Biliary Cast - Complication of Cholangitis and Pancreatitis in a Pancreas Divisum Patient
F. Graur, H. Neagos, A. Cavasi, N. Al HajjarClinical case, no. 5, 2014
We report a rare cause of "biliary cast" secondary to cholangitisand pancreatitis, in a 60-year-old female patient withpancreas divisum. She was admitted in our hospital with anacute pancreatitis (alcoholic etiology was excluded) complicatedwith pancreatic abscess and obstructive jaundice. The patienthad undergone a complex surgical intervention: cholecystectomy,choledocotomy with extraction of the biliary thrombus,external biliary drainage through a T tube, evacuation of thepancreatic abscess, sequestrectomy, peritoneal lavage and multipledrainages. In spite of the surgical and intensive care support,the biliary drainage through the T tube had ceased and theobstructive jaundice had reappeared in a more accentuatedfashion. Endoscopic retrograde cholangiography showedcomplete pancreas divisum and diffuse multiple stenosisalternating with dilatation of the intrahepatic biliary tree (apattern of sclerosing cholangitis). An endoscopic prosthesis wasplaced inside the right hepatic bile duct. Despite the use ofthe combined endoscopic plus UDCA (ursodeoxycholicacid) treatment for the management of the biliary castsyndrome, the evolution was unfavorable with hepatic coma,septic shock and finally death. The necropsy revealed anextensive biliary cast in the entire biliary tree and pyogeniccholangitis. The patient had a fatal outcome despite allthe surgical, endoscopic and conservative efforts, withdevelopment of intraductal biliary obstruction and secondarypyogenic cholangitis. Biliary cast syndrome is a rare but veryaggressive entity and its management is often difficult despitethe advances in surgery and endoscopy treatments.
