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Ischemic Cholangiopathy

By Nicholas T. Orfanidis, MD, Clinical Assistant Professor, Thomas Jefferson University Hospital

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Ischemic cholangiopathy is focal damage to the biliary tree due to disrupted flow from the hepatic artery via the peribiliary arterial plexus.

Common causes of ischemic cholangiopathy include

  • Vascular injury during orthotopic liver transplantation or laparoscopic cholecystectomy

  • Graft-rejection injury

  • Chemoembolization

  • Radiation therapy

  • Thrombosis resulting from hypercoagulability disorders

Bile duct injury (ischemic necrosis) results, causing cholestatis, cholangitis, or biliary strictures (often multiple). Ischemic cholangiopathy most commonly occurs in people who have had a liver transplant.

Symptoms (eg, pruritus, dark urine, pale stools) and results of laboratory tests and imaging studies may indicate cholestasis.


  • Magnetic resonance cholangiopancreatography, ERCP, or both

The diagnosis is suspected when cholestasis is evident in patients at risk, particularly after liver transplantation. Ultrasonography is the first-line diagnostic imaging test for cholestasis, but most patients require magnetic resonance cholangiopancreatography, ERCP, or both to rule out other causes such as cholelithiasis or cholangiocarcinoma (see Imaging Tests of the Liver and Gallbladder).


  • For rejection, antirejection therapy and possibly retransplantation

  • For biliary strictures, balloon dilation and stenting

Treatment is directed at the cause. After liver transplantation, such treatment includes antirejection therapy and possible retransplantation. Biliary strictures warrant endoscopic balloon dilation and stenting.