I had almost three years of perfect health following my liver transplant until my liver enzymes tripled in May. An abdominal ultrasound and liver biopsy showed no abnormalities. However, a magnetic resonance cholangiopancreatography found slight dilation of my common bile duct. My transplant team initially decided to monitor my bloodwork before conducting an invasive procedure.
In late August, I met with Dr. William Stassen, my gastroenterologist, to discuss my colonoscopy. The day before, he and my transplant hepatologist had spoken about my worsening liver function. They agreed to have Dr. Stassen’s colleague, Dr. Binh Pham, perform an endoscopic retrograde cholangiopancreatography (ERCP) immediately.
What is an ERCP?
Inflammatory bowel disease (IBD) patients are at high risk of developing disorders of the pancreas and the biliary tract, which includes the liver and the gallbladder.
To diagnose and treat these conditions, a gastroenterologist guides an endoscope — a camera attached to a flexible tube — through the patient’s mouth, esophagus, stomach, and small intestine. The doctor injects dye through a catheter to view pancreatic or biliary ducts by X-ray. The flow of the dye can indicate pancreatic disease, gallbladder inflammation or stones, and biliary conditions.
The gastroenterologist can insert tools into the scope to crush and remove stones in the bile ducts or gallbladder. The doctor can also collect tissue samples or perform a biopsy. In my case, Dr. Pham widened my biliary duct stricture with balloons and a stent.
I had my first ERCP in 1997 to diagnose and treat primary sclerosing cholangitis (PSC). Until I changed gastroenterologists in 2006, I had ERCPs almost yearly so my doctor could evaluate the progression of my disease and place or revise balloons and stents. I tolerated the procedure well and could return to my normal routine the next day.
Once, however, I came out of sedation as the team removed the endoscope. I became feverish and nauseated afterward. Even after that horrific incident, I wasn’t too nervous about my upcoming ERCP. Then, I learned that my liver transplant made the procedure more complex.
Having an ERCP with a Roux-en-Y
Surgeons have two options when transplanting a donor liver into the recipient. The first is a choledochocholedochostomy, which connects the donor’s and recipient’s common bile ducts. The second is a Roux-en-Y choledochojejunostomy or hepaticojejunostomy.
A Roux-en-Y involves surgeons bisecting the recipient’s small intestine at the jejunum or middle section. They stretch the long end of the intestine upward to attach it to the donor’s duct. Surgeons then reconnect the duodenum, the first segment of the small intestine, to a new opening in the jejunum.
The Roux-en-Y is the preferred method for PSC patients because the diseased bile ducts are often removed with the liver. Also, a study of United Kingdom PSC transplant patients discovered a higher risk of stricture complications in duct-to-duct reconstruction compared to Roux-en-Y.
During my Roux-en-Y, Pham had to maneuver the endoscope down my duodenum and then angle it upward to reach my biliary ducts. Stassen told me later that Pham is one of two gastroenterologists in south-central Texas to perform the intricate procedure successfully. That’s why my reluctant transplant team became so eager to intervene after talking to Stassen.
I don’t know if the Roux-en-Y or the protocols have changed over the last 15 years, but this ERCP was vastly different. Previously, I remained in bed. This time, the nurse strapped me to a cold, steel operating table.
Usually, the anesthetic courses coolly through my veins as I drift into unconsciousness. This time, the anesthesiologist warned me the medication would feel warm. As the warmth entering my hand turned into crackling static electricity as it moved up my arm, I panicked. I think I started hyperventilating as the sensation raced across my shoulder to my neck. The last thing I remember is my lips going numb.
As expected, my throat was sore afterward. But I was shocked that my entire core ached like I’d done a major workout. I was groggy and had brain fog for at least four days, too. Now I know what to anticipate when I have the balloons removed in November. I just hope this doesn’t become an annual procedure.
Using a 6-millimeter stent, Pham dilated the opening between my bile duct and intestine that scar tissue had almost completely closed. Stassen was so ecstatic after reviewing the ERCP report and images that he called from his personal line to celebrate Pham’s success.
My bloodwork from earlier this month found that 85% of my alkaline phosphatase was from my liver and 15% was from my bones. None of it came from my intestine, as I had assumed. The case of my elevated liver enzymes has been solved. If last week’s labs show improved liver function, both doctors foresee no further complications.
I dedicate this column to the memory of Supreme Court Justice Ruth Bader Ginsburg. Ginsburg had an ERCP in late July to revise a bile duct stent placed in August 2019. Her resilience in overcoming various health issues empowers me to battle my own with the same warrior spirit.
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