Recurrent cholangitis in the tropics: worm or cast?

Area of Science:

• Gastroenterology
• Hepatology
• Surgical Gastroenterology

Background:

• Biliary cast formation is an uncommon condition, particularly in patients without a history of liver transplantation.
• Proposed etiologies include bile stasis and gallbladder hypomotility, though the exact cause remains uncertain.
• Recurrent cholangitis can be a presenting symptom, necessitating thorough investigation of the biliary tree.

Observation:

• A 54-year-old male with diabetes and ischemic heart disease presented with recurrent cholangitis.
• Magnetic resonance cholangiopancreatography (MRCP) showed filling defects in the hepatic ducts, initially suspected to be parasites.
• Endoscopic extraction attempts were unsuccessful, prompting surgical intervention.

Findings:

• Surgical exploration revealed biliary casts and common bile duct stones.
• Intraoperative choledochoscopy facilitated the identification and extraction of the casts and stones.
• A bilio-enteric anastomosis was performed following the extraction.

Implications:

• This case underscores the importance of considering biliary casts in the differential diagnosis of obstructive biliary disease.
• While endoscopic retrieval is a first-line approach, surgical intervention is a viable and necessary option when endoscopic methods fail.
• Successful surgical management can resolve recurrent cholangitis and prevent further biliary complications.