P1770 - Persistent Ascites Post-Orthotopic Liver Transplantation: A Tertiary Care Center Case Series

Makeda Dawkins, MD¹, Daniel Basta, MD², Samuel McCabe, MD¹, Shekher Maddineni, MD¹, Tsipora Huisman-Goldstein, MD¹
1Westchester Medical Center, Valhalla, NY; 2Westchester Medical Center, Elmwood Park, NJ

Introduction: Persistent ascites, defined as residual ascites four weeks post-liver transplantation, occurs in less than 6% of patients, however, carries a markedly increased risk of morbidity and mortality. Etiologies span from pre-hepatic, parenchymal, and post-hepatic abnormalities. This case series reviews three cases of persistent ascites focusing on portal flow, sinusoidal disease, and venous outflow.

Case Description/

Methods: Case 1: A 66-year-old female with alcohol-associated liver cirrhosis underwent orthotopic liver transplant via piggyback technique and presented with new-onset grade II high SAAG low protein ascites seven months post-transplant. MRI abdomen showed significant portal vein stenosis. Portogram confirmed severe anastomatic stenosis. A 14mm balloon was used to dilate the region and an uncovered balloon-mounted stent was deployed with brisk flow on repeat portogram. Complete resolution of ascites was noted two months post-procedure.

Case 2: A 38-year-old male post-orthotopic liver transplant presented with hepatocellular transaminitis and grade II high SAAG low protein ascites at two-month follow-up. AST 950 U/L ALT 1184 U/L T bilirubin 1.8mg/dL Alk Phosp 939 U/L. Liver histopathology showed severe acute cellular rejection, treated with intravenous methylprednisolone and thyroglobulin. He underwent transjugular intrahepatic portosystemic shunt placement four weeks later for refractory ascites.

Case 3: A 58-year-old female status post orthotopic liver transplant via piggyback technique presented with grade III. Transjugular hepatic venogram showed a focal hemodynamically significant stenosis of the central right HV with a pressure gradient of 8mmHg refractory to angioplasty. Contrast-enhanced CT chest and abdomen showed focal allograft herniation of segments 7 and 8 through a diaphragmatic hernia into the right hemithorax. Her persistent ascites was suspected secondary to external HV impingement, thus treated with primary repair of right-sided diaphragmatic hernia.

Discussion: Although refractory ascites is rare, it is associated with high morbidity and mortality. This series details successful treatment of three cases of persistent ascites post-liver transplant with differing etiologies, highlighting the need for algorithmic assessment. Clinical evaluation should be prompt, including histopathologic analysis to rule out rejection, review of the surgical transplantation approach, and assessment of the post-surgical anatomy to ensure allograft survival and improve patient prognosis.

Disclosures:
Makeda Dawkins indicated no relevant financial relationships.
Daniel Basta indicated no relevant financial relationships.
Samuel McCabe indicated no relevant financial relationships.
Shekher Maddineni indicated no relevant financial relationships.
Tsipora Huisman-Goldstein indicated no relevant financial relationships.

Makeda Dawkins, MD¹, Daniel Basta, MD², Samuel McCabe, MD¹, Shekher Maddineni, MD¹, Tsipora Huisman-Goldstein, MD¹. P1770 - Persistent Ascites Post-Orthotopic Liver Transplantation: A Tertiary Care Center Case Series, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.