Plasmapheresis and corticosteroid treatment for persistent jaundice after successful drainage of common bile duct stones by endoscopic retrograde cholangiography

Abstract

Prolonged cholestasis is a very rare complication of endoscopic retrograde cholangiography (ERC). Only few cases with this complication are reported in the English literature. We report persisting cholestatic jaundice in a 73-year old man after successful therapeutic ERC for choledocholithiasis. Serologic tests for viral and autoimmune hepatitis were all negative. A second-look ERC was normal also. He denied any medication except for prophylaxis given intravenous 1 g ceftriaxon prior to the ERC procedure. After an unsuccessful trial with ursodeoxycholic acid and cholestyramine for 2 wk, this case was efficiently treated with corticosteroids and plasmapheresis. His cholestatic enzymes became normal and intense pruritis quickly resolved after this treatment which lasted during his followup period. We discussed the possible mechanisms and treatment alternatives of intrahepatic cholestasis associated with the ERC procedure.

Prolonged cholestasis induced by endoscopic retrograde cholangiopancreatography

“…There are few similar reports in the literature and we believe our patient represents a further occurrence of this syndrome. In our case, the peak of hyperbilirubinaemia occurring 10–14 days post-ERCP followed by the onset of resolution after approximately a month (figure 4), corresponds with the two cases reported by Lee and colleagues3 and the single case reported by Saritas and colleagues 4. The histological features on liver biopsies are also compatible.…”

“…However, it has been postulated that this may be directly related to the radiocontrast medium used for the procedure, perhaps due to an idiosyncratic adverse reaction resulting in disruption of the hepatocyte canalicular membrane or interruption of transport pumps with subsequent intrahepatic cholestasis and jaundice 3 4…”

“…In the few published case reports, UDCA and cholestyramine therapies have usually been tried in the first instance and this combination was successful in our patient. A favourable response to glucocorticoids has also been reported in cases refractory to treatment with UDCA, and plasmapheresis has been employed successfully in some patients 3 4. Given the potential for spontaneous resolution, it has been suggested that UDCA could be reserved for those who have failed to improve after 2 weeks post-ERCP, with steroids being added for those whose biochemical abnormalities persist on UDCA 3…”

Severe cholestatic hyperbilirubinaemia secondary to thyrotoxicosis complicated with bile cast nephropathy treated with plasma exchange and haemodialysis

“…In our case, a trial of ursodiol and cholestyramine was administered to decrease the enteric reabsorption of bile acids but was unsuccessful at lowering the total bilirubin. Plasma exchange can decrease both total and direct bilirubin 14 15. Together with haemodialysis, it may successfully treat bile cast nephropathy 6 16.…”

Successful management of acute bilirubin encephalopathy in a dog with immune‐mediated hemolytic anemia using therapeutic plasma exchange

“…This was primarily prescribed to treat the severe hyperbilirubinemia. This technique has been infrequently utilized to manage hyperbilirubinemia in people for neonatal bilirubin encephalopathy, liver failure, leptospirosis, posthepatic bile duct obstruction, and hemolysis following implantation of a left ventricular assist device . Guidelines for the use of TPE with hyperbilirubinemia are available but are based on limited evidence and do not include recommendations on session intensity or frequency.…”