\ERCP for Diagnosis and Extraction of Choledochal Phytobezoar Causing Right Upper Quadrant Abdominal Pain and Cholestasis in a Patient Without Prior Sphincterotomy or Biliary Instrumentation.

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A 72-year-old white man with diabetes mellitusand gastroesophageal reflux, with no history of liver disease, hepatobiliary instrumentation, sphincterotomy, or abdominal trauma, presented with acute right upper quadrant abdominal pain and diaphoresis that had started 1 hour earlier. Physical examination revealed a soft and nontender abdomen. The initial serum liver function test results were all within normal limits but rose acutely to a serum alkaline phosphatase of 224 U/L, aspartate aminotransferase of 355 U/L, alanine aminotransferase of 531 U/L, and total bilirubin of 2.4 mg/dL after 48 hours. Abdominal US revealed a normal gallbladder containing no gallstones and no biliary dilatation. MRCP demonstrated a 5-cm-long linear filling defect (A, arrow) within the bile duct without biliary dilatation or stricture. ERCP revealed no choledocholithiasis and confirmed the presence of the 5-cm-long foreign body (B,arrowhead). This foreign body was first retracted into the duodenum by balloon pull-through (C foreign body in duodenum, encrusted with bile) and then extract at ERCP. Gross pathologic examination of the extracted foreign body revealed a phytobezoar in the form of a twig (D). Histologic analysis of the foreign body revealed the characteristic histologic features of a tree branch (E), with characteristic tree tubules and with a crust of reddish-brown bile. The abdominal pain rapidly resolved, and the elevated liver function test results rapidly normalized after the extraction.