A unusual case of multifocal pyogenic abscess formation following ERCP procedure
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 upp...
Main Authors: | , , , , , , |
---|---|
Format: | Article |
Language: | English |
Published: |
BMC
2020-05-01
|
Series: | BMC Surgery |
Subjects: | |
Online Access: | http://link.springer.com/article/10.1186/s12893-020-00759-y |
id |
doaj-ba4882b6c69d44b4ac400b77e9910b92 |
---|---|
record_format |
Article |
spelling |
doaj-ba4882b6c69d44b4ac400b77e9910b922020-11-25T03:10:25ZengBMCBMC Surgery1471-24822020-05-012011610.1186/s12893-020-00759-yA unusual case of multifocal pyogenic abscess formation following ERCP procedureFahed Merei0Galina Shapiro1Ibrahim Abu Shakra2Amitai Bickel3Samer Ganam4Maxim Bez5Eli Kakiashvili6Department of Surgery A, Galilee Medical CenterMedical Corps, Israel Defense ForcesDepartment of Surgery A, Galilee Medical CenterDepartment of Surgery A, Galilee Medical CenterDepartment of Surgery A, Galilee Medical CenterMedical Corps, Israel Defense ForcesDepartment of Surgery A, Galilee Medical CenterAbstract 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.http://link.springer.com/article/10.1186/s12893-020-00759-yPost-endoscopic retrograde cholangiopancreatographyComplicationsAscending cholangitisEpidural abscessPsoas abscesses |
collection |
DOAJ |
language |
English |
format |
Article |
sources |
DOAJ |
author |
Fahed Merei Galina Shapiro Ibrahim Abu Shakra Amitai Bickel Samer Ganam Maxim Bez Eli Kakiashvili |
spellingShingle |
Fahed Merei Galina Shapiro Ibrahim Abu Shakra Amitai Bickel Samer Ganam Maxim Bez Eli Kakiashvili A unusual case of multifocal pyogenic abscess formation following ERCP procedure BMC Surgery Post-endoscopic retrograde cholangiopancreatography Complications Ascending cholangitis Epidural abscess Psoas abscesses |
author_facet |
Fahed Merei Galina Shapiro Ibrahim Abu Shakra Amitai Bickel Samer Ganam Maxim Bez Eli Kakiashvili |
author_sort |
Fahed Merei |
title |
A unusual case of multifocal pyogenic abscess formation following ERCP procedure |
title_short |
A unusual case of multifocal pyogenic abscess formation following ERCP procedure |
title_full |
A unusual case of multifocal pyogenic abscess formation following ERCP procedure |
title_fullStr |
A unusual case of multifocal pyogenic abscess formation following ERCP procedure |
title_full_unstemmed |
A unusual case of multifocal pyogenic abscess formation following ERCP procedure |
title_sort |
unusual case of multifocal pyogenic abscess formation following ercp procedure |
publisher |
BMC |
series |
BMC Surgery |
issn |
1471-2482 |
publishDate |
2020-05-01 |
description |
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. |
topic |
Post-endoscopic retrograde cholangiopancreatography Complications Ascending cholangitis Epidural abscess Psoas abscesses |
url |
http://link.springer.com/article/10.1186/s12893-020-00759-y |
work_keys_str_mv |
AT fahedmerei aunusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT galinashapiro aunusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT ibrahimabushakra aunusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT amitaibickel aunusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT samerganam aunusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT maximbez aunusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT elikakiashvili aunusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT fahedmerei unusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT galinashapiro unusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT ibrahimabushakra unusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT amitaibickel unusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT samerganam unusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT maximbez unusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure AT elikakiashvili unusualcaseofmultifocalpyogenicabscessformationfollowingercpprocedure |
_version_ |
1724658763867095040 |