Endoscopic management of liver abscess with biliary communication.

BACKGROUND AND STUDY AIMS: The formation of a communication between liver abscesses and intrahepatic bile ducts is an uncommon cause of bile leak. The surgical management of biliary fistulas is associated with high morbidity and mortality. We performed a prospective study of the endoscopic management of liver abscess communicating with bile ducts. PATIENTS AND METHODS: We studied 38 patients with liver abscesses that had ruptured into the intrahepatic bile ducts. The presence of a biliary fistula was suspected by jaundice and/or by the appearance of bile in percutaneous drainage effluent from a liver abscess and was confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Subsequently, patients underwent treatment by endoscopic sphincterotomy and either biliary stenting or nasobiliary drainage. Nasobiliary drains or biliary stents (both 7-Fr) were placed according to standard techniques. Nasobiliary drains were removed when bile leakage stopped and closure of the fistula was confirmed by cholangiography; stents were removed after an interval of 4-6 weeks.
RESULTS: Of the total of 586 patients with liver abscesses, seen over a 10-year period, there were 38 (30 amebic, 8 pyogenic) patients who developed a biliary fistula between the liver abscess cavity and the intrahepatic bile ducts (right intrahepatic bile ducts in 30 patients, left intrahepatic bile ducts in 8 patients). We performed either endoscopic sphincterotomy with insertion of a nasobiliary drain (n = 18) or endoscopic sphincterotomy with biliary stenting (n = 20). The fistulas healed in all patients after a median time of 6 days (range 4-40 days) after endoscopic treatment. The nasobiliary drainage catheters and stents were removed after 8-40 days of their placement.
CONCLUSIONS: Endoscopic therapy is an effective mode of treatment for biliary fistulas complicating liver abscesses.