Case Presentation
CC: Recurrent abdominal pain HPI: 52 yo man
1 yr ago was admitted with pancreatitis epigastric pain radiating to his back nausea w/o emesis. EtOH 2-3/wk. lipase > 1,000 Normal-LFTs, Ca, Tri CT peripanc edema Sono no stones 9 mos ago outpt – normal labs, sono
Case Presentation
PMHx: hypertension, pancreatitis PSHx: none All: NKDA Meds: ACE-I FHx: (-) SHx: Married. No tobacco. EtOH 2-3/wk PE: AF-VSS mild epigastric tend Labs: Lipase > 1,000 NL-LFTs, Ca, Tri Radiology: Sono – no stones; CT – peripanc edema
Acute Pancreatitis
Associated Conditions
• • • • • • • • • • • Cholelithiasis 80% Ethanol Idiopathic Microlithiasis/sludge Medications
– – – – 6MP/azathioprine Hydrochlorothiazide Pentamadine Stavudine
ERCP Trauma Pancreas divisum Hereditary Hypercalcemia Viral infections
– Mumps, coxsackie
• Hyperlipidemia
• End-stage renal disease • Penetrating peptic ulcer • Sphincter of Oddi
Biliary Sludge
Rajeev Jain, M.D.
Biliary Sludge
Definition
• Low-level echoes that layer in the dependent portion of the gallbladder w/o acoustic shadowing
– – – – Microlithiasis (stones<3mm) Biliary sand or sediment Pseudolithiasis Microcrystalline disease
Conrad MR et al. Am J Roentgen 132:967-72;1979 Ko CW et al. Ann Intern Med 130:301-11;1999
Biliary Sludge
Composition
• Calcium bilirubinate • Cholesterol monohydrate • Mucus
Ko CW et al. Ann Intern Med 130:301-11;1999
Biliary Sludge
Pathogenesis
• Similar to gallstones
– Supersaturation
• Increased Chol:Bile ratio
– Nucleation factors – Gallbladder Sludge Microlithiasis Gallstones dysmotility
Associated Clinical Conditions
• Idiopathic • Nutrition/Weight related
– TPN, fasting, wt loss
Biliary Sludge
• Acute illness
– ICU – Spinal cord injury – Surgery
• Pregnancy • Chronic illness
– AIDS – Cirrhosis – Sickle cell
• Transplantation • Medications
– Ceftriaxone – Cyclosporine – Octreotide
Levy M. Gatrointest Endosc 55:286-93;2002
Biliary Sludge
Diagnosis
• Transabdominal ultrasound (TUS) • Bile microscopy
– Duodenal aspiration after CCK infusion
• Endoscopic • Nasogastric tube
– Endoscopic retrograde cholangiography (ERCP)
• Endoscopic ultrasound (EUS) • Magnetic resonance cholangiography (MRCP)
Biliary Sludge
Diagnosis
Test
Transabdominal ultrasound Bile microscopy Endoscopic Ultrasound
Sensitivity
50-60% 65-90% ~95%
Levy M. Gatrointest Endosc 55:286-93;2002
Biliary Sludge
Diagnosis - TUS
Biliary Sludge
Diagnosis - EUS
Biliary Sludge
Diagnosis - ERCP
Biliary Sludge
Clinical Presentation
• • • • •
Asymptomatic Biliary pain Cholecystitis Cholangitis Pancreatitis
Biliary Sludge
Natural History
15%
15%
50%
Resolution Asymptomatic Gallstones Symptoms
20%
Lee SP et al. Gatroenterology 94:170-6;1988
Biliary Sludge
Natural History
40% Resolution
Biliary Sludge
40% Appear & Disappear
20% Gallstones
Levy M. Gatrointest Endosc 55:286-93;2002
Frequency of Microlithiasis in Idiopathic Acute Recurrent Pancreatitis
Study Frequency Percent
Venu 1989 Ros 1991
Lee 1992
8/116 37/51
21/29
7 73
72
Sherman 1993
Nash 1996
7/13
5/88
54
6
Kaw 1996 Overall
15/25 93/322
60 29
Levy M. Gatrointest Endosc 55:286-93;2002
Biliary Sludge
Treatment Algorithm
Jain R. Curr Treat Options Gastroenterol. 7(2):105-9;2004
Recurrent Acute Pancreatitis
Biliary Sludge
Jain R. Curr Treat Options Gastroenterol. 7(2):105-9;2004
Case Presentation
• EUS: gallbladder sludge • Laparoscopic cholecystectomy • 2 years without acute pancreatitis