Idiopathic cholangiopathy in a biliary cast syndrome necessitating liver transplantation following head trauma. 
The development of total biliary casts is very unusual, especially in patients who have not undergone liver transplantation.  The aetiology of these casts is uncertain but several factors are believed to play a role, including periods of fasting, haemolysis, cholangitis and recent surgery.  Resultant bile stasis and/or gallbladder hypocontractility promote sludge and subsequent stone formation.  Here we present the case of a previously well 66-year-old woman who developed a total biliary cast several weeks after being involved in a road traffic accident during which she sustained head injuries but no obvious liver insult.  This cast was removed at laparotomy but the patient had resultant diffuse biliary tree abnormalities and persistent cholestasis and subsequently required a liver transplant.  The possible aetiologies of biliary cast formation and subsequently cholangiopathy necessitating transplantation in this patient are described.