Volume 20, Issue 11 , Pages 1429-1430, November 2009
Transient Bacteremia after a Percutaneous Liver Biopsy
Article Outline
Clinical Case
A 52-year-old woman with elevated liver enzyme levels was referred to the interventional radiology department for a percutaneous liver biopsy. She had a previous surgery for a type I choledochal cyst for which a Roux-en-Y hepaticojejunostomy was performed. Her medical history was otherwise unremarkable and she had no preexisting liver disorder. The procedure was performed under moderate sedation. After infiltrating the skin and liver capsule with local anesthetic agent, a 17-gauge needle was advanced under ultrasound guidance into the left lobe of the liver with a subcostal window. This is the routine access employed for liver biopsies in our institution. Then, with use of coaxial technique, four 18-gauge core biopsies were performed. The coaxial needle was removed after embolization of the needle tract with Gelfoam slurry (Pharmacia & Upjohn, Kalamazoo, Michigan). Direct manual compression was applied to the skin entrance site. The patient tolerated the procedure well.
In the recovery room, the patient reported pain at the biopsy site, which was well controlled with analgesic medications. Two hours after the procedure, the patient developed shaking chills, nausea, vomiting, and increasing abdominal pain. A computed tomography (CT) scan demonstrated air within the intrahepatic biliary radicals, particularly on the left side. There was no evidence of a hematoma or bile leak. Laboratory workup revealed an increase in blood cell white count from 5,400/dL before the procedure to 10,100/dL after the procedure. She was admitted for 23 hours of observation in the anticipation of the development of septicemia. She was treated with levofloxacin (500 mg intravenously, one dose). The next morning, she was afebrile and did not report any symptoms except for mild pain at the biopsy site. She was discharged and prescribed pain medications. Blood cultures were drawn at the time of the acute event, and no organisms had grown after 5 days of observation. Liver biopsy results revealed “mild acute cholangiolitis and cholestasis suggestive of biliary outflow impairment and/or sepsis.”
What Happened and Why
The patient had a previous surgery for a type I choledochal cyst resulting in a Roux-en-Y hepaticojejunostomy. In these patients, the biliary system can be colonized by the gut flora. While the biopsy was being performed, the needle traversed the biliary tree into the vascular system. This resulted in spillage of the gut flora into the bloodstream, resulting in bacteremia.
Discussion
Liver biopsy is a frequently performed procedure. Numerous studies have shown that percutaneous liver biopsy is associated with overall procedure-related complication rates of 0.2%–5.9% (1). The most common complication is pain, which occurs in as many as 30% of cases. Significant bleeding occurs in 0.35%–0.5% of all procedures. However, subclinical bleeding occurs in a much higher percentage of patients, with as many as 23% of patients having intrahepatic or subcapsular hematomas (2). Infectious complications are reported only rarely and occur in approximately 0.6% of all liver biopsies. The infectious complications are more common in patients with biliary abnormalities, with a reported incidence of 3.7% (3). Bubak et al (3) observed that the risk of infection in patients with Roux-en-Y anastomosis (9.8%) was significantly increased compared with patients with choledochojejunostomy (1.4%). However, even in patients with Roux-en-Y anastomosis, biliary dilation was a prerequisite for the development of infection (4). Bacteremia in these patients is predominantly caused by enteric organisms. The free reflux of bowel contents into the biliary system permits colonization of the biliary tree by enteric flora.
The present case highlights the risk of bacteremia after a liver biopsy in patients with preexisting biliary abnormalities. A CT scan of the abdomen from 1 year earlier demonstrated a similar degree of left-sided pneumobilia. This is expected in patients with Roux-en-Y hepaticojejunostomy as a result of the patency of the anastomosis and the absence of a competent valve. There were no clinical or laboratory signs of biliary obstruction, so the patient was not assessed further for biliary obstruction. Patients with Roux-en-Y anastomoses commonly have enteric organism colonization in the biliary tree. In our patient, although blood culture findings were negative, it is clear that her clinical picture was consistent with a transient bacteremia.
A history of biliary surgery in these patients should alert the interventional radiologist about the possibility of the complication of bacteremia. The use of a prophylactic antibiotic to cover the gut flora is controversial (5). The current data on the use of prophylactic antibiotics are inconclusive, and we believe that, for patients in whom biliary sepsis is suspected (as in the present patient), it is prudent to use an antibiotic to cover the enteric flora that colonizes the biliary system, such as a combination of piperacillin and tazobactam.
References
- . Complications following percutaneous liver biopsy: a multicentre retrospective study on 68,276 biopsies. J Hepatol. 1986;1:75–85
- . Septicemia as a complication of liver biopsy. Am J Gastroenterol. 1981;76:145–147
- . Complications of livery biopsy in liver transplant patients: increased sepsis associated with choledochojejunostomy. Hepatology. 1991;14:1063–1065
- The nature of complications following liver biopsy in transplant patients with roux-en-Y choledochojejunostomy. Hepatology. 1994;20:651–653
- . Guidelines on the use of liver biopsy in clinical practice. Gut. 1999;45(suppl 4):IV1–IV11
None of the authors have identified a conflict of interest.
PII: S1051-0443(09)00814-8
doi:10.1016/j.jvir.2009.08.004
© 2009 SIR. Published by Elsevier Inc. All rights reserved.
Volume 20, Issue 11 , Pages 1429-1430, November 2009
