An Unusual Cause of Prolonged Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Jaundice

Abstract

Elevated liver function tests (LFTs) can be caused by numerous etiologies such as infection, choledocholithiasis, toxins, and chronic disorders. It can also occur after invasive procedures like endoscopic retrograde cholangiopancreatography (ERCP). Here we present the case of a young woman who suffered an unusual complication, prolonged jaundice after ERCP, of which the etiology was initially unclear. A 32-year-old woman with history of cholelithiasis presented with abdominal pain. Her LFTs were elevated, including total bilirubin of 3.8 and direct bilirubin of 2.1. A right upper quadrant ultrasound revealed cholelithiasis and common bile duct (CBD) dilation at 11 mm. ERCP confirmed these findings as well as a distal CBD stone which was removed; a plastic biliary stent was placed. Gastritis was noted and confirmed histologically to be due to H. pylori. She was discharged on pantoprazole, clarithromycin, and amoxicillin. As an outpatient, she underwent laparoscopic cholecystectomy; at this time her total bilirubin was 3.4. At follow-up two weeks later, she complained of continued pruritis and jaundice. She was admitted as her total bilirubin was found to be worsening at 4.1. A second ERCP did not reveal bile leak, stenosis, or stone retention. She was discharged however at one week follow-up she still reported pruritis and jaundice. Extensive laboratory work-up including viral and autoimmune hepatitis were negative. On careful review, it was found that she had been erroneously prescribed four weeks of clarithromycin, instead of the standard two week regimen for H. pylori. The drug was discontinued. At follow-up four weeks later, her pruritis and jaundice had resolved and her LFTs were greatly improved (total bilirubin 1.1). Six months later all liver enzymes were within normal range. In this case, the cause of the patient's jaundice and elevated LFTs was initially unclear. Prolonged jaundice after ERCP and subsequent cholecystectomy is a rare complication. Post-cholecystectomy jaundice could be caused by ischemia, viral hepatitis, bile leak, biliary stricture, or infection. Here, a second ERCP did not reveal any such complications which could have explained her symptoms. The chronology of events and LFT trends favored the cause of liver insult as due to clarithromycin. We posited that this was due to drug-induced liver injury (DILI). Discontinuation of the offending agent, as in our patient, lead to resolution of symptoms and laboratory derangements.FigureFigureFigure