S5466 Persistent Ascites Post-Orthotopic Liver Transplantation: A Tertiary Care Center Case Series

Introduction: Persistent ascites, defined as residual ascites 4 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 3 cases of persistent ascites focusing on portal flow, sinusoidal disease, and venous outflow. Case Description/Methods: Case 1: A 66-year-old woman with alcohol-associated liver cirrhosis underwent orthotopic liver transplant via piggyback technique and presented with new-onset grade II high SAAG low protein ascites 7 months post-transplant. MRI abdomen showed significant portal vein stenosis. Portogram confirmed severe anastomatic stenosis. A 14 mm 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 2 months post-procedure. Case 2: A 38-year-old man post-orthotopic liver transplant presented with hepatocellular transaminitis and grade II high SAAG low protein ascites at 2-month follow-up. AST 950 U/L alanine aminotransferase 1,184 U/L T bilirubin 1.8 mg/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 4 weeks later for refractory ascites. Case 3: A 58-year-old woman 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 8 mmHg refractory to angioplasty. Contrast-enhanced computed tomography 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 3 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.