Successful Diagnosis and Treatment of Biliary Cast Syndrome after Orthotopic Liver Transplantation by Percutaneous Transhepatic Choledochoscopy: A Case Report

Biliary cast syndrome (BCS) is an unusual complication of orthotopic liver transplantation (OLT). BCS is characterized by multiple intrahepatic biliary strictures, ductal dilatation, intrahepatic abscesses, and biliary anastomotic leakage. The symptoms of BCS usually include high fever, jaundice and cholestatic liver enzyme elevation; similar to the symptoms observed in some patients with intrahepatic bile duct stones. The etiology of cast development is not fully known, and its management is difficult. Limited success using endoscopic retrograde cholangiopancreatography (ERCP) or open exploration to clear casts has been reported, and failure usually results in retransplantation. We describe a diabetic man who developed a BC after deceased donor liver transplantation. Percutaneous transhepatic biliary cholangiography was performed and revealed a filling defect in both the right and left intrahepatic systems, extending down to the anastomosis. Percutaneous transhepatic choledochoscopy proved that it was consistent with BCs, and the casts were removed by stone retrieval basket, foreign body pliers, and adsorber.