Endoscopic Management of Post-Transplant Bile Leak in a 2-Year-Old Child: A Challenging ERCP in the Context of Anastomotic Stricture and Acute Ductal Angulation: a case report.

Biliary complications, including bile leaks and strictures, are among the most serious postoperative issues following pediatric liver transplantation. Managing these in infants and toddlers is particularly challenging due to small anatomy and limited pediatric ERCP expertise. We present a 2-year-old boy with propionic acidemia who underwent liver transplantation complicated by hepatic artery thrombosis, requiring surgical revision. He subsequently developed jaundice, ascites, and cholestasis. MRCP revealed a bile leak at the duct-to-duct anastomosis with a significant stricture and acute angulation. ERCP was technically challenging but successful with stent placement, resulting in rapid clinical improvement. This case highlights the technical complexity and therapeutic value of ERCP in very young pediatric post-liver transplant patients. It demonstrates that with appropriate technique and careful planning, even anatomically challenging bile leaks can be successfully managed endoscopically.