The document provides information on the evaluation and management of liver transplant recipients and donors. It outlines the various imaging and tests required pre-operatively, peri-operatively and post-operatively for recipients and donors. This includes tests to evaluate the liver and biliary anatomy, vascular patency and fitness. It also describes the follow-up protocol, including Doppler ultrasound and CT scans to monitor for any vascular complications, biliary issues or collections. Algorithms are provided for evaluation of abnormal liver lesions and management of post-operative complications.

4. Pre-OP Per-OP
Post-
OP
Liver imaging

5. Recipient
Donor

6. Diagnosis/Status/Evaluation:
 USG
 TRI-PHASIC CT-SCAN /MRI
(Abdomen & Chest
 Others ( Pet-Scan, Bone-Scan)
 Doppler USG
› Acute PV Thrombosis
(Immediate Pre-Op)
Fitness:
› Chest X-ray
› 2D-Echocardiography
› Thallium Scan/ Stress Echo
› Angiography
Step 1:
 FIBROSCAN / LIVER BIOPSY ( If
HBcAb reactive/ raised Transaminases)
Step 2:
 TRI-PHASC CT-SCAN(Donors
Protocol)
 MRCP
 Pelvic USG ( Immediate pre-op
evaluation in Females to rule out
pregnancy and PID )
Fitness:
› Chest X-ray
› 2D-Echocardiography
RECIPIENT DONOR

7. Multiphasic CT-Scan

9. History/Examination/USG Abdomen
Cirrhosis
Yes No
AFP/Hepatic Mass(USG)CTPA CTPB CTPC
AFP/Hepatic Mass
Decompensation
(Ascites/PSE/Hepatic Mass)
MPCT Abdomen

10.  Liver
› Size
› Surface
› Margins
› Lesions
 Type
 Location
 Size
 Extent ( Local & Extra-Hepatic)
› Arterial Anatomy
› Portal Vein
› Hepatic Veins & IVC.
 Spleen
 Varices / Shunting
 Extra-Hepatic findings
› Lungs
› Renal
› Lymphnodes
› Ascites.
RECIPIENT

11. Per-Op cholangiogram
Repeat MRCP
If MRCP Not Clear
MRCP
Biliary Anatomy
Multiphasic CT Scan
Volumes
Multiphasic CT Scan
LAI Liver Vascular Anatomy
Step 1 Ok

12.  Liver Texture
› LAI
 Fatty Texture
 Fibroscan.
 Biopsy.
› Focal lesion
 Benign.
 Malignant.
 Vascular Anatomy &
Reconstruction
 Volumes.
 Extra-hepatic Evaluation.
› Lymphnode
enlargement.
› Abdominal /Chest
pathology
› Stones & Calcification.
DONOR

13. Recipient
Donor

14. Doppler USG:
› Hepatic Artery
 Velocity & Waveform
 Direction
 Acceleration Time
 Resistive Index
› Portal Vein
 Velocity & Waveform
 Direction
 Flow Volume
› Hepatic Veins
 Velocity & Waveform
 Phase ( Tri-Phasic , Bi-
Phasic, Mono-Phasic)
Cholangiography:
Biliary Anastomosis & Leakage

15. Normal Hepatic Artery
(Transplant Patients )
• PSV <200 cm/sec
• RI = 0.5-0.8
RI May be slightly above 0.8 in
immediate post-operative period
• 2/2 Liver Edema
• continue to follow should
normalize within 3-7 days
• Elevated RI
• Older Patients Grafts (>50)
•Increased pre-intraoperative
ischemic times.

16. Portal Vein
• Monophasic wave
form with respiratory
phasicity
Like bile duct may see
mismatch at portal vein
anastomosis ( Particularly in
Peds Patients.

17. Triphasic Waveform reflecting right artial contractions

18.  Cholangiography:
Pre-Hepatectomy
Post Hepatectomy

19. Pre – Hepatectomy:
Anatomy and Location of Bile Ducts

20. Post – Hepatectomy:
Post repair stenosis & Leakage

21. Recipient
Donor

22.  Chest X-Ray (5 days)(3 days)
› Pleural Effusion
› Pnemothorax
› Infection
› According to need after any intervention
 Doppler USG (5 days)
› Vascular Patency
 Hepatic Artery
 Portal Vein
 Hepatic Veins.
› Biliary Complications
 Bile Leak
 Bile Duct dilatation
 Cholangitis
› Collections
 Intra Hepatic
 Hematoma
 Biloma
 Abscess
 Extra-Hepatic
 Pleural Cavity
 Abdomen
 Pelvic

23. Follow Up
Doppler
CT Scan
CT Angio
IR
Surgical
Exploration
Continue
Follow-up
Artery Not Detected
Artery Not Detected
Artery Not Detected
Arterial Canulation +
Anticoagulation
Arterial Re-
Anastomosis
Native Arterial
Anastomosis AHC
Artery
Detected

24. Altered LFT’s
Doppler
Artery Detected
Liver
Parenchyma
Normal/Biliary
Dilatation
MRCP
Biliary
dilatation/
Narrowing
Yes
ERCP
Stenting/Dilatation /PTBD /Surgery
<3month/>3months/failed ERCP/Failed PTC
NO
Continue
Medical
Treatment
Normal/
ALTERED
CT-Scan
Inconclusive
Biopsy
Rejection
Pulse Therapy
Artery Not
Detected
CT Scan

25. Abdominal
Distension
US Abdomen / CT Abdomen
(plain)
Collection ( Ascites , Hematoma, Biloma )
Drain Re-Adjustment
Aspiration
Drain Placement

26.  Chest X-Ray (5 days)(2 days)
› Pleural Effusion
› Pnemothorax
 Doppler USG (First day)
› Vascular Patency
› Hepatic paranchyma
CXR & USG B4 Discharge :
Collections
 Intra Hepatic
 Extra-Hepatic
 Pleural Cavity
 Abdomen
 Pelvic

27. Abdominal
Distension
US Abdomen / CT Abdomen
(plain)
Collection ( Ascites , Hematoma, Biloma )
Drain Re-Adjustment
Aspiration
Drain Placement

29. - 30 Y/F with mild abdominal pain.
- Focal hypoechoic liver lesion on USG.
- No other significant history.
CASE: 1

30. CASE: 2
- 40 years old farmer with high grade fever and abdominal pain.
- On USG mixed echogencity abnormal lesion in right lobe.
- No other relevant past history.

31. CASE: 3
- 28 years old boy with history of fall.
- Hyper echoic single lesion on USG.
- Alpha feto protein 8.0

32. - 40 years old farmer with fever and mild abdominal pain.
- On USG well defined mixed echogencity liver lesion.
- No other relevant past history.
CASE: 4

33. CASE: 5
- 22 years married girl with history of contraceptive pills 01 year.
- Mild right hypochondrium pain.
- On USG a well defined hypo echoic lesion .

34. - 40 years old farmer with fever and mild abdominal pain.
- On USG well defined mixed echogencity liver lesion.
- No other relevant past history.
CASE: 4

35. - 49 years male, known case of HBV/CLD.
- Alpha Feto Protein 338
-Abnormal lesion on USG during surveillance.
CASE: 6

36. Liver Lesions with Risk Factor for HCC,
↑Tumor Markers, H/O Wt.Loss, malignancy
Yes
Dynamic
CT/MRI
Typical
Vascular
Pattern
Yes
HCC
No
Hyper Vascular
metastasis/
ICCC/Others
NO
(Incidentaloma)
Solid
Dynamic
CT/MRI
Malignant
HCC/Metastasi
s
Benign
Central Scar
Yes
FNH
NO
HCA/BCA/Othe
rs
Cystic
Complex
Pattern
Yes
Complex Cyst
Infection
Yes
Abscess
Hydatid Cyst
NO
Musicsnous
Cyst
Hydatid Cyst
NO
Simple Cyst
Hemangioma

37. Liver Lesions with Risk Factor for HCC,
↑Tumor Markers, H/O Wt.Loss, malignancy
Yes
Dynamic
CT/MRI
Typical
Vascular
Pattern
Yes
HCC
No
Hyper Vascular
metastasis/
ICCC/Others
NO
(Incidentaloma)
Solid
Dynamic
CT/MRI
Malignant
Apperance
HCC/
Metastasis
Benign
Apperance
Central Scar
Yes
FNH
NO
HCA/BCA/
Others
Cystic
Complex
Pattern
Yes
Complex Cyst
Infection
Yes
Abscess
Hydatid Cyst
NO
Mucinous Cyst
Hydatid Cyst
NO
Simple Cyst
Hemangioma
(Blood Pool
Pattern)

38. Presentation abi baqi
he………

39. Dr. Munazza Zafar