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Case Report
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First case of a primary biliary phytobezoar | ||||||
Fahad Albogami1,3, Alan N. Barkun1,2, Kevin Waschke1 | ||||||
1Division of Gastroenterology, The McGill University Health Centre, Montreal General Hospital site, Montréal,
Canada
2Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, McGill University, Montreal, Canada 3Division of Gastroenterology, King Fahad Specialist Hospital, Dammam, Saudi Arabia | ||||||
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Albogami F, Barkun AN, Waschke K. First case of a primary biliary phytobezoar. Int J Case Rep Images 2018;9(1):43–46. |
ABSTRACT
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Introduction: We present a patient with an unusual cause of biliary obstruction. Keywords: Endoscopic retrograde cholangiopancreatography (ERCP), Phytobezoar, Post-biliary surgery | ||||||
INTRODUCTION
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Bezoar is defined as a foreign body resulting from accumulation of ingested material and classified according to its composition. A phytobezoar is the most common type of bezoar, and is composed of indigestible vegetable-like material. Phytobezoars are commonly reported in patients who have had previous gastric surgery [1][2]. They can occur at any site in the gastrointestinal tract; but most commonly are found in the stomach. However, biliary phytobezoars are extremely rare. We describe, for the first time, a case of a patient presenting with an obstructing biliary phytobezoar causing cholangitis in the absence of a history of abdominal surgery, sphincterotomy, spontaneous biliary-enteric fistula, or associated choledocholithiasis. | ||||||
CASE REPORT
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A 50-year-old male was presented with a five-month history of worsening recurrent biliary abdominal pain and fevers. There was no significant past medical history, including no previous biliary surgery. Physical examination showed only right upper quadrant tenderness. Workup of the patient revealed a total bilirubin of 7.4 mg/L, direct bilirubin 4.8 mg/L, aspartate aminotransferase 71 U/L, alanine aminotransferase 103 U/L, alkaline phosphatase 292 U/L, and gamma–glutamyl transferase 992 U/L. Abdominal ultrasound demonstrated a common bile duct (CBD) diameter of 6 mm, pneumobilia and cholelithiasis. A magnetic resonance cholangiopancreatography (MRCP) from another institution was reported as unremarkable. An endoscopic ultrasound (EUS) showed gallbladder sludge and stones, as well as CBD wall thickening with sludge in its mid to distal segments. At endoscopic retrograde cholangiopancreatography (ERCP), a CBD filling defect was noted. After sphincterotomy, a balloon catheter extracted what looked like a cast occupying the entire lower CBD, extending into the cystic duct (Figure 1). This was retrieved in one piece using a rat tooth forceps and sent for pathology. The patient was discharged without complication. Pathological analysis revealed the cast was made of vegetable material (Figure 2). | ||||||
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DISCUSSION
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A literature search revealed only eight cases of biliary phytobezoar described in the modern English medical literature. Four were isolated biliary phytobezoars [2][3][4][5], while the phytobezoar acted as a nidus for CBD stones in the other patients [2][6][7][8] (Table 1). In 1972, Ban et al. [6] described a biliary phytobezoar acting as nidus for symptomatic CBD stones that had developed in a patient two years post- choledochojejunostomy. Most reports describe the occurrence of a biliary phytobezoar presenting up to 40 years following a surgical bilioenteric anastomosis either with associated choledocholithiasis [9] , or alone [2][3][5] in one case as a result of a choledochoduodenal fistula 12 years post cholecystectomy [4]. There exist only two case reports of patients having developed a biliary phytobezoar in the absence of any bilioenteric anastomosis or fistula. In both, the bezoar acted as a nidus for CBD stone formation [7][8] as has also been noted with foreign bodies such as surgical clips [10]. Although the mechanism for developing a phytobezoar is not completely understood, a main contributing factor relates to ablation or bypass of the sphincter of Oddi due to surgical manipulation or fistula formation. The mechanism in the absence of any such altered anatomy remains unclear and some have suggested that intermittent stone passage may contribute [7]. Sphincter of Oddi manometry abnormalities were noted in one patient, and remain of unclear clinical significance [9]. In the current patient, although cholelithiasis was noted, no CBD stone was present in the phytobezoar. So, cholecystectomy was recommended. | ||||||
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CONCLUSION
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In conclusion, we describe the first reported case of an isolated biliary phytobezoar in the absence of previous biliary surgery or bilioenteric fistula. | ||||||
REFERENCES
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Author Contributions
Fahad Albogami – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published Alan N. Barkun – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published Kevin Waschke – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published |
Guarantor of Submission
The corresponding author is the guarantor of submission. |
Source of Support
None |
Conflict of Interest
Authors declare no conflict of interest. |
Copyright
© 2018 Fahad Albogami et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information. |
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