Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jan 27, 2021; 13(1): 132-143
Published online Jan 27, 2021. doi: 10.4254/wjh.v13.i1.132
Endoscopic retrograde cholangiopancreatography and liver biopsy in the evaluation of elevated liver function tests after liver transplantation
Augustin Attwell, Samuel Han, Michael Kriss
Augustin Attwell, Department of Medicine, University of Colorado-Denver, Denver, CO 80203, United States
Samuel Han, Department of Medicine, Ohio State University Wexler Medical School, Columbus, OH 43210, United States
Michael Kriss, Department of Medicine, University of Colorado Medical School, Aurora, CO 80045, United States
Author contributions: Han S designed and performed and research and wrote the manuscript; Kriss M designed the research and contributed to the analysis and revised the manuscript; Attwell A supervised the study and organized and edited the manuscript.
Institutional review board statement: This study was reviewed and approved by the Colorado Multiple Institutional Review Board.
Informed consent statement: As this was a retrospective study, informed consent was not required from patients.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: Certain additional data from the study results are available from the corresponding author at augustin.attwell@cuanschutz.edu. Otherwise no additional data is available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Augustin Attwell, AGAF, FASGE, Associate Professor, Department of Medicine, University of Colorado-Denver, 601 Broadway MC 4000 Denver, Denver, CO 80203, United States. augustin.attwell@cuanschutz.edu
Received: September 9, 2020
Peer-review started: September 9, 2020
First decision: October 23, 2020
Revised: November 2, 2020
Accepted: December 4, 2020
Article in press: December 4, 2020
Published online: January 27, 2021

Abnormal liver function tests (LFTs) in post-liver transplant (LT) patients pose a challenge in the timing and selection of diagnostic modalities. There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) in diagnosing post-transplant complications.


To evaluate the diagnostic performance of ERCP and LB in patients with non-vascular post-LT complications.


This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017. Diagnostic operating characteristics including accuracy, sensitivity and specificity for various diagnoses were calculated for ERCP and LB. The R factor (ratio of alkaline phosphatase to alanine aminotransferase) was also calculated for each patient.


Of the 1284 patients who underwent LT, 91 patients (74.7% males, mean age of 51) were analyzed. Anastomotic strictures (AS, 24.2%), acute cellular rejection (ACR, 11%) and concurrent AS/ACR (14.3%) were the most common diagnoses. ERCP carried an accuracy of 79.1% (95%CI: 69.3-86.9), LB had an accuracy of 93.4% (95%CI: 86.2-97.5), and the combination of the two had an accuracy of 100% (95%CI: 96-100). There was no difference between patients with AS and ACR in mean R factor (AS: 1.9 vs ACR: 1.1, P = 0.24). Adverse events did not differ between the two tests (ERCP: 3.1% vs LB: 1.1%, P = 0.31).


In patients with abnormal LFTs after LT without vascular complications, the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.

Keywords: Liver transplantation, Endoscopic retrograde cholangiopancreatography, Liver biopsy, Abnormal liver tests, Acute cellular rejection, Anastomotic biliary stricture

Core Tip: Patients commonly develop unexplained elevations in liver function tests after liver transplantation. After cross sectional imaging and basic lab tests, endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) are both performed in arbitrary fashion since the diagnostic capacity of each test remains unclear. In this study we found that ERCP and LB are both effective diagnostic tests in the setting of the 2 most common diagnoses, anastomotic biliary stricture and acute cellular rejection. Combining these tests increases the overall diagnostic accuracy to 100%, and both tests carried adverse event rates of < 5%. This study justifies combining ERCP and LB when the diagnosis remains elusive.