Recurrent pyogenic cholangitis or "oriental cholangiohepatitis' in occidentals: case reports of four patients

Oriental cholangiohepatitis masquerading as cholangiocarcinoma: A rare presentation that surgeons need to know

INTRODUCTION

The detection of an abnormal hepatic mass with ductal dilatation is highly concerning for malignancy. However, if such patients happen to be immigrants from endemic parts of Asia or South America, further investigations are necessary to rule out oriental cholangiohepatitis, a rare recurrent disease of the hepatobiliary system that can masquerade as cholangiocarcinoma.

PRESENTATION OF CASE

We report a case of a patient of South Asian origin who presented to us with acute cholangitis and moderately dilated left hepatic ducts. The findings were highly suspicious for advanced hepatic malignancy; however the laboratory and pathological investigations remained normal. We suspected an unlikely etiology and proceeded with conservative hepatic resection. The histology revealed cholangiohepatitis without any evidence of malignancy.

DISCUSSION

Cholangiohepatitis is a complex hepatobiliary disease that commonly manifests as recurrent cholangitis or overt biliary sepsis and can rarely present as an abnormal hepatic mass. It results from the development of intrahepatic or extrahepatic strictures that causes stone formation and biliary dilation in the absence of gallbladder disease. Although it is endemic in many parts of the world, it is rare in the western world, and therefore it can present as a significant diagnostic enigma.

CONCLUSION

Cholangiohepatitis is a rare clinical entity that requires a multi-disciplinary team approach. Surgery plays a dominant role in the management of such patients and therefore surgeons need to be aware of this disease.

Recurrent Pyogenic Cholangitis

Recurrent pyogenic cholangitis is a condition that most commonly affects patients of East Asian descent. It is characterized by recurrent bouts of cholangitis. Work-up with ultrasound, computed tomography, and more specifically magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP), reveals areas of biliary dilatation and stricturing, most commonly affecting the left hepatic ducts. Initial treatment includes supportive medical therapy with intravenous fluids and electrolytes, correction of coagulopathy if present, and antibiotics. Once stabilized, patients should receive urgent biliary decompression. This may be achieved using ERCP or percutaneous transhepatic cholangiogram (PTC). ERCP is excellent at decompressing more distal obstruction, whereas PTC provides reliable drainage of peripherally obstructed bile ducts. If disease is anatomically limited, surgical resection with excision of the extrahepatic bile ducts and involved intrahepatic segments (usually left lobe) should be performed. Otherwise, repeated radiographic and endoscopic procedures will be necessary to treat recurrent cholangitis. Liver transplant may be an option for patients with diffuse disease.

Current Management of Recurrent Pyogenic Cholangitis

Recurrent pyogenic cholangitis (RPC) is a chronic disease with multiple exacerbations requiring repeated biliary dilatation and stone removal. Even after adequate biliary drainage, most patients will have progression of intrahepatic disease. Management of patients with RPC is a multidisciplinary challenge for endoscopists, interventional radiologists, and surgeons because of the frequency and inaccessibility of strictures and stones. Complete stone clearance at any one operation is difficult. Hepaticojejunostomy with a subcutaneous afferent limb is a safe and effective way to provide access to the biliary tree for the management of patients with RPC. In our experience, trans-stomal cholangioscopic stricture dilatation followed by stone removal remains the basis of therapy in patients with RPC. By diligent surveillance, we should be able to eliminate or decrease the number of stones and prevent cholangitis and its sequelae.

Sonograhic Diagnosis of Oriental Cholangioheatitis

Oriental cholangiohepatitis, also known as recurrent pyogenic cholangitis, intrahepatic pigmented stone disease, or oriental cholangitis, is a disease commonly seen in countries in Southeast Asia. As immigration to the United States from these regions increases, the medical community encounters this disease more frequently. Symptoms of Oriental cholangiohepatitis include repeated attacks of abdominal pain, fever, chills, and jaundice. Localized stenosis of the bile ducts occurs, leading to stasis, infection, and obstruction. Symptoms usually reoccur throughout a period of time until a chronic condition exists. Sonographers and sonologists should familiarize themselves with the ultrasound findings associated with this entity.