S3397 Leave No Stone Unturned: Recurrent Pyogenic Cholangitis in the West

Introduction: Recurrent pyogenic cholangitis (RPC) is a chronic hepatobiliary condition characterized by recurrent biliary tract infections, intrahepatic pigmented stone formation, and progressive biliary obstruction. Though endemic to Southeast Asia, increased global travel and immigration have brought RPC into Western clinical settings. It can lead to abscesses, strictures, secondary biliary cirrhosis, and rarely, cholangiocarcinoma. RPC pathogenesis is multifactorial, relating to transient portal bacteremia and altered biliary drainage. This case series highlights the presentation, complexity, and treatment considerations of RPC in a Western tertiary care center. Case Description/Methods: Case 1: A 43-year-old Burmese woman with RPC, secondary biliary cirrhosis, and liver abscesses presented with cholangitis. Over 4 years, she had 4 hospitalizations for septic shock requiring multiple endoscopic retrograde cholangiopancreatography (ERCP)s with stent placements and computed tomography-guided drain placement. Despite a low Model for End-Stage Liver Disease 3.0 of 8, transplant evaluation was pursued due to recurrent infections. She remains unlisted due to a lack of a care partner. Case 2: A 42-year-old Burmese woman with RPC and chronic hepatic schistosomiasis was admitted with cholangitis. ERCP with partial stone clearance and a percutaneous internal-external biliary drain was performed. Post-procedure, she developed septic shock from polymicrobial bacteremia. Management has included multiple biliary drainages and a planned cholecystectomy prior to metallic stent placement to facilitate further ERCPs. Case 3: A 54-year-old Thai woman with a history of cholecystectomy and RPC presented with cholangitis. MRCP revealed an atrophic left hepatic lobe with dilated left intrahepatic bile ducts. ERCP showed left intrahepatic duct dilation with a filling defect; lithotripsy and stone extraction were performed. She underwent left lateral hepatic segmentectomy, revealing intrahepatic cholangiocarcinoma. Discussion: RPC is a rare but severe condition commonly seen in Southeast Asians. These cases emphasize its diagnostic and therapeutic complexity and the need for individualized, multidisciplinary care. Addressing social barriers is also essential for equitable care and access to advanced therapies, including liver resection and transplantation.