Case Report: Delayed non-calculous biliary obstruction after left hepatectomy associated with intraductal necrotic material with a biliary epithelial component

Abstract

Delayed biliary obstruction after hepatectomy is usually attributed to calculi, strictures, or recurrent malignancy. Intraductal necrotic material of biliary epithelial origin is uncommon and may mimic sludge or stones on imaging. A 70-year-old woman with a 15-year history of hepatitis C underwent left hepatectomy and cholecystectomy for a cirrhotic nodule at another institution. Five months later, she developed progressive jaundice, intermittent abdominal pain, and fever. MRCP and contrast-enhanced CT showed biliary dilatation with sludge-like or heterogeneous material in the common bile duct. ERCP revealed dark-red, soft intraductal material rather than calculi. After balloon dilation, forceps sampling at three intraductal sites, and multiple basket and balloon sweeps, the material was removed. Histology showed extensive necrosis and degenerated epithelioid cells, and CK7 and CK19 positivity supported a biliary epithelial component. Completion cholangiography showed free drainage without an obvious residual stricture. By post-ERCP day 3, total bilirubin had decreased to 114 μmol/L. At 1-month follow-up, jaundice had markedly subsided, serum transaminases, bilirubin, and alkaline phosphatase were within reference ranges, and no adverse symptoms were reported. This case highlights a rare non-calculous cause of delayed biliary obstruction after hepatectomy. When postoperative imaging suggests sludge or stones, ERCP can clarify the nature of the intraductal material, obtain tissue for pathological characterization, and restore biliary drainage.