Pyogenic liver abscess following endoscopic retrograde cholangiopancreatography procedure for choledocholithiasis


  • Juin Yeen Ooi Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
  • Ramamoorthy Velayutham Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia



Pyogenic, Liver, Abscess, ERCP, Choledocholithiasis


Pyogenic liver abscess (PLA) is a condition in which there is pus accumulation in the liver. It usually develops in the context of portal pyemia, through hematogenous seeding as well as via biliary disease. PLA is a rare, but important complication following biliary instrumentation such as endoscopic retrograde cholangiopancreatography (ERCP). We report a case of a 44-year-old man who initially presented with clinical features of ascending cholangitis. Laboratory investigations revealed leukocytosis as well as hyperbilirubinemia. Diagnosis of choledocholithiasis was then confirmed with an ultrasound examination, showing a 1×1 cm stone in the common bile duct. ERCP was performed and achieved stone clearance. However, the patient returned 1 month later with similar symptoms of right upper quadrant pain, fever and jaundice. Suspecting recurrent choledocholithiasis, an emergency ERCP was performed and showed pooling of radio-opaque contrast in the extra-biliary space. There were also multiple CBD stones seen. An urgent CT Abdomen was done and revealed multiple liver abscesses in bilateral liver lobes, with the largest measuring 4.5x5.9x2.1cm. The patient was treated conservatively with Augmentin and repeat ultrasound at 4 weeks interval showed no residual liver abscess.


Altemeier WA, Culbertson WR, Fullen WD, Shook CD. Intra-abdominal abscesses. Am J Surg. 1973;125:70.

Fatinathan C, Nawawi K, Periyasamy P, Zakaria S, Wong Z, Yaacob N et al. Pyogenic liver abscess: A 14-year retrospective analysis of the incidence trend and clinical outcomes at a Malaysian tertiary referral centre. Int J Infect Dis. 2020;101:138.

Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality.

Clin Infect Dis. 2004;39(11):1654.

Chin YK, Asokkumar R. Endoscopic ultrasound-guided drainage of difficult-to-access liver abscesses. SAGE Open Med. 2020;8:2050312120921273.

Tan YM, Chung AY, Chow PK. An appraisal of surgical and percutaneous drainage for pyogenic liver abscesses larger than 5 cm. Ann Surg. 2005;241:485.

Lam YH, Wong SK, Lee DW, Lau JY, Chan AC, Yiu RY et al. ERCP and pyogenic liver abscess. Gastrointest Endosc. 1999;9.

Peng Y, Lin C, Sung F. Risk of pyogenic liver abscess and endoscopic sphincterotomy: a population-based cohort study. BMJ Open. 2018;10..

Wu HM, Dixon E, May GR, Sutherland FR. Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review. HPB (Oxford). 2006;8(5):393-9.

Parikh JV, Dalal PR, Patel AM, Desai ID. Choledocho-Colonic Fistula: A Rare Presentation of Choledocholithiasis “A Rare Biliary-Enteric Fistula Associated Choledocholithiasis. Ind J Surg. 2021;83:790-2.

Carbajo AY, Brunie Vegas FJ, García-Alonso FJ, Cimavilla M, Torres Yuste R, Gil-Simón P et al. Retrospective cohort study comparing endoscopic ultrasound-guided and percutaneous drainage of upper abdominal abscesses. Dig Endosc. 2019;31(4):431-8.

Brand M, Bizos D, O'Farrell P Jr. Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography. Cochrane Database Syst Rev. 2010;1.






Case Reports