S2761 Recurrent Oriental Cholangiohepatitis Despite Partial Hepatic Resection

Abstract

Introduction: Recurrent pyogenic cholangiohepatitis (RPC), also known as “Oriental Cholangiohepatitis”, is commonly found in people of Southeast Asian origin. RPC is characterized by recurrent cholangitis secondary to bile stasis and stone formation proximal to biliary strictures. We present a case of recurrent pyogenic cholangiohepatitis with hepatic abscess in a Vietnamese male with history of partial hepatic resection. Case Description/Methods: A 42 year old Vietnamese male with a past medical history of recurrent pyogenic cholangitis and hepatolithiasis status post hepaticojejunostomy in 2009, followed by abscess resection with culture positive Klebsiella, segment 3 resection, and biliary stenting in 2013 presented with two days of RUQ pain, fevers and jaundice. On arrival, the patient was afebrile, tachycardic and mildly hypotensive. Laboratory evaluation demonstrated alkaline phosphatase 360 IU/L, total bilirubin 14.4 mg/dL, ALT 93 IU/L, AST 113 IU/L, WBC 24,000, INR 1.3. Findings on CT scan of the abdomen included 10 cm multiloculated liver abscess in segment 4A, dilated biliary tract with small pneumobilia and dense material, and a 3.9 x 2.8 cm mass-like hyperdense region in the portal triad region visualized in arterial phase. The patient was started on broad spectrum antibiotics and underwent percutaneous abscess drainage with 350 mL of purulent material removed. MRCP the following day redemonstrated a liver abscess measuring 9.5 cm, RUQ drain in place, diffuse dilatation of the intrahepatic and extrahepatic bile ducts with multiple filling defects consistent with calculi, and a 14mm common bile duct. Cultures from the abscess grew ESBL E.coli and Provotella, and the patient was transitioned to Ertapenem with plan to continue antibiotics for four weeks. The patient was discharged home with abscess drain in place. Discussion: RPC is a recurrent syndrome of cholangitis triggered by a parasitic infection which causes biliary fibrosis leading to strictures and stone formation within intrahepatic ducts, most often on the left. Treatment includes antibiotics, stricture dilation, biliary drainage, stone removal, and liver resection. Although liver resection of the segment decreases the risk of recurrent cholangitis, abscess, and eliminates the risk of carcinoma in that segment, resection does not resolve the biliary fibrosis throughout the remaining segments leaving the patient at risk for recurrence. Liver transplant can be considered for complicated cases that do not respond to conventional therapies.Figure 1.: 10 cm multiloculated liver abscess in segment 4A.