A CASE RECURRENT PYOGENIC CHOLANGITIS AFTER CHOLECYSTECTOMY

Abstract

TYPE: Late Breaking Case Report TOPIC: Critical Care INTRODUCTION: Recurrent Pyogenic Cholangitis (RPC) after cholecystectomy and choledocholithiasis treated with endoscopic retrograde cholangiopancreatography (ERCP) has been reported in less than two percent of patients. CASE PRESENTATION: A 78-year-old female status post ERCP and laparoscopic cholecystectomy for treatment of choledocholithiasis two years prior, now presenting with three days of right upper quadrant abdominal pain and fevers. Vital signs demonstrated fever, tachycardia, and hypotension. Physical examination revealed scleral icterus and right upper quadrant abdominal tenderness to palpation. Laboratory findings demonstrated thrombocytopenia, acute kidney injury, transaminitis, and hyperbilirubinemia. Intravenous fluids and antibiotics were initiated. Patient was admitted to the intensive care unit for management of severe sepsis secondary to severe acute cholangitis. Blood cultures grew Klebsiella pneumoniae. Magnetic resonance cholangiopancreatography (MRCP) showed choledocholithiasis and dilated common bile duct. ERCP was performed with cannulation of the common bile duct (CBD), sphincterotomy, and removal of sludge. No stones were seen on ERCP. The patient was discharged home with oral antibiotics. The patient returned to the hospital one week after discharge with worsening right upper quadrant abdominal pain and jaundice. Repeat ERCP showed a 10-millimeter stone in the CBD, which was unable to be removed. Biliary stent was placed. Abdominal pain and jaundice improved; she was discharged with oral antibiotics. DISCUSSION: RPC occurs due to repeated hepatolithiasis, which forms strictures secondary to repeated inflammation. Hepatolithiasis has been predicted to occur secondary to malnutrition, which decreases enzymes that inhibit bilirubin deconjugation. This in turn increases unconjugated bilirubin leading to hepatolithiasis. CONCLUSIONS: RPC requires a multidisciplinary approach to determine appropriate management. DISCLOSURE: Nothing to declare. KEYWORD: Recurrent Pyogenic Cholangitis