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Case Reports
. 2020 May 6;20(1):92.
doi: 10.1186/s12893-020-00759-y.

A unusual case of multifocal pyogenic abscess formation following ERCP procedure

Fahed Merei  1 , Galina Shapiro  2 , Ibrahim Abu Shakra  1 , Amitai Bickel  1   3 , Samer Ganam  1 , Maxim Bez  2 , Eli Kakiashvili  4   5
Affiliations
Case Reports

A unusual case of multifocal pyogenic abscess formation following ERCP procedure

Fahed Merei et al. BMC Surg. .

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing biliary and pancreatic disorders. Infection is the most morbid complication of ERCP and among the most common causes of ERCP-related death.

Case presentation: A 69-year-old man presented with right upper quadrant abdominal pain, obstructive jaundice and abnormal liver function tests. Ultrasound revealed cholelithiasis without bile duct dilation. After receiving intravenous antibiotics for acute cholecystitis, the patient was discharged. Two weeks later, an endoscopic ultrasound demonstrated gallstones and CBD dilation of up to 6.4 mm with 2 filling defects. An ERCP was performed with a papillotomy and stone extraction. Twenty-four hours post-ERCP the patient developed a fever, chills, bilirubinemia and elevated liver function tests. Ascending cholangitis was empirically treated using Ceftriaxone and Metronidazole. However, the patient remained febrile, with a diffusely tender abdomen and elevated inflammatory markers. A CT revealed a very small hypodense lesion in the seventh liver segment. Extended-spectrum beta-lactamase positive Klebsiella Pneumonia and Enterococcus Hirae were identified, and the antibiotics were switched to Imipenem and Cilastatin. The hypodense lesion in the liver increased to 1.85 cm and a new hypodense lesion was seen in the right psoas. At day 10 post-ERCP, the patient started having low back pain and difficulty walking. MRI revealed L4-L5 discitis with a large epidural abscess, spanning L1-S1 and compressing the spinal cord. Decompressive laminectomy of L5 was done and Klebsiella pneumonia was identified. Due to continued drainage from the wound, high fever, we performed a total body CT which revealed increased liver and iliopsoas abscess. Decompressive laminectomy was expanded to include L2-L4 and multiple irrigations were done. Gentamycin and Vancomycin containing polymethylmethacrylate beads were implanted locally and drainage catheters were placed before wound closure. Multidisciplinary panel discussion was performed, and it was decided to continue with a non invasive approach .

Conclusions: Early recognition of complications and individualized therapy by a multi-disciplined team is important for managing post-ERCP septic complications. Particular attention should be given to adequate coverage by empiric antibiotics.

Keywords: Ascending cholangitis; Complications; Epidural abscess; Post-endoscopic retrograde cholangiopancreatography; Psoas abscesses.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Liver abscess development on consecutive double contrast abdominal computed tomography scans. Scans were done on days 3 (a) 7 (b) and 26 (c) post-endoscopic retrograde cholangiopancreatography
Fig. 2
Fig. 2
Psoas abscess development on consecutive double contrast abdominal computed tomography scans. Scans were done on days 3 (a) 7 (b) and 26 (c) post- endoscopic retrograde cholangiopancreatography ERCP
Fig. 3
Fig. 3
Spinal epidural abscess as seen on magnetic resonance imaging of the lumbar spine on day 19 post-endoscopic retrograde cholangiopancreatography
See this image and copyright information in PMC

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