Introduction: We present a patient with an unusual cause of biliary obstruction. Case Report: A 50-year-old male was presented with a five-month history of worsening recurrent biliary abdominal pain and fevers. There was no previous biliary surgery. His workup revealed a normal bilirubin with elevation of other liver tests. Abdominal ultrasound demonstrated a common bile duct (CBD) diameter of 6 mm and cholelithiasis. A magnetic resonance cholangiopancreatography was unremarkable. An endoscopic ultrasound showed gallbladder sludge and stones, as well as CBD wall thickening with sludge in its mid to distal segments. At endoscopic retrograde cholangiopancreatography, 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. This was retrieved in one piece using a rat tooth forceps and sent for pathology. The patient was discharged without complication. Cholecystectomy was recommended. Pathological analysis revealed the concretion was made of vegetable material. There have only been eight cases of biliary phytobezoar described in the modern English medical literature. Most reports describe the occurrence of a biliary phytobezoar presenting up to 40 years following a surgical bilioenteric anastomosis either with associated choledocholithiasis or alone. 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, although the mechanism for developing a phytobezoar is not completely understood. Conclusion: We describe the first reported case of an isolated biliary phytobezoar in the absence of previous biliary surgery or bilioenteric fistula.
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