Objective    To investigate the pathogenesis of biliary cast syndrome following orthotopic liver transplantation (OLT) and explore the methods of treatment.     Methods    Clinical data of 325 cases of OLT performed at our institute from February 1999 to December 2005 were retrospectively analysed.     Results    Six patients developed biliary cast syndrome following liver transplantation. The accuracy rates of diagnosis by MRCP/ERCP were 100%. Of all biliary complication cases

2 cases were successfully removed cast from the bile duct by ERCP

and 4 cases received retransplantation.     Conclusion    The formation of biliary cast syndrome after OLT is mainly due to ischemia/reperfusion injury and bile duct ischemia. Cholangiography is helpful for diagnosis of biliary cast syndrome. With regard to treatment

endoscopic intervention is the first option

and operation follows unsuccessful intervention.