Ascending Cholangitis With Normal Bilirubin in Patients With Prior Biliary Instrumentation: A Case Series

Abstract

Introduction: Patients with prior instrumentation or biliary surgery may not present with classic laboratory changes associated with ascending cholangitis. Here we describe two cases of acute cholangitis in patients with normal bilirubin levels.Table 1: Laboratory Values at PresenationFigure 3Case 1: A 29 year old female was admitted with acute onset of fever, tachycardia, progressive right upper quadrant abdominal pain and nausea for several weeks. She had undergone laparoscopic cholecystectomy 9 years previously. Admission labs showed a leukocytosis, mildly elevated alkaline phosphatase (ALP) with normal transaminases and bilirubin (table 1). MRCP showed intrahepatic biliary duct dilation affecting the right system with a stricture at the site of the cholecystectomy clip. She was started on antibiotics, but her clinical status worsened over 24 hours and her labs remained unchanged. Urgent ERCP also showed the same findings and a plastic stent was placed with drainage of pus (figure 1). She subsequently improved and 10 days later underwent Roux-en-Y hepaticojejunostomy and subsequently recovered completely.Figure 1Case 2: A 77 year old female with chronic pancreatitis and recently placed covered metal stent placement for biliary stricture presented with a four days of diffuse abdominal pain, emesis, and chills. ALP, transaminases, and bilirubin were all within normal limits. She had a leukocytosis and elevated lactate (table 1). CT of the abdomen and pelvis was notable for pneumobilia and prominence of a poorly-defined pancreatic head. ERCP demonstrated that the metal stent was occluded with purulent material and was replaced with a plastic stent (figure 2). She clinically improved and one week later the temporary stents were removed. She was discharged to a skilled nursing facility for acute physical rehabilitation without recurrence.Figure 2Discussion: Ascending cholangitis with normal bilirubin has been described in primary sclerosing cholangitis (PSC) and biliary atresia (BA), but has not been reported in patients with prior biliary instrumentation or surgery. A review of the literature using the PubMed database with the search terms ‘cholangitis' and ‘normal bilirubin' found a total of 161 articles after excluding those associated with PSC and BA. No relevant reports were found. Conclusion: Physicians should have a high index of suspicion for acute cholangitis even when liver function tests are normal in patients with prior biliary tract intervention.