1360 Cholecystohepatic Fistula With Liver Abscess From Gallbladder Perforation in a Patient With Ascending Cholangitis

Abstract

INTRODUCTION: Ascending cholangitis can lead to liver abscess (LA). Intrahepatic gallbladder (GB) perforation with fistula formation is an uncommon cause of LA. The co-occurrence of all 3 phenomena is rare. CASE DESCRIPTION/METHODS: An 88-year-old man with a history of idiopathic fibrosing pancreatitis diagnosed 3 months prior that required stenting of the common bile duct (CBD) presented with 4 days of malaise, nausea, vomiting, and fever. Endoscopic retrograde cholangiopancreatography (ERCP) showed occluded CBD stent coated with stone material. Successful biliary sphincterotomy and stone extraction was performed. The patient's symptoms initially resolved but recurred later that day. On exam he was tachycardic, tachypneic, and febrile to 103.1 F, with pain in the right upper quadrant (RUQ) of the abdomen without guarding nor rebound. Labs showed WBC 33.4 k/mm3, total bilirubin 2.2 mg/dL, ALP 488 U/L, AST 43 U/L, ALT 39 U/L, and lipase 44 U/L. RUQ ultrasound (US) showed a heterogeneously hypoechoic right liver lesion 6.3 × 7.4 × 4.3 cm in size, consistent with LA and noted to be contiguous with the GB, which had a thickened wall, an irregular sloughing appearance concerning for gangrenous cholecystitis, and contained sludge, gallstones, and air. A percutaneous cholecystostomy drain was placed by interventional radiology (IR). Intra-procedure sinogram and US showed the LA to be connected to the GB. A second percutaneous drain was placed into the LA. Abscess cultures were polymicrobial. The patient was treated with 4 weeks of piperacillin-tazobactam, and then transitioned to amoxicillin-clavulanic acid with plans to continue antibiotic therapy for a total of 6 months. One month after discharge, computed tomography (CT) showed resolution of LA, and both IR drains were removed. Given clinical improvement, cholecystectomy has not been pursued due to advanced age. DISCUSSION: When ascending cholangitis and choledocholithiasis are successfully treated through ERCP but the patient does not improve clinically, LA should be considered. Intrahepatic GB perforation leading to fistula formation is a rare cause of LA that most commonly occurs in the elderly, particularly those with a history of chronic biliary disease. Exam and labs can be non-specific, while US and CT are useful diagnostically. Successful treatment involves ERCP, drainage of LA, an extended course of antibiotics, and, while cholecystectomy is preferred, percutaneous cholecystostomy appears to be a viable first option in high-risk patients.