Biliary cast syndrome is a rare disorder that is characterized by the presence of casts in the biliary ducts, causing obstruction leading to infection and hepatic and ductal damage. The syndrome is more commonly reported in liver transplant patients, being very unusual in other situations. We report a case in a patient that suffered a severe hepatic trauma that was successfully managed by endoscopic therapy.
IntroductionThe biliary cast syndrome is a rare phenomenon that develops due to precipitation of amorphous material in the bile ducts, forming casts that lead to obstruction with consequent infection and damage to liver parenquima and duct. The syndrome has
DiscussionThe formation of casts of the bile ducts (biliary cast syndrome) is caused by mechanisms not clearly understood, that involve factors such as ischemia, infection, hemolysis and liver surgery among others. These casts are made up primarily of calcium bilirrubinate, cholesterol crystals and mucus [5]. Recently, by using scanning electron microscopy and hematoxilin and eosin staining, studies showed that cast also contains blood vessels and collagen fibers [11,12]. From a theoretical standpoint, any situation that increases the viscosity of bile or decreases bile flow, may lead to the formation of casts. The vast majority of cases reported occurred in liver transplant patients, especially during the first few years of application of the technique, where graft preservation methods were less sophisticated than today. Some studies have linked the formation of the casts with the existence of faulty reconstructions of the biliary tract, which would cause injury to the biliary epithelium and trigger the precipitation of material in it. This in combination with infection and a cholesterol-saturated bile, play a role in the formation of casts after transplantation [7]. Moreover, the presence of ischemia is believed to be one of the main triggers of this syndrome, because it has been shown that the presence of casts after liver transplantation was accompanied by hepatic artery occlusion in 30% of cases [4]. Also, some drugs used post transplant, such as cyclosporine, may contribute to the emergence of casts, by inhibiting the secretion of bile, causing a functional bile stasis [8]. Furthermore, the presence of foreign bodies such as T tubes or prosthesis may act as a nidus for formation of stones or sludge [13]. Systemic bacterial or fungal infection, which causes intrahepatic cholestasis may also be a predisposing factor to the formation of casts in the bile ducts after liver transplantation [14]. Finally, many others have been associated as risk factors for the formation of biliary casts, such as, hepatic artery stenosis or thrombosis, biliary strictures, renal replacement therapy, ischemia-reperfusion injury, prolonged cold preservation, prolonged warm ischemia, hemolysis, pregnancy or AIDS virus infection [15][16][17][18].Casts can also occur in non-transplant patients, although that is extremely unusual; only a few cases have been published to...
