1283 Liver Abscesses as a Complication of Side-to-Side Choledochoduodenostomy

Abstract

INTRODUCTION: Side-to-side Choledochoduodenostomy (CDD) is a low morbidity surgical procedure commonly performed in the pre-Endoscopic Retrograde Cholangiopancreatography (ERCP) era to provide permanent relief and drainage of the common bile duct (CBD) in patients with retained or recurrent CBD stones, ampullary stenosis or stricture of the CBD. In side-to-side CDD, the distal bile duct becomes a poorly drained reservoir or “sump” as bile is unable to be drained from the area. Bile, stones, or debris may accumulate and lead to inflammation and bacterial growth. In many cases the inflammation in the sump can cause biliary obstruction, recurrent cholangitis, or pancreatitis, incurring the name “sump syndrome”. Although it is rare complication, sump syndrome carries a high mortality. In addition, hepatic abscesses have been reported as a complication. CASE DESCRIPTION/METHODS: A 61-year-old man, with a surgical history of cholecystectomy 15 years ago, presented with acute epigastric pain and severe sepsis. Laboratory studies suggested a biliary source of infection. A computed tomography showed multiple liver abscesses and pneumobilia. Urgent percutaneous biliary drainage with CBD sweep was performed. Cholangiogram demonstrated side-to-side CDD with residual debris in the sump. ERCP revealed choledolithiasis. Sphincterotomy and balloon extraction was performed to remove residual stones and debris. Distal biliary stricture was found and biliary stent was placed. The presentation of biliary disease complicated by liver abscess secondary to retrograde intrahepatic flow and history of side-to-side CDD with typical ERCP findings, established the diagnosis of sump syndrome. DISCUSSION: Hepatic abscesses have an incidence of 3.6 per 100,000 in the US. The majority of these cases are secondary to biliary tree disease, with pyogenic abscesses being the most common. There is limited data regarding abscesses as a late complication of sump syndrome, with few cases reported in the literature. This complication may be due to an obstruction between proximal CBD to duodenum, which leads to regurgitation of bile into intrahepatic bile ducts. Although the incidence of those abscesses is low, mortality remains as high as 12%. It is important to recognize the underlying cause of hepatic abscesses, as timely drainage and antibiotic therapy are essential to prevent significant morbidity. Furthermore, the restoration of normal bile flow from CBD via an ERCP is needed to eliminate any culprit source of infection and reduce recurrence.