Pyogenic Liver Abscess from Choledocholithiasis Accurately Diagnosed
“Introduction This case report details the diagnostic progression, laboratory interpretation, and clinical reasoning that resulted in the identification of a pyogenic liver abscess secondary to ascending cholangitis due to choledocholithiasis in a 62-year-old male. In compliance with confidentiality and data protection standards, the patient remains unnamed; age and sex alone do not constitute identifiable information under GMC Good Medical Practice or GDPR. This case underscores the significance of structured diagnostic reasoning in hepatobiliary disease, where overlapping symptoms may obscure the underlying pathology. By integrating clinical presentation with sequential laboratory and imaging investigations, the report demonstrates how biliary obstruction can progress to severe infection and hepatic abscess formation if not promptly recognized and treated. Patient Presentation A 62-year-old male presented with several weeks of right upper quadrant abdominal pain radiating to the right shoulder. He reported pale stools, pruritus, fatigue, and intermittent fever. These symptoms strongly suggested impaired bile flow, as pale stools indicate reduced stercobilin due to diminished biliary excretion, and pruritus is commonly associated with cholestasis. On examination, the patient was hypotensive and tachycardic, with rebound tenderness in the right upper quadrant. The combination of abdominal pain, jaundice, and fever raised immediate concern for biliary pathology, while haemodynamic instability suggested progression to systemic infection or sepsis. The chronicity of symptoms followed by acute deterioration suggested an evolving obstructive process with secondary infection. The initial clinical impression included gallstone disease, particularly cholecystitis or choledocholithiasis, given the pain and pale stools. However, the severity of systemic features necessitated a broad differential diagnosis and urgent investigation. Initial Differential Diagnosis The initial differential diagnosis included several hepatobiliary, pancreatic, cardiac and infectious conditions. Viral hepatitis was considered due to the presence of jaundice and RUQ discomfort, but the patient’s systemic instability and absence of prodromal viral symptoms made this less likely. Drug‑induced hepatitis was also considered; however, the patient reported no recent medication use, and drug‑induced liver injury typically presents with hepatocellular rather than cholestatic patterns. Acute pancreatitis was included in the differential due to the anatomical proximity of the pancreas to the biliary tree and the possibility of gallstone‑induced pancreatitis. However, pancreatitis usually presents with epigastric pain radiating to the back rather than the shoulder, and pale stools are less characteristic. Myocardial infarction was considered because cardiac ischaemia can present with atypical abdominal pain in older adults, but the presence of jaundice and pale stools made a cardiac cause unlikely. Simple acute cholecystitis was a plausible diagnosis, as it presents with RUQ pain, fever and leukocytosis. However, pale stools and pruritus are not typical features, and the degree of systemic instability suggested a more severe process. Acute cholangitis was strongly considered due to the classical Charcot’s triad of RUQ pain, jaundice and fever. The patient’s hypotension and tachycardia also suggested progression towards Reynolds’ pentad, indicating severe cholangitis with sepsis. Malignancy, including pancreatic cancer or cholangiocarcinoma, was included due to the patient’s age and the presence of obstructive jaundice. However, the acute deterioration and systemic inflammatory response were more consistent with infection than malignancy.”
Summary
Ascending cholangitis can progress to a pyogenic liver abscess, and cases linking choledocholithiasis to such abscesses have been documented in the medical literature. Older patients, including males in their sixties, are recognized as having higher risk for severe cholangitis and subsequent hepatic infection. The described clinical presentation and diagnostic reasoning are consistent with current authoritative sources.
Sources 58 searched
- Cholangitis - StatPearls - NCBI Bookshelf - NIH
However, a normal abdominal sonogram does not necessarily rule out ascending cholangitis. Abdominal computed tomography (CT) can be performed as an adjunct to investigate co-existing pathologies such as hepatic/pancreatic tumors, metastasis, or hepatic abscess.[20] Dilated intrahepatic and extrahepatic ducts, as well as inflammation of the biliary tree, can be appreciated.
- Acute cholangitis - Surgical Treatment - NCBI Bookshelf - NIH
However, direct cholangiography can exacerbate the cholangitis leading to severe sepsis and should always be combined with therapeutic drainage procedure whenever biliary obstruction is demonstrated. Poor prognostic factors include old age, female sex, acute renal failure, concomitant medical problems, pH < 7.4, bilirubin > 90 μmol/L, albumin < 30 g/L, platelet count < 150 × 109/L, preexisting cirrhosis, presence of liver abscess and malignant biliary obstruction.
- Liver Abscess - StatPearls - NCBI Bookshelf
The majority of these abscesses are categorized as pyogenic or amoebic, although a minority are caused by parasites and fungi. Although the incidence of liver abscess is low, it is essential to early detect and manage these lesions, since there is a significant mortality risk in untreated patients.
- Acute cholangitis - an update - PMC - NIH
Poor prognostic factors in the setting of acute cholangitis include old age, high fever, leukocytosis, hyperbilirubinemia and hypoalbuminemia[11]. Patients with comorbidities like cirrhosis, malignancy, liver abscess and coagulopathy also carry poor prognosis.
- Pyogenic hepatic abscesses secondary to choledocholithiasis eight years post-cholecystectomy: A case report - PMC
Two years ago, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy for symptomatic choledocholithiasis. However, the procedure was terminated early due to patient agitation, and confirmation of complete stone removal was not possible. A week later, the patient presented with sepsis and a new hypodense liver lesion was noted on CT, suggesting abscess formation.
- The Clinical Presentations of Liver Abscess Development After Endoscopic Retrograde Cholangiopancreatography with Choledocholithiasis: A 17-Year Follow-Up - PMC
Although uncommon, the development of liver abscess is recognized as a late but potentially life-threatening complication of ERCP, particularly in patients who have a compromised barrier between the hepatobiliary system and duodenum following ES.3,4 Given the low occurrence rate of liver abscess following ERCP for choledocholithiasis, our prior research has primarily concentrated on investigating its prevalence and risk factors.5 However, limited attention has been directed towards exploring the clinical presentations of liver abscesses in these patients, which would aid in comprehending the symptoms and facilitating early diagnosis.
- Ascending cholangitis as a cause of pyogenic liver abscesses complicated by a gastric submucosal abscess and fistula - PubMed
Ruptures of nonamebic (pyogenic) liver abscesses into the thorax and peritoneum are very uncommon; but, hepatoduodenal and hepatocolonic fistulas are ever more rare. We report a case where ascending cholangitis was associated with pyogenic liver abscess formation and a gastric fistula.
- Pyogenic Liver Abscess - an overview | ScienceDirect Topics
Ascending cholangitis and appendicitis ... [1,2]. However, a recent US-population based study revealed that the incidence of PLA has increased more than 2-fold during the past 35 years [2]....
- Pyogenic hepatic abscesses secondary to choledocholithiasis eight years post-cholecystectomy: A case report - ScienceDirect
Only approximately 0.4 % of these patients subsequently develop choledocholithiasis. The incidence of hepatic abscesses in these patients is unknown, but is likely low, considering there are approximately 2–15 cases of hepatic abscesses per 100,000 people in the US.
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