University of Missouri Columbia, MO, United States
Harleen K. Chela, MBBS, MD, Ayman Gaballah, MD, Vanessa Kuwajima, MD, MSPH, MBA University of Missouri, Columbia, MO
Introduction: Recurrent pyogenic cholangitis, or oriental cholangiohepatitis, is a separate entity from gallstone related biliary disease both clinically and pathologically. It’s a syndrome characterized by recurrent bacterial cholangitis, intrahepatic pigment stones, and biliary strictures.
Case Description/Methods: A 33-year-old female from Micronesia with history of hepatitis B, recent childbirth presented with epigastric abdominal pain, fever, jaundice. Labs: mild leukocytosis (14.87 x 109 /L), cholestatic pattern of liver enzymes (Total bilirubin: 2.93 mg/dl, ALP: 197 units/L, AST: 248 units/L, ALT: 220 units/L), lipase > 3000 units/L. Ultrasound abdomen revealed hyperechoic shadowing foci visualized in dilated intrahepatic biliary ducts in right hepatic lobe, likely due to choledocholithiasis and dilated CBD of 9 mm. MRI abdomen, MRCP: irregular dilation of intrahepatic bile ducts, multifocal areas of strictures mainly in right hepatic lobe, multiple pigmented stones in intrahepatic bile ducts with changes consistent with sequelae of recurrent pyogenic cholangitis. Changes of uncomplicated acute pancreatitis were seen. CT scan abdomen showed similar findings. Gastroenterology and infectious disease teams were consulted and 5-day course of ciprofloxacin completed given imaging findings and leukocytosis. Stool samples for ova and parasite exam were negative. For pigmented stones and strictures: outpatient ERCP was recommended for attempting stone removal in near future. However lost to follow up and returned with acute biliary pancreatitis few months later. She received supportive treatment with plans for outpatient serial ERCPs for stone extraction.
Discussion: Recurrent pyogenic cholangitis is uncommon in Western world and incidence in east Asia is decreasing. Biliary tract infection with parasites (Clonorchis sinensis, Fasciola hepatica, Opisthorchis species) are implicated in the pathogenesis, along with residing in rural areas and lower socioeconomic status. Colonization of biliary tract with parasite occurs, followed by biliary tract obstruction (due to pigmented stones, sludge, inspissated bile), and secondary bacterial cholangitis. Dietary factors, hygiene and Sphincter of Oddi dysfunction also play role. Recurrent pyogenic cholangitis may present clinically with ascending cholangitis and Charcot’s triad. Diagnosed based on clinical features, labs, and isolation of parasitic eggs in stool, duodenal or biliary fluid. Treatment: biliary decompression, stone removal and antibiotics for cholangitis.
Figure: Figures 1, 2: MRI abdomen/MRCP showing numerous intra and extra hepatic stones seen. Figure 3: CT scan abdomen showing intrahepatic and extrahepatic biliary ductal dilation
Harleen Chela indicated no relevant financial relationships.
Ayman Gaballah indicated no relevant financial relationships.
Vanessa Kuwajima indicated no relevant financial relationships.
Harleen K. Chela, MBBS, MD, Ayman Gaballah, MD, Vanessa Kuwajima, MD, MSPH, MBA. P1123 - Strictures and Stones: A Case of Recurrent Pyogenic Cholangitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.