Biliary Sludge and Acute Pancreatitis Following Treatment of Sexually Transmitted Infection

Abstract

Ceftriaxone has been shown to cause transient biliary and cholecystic sludge evident on imaging in asymptomatic subjects. This sludge may result in obstruction, and hence, acute pancreatitis and cholecystitis. Here we report a case of acute pancreatitis presenting three days following treatment with ceftriaxone which may be attributed to this phenomenon. No other risk factors could be identified. A 34 year old male patient with no past medical history presented to the hospital with the complaint of stabbing epigastric abdominal pain radiating to the back with associated nausea and vomiting of one day duration. He was seen by his primary care doctor three days prior to presentation for urethral discharge and was given an intramuscular injection of 250 mg ceftriaxone in addition to 1 g oral azithromycin with complete resolution of symptoms. Physical examination was notable for epigastric tenderness without rebound tenderness or guarding and was otherwise normal. Laboratory work up was remarkable for WBC 15200 per microliter and lipase 1961 U/L. Liver function test, serum calcium, triglycerides, and IgG4 were all within normal limit. Computed tomography (CT) scan of the abdomen confirmed findings of acute pancreatitis with well-defined pancreatic borders. This was followed by a right upper quadrant ultrasound which showed biliary and cholecystic sludge. Upon further questioning the patient denied alcohol and tobacco use, recent travel, or any prior history of mumps and herpes simplex virus infections. Furthermore, no family history of acute pancreatitis was reported. The time frame of symptoms and the absence of other risk factors point towards a drug adverse reaction. The patient was managed conservatively and discharged the following day with significant clinical improvement. Younger patients, patients receiving a prolonged or larger dose, and patients with impaired gallbladder emptying are at a greater risk for developing sludge secondary to ceftriaxone use. This is often asymptomatic with discontinuation of the drug usually resulting in resolution of this phenomenon. This case highlights the fact that ceftriaxone induced biliary sludge may rarely result in potentially serious adverse events including acute cholecystitis and pancreatitis.