This study was approved and registered by The Ethics Committee of The General Hospital of Chinese People's Armed Police Forces in January 2011, the Ethics committee approved relating screening, treatment and data collection. The patient signed a written informed consent form. All works were undertaken following the provisions of the Declaration of Helsinki. A 42-year-old male who had a long history of taking traditional Chinese medicine (essential components unknown) underwent an orthotropic liver transplantation in a local hospital on January 14, 2011, having been diagnosed with small venous occlusion disease of the liver subsequent to splenectomy, combined with incurable ascites. The patient was treated with tacrolimus as an antirejection therapy following the surgery, and developed right upper quadrant pain and fatigue. Routine liver function examinations were conducted which showed that the patient's alanine transaminase (ALT), aspartate transaminase (AST) and gamma-glutamyl transpeptidase (GGT) levels were normal and the alkaline phosphatase (ALP) level was 150-250 IU/l. The total bilirubin (TBIL) level gradually increased to 70 mmol/l and the direct bilirubin (DBIL) level gradually increased to 50 mmol/l, both of which were outside the normal range. The patient's serum albumin (ALB) level ranged from 25 to 30 g/l and cholinesterase (CHE) level ranged from 500 to 1300 IU/l. The patient's renal function test indices were: Urea, 20 mmol/l; uric acid (UA), 800-1,000 mumol/l; and creatinine (Cr), 130-140 mumol/l. An ultrasonic B scan of the abdomen showed that there was a low to moderate level of pleural effusion and a large amount of peritoneal effusion; the abdominal computed tomography (CT) and CT angiography (CTA) results showed that anastomotic stenosis was present in the liver artery and inferior vena cava (Fig. 1). The patient received balloon dilatation in the inferior vena cava three times in the local hospital. Following an abdominal CT review, it was revealed that there was no significant stenosis in the inferior vena cava anastomosis; however, the effusion in the patient's abdomen did not decrease. The patient was then prescribed a maintenance treatment comprising a continual protein supply, diuretic therapy, intermittent hydrothorax fluid extraction (with the maximum volume of 1,000 ml yellow-clear fluid) and catheter drainage of ascites (with a volume of 1,000-1,500 ml/day clear-yellow ascites).
The patient was admitted to The Institute of Organ Transplantation on April 24, 2011. The examination results on admission showed that the patient was weak and in a poor general physical condition. The patient cooperated well, but was only able to lie, not sit. A moderate yellowish discoloration of the patient's skin and sclera was observed. The right inferior pulmonary percussion result was dull. Auscultation of the bronchovesicular breath sound was weak, and moist and dry rales, as well as pleural friction rub sounds, were not audible in both lungs. The patient's abdomen was flat and gastroscopy showed no varicose veins in the gastrointestinal tract. The longitudinal splenectomy incision scar of the liver transplant procedure was present in the center of the upper abdomen in an 'L' shape, and had healed well. The patient's abdomen was soft without tenderness, rebound pain, muscle tension or masses. The liver tissue 6 cm under the patient's xiphoid process and 4 cm under the ribs was harder, with blunt edges, and auscultation showed a shifting dullness exited. There was no percussion pain in the region of the liver and kidneys. The patient's gurgling sound in the belly had a frequency of four times per minute and there was no edema in the lower extremities. The left abdominal drainage tube was not blocked and the volume of pale yellow ascites drainage was 1,000-1,600 ml per day, and the urine volume was 500-600 ml per day. The patient's routine blood examination, liver and kidney function and T/B lymphocyte subset test results are shown in Table I. The tests for tests for hepatitis and liver cancer were normal, the autoimmune hepatitis antibody spectrum for antinuclear antibody (ANA) was particle type (1:80) and the immunoglobulin G level and liver fibrosis tests were normal. Furthermore, the erythrocyte sedimentation rate (ESR), adenosine deaminase (ADA) and C-reactive protein (CRP) levels, tuberculosis anti-body (TBAB) and gamma-interferon antibody release test for Mycobacterium tuberculosis in the ascites were all normal. The patient's ascitic fluid was yellow, with a total cell number of 1.12x109/l, and the Rivalta test was negative. The ascites biochemical test results are shown in Table I. An abdominal ultrasound B-mode scan showed that there were diffuse lesions in the graft liver, with no evident blood flow abnormalities, and that the liver was enlarged. The liver was located 4.5 cm under the ribs, and the maximum thickness of the right, left and caudate lobes was 13.60, 8.41 and 2.07 cm, respectively. There was moderate peritoneal effusion and a small amount of right-sided pleural effusion. The lung CT revealed encapsulated effusion in the right side of the thorax, and there was right lower pulmonary atelectasis. The abdominal CT and CTA scan results showed that the liver volume had increased and that stenosis was present in the hepatic artery anastomosis. The test results of the liver biopsy (Fig. 2) showed that the hepatic vein was occluded, and that there was necrosis with blood stasis in the center of the liver, combined with chronic cholangitis.
The patient was treated with methylprednisolone (500 mg/day) as a pulse treatment for two days, with adjuvant antisecretory, gastric mucosa-protective, antibiotic and antiviral (ganciclovir) therapies. When the patient began vomiting on the third day, the pulse treatment was stopped and changed to oral Medrol (Methylprednisolone; 28 mg/day), while the tacrolimus (Prograf) antirejection therapy was stopped and changed to sirolimus tablets (2 mg/day). However, the routine blood examination results for hemoglobin (HGB) decreased significantly (ranging from 80 to 85 g/l), which resulted in the antirejection treatment being adapted with enteric-coated mycophenolate sodium tablets (540 mg/12 h, 3 weeks). In addition, the patient received fluid infusion and treatments to protect the liver, lower transaminase levels, remove jaundice and dieresis, increase ALB and improve the microcirculation of the liver [2 ml/day Prostaglandin E1 injection and 50 ml/day Danhong injection]. The liver gradually reduced in size and was located 2 cm under the xiphoid process and 2 cm under the ribs. The peritoneal drainage volume decreased gradually to 800-1,000 ml/day, the urine volume increased and liver and renal function improved gradually. The liver and kidney function examination results on the patient's 40th day of hospital treatment (Table I) showed that the levels of ALT, AST, TBIL, B macroglobulin, DBIL, urea, UA and Cr had decreased markedly, while the level of CHE had increased. The results of the abdominal ultrasound B-mode scan showed that no significant ultrasonographical or blood abnormalities existed in the graft liver (Fig. 2). The maximum thickness of right, left and caudate lobes was 11.25, 7.84 and 1.69 cm, respectively.
The general condition of the patient improved markedly and an increase in appetite, weight gain and the ability to walk 2-3 km were observed. The patient underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure on June 18, 2011 (day 66 of hospital treatment), from which he recovered well. One week later, the patient's ascites had disappeared and his liver and renal function had returned to normal.