Authors: Hanrui Yang, Kuan Hu, Ledu Zhou
Categories: Case Report, Case report, Hemobilia, Hepatolithiasis, Postoperative infection
Source: International Journal of Surgery Case Reports
Intrahepatic cholelithiasis is a common disease for which laparoscopic liver resection is one of the treatment options. Here is a case of a patient who developed atypical complications after liver resection.
A 59-year-old patient with intrahepatic cholelithiasis underwent laparoscopic left hemihepatectomy in our hospital. However, the patient developed recurrent fever and jaundice after surgery. And with multiple treatments, the symptoms improved and the diagnosis was finally confirmed.
This case has some educational value as it shows that post-operative hepatic stones can lead to biliary hemorrhage due to infection and that imaging and signs can be deceptive to some extent.
In patients with intrahepatic cholelithiasis who present with symptoms of fever and jaundice after hepatectomy, hemobilia cannot be completely ruled out, even if the fecal occult blood test is negative.
Keywords: Case report, Hemobilia, Hepatolithiasis, Postoperative infection
Hepatolithiasis is common in East Asia [1,2]. Laparoscopic hepatectomy is known to be one of the most effective ways to cure hepatolithiasis, with the advantages of low recurrence rate and minimal invasion [[3], [4], [5]]. Hemobilia is a rare postoperative complication [6], which has been rarely reported and can have serious consequences if not diagnosed and treated in time. We report a case of atypical hemobilia due to postoperative wound infection after a laparoscopic hepatectomy in my hospital. This work has been reported in line with the SCARE criteria [7].
A 59-year-old man with hepatolithiasis underwent laparoscopic left hemihepatectomy in our hospital. His medical history included hypertension and diabetes mellitus. And his preoperative physical examination, tumour markers (AFP: 3.45 ng/ml, CEA:1.25 ng/ml, CA19–9:5.55 U/ml), ultrasound and CT did not reveal the evidence of tumour. Magnetic resonance cholangiopancreatography (MRCP) showed multiple stones in the left intrahepatic bile duct with mild dilatation of the common bile duct (CBD) (Fig. 1). The left half of the liver was completely resected and the common bile duct was explored without residual stones. No tumour was found during the surgical procedure. Meanwhile, stones were found in the sagittal part of the left intrahepatic bile ducts during specimen dissection (Fig. 2).
Fig. 1 MRCP shows multiple stones (arrows) in the left intrahepatic bile duct, the left intrahepatic bile duct is dilated by about 8 mm, and the common bile duct is slightly dilated by about 12 mm.
Fig. 2 (a) Laparoscopic view of the remaining liver. (b) Stones (arrows) are found in the sagittal part of the left intrahepatic bile duct during the dissection of the specimen.
The patient recovered well and was discharged 5 days after surgery. However, on the tenth day after surgery, the patient developed chills, fever, and mild jaundice without abdominal pain. The percentage of neutrophils was elevated (80.5 %). His total and direct bilirubin levels were elevated (40.1 μmol/l and 23.7 μmol/l, respectively) too, while hemoglobin and fecal occult blood were normal. An ultrasound showed a dilated CBD with suspicion of sedimented stones, whereas MRCP showed no stones in the common bile ducts, but an effusion in the surgical area (Fig. 3). Our initial suspicion was bacteremia after ruling out bilioma. After receiving anti-infectives, the patient's condition has improved.
Fig. 3 (a) MRCP shows no stones in the intrahepatic and common bile ducts, while dilation is only found in the common bile ducts about 13 mm. (b) MRCP shows postoperative intraperitoneal fluid in the operative area (arrow), about 6∗2 cm.
However, on postoperative day 20, he developed chills and fever again, with obvious jaundice on the skin and sclera. Total bilirubin was 384.5 μmol/l and direct bilirubin was 221.1 μmol/l. And the patient's leukocyte count and percentage of neutrophils were elevated (13 × 10^9/l and 83.8 %, respectively). Blood culture showed Enterococcus faecalis infection. Ultrasonography showed moderate echogenic filling in the dilated CBD with multiple small intense light clusters, which were suspected to be sedimentary stones, cholestasis, or small stones. There was also an anechoic area at the operative site with no apparent dilatation of the intrahepatic bile ducts (Fig. 4). Endoscopic retrograde cholangiopancreatography (ERCP) was performed to investigate the presence of stones but failed due to the inability to pass through the pylorus. Repeat laboratory tests revealed a hemoglobin level of 70 g/dl (baseline 100 g/dl) with positive stool occult blood.
Fig. 4 (a) Ultrasound shows moderate echogenic filling in the dilated CBD with multiple small intense light clusters, which are suspected to be sedimentary stones, cholestasis, or small stones. (b) Ultrasound shows an anechoic area in the surgical field, approximately 59.7 mm × 20.8 mm.
The above findings lead us to consider that the post-hepatectomy vasculo-biliary fistula caused by infection represents the final diagnosis.
We hoped to alleviate the conditions of the vasculo-biliary fistula and clot accumulation in the common bile duct by ameliorating the local infection. In addition, choledocholithiasis drainage was thought to increase the patient's physical and psychological trauma, as well as a certain economic cost. An ultrasound-guided peritoneal fluid puncture and drainage procedure was performed. Approximately 100 ml of dark green fluid was drained after 24 h (Fig. 5). The patient's symptoms improved significantly after drainage. The culture of the drainage fluid further confirmed an Enterococcus faecalis infection. Anti-infective therapy was continued until the patient was fully recovered, and the drainage tube was removed after 30 days.
Fig. 5 Dark green drainage from the surgical site.
Post-operative hemobilia is less common than infection and bile leakage following hepatolithiasis surgery [8,9], particularly hemobilia caused by post-operative infection. The clinical presentation of hemobilia often includes recurrent epigastric pain, gastrointestinal bleeding, and obstructive jaundice [10]. In this case, the patient presented with symptoms of chills and fever and elevated blood counts following surgery. An initial consideration was that the patient may have suffered from an infection caused by residual stones in the biliary tract, based on the results of an ultrasound examination. However, when the patient became febrile again, with a rapid elevation of bilirubin and a positive fecal occult blood test, it was postulated that the patient's jaundice was related to biliary hemorrhage. What's more, we speculated that the patient's jaundice fluctuated in response to alterations in the amount of bleeding, which meant a significant elevation in bilirubin levels always occurred after there were blood clots obstructed the common bile duct.
Abnormal connections between blood vessels and bile ducts are typically the result of contusion, which may be caused by direct tearing of the involved structures or by damage to the vessel wall, which subsequently becomes necrotic and ruptures into the bile ducts. Additionally, localized infected necrotic liver tissue may erode the blood vessels surrounding it, leading to bleeding. Inflammatory conditions, calculi, and neoplasms within the bile duct occasionally produce the same phenomenon. In the case of this patient, the patient initially presented with symptoms of infection, then jaundice, and finally a positive fecal occult blood test. It is therefore reasonable to conclude that a localized infection was caused by cholestasis, which resulted in damage to the vessel wall and eventually led to a vasculo-biliary fistula.
Unnecessary exploratory laparotomy instead of drainage could have been performed if biliary bleeding due to postoperative infection had not been considered. Correct diagnosis not only allows the patient to recover quickly, saving time and money but also avoids iatrogenic injury. Overall, we believe this is a good case with educational value.
When patients with intrahepatic cholelithiasis present with symptoms of fever and jaundice after hepatectomy, hemobilia cannot be completely excluded, even if fecal occult blood is negative. Controlling the infection is an important part of treatment, but the key is to get rid of the cause.
Ethical approval is not applicable. The case report is not containing any personal information.
This study is supported by grants from National Natural Science Foundation of China (82103300, 82102743).
Hanrui Yang: literature review, paper writing, picture editing assistant in the surgery and review the paper.
Kuan Hu: editing and review of the paper.
Ledu Zhou: the lead surgeon for that surgery, direct the entire diagnostic and therapeutic process and contribute to the case discussion.
Kuan Hu
NA
Written informed consent was obtained from the patient to publish this case report and accompanying images. On request, a copy of the written consent is available for review by the Editor-in-Chief of this journal.
There are no conflicts of interest to declare by all the authors.
Kuan Hu, Email: kuan.hu@csu.edu.cn.
Ledu Zhou, Email: zhould@csu.edu.cn.