Author: Dr. O. Adeyi
*This is part two of a series – make sure to read part one first to get the whole story!*
Thankfully, John’s surgery uneventful, but the transplant surgeon, Dr. Ahote, worried about a nodule he noticed on the liver that he was about to transplant. As a precaution he had biopsied the nodule and asked the pathologist to advice him what the nodule was.
Dr. Bud Forrest, the pathologist, was not a stranger to late night calls as he runs a 24-hour shift whenever he is on call. He was available to do a quick processing on the biopsy and announced to a relived Dr. Ahote the nodule was only a bile duct hamartoma that did not preclude use of the liver for transplant.
Such quick processes (or frozen tissue diagnoses) are precious steps that enable a pathologist to rapidly examine a biopsy, sometimes while a patient is still under anesthesia, and sometimes leads to significant change in surgical plans. This is especially important in patients undergoing surgery for cancer, or as in this case, to evaluate the quality of a donor organ being planned for transplantation.
John was a great patient, and his recovery was a dream. As part of his post-operative follow up, a clinical pathologist (a different pathologist than Dr. Forrest) oversees the daily monitoring of biochemical tests (such as liver enzymes) to ensure quality and appropriate interpretation. John’s liver enzymes (substances found in the blood whose levels change in parallel to injury to liver tissue) quickly settled down in the first week of transplant.
However by the middle of the second week, on the eve of his discharge, the liver enzymes began to go up signaling some new injury was present. This was not unusual and nothing a slight adjustment of his drugs to prevent his body rejecting the organ would not fix. However John’s discharge had to be postponed to ensure the drug adjustments did the trick. But it didn’t work and the enzymes continued to rise.
This was definitely unusual; if this is a simple case of rejection the steps already taken should at least in part alter the rising trend.
So if this isn’t rejection, what is it?
Why is the liver showing signs of new injury having initially recovered as expected after transplant?
It is now 14 days post-transplant and four days of persistent rise in liver enzymes – so now is the time when we do a liver biopsy, as only the pathologist could help. Doing a biopsy entails inserting a special needle through the skin into the liver. This could be done sometimes by simply feeling for the liver but most times are done by radiologists, who use X-ray equipment to visualize the liver and guide the needle properly.
A piece of tissue is obtained and sent to the pathologist in a special preservative. Dr. Forrest received a call from Ms. Bends, the transplant nurse co-coordinator, who explained to him why they had just done an urgent liver biopsy on John with the hope of getting Dr. Forrest’s opinion before the end of the day.
Dr. Forrest was used to this situation since he works in a big transplant hospital; in fact, this type of biopsy could be regarded as the norm as hardly a day goes by without a few such biopsies coming in from one or more of the liver, kidney, lung, or heart transplant service.
Dr. Forrest understood the significance of making the right call on these biopsies as a wrong diagnosis could potentially lead the clinicians in the wrong direction – the last thing anyone wanted was to lose a patient or the graft, which is invariably scarce, to wrong treatment.
The pathologist in Dr. Forrest knows there is no room for errors and understands the urgency of the situation – so, what’s responsible for John Marshall’s enzyme count?
Is his body rejecting the new liver?