From the Guidelines
The patient should be taken to the emergency department or transplant center urgently for assessment, as the combination of norovirus infection and new onset of white stools (acholic stools) suggests potential biliary complications that require immediate medical evaluation. For a 67-year-old male liver transplant recipient with norovirus infection and new onset of white stools, the clinical presentation is concerning for biliary obstruction or other complications that are common in transplant recipients, as noted in studies on biliary complications in liver transplant patients 1. The patient's history of liver transplant and recent norovirus infection increases the risk for biliary complications such as bile leaks, bilomas, anastomotic strictures, and diffuse biliary strictures, which can occur in up to 10-25% of posttransplant patients 1.
Initial Management
Initial management should include:
- Supportive care with intravenous fluids to prevent dehydration from the norovirus infection
- Symptomatic management of norovirus infection with antiemetics like ondansetron 4-8mg every 8 hours as needed
- Careful fluid and electrolyte monitoring
- Diagnostic workup to include liver function tests, bilirubin levels, ultrasound of the liver and biliary tract, and possibly MRCP or ERCP to evaluate for biliary obstruction
Biliary Complications
Biliary complications in liver transplant recipients can be related to the type of biliary reconstruction used during the transplant, with duct-to-duct anastomosis and Roux-en-Y choledochojejunostomy being the two primary methods 1. The patient's white stools indicate an absence of bile pigment reaching the intestine, which could result from biliary strictures, stones, or other obstructions. These complications are more concerning in transplant recipients, as they can lead to graft dysfunction and other serious outcomes.
Immunosuppression Adjustment
Immunosuppression may need temporary adjustment under the guidance of the transplant team to manage the norovirus infection and potential biliary complications. This situation represents a potentially serious complication, and close monitoring and management by the transplant team are essential to prevent dehydration, renal function compromise, and medication absorption issues.
From the Research
Patient Presentation
The patient is a 67-year-old male with a history of liver transplant, recently diagnosed with norovirus infection, and now presenting with white stools (acholic stools).
Potential Complications
- Biliary complications are a major cause of morbidity in liver transplant recipients, with an incidence of 10-30% following whole-organ transplantation 2, 3.
- Norovirus infection can cause chronic diarrhea in immunocompromised patients, including transplant recipients, with a duration of chronic diarrhea varying from four weeks up to nine years 4, 5.
- The patient's new onset of white stools may indicate a biliary complication, such as a biliary obstruction or leak, which can be related to various factors, including technical reasons, hepatic artery patency, or chronic ductopenic rejection 2, 3.
Management
- The management of biliary complications after liver transplantation requires a multidisciplinary approach, with conservative, interventional, and endoscopic treatment options available 2, 3.
- For norovirus infection, rapid diagnostic modalities and newer therapies are being explored, including oral immunoglobulins, nitazoxanide, and ribavirin 5, 6.
- The patient's condition should be closely monitored, and further evaluation, including imaging studies and laboratory tests, may be necessary to determine the underlying cause of the white stools and to guide treatment.