Atypical Cause of Recurrent Cholangitis: Green Leafy Vegetables in the Biliary Tree

Abstract

Purpose: Acute abdominal pain is a commonly reported symptom with a broad differential diagnosis. We present a challenging case with an interesting cause of cholangitis. A 61-year-old female presented to a gastroenterology clinic for right upper quadrant abdominal pain. Past medical history included a cholecystectomy secondary to symptomatic cholelithiasis 5 years prior. One year after her surgery, she began experiencing recurrent episodes of sharp right upper quadrant abdominal pain lasting 30 minutes at a time, and associated with fevers, nausea, and vomiting. She also endorsed progressive symptoms of early satiety, bloating, and regurgitation. The episodes were relieved by endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and biliary stent placement. However, there had been an increased frequency of these episodes and she underwent 5 ERCPs within the last 4 years. The most recent suggested proximal common bile duct strictures and the biliary stents were removed at the time. On presentation to our clinic, the patient was asymptomatic. A repeat ERCP was done to better understand her anatomy and determine the cause of her recurrent pain; findings demonstrated a widely patent sphincterotomy site. The biliary tree was swept with a 15-mm balloon and produced clear golden bile, followed by a celery-like material and fruit skins (Image 1). No stones or typical biliary sludge were seen and vegetable matter was confirmed by pathology. The patient was advised to eat a low-residue diet and has been free of recurrent exacerbations. Acute cholangitis commonly presents with right upper quadrant abdominal pain, fever, and jaundice. While it is often secondary to biliary obstruction or stasis, this patient presented with recurrent cholangitis due to obstruction by food particles. Repeat sphincterotomies had enlarged the diameter by which food particles can travel retrograde through the biliary tree. This was likely exacerbated by an underlying motility disorder that allowed food to linger in the biliary system.Figure