A Case of Biliary Cast Developed in a Patient with Long-Standing Biliary Sludge
An 80-year-old man was admitted with a complaint of abdominal pain and fever. The patient's history included brain surgery due to head trauma approximately 1 year ago; he had remained in a bed-ridden state since then. The patient had a blood pressure of 109/66 mm Hg, a heart rate of 122 beats/min, a respiration rate of 30 breaths/min, and a body temperature of 38.4℃. Physical examination revealed tenderness at right upper quadrant of abdomen. Laboratory examination revealed a hemoglobin of 14.2 g/dL (normal range, 13 to 17); white blood cell, 29,900/mm3 (normal range, 4,000 to 10,000); platelet, 296,000/mm3 (normal range, 130,000 to 350,000); total bilirubin, 2.5 mg/dL (normal range, 0.22 to 1.2); aspartate aminotransferase (AST), 742 IU/L (normal range, <40); alanine aminotransferase (ALT), 422 IU/L (normal range, <40); alkaline phosphatase (ALP), 1,593 IU/L (normal range, 66 to 220); and γ-glutamyl transpeptidase 1,321 IU/L (normal range, 8 to 66). Abdominal computed tomography showed dilatation of the biliary tract and gallbladder at first. We performed percutaneous transhepatic cholecystostomy for the purpose of immediate decompression of the biliary tract. The patient became stable and his vital signs were stabilized. Follow-up tubography via percutaneous cholecystostomy showed multiple tubular filling defects in the extrahepatic bile duct (). Endoscopic retrograde cholangiopancreatography (ERCP) revealed the same features; therefore, we performed endoscopic sphincterotomy followed by basket retrieval of the black colored tubular structures from the extrahepatic bile duct (). Histology of the biliary tubular structures showed aggregates of bile pigmented amorphous materials, consistent with biliary cast (). Within a few weeks after the ERCP, his liver blood tests had returned to normal. Currently, almost 16 months after the removal of the biliary cast, he was found to be asymptomatic and maintained a normal range of liver biochemistries.\nOne year before admission, he had suffered head trauma after falling from his bicycle. A head computed tomography scan showed acute subdural and subarachnoid hemorrhage. He underwent emergent brain surgery, followed by management in the intensive care unit (ICU) for several weeks. After that, he was stable but remained in a bedridden state. At approximately 1 month after the brain surgery, his liver biochemistry, which had remained in the normal range since admission, began to deteriorate: a bilirubin of 0.5 mg/dL, AST of 51 IU/L, ALT of 92 IU/L, ALP of 361 IU/L, and γ-glutamyl transpeptidase of 525 IU/L. We performed an investigation of possible causes for abnormal liver biochemistry, such as drugs, viral infections, and etc. However, an abnormal ultrasonographic finding, gallbladder distention filled with a large amount of sludge, was proven to be the only cause of abnormal liver biochemistry (). Despite abnormal liver biochemistry, the patient did not show acute cholangitis; in addition, he maintained stable vital signs and had no complaints. Considering the poor general status with bed-ridden state, he received only supportive care with intermittent blood tests. shows the patient's liver biochemistry during the past year, showing wax and wane, with constant deterioration, since 4 months before developing acute cholangitis and being admitted to the hospital.