0:01

So this is a patient who, uh, I believe came

0:03

from an outside institution, and so we really

0:06

didn't have a lot of history, but you know what

0:08

we had was a patient in his 60s with abdominal pain.

0:12

And here's a CT scan, and we were

0:15

asked to look at it and figure

0:16

out what we thought was going on.

0:18

So, axial images with intravenous contrast.

0:21

Let's focus on the liver to start

0:22

with, and very quickly you see

0:24

there's a large mass in the liver.

0:27

The borders are quite irregular,

0:29

and it's really big.

0:31

It's encompassing large portions of

0:34

both the right and left hepatic lobes.

0:36

It's a fairly solitary mass.

0:38

There's a component here, I think, that's

0:39

just sort of connected to it inferiorly,

0:42

but it's sort of an isolated mass.

0:43

You can see that it's having mass effect

0:45

upon the portal veins over here, which

0:47

look like they're almost draped over it.

0:49

And there's probably some inflammatory

0:50

change with the adjacent liver.

0:51

You can see the liver here a

0:53

little bit more hypodense than the

0:54

adjacent liver parenchyma over here.

0:57

And so irregular borders, large hepatic mass.

0:59

And so what else can we glean from this patient?

1:02

Well, the other thing we notice is that

1:03

the patient is post liver transplant.

1:06

Okay.

1:06

I know that because you can look at the IVC over

1:08

here and notice there's some sutures around it.

1:11

And there's not a whole lot of

1:13

procedures in which you'll start

1:14

to see sutures surrounding the IVC.

1:16

And one of the reasons you see that is

1:18

because almost all these transplants utilize

1:20

something called a piggyback technique for

1:23

IVC anastomosis where the donor IVC is done.

1:27

Attached to the recipient IVC and

1:30

this anastomosis, this bright hyper

1:32

dense stuff here is the anastomosis

1:34

is just where that suture line is.

1:36

And you can see here is the donor

1:38

IVC and here's the recipient IVC.

1:40

So that alone informs me that

1:42

the patient is post-transplant.

1:44

And so if I start to see a large sort of

1:48

cystic mass with irregular borders, certainly

1:50

looks like it, it should be infected and

1:53

certainly could be infected in a patient

1:55

who has a liver transplant, my mind

1:58

immediately goes to could this reflect a

2:01

biloma, could that biloma be infected.

2:05

And that's sort of one of the

2:06

things you have to think about.

2:08

And when you think

2:09

go down that pathway.

2:11

The next thing you have to think

2:13

about is why do patients get bilomas

2:16

in the post-transplant setting?

2:17

Common reason is because the

2:20

hepatic artery is compromised.

2:22

Either it's completely thrombosed

2:24

or it has severe stenosis.

2:26

As a result, you have limited

2:28

arterial supply to the liver.

2:31

That itself is not a huge deal because you have

2:34

the portal vein that supplies most of the liver.

2:37

But it is a big deal to the bile ducts

2:39

because the hepatic artery is the sole

2:42

vascular supply to the biliary tree.

2:45

If that vascular supply is compromised for any

2:48

reason, you're going to get biliary ischemia.

2:51

And as a result, bile leaks with these bilomas

2:55

that form can get infected and have quite

2:58

devastating consequences for the patient.

3:01

So, a large collection in a transplant patient,

3:04

I'm thinking of biloma, so the next thing

3:05

I've got to look at is the hepatic arteries.

3:07

So let's look at the aorta and see if we can

3:10

find the hepatic arteries in this patient.

3:12

This is the celiac artery.

3:14

And really, from the celiac, granted

3:16

this is not a CTA, it's not a study

3:19

that's optimized to look at the arteries.

3:21

But nevertheless, you should be seeing

3:23

something going to the liver, and you really

3:26

don't see anything going rightward toward

3:28

the liver, where you expect to see it.

3:30

In fact, if you look very closely, you

3:32

can see that maybe there's a little

3:34

blip of it wanting to come out here.

3:37

For the most part, it's just soft tissue here.

3:39

There's no hepatic artery that I can see.

3:41

Visualize that even, you

3:43

know, it's going to the liver.

3:45

So now I'm much more concerned about hepatic

3:47

artery thrombosis with bilomas forming.

3:50

And the other interesting thing in this

3:51

patient, and we don't have a lot of

3:52

history, but there's in fact, this graft

3:54

that's coming from the aorta, right?

3:56

Look at it over here.

3:57

It's coming all the way upwards, all

3:59

the way upwards, all the way upwards.

4:00

And then in fact, that's going to the liver.

4:02

So in some liver transplant patients, you

4:05

know, they create these hepatic arterial

4:07

grafts, which is what this is in this patient.

4:10

In order to supply the liver.

4:12

But if you look at the graft itself,

4:14

it's completely thrombosed as well.

4:15

There's no contrast going through it.

4:18

So these overall findings are very

4:21

concerning for hepatic artery thrombosis

4:24

in a post-liver transplant patient,

4:26

resulting in biliary ischemia

4:28

and biliary leaks with a large biloma.

4:31

Forming in the liver.

4:33

And in fact, this is what

4:34

happened in this patient.

4:36

And this requires a lot of treatment in

4:38

terms of not only draining the biloma,

4:40

but trying to open up that hepatic

4:41

artery in order to provide flow to the

4:45

hepatic parenchyma and the biliary tree.

4:48

And so here we have images from an IR

4:50

study where they've tried to treat

4:52

this biloma with a drainage catheter.

4:54

They've attempted to sort of

4:56

open up the hepatic artery.

4:58

But the reason I wanted to show this is you

5:00

know, they're injecting the biliary

5:01

tree over here, and what you can see

5:03

nicely, um, is that there are bile leaks.

5:07

You see how when they inject the bile ducts

5:09

over here, some of the bile ducts are leaking,

5:12

and that's as a result of that biliary

5:13

ischemia due to that hepatic artery thrombosis.

5:17

And some of those bile leaks over here

5:20

over time will organize in the liver and

5:22

form that large biloma that we can see

5:25

on our images, and that's being drained

5:27

by this drainage catheter over here.