Escherichia coli Bacteremia Following Liver Biopsy: A Case Report of Hemobilia Related Cholangitis From Transjugular Liver Biopsy

Abstract

Purpose: To present an orthotropic liver transplant (OLT) patient who had transjugular liver biopsy and developed sepsis secondary to cholangitis and bacteremia in the setting of hemobilia. Case: The patient was a 61 yo M with a history of OLT with Roux-en-Y hepaticojejeunostomy (HJ) in 2008 for cryptogenic cirrhosis. The patient did well for ten years but was referred for liver biopsy to assess for graft rejection. The biopsy was performed in a transjugular approach without immediate complication. Two days post biopsy, he developed rigors, nausea with vomiting, right upper quadrant abdominal pain, leukocytosis, and fever. Blood cultures grew E. coli. Liver ultrasound demonstrated mild left lobe intrahepatic bile ductal dilatation. MRCP was consistent with hemobilia (Image 1, Image 2). Bilirubin increased post biopsy from 1.5mg/dl on admission to 10mg/dl. A percutaneous biliary drain was placed and culture of the drain fluid grew extended-Spectrum Beta-Lactamase (ESBL) E. coli. The patient was treated with meropenem with resolution of infection and hyperbilirubinemia. The patient never developed melena and the hemoglobin remained stable. Discussion: Hemobilia is a rare complication of liver biopsy whether it is performed with a percutaneous or transjugular approach. Hemobilia can cause biliary infection due to retention of “clotted blood” within the common bile duct, particularly if there is underlying pathology which impairs drainage. In a patient with Roux-en-Y (HJ), there is a lack of a native ampulla which usually serves as a competent valve. This altered anatomy could predispose to reflux of bowel contents into the biliary tree, allowing bacteria to colonize, particularly if there is underlying biliary dilation or stricture. While hemobilia is a rare complication of liver biopsy we believe that underlying Roux-en -y (HJ) may predispose the patient to a septic complication should it occur. Our experience suggests that in order to minimize morbidity from liver biopsy that patients with Roux-en-Y (HJ), with or without evidence of impaired biliary drainage, should be considered for pre-operative prophylactic antibiotics cover enteric flora.2246_A Figure 1. T1 cross-sectional image from abdominal MRI MRCP w/o contrast showing mild prominence of the intra and extrahepatic biliary ducts2246_B Figure 2. T1 image from abdominal MRI MRCP w/o contrast showing mild prominence of the intra and extrahepatic biliary ducts2246_C Figure 3. T2 image which demonstrates proteinaceous signal within the intra and extrahepatic bile duct to the level of the hepaticojejunostomy consistent with hemobilia