IS Case 397: Biliary necrosis (ischemic cholangitis) with biloma after orthotopic liver transplant

Jeremy Sykes, MD

2009 URMC Imaging Sciences
Publication Date: 2010-03-09


Patient is a 50-year-old male with history of orthotopic liver transplant four years ago, followed at outside institution. Now with increased bilirubin, jaundice, weakness.


The images below demonstrate a large, irregular, hypoechoic lesion of the right liver lobe, consistent with a biloma as a consequence of ischemic cholangitis status post orthotopic liver transplant. Resistive indices (not shown) of the hepatic arteries were uniformly decreased relative to the prior study four years ago, suggesting a more proximal arterial stenosis/obstruction.


Biliary necrosis (ischemic cholangitis) with biloma after orthotopic liver transplant


Biliary necrosis refers to destruction of the intrahepatic bile ductal epithelium as a consequence of lack of hepatic artery blood flow and is an important complication in the setting of orthotopic liver transplantation (OLT). Biliary complications are the leading causes of liver dysfunction/failure in transplant patients and occur in 10–30% of such patients.

Biliary necrosis is a subset of ischemic cholangitis, which is a collective term for ischemic bile duct necrosis, cholangitis caused by ischemia but without necrosis, and biliary fibrosis as a manifestation of ischemic damage. Imaging findings may include biliary strictures or biliary duct irregularity with intrahepatic biloma formations. Biliary strictures are generally associated with hepatic arterial thrombosis in approximately 40% of cases, whereas biliary necrosis is associated with hepatic arterial thrombosis in nearly 100% of cases.

Magnetic resonance cholangiopancreatography (MRCP), ultrasound, and percutaneous cholangiogram may be used in the diagnostic evaluation. Key imaging findings for biliary necrosis include an irregular appearance of the walls of the biliary tree with leakage of contrast from the normal confines of the duct in association with biloma formations. Direct hepatic artery assessment with Doppler ultrasound or hepatic artery angiogram (CT or direct) demonstrates lack of flow in the proper hepatic artery. In the setting if ischemia, a "parvus tardus" waveform with low resistive index may be seen on Doppler ultrasound evaluation.

Treatment for biliary necrosis usually involves re-transplantation, if possible.


  1. Valls C, Alba E, Cruz M, et al. Biliary complications after liver transplantation: diagnosis with MR cholangiopancreatography. AJR Am J Roentgenol. 2005 Mar;184(3):812-20. PMID: 15728602
  2. Jersey SL. Biliary Necrosis (Ischemic Cholangitis). MedPix Medical Image Database, Atlas, and Teaching File.

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