliary tree) fistulae.
II- Venous complications: involve the inferior vena
cava or the PV and consist of thrombosis or
stenosis)
Dr Ahmed Esawy

5. 2- Biliary complications :
(i) Biliary duct obstruction (due to stricture
anastomotic or nonanastomotic.
(ii) Bile leak.
(iii) other rare biliary complications).
.
Dr Ahmed Esawy

6. 3-Parenchymal complications
-Rejection Acute or Chronic rejection.
-Hepatic infarction
–Hepatic abscess
–Biloma
–Recurrence of malignancy
–Fatty liver
–Complication of biopsy
Dr Ahmed Esawy

7. 4- Post-transplant lymphoproliferative disorders
5- Post-transplant malignancies.
6- Postoperative abdominal complications.
Hemorrhage
Bowel obstruction
7- Chest complications.
Pulmonary calcinosis
Edema
Pneumonia
Pulmonary infarction
8- Neurological complications.
Hemorrhage
Ischemia
Abscess and PTLDDr Ahmed Esawy

8. 10- Infection and fever.
11- Recurrent liver disease.
12- Other long-term complications.
a-Arterial hypertension.
b-Diabetes mellitus
Dr Ahmed Esawy

9. EARLY POSTOPERATIVE EVALUATION
Normal postoperative findings
Ascites
Perihepatic fluid
Rt pleural effusion
Small lymph nodes
Periportal collar
Regeneration(LRLT)
Dr Ahmed Esawy

10. Vascular Complications
Hepatic artery Hepatic veins
Portal vein IVC
Dr Ahmed Esawy

11. • Duplex image of the
right hepatic vein shows
normal venous phasicity
due to respiration
Dr Ahmed Esawy

12. • Normal hepatic vein on
Doppler, showing
variation during the
cardiac cycle (Quoted
from Sutton et al., 2003).
Dr Ahmed Esawy

13. Venous and Biliary Anatomy
• Normal hepatic venous drainage
• the hepatic vein from the
posterior segment of the right
lobe of the liver (short arrow)
joins the main right hepatic vein
(long arrow) to empty as one
vessel into the inferior vena cava.
Dr Ahmed Esawy

14. • Accessory right hepatic vein
draining into the inferior vena cava
in a 51-year-old man. (a) accessory
right hepatic vein in the posterior
segment (open arrow). The main
right hepatic vein is also visible
(solid arrow).
• (b) Axial volume-rendered image
shows separate drainage of the
accessory right hepatic vein into
the inferior vena cava (arrow).
Dr Ahmed Esawy

15. • main portal vein
• a normal continuous waveform with mild velocity variations due to respiration
• with peak flow velocity of approximately 31 cm/s.
• (Russ PD et al 2004)
Dr Ahmed Esawy

16. • Early post-transplantation evaluation of the portal vein by using spectral Doppler
sonography depicts a normal waveform with peak flow velocity of approximately
31 cm/s.
• (Russ PD et al 2004)
Dr Ahmed Esawy

17. • Variant pattern of branching of
the portal vein, which trifurcates
at the hilum in a 38-year-old man
who underwent evaluation as a
possible donor for living-related
liver transplantation. Coronal
volume-rendered image of the
abdomen enhanced with
intravenous contrast material
shows an early branch of the
portal vein (long arrow) to the
posterior segment of the right
lobe of the liver. Branches to the
left lobe (short arrow) and
anterior segment of the right lobe
are also visible.
Dr Ahmed Esawy

18. • normal hepatic artery at the porta hepatis
• a rapid systolic upstroke with continuous low-velocity diastolic flow
• Normal systole 30-40 cm/sec
• Normal daistole 10-15 cm/sec
• RI more than 0.5
• AT 2-3
Dr Ahmed Esawy

19. • Normal Hepatic artery on Doppler. A normal hepatic
arterial signal is demonstrated on the corresponding
spectral display (Quoted from Sutton et al., 2003).
Dr Ahmed Esawy

20. HEPATIC
ARTERY
Dr Ahmed Esawy

21. Hepatic artery thrombosis
VASCULAR
COMPLICATIONS
12% of adult & 42% of pediatric
Focal ischemia, infarction,
liquifactive necrosis & abscess.
Bile duct necrosis, leak & non
anastomotic strictures Dr Ahmed Esawy

22. VASCULAR COMPLICATIONS
Hepatic artery stenosis
Anastomotic (common)
Non anastomotic with diffuse
intrahepatic narrowing
(rejection)
Dr Ahmed Esawy

23. Hepatic artery complications:
• Hepatic artery stenosis.
• tardus parvus waveform with a
prolonged acceleration time of 220
cmsec, and a low RI of 0.4.distal to
stenosis
• B- Insonation of the vessel more
proximally sowed a focal high-velocity
segment (Quoted from Rumack et al.,
1998).
Dr Ahmed Esawy

24. Hepatic artery thrombosis
Spectral Doppler ultrasound waveform of right
hepatic artery after orthotopic liver transplantation.
Typical rounded tardus parvus waveform, indicative
of upstream arterial thrombosis.
Dr Ahmed Esawy

25. Hepatic Artery Thrombosis
• CT scan shows hepatic artery
thrombosis at the area of
anastomosis (large arrow) with
patency of some distal vessels
(small arrow), probably due to
formation of collateral vessels.
Dr Ahmed Esawy

26. • Volume-rendered
reconstruction image
(anterosuperior view)
shows hepatic artery
thrombosis (arrow).
Dr Ahmed Esawy

27. Hepatic artery pseudoaneurysm
Contrast-enhanced CT scan shows a 4x5cm
hepatic artery pseudoaneurysm in the porta
hepatis. The peripheral hypo-attenuation is
consistent with mural thrombus.Dr Ahmed Esawy

28. Pseudoanneurysms:
• They appear as a rounded area with
internal swirling color flow pattern
like a "yin yang".
• (A) subhepatic cystic mass.
• (B) vascular nature of this cyst.
• (C) a pulsatile high-velocity arterial
jet at the entry point to the
aneurysm.
• (D) Flow within the mass is low-
velocity and monophasic (Quoted
from Rumack et al., 1998).
Dr Ahmed Esawy

29. Arterioportal
Fistula
• Helical CT scan (a) and maximum-
intensity projection reconstruction
image (anterosuperior view)
• (b) show a large arterioportal fistula
secondary to liver biopsy in segment
V (arrows), which is seen as transient
hepatic parenchymal enhancement
during the hepatic arterial phase.
Dr Ahmed Esawy

30. • Hepatic artery thrombosis
• Corresponding contrast material-
enhanced CT image shows the infarcts.
Dr Ahmed Esawy

31. Vascular focal cystic
structure
Hepatic artery pseudoaneurysm
Dr Ahmed Esawy

32. Hepatic infarction following
hepatic arterial thrombosis
Dr Ahmed Esawy

33. focal parenchymal necrosis
(arrowheads)
following hepatic arterial
thrombosis.
Dr Ahmed Esawy

34. PORTAL
VEIN
Dr Ahmed Esawy

35. VASCULAR COMPLICATIONS
Portal vein anastomotic
stenosis abrupt 3- to 4-fold increase in velocity
Aliasing on color Doppler US reflects
turbulent flow associated with PVS.
(Boraschi PE et al 2004)
Dr Ahmed Esawy

36. VASCULAR COMPLICATIONS
Portal vein anastomotic stenosis
Dr Ahmed Esawy

37. Portal vein stenosis
& thrombosis
Spectral Doppler sonogram of the portal vein was
obtained at the onset of graft dysfunction, markedly
accelerated flow to 150 cm/s was documented
Dr Ahmed Esawy

38. Portal Vein thrombosis
Echogenic material is seen in the
vessel lumen (arrows).
Dr Ahmed Esawy

39. • acute incomplete thrombosis
of main stem of portal vein
(arrow) with associated
periportal intrahepatic edema,
ascites, and central bile duct
dilatation.
Dr Ahmed Esawy

40. Portal Vein Thrombosis or Stenosis
• hyperattenuating acute
thrombosis of the left
portal vein (arrow).
Dr Ahmed Esawy

41. • Portal vein thrombosis (Case H). No Doppler
signal can be obtained from a 5 mm sample
gate positioned over the centre of the portal
vein (Quoted from Sutton et al., 2003).
Dr Ahmed Esawy

42. • MPR image shows
severe stenosis of the
portal vein at the
hepatic hilum (arrow).
Dr Ahmed Esawy

43. Portal Vein Complications:
• portal vein stricture.
• (A) aliasing in the anastomotic
consistent with a stricture.
There is poststenoticc
turbulence
• (B) Portal vein duplex signal at
the stricture shows over a
fivefold velocity increase to
110 cm/sec.
• (C) Portal vein duplex signal
proximal to the stricture is
normal, velocity approximately
20 cm/sec (Quoted from
Rumack et al., 1998)
Dr Ahmed Esawy

44. • Anastamotic stricture at the
portal vein anastomosis (arrow)
following transplantation
(Quoted from Ward et al., 1996).
Dr Ahmed Esawy

45. Left portal vein
thrombosis
Dr Ahmed Esawy

46. Extrahepatic portal venous stenosis
Dr Ahmed Esawy

47. • acute incomplete thrombosis of
main stem of portal vein (arrow)
with associated periportal
intrahepatic edema, ascites, and
central bile duct dilatation.
Dr Ahmed Esawy

48. Dr Ahmed Esawy

49. VASCULAR COMPLICATIONS
IVC stenosis IVC
thrombosis
Dr Ahmed Esawy

50. • (a) CT scan shows an end-to-end
anastomosis between the donor
IVC and the stump of the
recipient hepatic veins (arrow),
which was created with the
piggyback technique.
• (b) CT scan obtained at the caudal
level shows the donor IVC (small
arrow) and recipient IVC (large
arrow).
Dr Ahmed Esawy

51. IVC stenosis
Dr Ahmed Esawy

52. IVC stenosis and thrombosis
CT scan shows a thrombus in the
recipient IVC at the suprahepatic level
(arrow) and infected bilomas.Dr Ahmed Esawy

53. IVC
Stenosis or Thrombos
• stenosis of the IVC in its retrohepatic
course (arrow) due to swelling of the
liver graft.
Dr Ahmed Esawy

54. • CT scan shows a thrombus in
the recipient IVC
Dr Ahmed Esawy

55. IVC thrombosis
Dr Ahmed Esawy

56. hepatic vein thrombosis
Dr Ahmed Esawy

57. irregular enhancement of the transplanted liver
. This finding suggests hepatic congestion
Hepatic congestion due to hepatic venous
anastomotic stenosis
Dr Ahmed Esawy

58. 2- Biliary complications :
(i) Biliary duct obstruction (due to stricture
anastomotic or nonanastomotic.
(ii) Bile leak.
(iii) other rare biliary complications).
(IV) dysfunction of the sphincter of Oddi
• (V) Bile duct Ischemia
Dr Ahmed Esawy

59. Biliary Tract Complications
Obstruction Dilatation
Leak Strictures
Bile Duct
Ischemia
Dr Ahmed Esawy

60. Biliary Obstruction
Strictures
T-tube stent dysfunction
kinking of extrahepatic ducts
cystic duct mucocele
biliary sludge or stones
BILIARY COMPLICATIONS
Dr Ahmed Esawy

61. T-tube choledochotomy
bile duct anastomosis sites
duct necrosis caused by
arterial insufficiency
bilomas or bile peritonitis
Biliary leak
BILIARY COMPLICATIONS
Dr Ahmed Esawy

62. Biliary strictures
Anastomotic strictures:
Scar formation
Nonanastomotic strictures:
Preservation injury
BILIARY COMPLICATIONS
Dr Ahmed Esawy

63. Ductal dilatation
Obstructive
Nonobstructive
papillary dyskinesia
BILIARY COMPLICATIONS
Dr Ahmed Esawy

64. Bile leak
CT scan shows an extensive biloma at the
hepatic hilum (*) in a transplant recipient with
failure of the end-to-end suture between both
common bile ducts.
Dr Ahmed Esawy

65. • CT scans show pronounced dilatation
of the intrahepatic bile ducts, with
multiple intraluminal defects
corresponding to biliary sludge lithiasis
(arrows).
• (Quiroga S et al 2001)
Dr Ahmed Esawy

66. CT scans show pronounced
dilatation of the intrahepatic
bile ducts, with multiple
intraluminal defects
corresponding to biliary sludge
lithiasis (arrows). Dr Ahmed Esawy

67. Anastomotic stricture of the bile
duct.
ERCP
HA
Dr Ahmed Esawy

68. • Recurrent sclerosing
cholangitis 1 years after
orthotopic liver
transplantation.
Dr Ahmed Esawy

69. • Intrahepatic bile duct dilatation
in a 14-year-old boy 2 months
after living related
transplantation to treat biliary
atresia.
Dr Ahmed Esawy

70. • Bile duct damage due to
hepatic arterial thrombosis
Dr Ahmed Esawy

71. intrahepatic bile duct dilatation due to
anastomotic stricture, biliary stones
Dr Ahmed Esawy

72. • Intrahepatic biloma as
multiple round low-
attenuation areas (arrows)
and intrahepatic bile duct
dilatation (arrowheads).
Dr Ahmed Esawy

73. • Biliary stone.
Dr Ahmed Esawy

74. • dilated intrahepatic bile
ducts caused by stenosis of
hepaticojejunostomy (not
shown).
Dr Ahmed Esawy

75. Post-transplant H.C.C
CT scan shows recurrence of hepatocellular
carcinoma in the abdominal wall (large
arrow) and liver graft (small arrows).
III-Post-transplant Malignancies
Dr Ahmed Esawy

76. Post-transplant H.C.C
Post-transplant contrast-enhanced axial
gradient-echo MR image obtained during arterial
phase shows early enhancing nodules (arrows) in
right hepatic lobe, indicating recurrent H.C.C.
Dr Ahmed Esawy

77. • CT scan shows gastric
lymphoma (thick arrow)
with regional lymph nodes
(thin arrow)
Lymphoproliferative Disorders
Dr Ahmed Esawy

78. • Recurrent hepatocellular carcinoma
Dr Ahmed Esawy

79. • Posttransplantation
lymphoproliferative disease.
Dr Ahmed Esawy

80. • Nodal and splenic PTLD.
Dr Ahmed Esawy

81. • Patterns of hepatic PTLD. As well-
defined low-attenuating liver
lesions (arrowheads),
representing the most common
pattern of disease
Dr Ahmed Esawy

82. • Patterns of hepatic PTLD
• As a large geographic region
(arrowheads) of low
attenuation from infiltration
by PTLD.
Dr Ahmed Esawy

83. Patterns of
hepatic PTLD
periportal soft-tissue infiltration
(arrows). Diagnosis was made at
biopsy. Note also splenic
enlargement (S).
Dr Ahmed Esawy

84. • Posttransplantation
lymphoproliferative disorder
Dr Ahmed Esawy

85. • Patterns of gastrointestinal PTLD. prominent low-attenuating wall
thickening and aneurysmal dilatation (arrowheads) of a segment of
small bowel. Dr Ahmed Esawy

86. Patterns of gastrointestinal PTLD
central low attenuation involving the sigmoid colon.
Dr Ahmed Esawy

87. • Abdominal wall and peritoneal PTLD.
• lobulated omental soft-tissue mass (curved
arrow) adjacent to the transverse colon and
a nodular mass (straight arrow) in
subcutaneous tissue of anterior abdominal
wall.
Dr Ahmed Esawy

88. PARENCHYMAL COMPLICATIONS
 Hepatic infarction
 Hepatic abscess
 Biloma
 Rejection
 Recurrence of malignancy
 Fatty liver
 Complication of biopsy
Dr Ahmed Esawy

89. PARENCHYMAL COMPLICATIONS
Hepatic Infarction
Peripheral or central
Wedge shaped
No contrast
enhancement
Dr Ahmed Esawy

90. PARENCHYMAL COMPLICATIONS
Hepatic Abscess Biloma
Dr Ahmed Esawy

91. Acute Chronic
PARENCHYMAL COMPLICATIONS
Non specific findings
Reduced PV flow
velocity
Periportal collar
Arterial occlusion
Bile ducts obliteration
REJECTION
Dr Ahmed Esawy

92. Primary Graft Failure:
• Primary graft failure occurs in approximately 7% of patients
and is a very serious complication. The patient
decompensates quickly, and a desperate search for a new
graft must be initiated. Patients show markedly abnormal liver
function, coagulopathy, oliguria, and severe CNS changes
(including seizures and status epilepticus). Stage IV coma,
alkalosis, hyperkalemia, and hypoglycemia characterize the
terminal phase of this acute hepatic decompensation. (Jalan
R et al 1997)
• Urgent re-transplantation is the solution to this complication
if it can be performed before pneumonia or irreversible coma
occurs. (Jalan R et al 1997
Dr Ahmed Esawy

93. • CT scan shows multiple
areas of ischemia
(arrows) in the right
lobe of a patient with
arterial stenosis.
Dr Ahmed Esawy

94. • CT scan shows segment IV
ischemia (arrow) due to
absence of arterial
vascularization in the graft.
Dr Ahmed Esawy

95. • CT scan shows small peripheral
calcifications (arrow), probably
over ischemic preservation lesions.
Dr Ahmed Esawy

96. • shows perihepatic
hematoma (arrows).
Dr Ahmed Esawy

97. • Note postoperative seroma (asterisk) adjacent to parenchymal resection site of
graft (marked by high-density line representing staples), portal vein (arrow),
common hepatic artery (white arrowhead), and perivascular edema (black
arrowheads).
Dr Ahmed Esawy

98. • Decreased liver parenchymal density
• CT image reveals homogeneous low-attenuation parenchyma due to
Microvesicular steatosis in the hepatic lobule
Dr Ahmed Esawy

99. • Periportal collar
• (a) central periportal low-
attenuation area (arrows) and a
small perihepatic fluid
collection (arrowhead).
• (b) peripheral periportal collar
signs (arrows).
• acute purulent cholangitis and
cholestasis.
Dr Ahmed Esawy

100. • Abscess
Dr Ahmed Esawy

101. • round hematoma in segment 4b
as a focal, well-defined cystic
structure with dependent internal
echoes, which delineate a fluid-
fluid level (arrowheads in
• The donor had been in a motor
vehicle accident.
Dr Ahmed Esawy

102. the differential diagnosis for diffuse
parenchymal abnormality in the transplanted
liver is also wide and includes
• rejection
• ischemia
• hepatitis
• cholangitis
Dr Ahmed Esawy

103. Hepatic infarction or necrosis
Dr Ahmed Esawy

104. CT scan shows an extensive
peri- and retrohepatic
hematomas (arrows).
Dr Ahmed Esawy

105. • Intraperitoneal
hematoma
Dr Ahmed Esawy

106. • Paraduodenal hematoma
images show a high-
attenuation focal fluid
collection (arrow) at the
paraduodenal space.
Dr Ahmed Esawy

107. • Adrenal hemorrhage.
Dr Ahmed Esawy

108. CT scan shows an extensive biloma at the hepatic
hilum (*) in a transplant recipient with failure of the
end-to-end suture between both common bile ducts.
Dr Ahmed Esawy

109. • extensive peri- and
retrohepatic hematomas
(arrows).
Dr Ahmed Esawy

110. • scan shows a large,
hyperattenuating
subcapsular hematoma,
Dr Ahmed Esawy

111. Contrast-enhanced axial gradient-echo MR image after liver
transplantation shows hypo-intense hepatic mass with
enhanced thick wall (arrow). Diagnosis of abscess was
confirmed by percutaneous drainage.
Dr Ahmed Esawy

112. Chest Complications
CT scan shows cavitated lung infiltrates
(arrow) in an OLT patient due to
Aspergillus lung infection.
Dr Ahmed Esawy

113. Neurological Complications:
-Hemorrhage
-Ischemia
-Abscess
-PTLD
-alterations of consciousness
-seizures, stroke, tremor
-polyneuropathy.
CT or MRI can be used to detect and differentiate many of the
causes for these symptoms. (Emre S et al 1994)
Dr Ahmed Esawy

114. Infection & Fevers:
• Immunosuppressive therapy leads to a
significant increase in the likelihood of
infections in transplant recipients and this
complication remains the commonest overall
cause of mortality. The risk of infection by
viral, fungal and bacterial agents is well
documented, the responsible organisms
including CMV, invasive candidiasis,
aspergillus, legionella and the more
opportunistic pneumocystis carinii. (O'Grady J
& Sutherland S 1995)
Dr Ahmed Esawy

115. • echogenic focus with a
hypoechoic rim (arrow) in
the left hepatic lobe. (b)
Corresponding contrast-
enhanced CT image shows
the lesion (arrow).
Recurrent liver disease
Dr Ahmed Esawy

116. Other long-term complications:
• (i) Arterial hypertension:
• (ii) Diabetes mellitus
Dr Ahmed Esawy

117. Rejection
(i) Acute rejection: Occur in about 40% of patients during the first 3 months
post-transplant, but commonly 7-14 days after operation. The immune system
attack the transplanted liver and destroy it.
(ii) Chronic rejection: Ducts suffer from direct immunological injury and
ischemia from the obliterative arteriopathy results in progressive jaundice and
allograft dysfunction.
The characteristics of chronic rejection in recipients of LT are progressive bile
duct disappearance and obliterative arteriopathy (known as ductopenia), which
results in progressive jaundice and allograft dysfunction
- Graft biopsy with histologic examination should be performed, if safe, to
document rejection. Adult liver biopsies are routinely performed at the bedside
with or without ultrasound guidance.
- The role of imaging methods consists of excluding the other complications have
clinical signs and symptoms similar to those of rejection.
Dr Ahmed Esawy