Ischemic Cholangiopathy—Case Presentation and Review of Literature

Introduction Ischemic cholangiopathy (IC) is a devastating complication typically as a result of hepatic artery insufficiency. The most common etiology is iatrogenic–typically following transplant involving hepatic artery anastomosis. Other etiologies include liver allograft rejection, radiation vasculopathy, de novo hepatic artery thrombosis, and overzealous hepatic artery embolization with chemo impregnated or bland beads. On imaging, the condition is characterized by multiple diffuse biliary strictures in the involved vascular territory combined with areas of biliary dilation and can progress to frank abscess/biloma formation. Depending on the extent and velocity of the arterial occlusion, ischemic cholangiopathy may present as acute formation of biliary casts, bile duct necrosis, or chronic disease. Biliary sepsis is a common cause of both short- and long-term morbidity and mortality.

Case Report A 68-year-old male patient with a history of pancreatic cancer 15 years after a Whipple procedure (in remission) presented to the emergency department with the signs and symptoms of cholangitis, lactate 3.6, and elevated liver enzymes and total bilirubin and was febrile (102.7°F). An imaging revealed biliary necrosis and two large right liver lobe bilomas/abscesses. Those abscesses were drained separately. The patient eventually received two right transhepatic biliary drains. It was later discovered that the patient had thrombosed his hepatic artery. He had a history of chronic superior mesenteric artery (SMA) occlusion—it was unknown whether this was a primary vascular pathology, or the SMA occlusion was related to the Whipple. He now requires frequent drain exchanges (monthly), but otherwise leads a normal life.

Learning Points

• Review the current knowledge on ischemic cholangiopathy, including epidemiology, clinical findings, diagnostic criteria, imaging manifestations, and management.

• Familiarize clinicians with this devastating complication.

• Educate newer trainees on the pathophysiology and management of this condition.