We report a patient with intrahepatic cholangitis due to a complication of laparoscopic cholecystectomy, ligation of the right hepatic duct. This case represented a diagnostic challenge, as the patient presented 5 years after the initial surgery. The etiology was ascertained only after repeated unsuccessful attempts to visualize the right hepatic duct via MRCP, ERCP and percutaneous cholangiogram. The patient responded well to an extended course of antibiotics and will likely need a definitive surgical intervention to prevent recurrent infections.
A 55-year-old gentleman presented with a 6-week history of nausea, vomiting, diarrhea, fevers, night sweats and a 15-pound weight loss. The patient also recalled a short episode of diarrhea that resolved a few days prior to the onset of these symptoms.
His past medical history included a laparoscopic cholecystectomy for acute cholecystitis 5 years earlier. The patient took no medications, denied tobacco use or illicit drug use, and reported mild alcohol consumption. He denied any travel, pets, or sick contacts.
Physical exam revealed a thin, jaundiced man in no distress. Cardiorespiratory examination was unremarkable. His abdomen was nondistended, soft, with right upper quadrant tenderness, and a liver edge was palpable 3 cm below the right costal margin.
Notable admission laboratory values included the following: white blood cell count 40.0 K/uL (3.5-11), 74% neutrophils, 18% bands, 2% lymphocytes; hemoglobin 9.6 g/dL (MCV 93fL (80-100)); platelets 907 K/uL (150-450); ESR 108 mm/hr; protein 5.8 mg/dL (6.0-8.3); albumin 2.3 g/dL (3.5-5.0); total bilirubin 17.2 mg/dL (0.1-1.0); direct bilirubin 11.6 mg/dL; indirect bilirubin 5.7 mg/dL; AST 116 U/L (8-37); ALT 105 U/L (8-35); alkaline phosphatase 689 U/L (50-150); lipase 158 U/L; PT/INR 17.2 seconds (13.0-15.3)/1.30 (0.90-1.11); and PTT 36.3 seconds.
Hepatitis serologies, HIV, ANA, pANCA, Entamoeba histolytica antibody, anti-smooth muscle antibody, CMV IgM, and EBV IgM were all negative. Repeated blood, urine, and stool cultures were negative.
Right upper quadrant ultrasound, abdominal CT scan, and MRCP failed to reveal biliary duct dilatation, nor an obvious source of obstruction. ERCP also did not demonstrate a stone or stricture.
Notably, the endoscopist was unable to identify the right hepatic system. Two attempts via percutanous cholangiogram were also unsuccessful in visualizing the right hepatic biliary tree. Subsequent liver biopsy revealed grade II portal fibrosis and a dense inflammatory cell infiltrate consistent with intrahepatic cholangitis.
Review of the imaging studies suggested asymmetric liver injury, more prominent on the right side. Therefore, bilobar liver biopsies were obtained, which demonstrated cholestasis with portal fibrosis, and the right lobe more severely affected than the left (see Figures 1-4). It was felt that this finding represented a chronic process, most likely due to occlusive injury to the right hepatic duct during the remote cholecystectomy. Slow, but progressive damage to the right hepatic lobe ultimately predisposed the liver to a bacterial infection.
Figure 1 Right portal
Figure 2 Left lobule
Figure 3 Left portal
Figure 4 Right lobule
Management and Outcome
The patient was treated empirically for cholangitis with piperacillin/tazobactam and oral metronidazole, later narrowed to only metronidazole, tapered over six weeks. He gradually improved with resolution of his clinical symptoms and laboratory abnormalities.
The patient was also referred to surgery for possible right hepatic lobectemy once the cholangitis resolved.
Nearly 700,000 laparoscopic cholecystectomies are performed annually in the United States. A report that combined data from several large studies with a total of 8856 laparoscopic cholecystectomies found that serious complications occurred in 2.6% of these cases, including major bleeding, wound infection, bile leak, and biliary injury. Bile duct injury in particular occurs during 0.4 to 0.5% of laparoscopic cholecystectomies, compared with 0.1 to 0.2% of open operations .
Most complications present in the immediate post-operative period. Biliary leaks recognized at the time of surgery are repaired immediately. Otherwise, major biliary leakage usually presents 2 to 10 days postcholecystectomy. Affected patients typically present with fever, abdominal pain, and/or bilious ascites.
Injury to the bile duct that causes obstruction rather than transection is rarer, and does not result in bile leakage. An occlusive injury instead results in segmental cholestasis in the liver, and leads to atrophy of the affected lobe. These patients, as in this case, remain asymptomatic for years, then present with right upper quadrant pain and fever due to cholangitis .
Because damage progresses gradually, infection can develop over weeks to months rather than the acute presentation typically associated with cholangitis. Diagnosis is usually made by ERCP that demonstrates an occluded right hepatic duct or non-filling right system. Treatment is surgical, involving a heapticojejunostomy or segmental resection of the affected lobe.
This case is instructive as the patient presented 5 years after the initial cholecystectomy. Clinicians should consider long-term iatrogenic complications in patients presenting with hepatitis or cholangitis of uncertain etiology.
This article was first published on GastroHep.com on 17 October 2003.
Dr Leslie Hoffman, MD1
Dr David Rubin, MD2
(1) Department of Internal Medicine and (2) Department of Gastroenterology, University of Chicago Hospital, Chicago, Illinois, USA
Dr Leslie Hoffman
Department of Internal Medicine, University of Chicago Hospital, Chicago, Illinois, USA
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- Afdhal NH. Complications of laparoscopic cholecystectomy. http://www.uptodateonline.com 25 July 2003.