S1821 Rare Case of Recurrent Liver Abscess Caused by Choledocodoudenal Fistula in Ampullary Diverticulum

Abstract

Introduction: Choledocodoudenal Fistula is a rare condition that may be caused by Choledocholithiasis, surgical or laparoscopic cholecystectomy, duodenal ulcer and tumor invasion. Choledocodoudenal fistula has no specific symptoms and may be accidentally discovered during upper GI endoscopy; but in some cases, it may lead to recurrent cholangitis and liver abscess. In this article, a case of recurrent liver abscess caused by Choledocodoudenal fistula in ampullary diverticulum is reported. Case Description/Methods: A 68-year-old male was admitted to outside facility because of abdominal pain and liver lesion on ultrasound. The abdominal CT showed large heterogeneous mass measuring more than 16*11 cm with single porta hepatis enlarged lymph node measuring about 2*1cm. Hepatocellular Carcinoma was suspected, but liver biopsy revealed active hepatitis with areas of necrosis and supportive inflammation. He was Referred to ALAhli Hospital for evaluation of liver abscess (Table). ERCP showed Tiny Ampullary orifice in large diverticulum (Figure). The injection of the contrast revealed a fistula at the apex of diverticulum with good drainage through it. In cases of liver abscess secondary to fistula complication, surgical or medical management may be needed. The liver abscess in this case study was treated medically. Discussion: A management strategy for CDF depends on correcting the underlying cause. As this condition is most commonly stone induced Endoscopic sphincterotomy is the gold standard for CBD stone extraction, however this approach has been found to be successful in only 12% of cases of large stone extraction, usually requiring additional therapies. Endoscopic papillary balloon dilation is an alternative approach to maintain the function of the sphincter and to reduce the morbidity associated with traditional endoscopic sphincterotomy. Currently, the approach of sphincterotomy followed by balloon dilation has provided the best outcomes. Patients with multiple abscesses should receive antibiotics for 4–6 weeks. Percutaneous drainage is the treatment of choice for liver abscesses. Operative drainage is indicated for patients with an identified intra-abdominal focus of infection and for those in whom percutaneous drainage is not feasible or has failed. Anatomic liver resection is rarely required and is withheld for cases of underlying surgical hepatobiliary pathology. In our patient we choose the medical treatment with antibiotics in combination with image-guided percutaneous drainage with excellent outcome.Figure 1.: Ampulla in large Diverticulum. Table 1. - Laboratory results of the patient upon admission to Al-Ahli Hospital WBC 7.8K/ul S. Albumin 2.1g/dl Sodium 133mEq/L HCT 50% SGPT 6mg/dl Potassium 3.7 mEq/L Hemoglobin 16.8% SGOT 15mg/dl Cholride 107mmol/l Platelets 173K/ul Bilirubin(T) 0.6mg/dl S. Creatinine 0.85mg/dl ESR 75mm/hour Bilirubin(D) 0.4mg/dl BUN 17mg/dl INR 1.3 ALK.PHOS 171 U/L CRP 190mg/l