Recurrent Pyogenic Liver Abscesses Secondary to Retained Surgical Metal Coil Within the Bile Duct

Abstract

Introduction: Recurrent pyogenic abscesses are typically caused by bile stasis or stone formation proximal to biliary strictures leading to recurrent episodes of cholangitis. The Southeast Asian population is affected at a higher rate than others with an epidemiologic association with biliary parasites, which are endemic to the area. However, there is no conclusive evidence supporting the role of these infections in the pathogenesis of recurrent pyogenic cholangitis. We present a unique case of iatrogenic recurrent pyogenic cholangitis. Case Report: A 53 year-old female with a history of recurrent hepatic abscesses presented to our hospital with jaundice. She had a strong history of autoimmune disease including mixed connective tissue disease, dermatomyositis, and Hashimoto's thyroiditis. Her past surgical history was significant for cholecystectomy and common bile duct exploration. Abnormal labs included elevated WBC 23.5 k/mcL and elevated liver enzymes including AST 96 U/L, ALT 47 U/L, ALP 268 U/L, and total bilirubin 21.7 mg/dL. MRI abdomen was significant for multiple abscesses within the left lobe of the liver with largest measuring 3.7 cm x 2.1 cm with bile ducts seen leading to the abscess, suggesting possible communication with the biliary tree. Intra and extrahepatic biliary ductal dilatation was visualized with a 9 mm filling defect within the distal common bile duct. ERCP was performed for further evaluation. Cholangiogram was abnormal with multiple filling defects within the CBD as well as a metal coil moving freely within the bile duct. Biliary sphincterotomy and multiple balloon sweeps were performed with extraction of sludge and stones. The metal coil was brought down to the ampulla and removed with rat-tooth forceps. Two straight plastic biliary stents were placed side-by-side individually under fluoroscopic guidance. Excellent biliary drainage was subsequently noted. We identified the metal coil as a surgical item that was retained in the patient's bile duct after her cholecystectomy with common bile duct exploration. Subsequently, the patient was treated with antibiotics and is now doing well s/p repeat ERCP with removal of previously placed biliary stents and without recurrence of hepatic abscesses. Conclusion: The incidence of retained surgical items varies from 1:1000-1500 to 1:5500-18670. The majority of patients with retained surgical items are symptomatic with abdominal pain being the most common complaint. Our patient was unique and unfortunate in that she developed recurrent pyogenic abscesses from the retained surgical metal coil.