Pyogenic liver abscess following endoscopic retrograde cholangiopancreatography procedure for choledocholithiasis

Abstract

Pyogenic liver abscess (PLA) is a condition in which there is pus accumulation in the liver. It usually develops in the context of portal pyemia, through hematogenous seeding as well as via biliary disease. PLA is a rare, but important complication following biliary instrumentation such as endoscopic retrograde cholangiopancreatography (ERCP). We report a case of a 44-year-old man who initially presented with clinical features of ascending cholangitis. Laboratory investigations revealed leukocytosis as well as hyperbilirubinemia. Diagnosis of choledocholithiasis was then confirmed with an ultrasound examination, showing a 1×1 cm stone in the common bile duct. ERCP was performed and achieved stone clearance. However, the patient returned 1 month later with similar symptoms of right upper quadrant pain, fever and jaundice. Suspecting recurrent choledocholithiasis, an emergency ERCP was performed and showed pooling of radio-opaque contrast in the extra-biliary space. There were also multiple CBD stones seen. An urgent CT Abdomen was done and revealed multiple liver abscesses in bilateral liver lobes, with the largest measuring 4.5x5.9x2.1cm. The patient was treated conservatively with Augmentin and repeat ultrasound at 4 weeks interval showed no residual liver abscess.