Biliary Cast Formation with Sclerosing Cholangitis in Critically Ill Patient: Case Report and Literature Review

Abstract

Sclerosing cholangitis in critically ill patients (SC-CIP) is a rare condition that is not familiar to many radiologists. In addition, the associated imaging findings have not been described in the radiological literature. We report a case of biliary cast formation with SC-CIP and describe the radiological findings of CT, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiography (ERC). A diagnosis of SC-CIP should be considered in intensive care unit (ICU) patients with persistent cholestasis during or after a primary illness. The typical CT, MRCP and ERC findings include new biliary casts in the intrahepatic duct with multiple irregular strictures, dilatations, and relative sparing of the common bile duct.

Secondary sclerosing cholangitis in a critically ill patient

“…Secondary sclerosing cholangitis is rare in native, nontransplanted livers, yet as mentioned, recent literature describes secondary sclerosing cholangitis in patients recovering from critical illness in the intensive care unit (1)(2)(3)(4)(5)(6)(7)(8). Biliary stasis and sludge is common in the critically ill, particular in patients with neurosurgical intervention or recent abdominal surgery, such as in the presented patient.…”

“…SC-CIP is characterized by persistent, progressive cholestasis with sclerosing cholangitis on cholangiography (8). Clinical signs typically feature early rapid and marked increase in alkaline phosphatase and gamma-glutamyl transferase with mild increase in serum bilirubin (1,8). Cholestasis is typically persistent, even in cases where there has been resolution of the patient's primary illness.…”

“…entity with fewer than 100 reported cases in the Critical Care and Gastroenterology literature (2-7), and only a single report in the radiology literature (8). SC-CIP is a disease entity that occurs in critically ill patients with no history of prior liver disease and without a pathological process to explain bile duct obstruction, though is thought to develop in the setting of cholestasis and biliary cast formation (8).…”

“…Fasting and chronic total parenteral nutrition promote gallbladder hypocontractility (14), predisposing to stasis. SC-CIP is characterized by persistent, progressive cholestasis with sclerosing cholangitis on cholangiography (8). Clinical signs typically feature early rapid and marked increase in alkaline phosphatase and gamma-glutamyl transferase with mild increase in serum bilirubin (1,8).…”

“…SC-CIP is a disease entity that occurs in critically ill patients with no history of prior liver disease and without a pathological process to explain bile duct obstruction, though is thought to develop in the setting of cholestasis and biliary cast formation (8).…”