S2419 Recurrent Oriental Cholangiohepatitis

Abstract

INTRODUCTION: Recurrent cholangiohepatitis was first recognized as a clinical entity in the 1930s and is most commonly found in people of Southeast Asian origin. We present a case of recurrent pyogenic cholangiohepatitis with hepatic abscess in a patient of oriental origin. CASE DESCRIPTION/METHODS: 58 y/o male with medical history of hypertension who was admitted with 4 days of fevers and RUQ abdominal pain. He was hypotensive with leukocytosis and elevated lactate. He had a history of Choledochoduodenostomy, done in Korea, due to primary intrahepatic choledocholithiasis. CT A&P showed left hepatic lobe mass containing dilated fluid-filled structures, left hepatic lobe atrophy, and pneumobilia and broad spectrum antibiotics were initiated. IR guided drainage of liver lesion was performed and catheter tube was placed. Fluid drained grew E. Coli and VRE. AFP, CEA, and CA 19-9 were negative. Stool negative for O&P. MRCP showed intrahepatic ductal dilatation of the left hepatic lobe and central intrahepatic ductal dilatation in the right hepatic lobe. EUS showed hepatic abscess and a gastrohepatic lymph node was biopsied, which showed reactive lymphoid tissue and no malignant cells. ERCP was done, but strictures in left intrahepatic bile ducts were not amenable for stent placement and drainage. PTC was performed and internal biliary drainage catheter was placed. Diagnosis of Oriental Cholangiohepatitis was made. Patient was offered left liver lobectomy for definitive treatment, he deferred. He clinically improved and was discharged. DISCUSSION: Oriental Cholangiohepatitis is characterized by recurrent cholangitis secondary to bile stasis and stone formation proximal to biliary strictures. Left hepatic duct, especially the left lateral segmental duct, is most commonly affected. Pneumobilia and hepatic atrophy are common findings on imaging. Intrahepatic calculi are visualized in up to 90% cases. Management includes antibiotic therapy, stricture dilation, biliary drainage, stone removal and liver resection. ERCP has advantage of therapeutic intervention over MRCP. Liver resection decreases the risk of recurrent attacks of cholangitis, abscess and eliminates the risk of carcinoma in the atrophic segment of liver. Incidence of oriental cholangiohepatitis is increasing in the western world due to immigration and diagnosis should be considered in patients in epidemiologic and clinical settings, with radiologic findings of intrahepatic ductal dilation even in the absence of visualization of intrahepatic stones.