S1568 Decades-Long Recurrent Gram Negative Sepsis Secondary to Suture-Seeded Biliary Stone Following Choledochojejunostomy

Introduction:

Biliary enteric anastomosis is an intervention reserved for complicated obstructive biliary disease. Cholangitis and bacteremia remain serious complications of this therapeutic approach. We present a case of recurrent gram negative bacteremia which confounded practitioners for decades in a patient who underwent a choledochojejunal anastomosis 40 years prior.

Case Description/Methods:

A 92 yr old male with a previous medical history of complicated cholecystectomy and recurring gram negative bacteremia presented to the ED with complaints of nausea and vomiting without abdominal pain. He described his cholecystectomy 40 years prior as being complex and requiring a prolonged hospital course. Since then, he had sporadic episodes of nausea, vomiting, and right upper quadrant pain requiring hospitalization every 2-3 years often associated with gram negative bacteremia without clear source identification. During a previous admission 2 years prior, the patient was found to have bacteremia with organisms including K. pneumoniae, E. coli, E. faecalis, and S. salivarius. A CT scan conducted at that time found no evidence of intra-abdominal pathology other than pneumobilia (Figure 1A) and urinalysis showed no evidence of UTI. During his current admission, repeat abdominopelvic CT (Figure 1B) found stable pneumobilia and again found no other evidence of intra-abdominal process. Blood cultures grew piperacillin-tazobactam resistant E. coli and he was started on a course of ceftriaxone. Given the persistent involvement of enteric organisms, evaluation of possible GI sources was conducted. ERCP with cholangioscopy discovered a choledochojejunostomy containing a large biliary stone (Figure 1C) which was seeded to the sutures (Figure 1D) used to create the anastomosis. The stone was successfully treated with electrohydraulic lithotripsy. Given his age and risk factors, it was decided to not pursue surgical reversal of the anastomosis. He was discharged home with a rotating cycle of oral antibiotics to continue prophylaxis indefinitely.

Discussion:

Reflux of bacteria and chyme is a leading hypothesis in the development of cholangitis and bacteremia in patients with a biliary-enteric anastomosis. In this case, the presence of a biliary stone on the suture line may have contributed to entrapment and stasis of refluxed contents in the biliary tree. Earlier endoscopic evaluation of the biliary tree may have led to a reduction in hospitalizations, exposure to antibiotics, and improved quality of life for this patient.

Figure 1.: CT findings of pneumobilia two years prior (A) with subsequent CT findings on readmission 2 years later showing air communication between duodenum and biliary tree (B). Cholangioscopy showing biliary stone seeded on suture line at mouth of anastomosis (C) with residual suture line seeding after lithotripsy (D).