A 37-year-old Filipino man presented with epigastric and right upper quadrant pain and an associated fever. He was tender, but negative for Murphy's sign. There was a leukocytosis (white cell count 14 × 10 9 /L), but liver function tests were unremarkable. Blood cultures grew Haemophilus influenza and streptococci.Ultrasound demonstrated choledocholithiasis, and computed tomography (CT) showed multiple intra-and extrahepatic stones with atrophy of the left lobe of the liver (Fig. 1). The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), where multiple small stones were extracted. A 3-cm stone impacted in the left hepatic duct was bypassed with a stent (Fig. 2). This was eventually broken down with peroral cholangioscopic lithotripsy (POCSL) in a separate session. Despite this treatment, the patient presented a few months later with a further episode of cholangitis. This resolved after ERCP, where the stent was found to be blocked.An elective left hemihepatectomy with on-table cholangioscopy and a right Roux-en-Y hepaticojejunostomy was performed. On-table cholangioscopy allowed removal of residual stones from the right side of the biliary tree. The blind stump of the hepaticojejunostomy was left long, sutured to the peritoneum of the anterior abdominal wall and marked by six clips as an access loop to facilitate future percutaneous cholangioscopy, in the event of recurrent stones.Examination of his pathology showed intrahepatic strictures and dilatation with pigment stones (Fig. 3). The post-operative recovery was complicated by an early small bowel obstruction; however, this was managed non-operatively. Since his operation, he has had no further presentations with cholangitis and does not complain of further pain.Recurrent pyogenic cholangitis (RPC) is a rare disease in Western countries. Its previous name, oriental cholangiohepatitis, gives away that it is endemic in Asia, with a prevalence as high as 47% in Fig. 1. Computed tomography scan on presentation showed a dilated biliary tree, more so on the left (arrowheads). There was a large 3-cm intrahepatic calculus (arrow). There is subtle atrophy of the left lobe. Fig. 2. Endoscopic retrograde cholangiopancreatography showing positioning of a wire across the left-sided, intrahepatic stricture. The large, calculus (arrow) and dilated proximal ducts (arrowhead) are highlighted.Fig. 3. Macroscopic pathology specimens showed dilated intrahepatic ducts with intrabililary pigment stones (arrow).
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