508

CASE REPORT
A rare case of massive hepatic abscess 6 years after ERCP due
to retained biliary stent
Ioannis G. Gkionis1, Michail I. Giakoumakis1, Ifigenia Tzartzalou1, George Kavallaris2, Pinelopi Nicolaou3,
Emmanouil Vardas3, and Aggelos Laliotis1
Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece, 2Department of Imaging, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece, 3Department of Gastroenterology, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
1

Abstract : Backround : ERCP combined with the insertion of biliary endoprosthesis is considered a daily practice endoscopic intervention for the treatment of choledocholithiasis. Nevertheless, retained biliary stents for a
prolonged period without follow up may cause serious complications. Case presentation : We present the case ofa 62-year-old man who was hospitalized with symptoms of vomiting, abdominal pain, fatigue and fever. Clinicalexamination and laboratory results were indicative of an intra abdominal infection. Ultrasound and CT scans
were performed, identifying a 17x11.3x7.7 cm. The cause of this lesion was a retained stent in the common bile
duct which was placed 6 years ago via endoscopic retrograde cholangiopancreatography. The patient did notattend his follow up appointments after his initial ERCP. Patient’s clinical status deteriorated, and an urgent
ERCP was performed replacing the retained stent, followed by ultrasound-guided pigtail stent insertion into
the hepatic abscess and administration of antibiotics intravenously. Patient’s clinical condition was improved
and after two months of surveillance complete resolution of the hepatic abscess was achieved. Conclusion : The
insertion of biliary stents is common endoscopic technique, but close follow up is of outmost importance. J. Med.
Invest. 70 : 508-512, August, 2023
Keywords : Pyogenic hepatic abscess, ERCP, Stent, Follow up, Case management

INTRODUCTION

CASE PRESENTATION

Endoscopic retrograde cholangiopancreatography (ERCP) is
widely accepted as the gold standard technique for the treatmentof choledocholithiasis and, is usually combined with the endoscopic insertion of biliary endoprosthesis in order to establish
and secure patency of the common bile duct (CBD) (1, 2). Biliary
stents are tubular devices made of plastic or metal, and is recommended to be replaced or removed within 2-6 months from
insertion (1-4).
Retained biliary stents for a prolonged period without follow
up may cause serious, or even life-threatening, complications
such as acute cholangitis, pancreatitis, internal stent migration,
endoprosthesis occlusion and obstructive jaundice (3-12). In
these cases, the mortality rate can reach up to 12% (3). The formation of liver abscess is a rare complication of a forgotten stentin the CBD. Only 2 cases have been described in literature to thebest of our knowledge (7, 8).
We present the case of a 62 year-old male patient with liverabscess due to retained biliary stent, who was treated via
ultrasound (U / S) guided drainage of the abscess and administration of antibiotics intravenously. This report aims to bring toclinicians’ attention this relatively rare entity and highlight the
management options.

We present the case of a 62 year-old Caucasian male patient
who was hospitalized with symptoms of vomiting, abdominal
pain, fatigue and fever. The symptoms have begun 3 days
before his admission to the hospital. His vital signs on theadmission were the following : Temperature = 38.5ºC, Heartrate = 95 beats / min, Respiratory rate = 23 breaths / min, Bloodpressure = 110/70 mmHg. The patient was pale but with goodnutrition status (Body Mass Index = 20.2 kg / m2). Moreover, his
tobacco use was 30 pack-years and he did not consume alcohol.
Patient’s past medical history included hypothyroidism treated with levothyroxine and CBD stent placement after an ERCP,
6 years ago, due to an episode of obstructive jaundice. A CBD
stricture, related to inflammation, was identified as the cause of
the jaundice. Cytological samples taken from the stricture were
negative for malignancy and a plastic 10 Fr-10 cm stent wasinserted. Patient did not appear on the scheduled appointments
for evaluation of the biliary stent. Furthermore, there was noprevious surgical history.
On inspection, he was ill-looking and had signs of dehydration. The clinical examination revealed sensitivity in the rightupper quadrant of the abdomen without tenderness, whereas,
the bowel sounds were normal. In addition, there was no blood or
palpable mass on digital rectal examination. Furthermore, theclinical examination of cardiopulmonary and urogenital systems
revealed no abnormal signs.

Abbreviations• ERCP = Endoscopic retrograde cholangiopancreatography• CBD = Common bile duct
• CT = Computed tomography• U / S = UltrasoundReceived for publication December 12, 2022 ; accepted March 29,
2023.
Address correspondence and reprint requests to Aggelos Laliotis, Department of General Surgery, Venizeleio General Hospital, Leoforos
Knossou 44, Heraklion, 71409, Crete, Greece and E-mail : laliotisac@
gmail.com

The Journal of Medical Investigation Vol. 70 2023

The Journal of Medical Investigation Vol. 70 August 2023

509

The blood tests revealed elevated inflammatory markers,
anaemia, jaundice electrolyte disorders, as well as deteriorationof the liver function (Table 1). The results of all other laboratory
markers were within normal range (Table 1).

Table 1. Blood test results on admission
Blood test markers

On admission

Normal range valuesWBC

19.1703.800-10.500 / mL

Hct

29.5

41-53.8%

Hb

9.2

13.4-17.4 g / dL

PLT

301

150-400 K / μl

CRP

38.97

< 0.5 mg / dLUR48

15-50 mg / dL

CR

0.95

0.7-1.3 mg / dL

K-

3.4

3.5-5.1 mmol / L

Na+

127

136-145 mmol / L

TA-BIL

2.04

0.3-1.2 mg / dL

D-BIL

1.3

0-0.5 mg / dL

SGOT

125

0-35 U / L

SGPT

116

0-55 U / L

GGT

322

0-50 U / L

ALP

348

40-150 U / L

CEA

2.64

0-5 ng / ml

AFP

0.96

0.89-8.78 ng / ml

CA 19-9

27.48

0-37 U / ml

PSA Total

0.389

0-4 ng / ml

TSH

0.38380.35-4.94 μUI / mL

Figure 1. Hepatic abscess and stent in CBD.

CT of the abdomen depicting a 17x11.3x7.7 cm hepatic abscess in theright hepatic lobe and a stent in CBD causing slight dilation of intrahepatic bile ducts. The green arrow is demonstrating the hepatic
abscess, whereas the red one is depicting the stent in CBD.

Note.
WBC = White blood cells, Hb = Haemoglobin, Hct = Haematocrit,
PLT = Platelets, CRP = C-reactive protein, UR = Urea, Cr = Creatinine, Na+ = Sodium, K+ = Potassium, TA-BIL = total bilirubin,
D-BIL = direct bilirubin, SGOT = Serum glutamic oxaloacetictransaminase, SGPT = Serum glutamic pyruvic transaminase,
GGT = Gamma glutamyl transferase, ALP = alkaline phosphatase, CEA = Carcinoembryonic antigen, AFP = Alpha Fetoprotein, CA 19-9 = Cancer antigen 19-9, PSA Total = Prostate specific antigen Total, TSH = Thyroid stimulating hormone

Figure 2. Hepatic abscess, stent in CBD and gallbladder.
Taking into consideration all findings from the clinical examination and the blood tests, an abdominal U / S was performed,
revealing a 17x11.3x7.7 cm hypoechogenic lesion with irregular borders and hyperechogenic rim in the right hepatic lobe,
followed by computed tomography (CT) of the abdomen. The
latter confirmed the findings of U / S, and, in addition depicted
a stent in CBD causing slight dilation of intra-hepatic bile ducts(Figure 1). Furthermore, the gallbladder was distended without
gallstones (Figure 2). The serological tests were negative forhepatitis, HIV infection and echinococcosis, whereas the tumourmarkers in blood were normal (Table 1).
Due to deterioration of his clinical status with exacerbationof abdominal pain, presence of electrolyte disorders and onsetof fever, the patient underwent an urgent ERCP 6 hours after
his admission to the hospital and replacement of the previously
inserted plastic stent with a new one plastic 7 Fr–10 cm stent.
The replaced stent was partially obstructed and many smallgallstones and biliary sludge were removed from the CBD. The
U / S-guided pigtail stent insertion into the hepatic lesion released a substantial amount of brownish fluid which was sent for
microbial and cytological analysis. The cytological examination

CT of the abdomen depicting the hepatic abscess, the stent in CBD
and the gallbladder. The green arrow is demonstrating the hepatic
abscess, the red arrow is depicting the stent in CBD and the yellow
arrow is showing the gallbladder.

of the specimen was negative for malignancy, whereas thecultures revealed the growth of Enterococcus faecalis and Klebsiella pneumoniae. The initial empiric antibiotic therapy withceftriaxone, metronidazole and gentamicin was modified according to pus cultures to ciprofloxacin and linezolid. The clinicalcondition of the patient was improved and an abdominal CT was
performed 8 days after his admission to the hospital revealing
significant decrease in the dimensions of the liver abscess (Figure 3). Nevertheless, a second pigtail stent was inserted (Figure3). The patient received intravenously 0.8 gr Ciprofloxacin / dayfor 22 days and 1.2 gr Linezolid / day for 22 days. He also received
1 gr Ciprofloxacin / day and 1.2 gr Linezolid / day per os, for 30days after his discharge.
The patient was discharged 27 days after his admission
to the hospital and he underwent regular follow up meetings
with clinical examination, blood tests and CT of the abdomen.

I. G. Gkionis, et al. Hepatic Abscess 6 years after ERCP510

His last follow up was in November 2021, 2 months after his
hospitalization, in which he was found in good clinical condition.
The abdominal CT depicted complete resolution of the hepatic
abscess and, both the pigtail stents in the hepatic lesion and thestent in the CBD, were removed (Figure 4).

Figure 3. Insertion of pigtail stents into the hepatic abscess.

CT of the abdomen showing two pigtail stents inserted into thehepatic abscess. The arrows are demonstrating the pigtail stents.

Figure 4. Complete resolution of the hepatic abscess.

CT of the abdomen revealing complete resolution of the hepatic
abscess.

DISCUSSIONERCP is an extremely useful endoscopic technique used indaily practice for both diagnosis and treatment of biliary pathology. Insertion of biliary endoprosthesis during ERCP is considered the treatment of choice for patients of any age, in order toestablish and maintain the bile flow in case of stone impaction in
the CBD with a success rate of up to 95% (1, 2).
Biliary stents are tubes made of plastic or metal in different
sizes and shapes, used to relieve obstruction in the biliary tree orto treat biliary leaks (1, 2). Plastic stents are considered a valuable option for benign biliary strictures, although they are related to a notable complication rate (36.5% for single and 20.3% formultiple plastic stents) (13, 14). Compared to uncovered metal
stents (39.5% complication rate), plastic stents are cheaper andsafer (13, 14). However, fully covered metal stents are related toa similar complication rate (23.8%) with the plastic stents, but
at a significantly higher cost (15). Nevertheless, metal stents
have higher patency rates, and for this reason are considered themainstay treatment for hilar malignancy and inoperable malignant strictures of the common bile duct (16).
Patient’s adherence to follow-up is crucial. Regular appointments should be scheduled every 2-6 months after the initialinsertion of endoprosthesis, and continues until the removalof the biliary stent (1-4, 11). Biliary stents are foreign bodies
and, therefore, if kept for a prolonged period they contribute toformation of stones in the CBD and bacterial proliferation (312). A combination of biliary stasis, bile infection and microbial
translocation is considered as the most probable mechanism ofhepatic abscess formation in our case. Ascending cholangitis,
due to occlusion of retained biliary stents, was also considered
responsible for the formation of hepatic abscesses in the othertwo similar cases reported in literature (7, 8) (Table 2).
In general, hepatic abscesses may vary from a small (≤ 5 cm)
to giant size (> 10 cm). The majority of hepatic abscesses present
with an average size between 5 cm to 10 cm, and these lesions
are characterized as “large” (17). They usually present with a
combination of malaise, abdominal pain, fever and obstructive
jaundice (18, 19).
Early diagnosis is crucial for appropriate treatment, andabdominal imaging is pivotal in confirming the diagnosis. Abdominal U / S and CT are the most commonly used diagnostic
modalities while further imaging with MRI is included in patient’s workup (20). Abdominal CT has a sensitivity of 97% in
diagnosing liver abscess, and is considered the gold standard
imaging technique (9). The double target sign is a characteristic
imaging feature of hepatic abscess demonstrated on CT scan,in which a central low attenuation lesion filled with liquid isTable 2. Comparison of the 3 cases with hepatic abscess due to retained biliary stent presenting patients’ age, symptoms, abscess’s characteristics, characteristics of retained stent and management
AuthorSymptoms

Abscess location

Alhaddad O
et al. (7)62-Abdominal pain
-Fever- Jaundice

Right hepatic
lobe

10x10 cm

Plastic stent

20 years-ERCP-Pigtail stent insertion
to abscess-Antibiotics

Rajmohan R
et al. (8)37-Abdominal pain
-Fever-Diarrhea

Hepatic dome

Multiple, < 3 cm

Multiple plastic
stents

10 years-ERCP-Antibiotics

62-Vomiting-Abdominal pain
-Fever- Jaundice

Right hepaticlobe

6 years-ERCP-Pigtail stent insertion
to abscess-Antibiotics

Gkionis et al.

Abscess size

Characteristics
Duration ofof retained stent retained stentAge

17x11.3x 7.7 cm

Plastic stentManagement

The Journal of Medical Investigation Vol. 70 August 2023
surrounded by a high attenuation inner rim representing themembrane of the abscess and a low attenuation outer ring depicting the edema of the liver parenchyma (18). Moreover, CT
is extremely helpful in guiding accurate percutaneous drainage
which is nowadays the most widely accepted approach in terms oftreatment along with antibiotic administration (21).
In the vast majority of cases the abscess is polymicrobial andthe most commonly involved pathogens in the formation of hepatic abscesses are Escherichia Coli, Klebsiella pneumoniae, Bacteroides and Enterococcus (17). In abscesses due to retained biliary
endoprosthesis the first step in patient’s management, shouldbe the removal or replacement of the forgotten stent via ERCP
followed, in most cases, by a combination of antibiotic therapy
and adequate drainage (19). The antibiotic regimen should covera wide spectrum of microbes and for that reason should consistof ampicillin combined with an aminoglycoside and metronidazole (18). Antibiotic therapy alone, without drainage, should bereserved only for patients in good clinical status and those whohave multiple micro abscesses, smaller than 3 cm in diameter,
not amenable to drainage (18). The antibiotic treatment canbe modified based on the results of blood or pus cultures. The
duration of the antibiotic therapy should be individualized on
the basis of the clinical response and most of the patients should
receive antibiotics for 4-6 weeks (17-19).
Drainage of pyogenic liver abscesses is the mainstay treatment
and can be performed surgically or with the use of minimallyinvasive techniques. Image guided percutaneous drainage has
success rate up to 90% and has become the treatment of choice
in most centers, while surgical drainage nowadays is reservedfor patients who fail to respond to treatment with percutaneous
drainage and antibiotics or have concurrent intraabdominal pathology which requires surgical management (21).
In conclusion, CBD patency should be always checked after insertion of biliary endoprosthesis as it can lead even to the formation of hepatic abscess, a rare but potentially lethal complication.
Clinical vigilance, early appropriate imaging, rapid removal of
the endoprosthesis along with drainage and antibiotic treatment
are pivotal in the management of this rare clinical scenario.

CONCLUSION
The formation of hepatic abscess due to retained biliary stentis a rare complication of ERCP. Obviously, close follow up is ofoutmost importance.

ACKNOWLEDGEMENTS
None.

DECLARATIONS
Funding : There was no funding.
Conflict of Interests : Authors have no potential competing interests or conflicts to report.
Ethics approval and consent to participate : This case report
was conducted in accordance with the ethical standards of theinstitutional and national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable
ethical standards. The case report was approved by the Ethics
Committee of the Scientific Board of Venizeleio General Hospitalof Heraklion (Decision No.127 / Meeting 24 / 04-10-2022). Written
informed consent was obtained from the patient. A copy of thewritten consent is available for review by the Editor-in-Chief of511

the journal.
Consent for publication : Written informed consent was obtained
from the patient for the publication of this case report and any
accompanying images. A copy of the written consent is available
for review by the Editor-in-Chief of the journal.
Availability of data and material : The datasets generated andanalysed during the current study are available from the corresponding author on reasonable request.
Authors Contribution : IG, MG, GK and PN analyzed and interpreted the patient’s data. The first draft of the manuscript was
written by IG, MG and supervised by AL. All authors commented on previous versions of the manuscript. AL and EV participated in design and coordination. All authors read and approved
the final manuscript.

REFERENCES
1.

Dumonceau JM, Tringali A, Papanikolaou IS, Blero D,
Mangiavillano B, Schmidt A, Vanbiervliet G, Costamagna
G, Devière J, García-Cano J, Gyökeres T, Hassan C, Prat F,
Siersema PD, Van Hooft JE : Endoscopic biliary stenting :indications, choice of stents, and results : European Societyof Gastrointestinal Endoscopy (ESGE) Clinical Guideline Updated October 2017. Endoscopy 50 : 910-930, 2018
2. Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman
DS, Qumseya BJ, Cortessis VK, Schilperoort H, Kysh
L, Matsuoka L, Yachimski P, Agrawal D, Gurudu SR,
Jamil LH, Jue TL, Khashab MA, Law JK, Lee JK, Naveed
M, Sawhney MS, Thosani N, Yang J, Wani SB : ASGE
guideline on the role of endoscopy in the evaluation andmanagement of choledocholithiasis. Gastrointest Endosc
89 : 1075-1105.e15, 2019
3. Kim SJ, Ohanian E, Lee F, Nam B, Che K, Laine L, Kim
SE, Kim JJ : Predictors and outcomes of delayed plastic biliary stent removal following endoscopic retrograde cholangiopancreatography. Scand J Gastroenterol 52 : 1128-1132,
2017
4. Sohn SH, Park JH, Kim KH, Kim TN : Complications andmanagement of forgotten long-term biliary stents. World J
Gastroenterol 23 : 622-628, 2017
5. Lesetedi C, Motsumi MJ : Forgotten metal stent (3 years)
presenting with a high burden of intra- and extra-hepatic
ducts stones and cholangitis. J Surg Case Rep 2019 : rjz294,
2019
6. Barai V, Hedawoo J, Changole S : Forgotten CBD stent (102months) with stone-stent complex : A case report. Int J Surg
Case Rep 30 : 162-164, 2017
7. Alhaddad O, Elsabaawy M, Edrees A, Elshimy E, Elsabaawy
D, Mansour T : A case report of COVID-19 evoked cholangitic liver abscess. Egypt Liver J 12 : 5, 2022
8. Rajmohan R, Charudatta W, Bobby J, Shino P, Pranay S,
Santosh K, Paul M, Kaleem R : A case of forgotten biliary
stent presenting as multiple liver lesions : A single institution experience. The American Journal of Gastroenterology
116 : pS1426, 2021
9. Catalano O, De Bellis M, Sandomenico F, de Lutio diCastelguidone E, Delrio P, Petrillo A : Complications ofbiliary and gastrointestinal stents : MDCT of the cancer
patient. AJR Am J Roentgenol 199 : W187-96, 2012
10. Odabasi M, Arslan C, Akbulut S, Abuoglu HH, Ozkan
E, Yildiz MK, Eris C, Gunay E, Tekesin K, Muftuoglu
T : Long-term effects of forgotten biliary stents : a case series and literature review. Int J Clin Exp Med 7 : 2045-52,
2014
11. Jaleel R, Simon EG, Gupta P, Patnaik I, David D, Chowdhury

512

I. G. Gkionis, et al. Hepatic Abscess 6 years after ERCPSD : Retained biliary plastic stents - lest we forget. Trop
Doct 51 : 177-180, 2021
12. Merei F, Shapiro G, Shakra IA, Bickel A, Ganam S, Bez
M, Kakiashvili E : An unusual case of multifocal pyogenic
abscess formation following ERCP procedure. BMC Surg
20 : 92, 2020
13. van Boeckel PGA, Vleggaar FP, Siersema PD : Plastic or
metal stents for benign extrahepatic biliary strictures : asystematic review. BMC Gastroenterol 9 : 96, 2009
14. Ramchandani M, Lakhtakia S, Costamagna G, Tringali
A, Püspöek A, Tribl B, Dolak W, Devière J, Arvanitakis
M, van der Merwe S, Laleman W, Ponchon T, Lepilliez V,
Gabbrieli A, Bernardoni L, Bruno MJ, Poley JW, Arnelo U,
Lau J, Roy A, Bourke M, Kaffes A, Neuhaus H, Peetermans
J, Rousseau M, Nageshwar Reddy D : Fully covered self-expanding metal stent vs multiple plastic stents to treat benign biliary strictures secondary to chronic pancreatitis : A
multicenter randomized trial. Gastroenterology 161 : 185195, 2021
15. Kaasis M, Boyer J, Dumas R, Ponchon T, Coumaros D,
Delcenserie R, Canard JM, Fritsch J, Rey JF, Burtin
P : Plastic or metal stents for malignant stricture of thecommon bile duct? Results of a randomized prospective
study. Gastrointest Endosc 57 : 178-82, 2003
16. Jha AK, Jha P, Jha SK, Keshari R : Plastic versus metal

stents for inoperable gallbladder cancer with hilar biliary
obstruction : the jury is still out. Ann Gastroenterol 34 : 1219, 2021
17. Du ZQ, Zhang LN, Lu Q, Ren YF, Lv Y, Liu XM, Zhang
XF : Clinical characteristics and outcome of pyogenic liverabscess with different size : 15-year experience from a single
center. Sci Rep 6 : 35890, 2016
18. Lardière-Deguelte S, Ragot E, Amroun K, Piardi T, Dokmak
S, Bruno O, Appere F, Sibert A, Hoeffel C, Sommacale D,
Kianmanesh R : Hepatic abscess : Diagnosis and management. J Visc Surg 152 : 231-43, 201519. Shi SH, Zhai ZL, Zheng SS : Pyogenic liver abscess ofbiliary origin : The existing problems and their strategies.
Semin Liver Dis 38 : 270-283, 201820. Sheybani A, Gaba RC, Lokken RP, Berggruen SM, Mar
WA : Liver Masses : What physicians need to know aboutordering and interpreting liver imaging. Curr Gastroenterol Rep 19 : 58, 2017
21. Al-Sayaghi KM, Alhujaily M, Zaky MK, Alhasan AS,
Babikir TB, Alnehmi FS, Abdalrahman HH, Abdelmalik
MAA, Ali AM, Fadlalmola HA, Swamy DSV : Percutaneous needle aspiration versus catheter drainage in the management of liver abscess : an updated systematic review andmeta-analysis. ANZ J Surg doi : 10.1111/ans.18129.