Primary sclerosing cholangitis (PSC) is a progressive, cholestatic disease of the liver that is marked by inflammation of the bile ducts and damage to the hepatic biliary tree. Approximately 60–70% of patients also have inflammatory bowel disease and progression of PSC can lead to ulcerative colitis and cirrhosis of the liver. Due to limited understanding of the etiology and mechanism of PSC, the only existing treatment option is orthotopic liver transplantation (OLT); however, recurrence of PSC, after OLT is estimated to be between 5% and 35%. We discuss the successful treatment of a pediatric patient, with recurrent PSC, after OLT with oral Vancomycin. 1. Introduction Primary sclerosing cholangitis (PSC) is a progressive inflammatory disease, of unknown etiology and with significant morbidity and mortality, which damages the intra- and/or extrahepatic biliary tree leading to portal hypertension and cirrhosis of the liver. The clinical course is variable including hepatobiliary carcinoma, especially cholangiocarcinoma in 6–20% of patients [1–6]. Additionally, it is estimated that 60–70% of people with PSC have inflammatory bowel disease [7, 8]. Orthotopic liver transplantation (OLT) is the only treatment option for patients with end-stage liver disease due to the progressive damage caused from PSC [9, 10]. The recurrence of PSC in the new graft is estimated to be between 5–35% [11–13]. We report the successful treatment of a patient after OLT, who had shown recurrence of disease, with oral Vancomycin. 2. Case Report A 12-year-old girl presented with a three-week history of jaundice and lethargy, with periumbilical pain every other day. There had been no recent travel or sick contacts. Screening tests revealed platelet level was low (89？K/uL; normal range 150 to 400). Antinuclear Antibody (ANCA) was positive with a homogeneous pattern, and Antinuclear Antibody Titer was elevated (640; normal range <40). Serum copper was normal at 1065？ug/L and ceruloplasmin was normal at 24？mg/dL. γ-Glutamyl transpeptidase (GGT) level was elevated (139？U/L; reference range from 5 to 36). C-Reactive Protein (CRP) was elevated at 2.80？mg/dL; reference range was from 0.0 to 0.5. PTT was elevated at 48.6？sec; normal range was from 23.3 to 33.8. Prothrombin Time was elevated at 21.0？sec; normal range was from 11.8 to 14.2. INR was increased to 1.9？sec; normal range was from 0.9 to 1.1. Erythrocyte sedimentation rate (ESR) was elevated at 107？mm/hr; bilirubin was elevated at 3.5？mg/dL, and ammonia was elevated at 55？umol/L. Patient underwent an open liver biopsy, which
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