Biliary Cast Syndrome in an Opium Inhaler
A 52-year-old man, who was a known case of opium addiction, presented with the chief complaint of epigastric pain for 1 week prior to admission. Physical examination showed moderate right upper quadrant tenderness. There were no significant disorders in his past medical history. Routine laboratory evaluation revealed cholestatic liver enzyme elevation with alkaline phosphatase 1,810 IU/l (reference range 80–306 IU/l), total bilirubin 0.5 mg/dl (reference range 0.1–1.2 mg/dl) with normal aminotransferases, high erythrocyte sedimentation rate (90 mm/s) and normal prothrombin time. Serum levels of fasting blood sugar, blood nitrogen urea, creatinine, triglyceride, total and low-density lipoprotein cholesterol and uric acid as well as thyroid function tests were in the normal range.\nUltrasound demonstrated a dilated common bile duct. An abdominal CT scan demonstrated dilated intrahepatic and extrahepatic bile ducts (the common bile duct measured 11 mm). Magnetic resonance cholangiopancreatography showed a distended gallbladder and a dilated bile duct with the conclusion of ampullary and periampullary lesion (fig. ). Endoscopic retrograde cholangiopancreatography showed a linear filling defect in the intra- and extrahepatic duct (fig. ). A long biliary cast was successfully removed using an extractor balloon (fig. ).\nThe patient was discharged without any complication. After removal of the biliary cast he is receiving ursodeoxycholic acid (UDCA) 750 mg per day and does not report any problem 4 months after treatment. His last laboratory evaluation revealed a significant decrease in erythrocyte sedimentation rate (30 mm/s) and a mild decrease in alkaline phosphatase (1,423 IU/l).