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The development of biliary sludge, in the absence of anastomotic obstruction in the common bile duct, has become a very rare complication following orthotopic liver transplantation since the adoption of modern techniques of biliary reconstruction and routine biliary flushing before cold preservation. We describe the successful treatment of this serious complication in an 18-year-old woman whose biliary sludge aggregated into firm casts occupying the extrahepatic and intrahepatic bile ducts causing obstruction and cholangitis necessitating operative intervention followed by interventional radiological approaches to treat the intrahepatic bile duct strictures. Postoperative choledochofiberscopy was also used to remove the retained biliary casts. The pathogenesis of biliary sludge appeared to be multifactorial, but cold ischemic damage to the bile duct wall seemed to play an important role in this case.
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