Excerpt from Transplants, Liver

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Background

Application and success of orthotopic liver transplantation (OLT) has continued to grow, and liver transplantation has become accepted therapy for several causes of irreversible liver disease. As of 2005, 76,575 liver transplants had been reported to the United Organ Sharing network since it created a national database in 1988. In 2005, 6,444 liver transplants were performed and 17,645 patients were on the waiting list for transplantation. With the increased number of transplants, chances are greater that a transplant patient will present to the ED. Basic knowledge of medical care involved in treatment of the transplant patient will assist ED physicians in evaluation.

The most common indications for liver transplantation in the United States are hepatitis C virus (30%) and alcoholic liver disease (18%). Others include idiopathic/autoimmune liver disease (12%), primary biliary cirrhosis (10%), primary sclerosing cholangitis (8%), acute liver failure (7%), hepatitis B virus (6%), metabolic liver disease (eg, inborn errors of metabolism) (3%), cancer (3%), and others (3%). Biliary atresia is a common indication in pediatric patients. Chances of survival following orthotopic liver transplantation are good, with a 5-year survival rate of 72%. The most common causes of death in liver transplant patients (beyond the early in-hospital transplant period) are infection, rejection, and malignancy.

For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Hepatitis Center. Also, see eMedicine's patient education article, Cirrhosis.

Transplantation considerations

Orthotopic liver transplantation involves excision of the recipient's liver and division of the inferior vena cava, superior vena cava, portal vein, hepatic artery, and common bile duct. Because of the disruption of portal and inferior vena caval blood flow, venovenous bypass is necessary to divert blood from these vessels to the superior vena cava during the anhepatic phase of the procedure. The donor liver is anastomosed at the vascular sites with care taken to preserve hepatic arterial blood flow. The bile duct is usually anastomosed to the recipient's, but choledochojejunostomy may be performed. A T-tube is used to stent the biliary duct postoperatively for several weeks, allowing monitoring of bile production as one marker of postoperative hepatic graft function.

A number of complications are possible in the immediate postoperative period, including acute rejection and early graft failure, as well as vascular and biliary complications. However, these early complications usually are identified during the posttransplant hospital stay and are not observed by the emergency physician. Complications likely to be observed in the ED are discussed later in this article.

Please click here to view the full topic text: Transplants, Liver