Case Presentation

CC: Recurrent abdominal painHPI: 52 yo man

1 yr ago was admitted with pancreatitisepigastric pain radiating to his backnausea w/o emesis. EtOH 2-3/wk.lipase > 1,000 Normal-LFTs, Ca, TriCT peripanc edema Sono no stones

9 mos ago outpt – normal labs, sono

Case Presentation

PMHx: hypertension, pancreatitisPSHx: noneAll: NKDA Meds: ACE-I FHx: (-)SHx: Married. No tobacco. EtOH 2-3/wkPE: AF-VSS mild epigastric tendLabs: Lipase > 1,000 NL-LFTs, Ca, TriRadiology: Sono – no stones; CT –

peripanc edema

Acute PancreatitisAssociated Conditions

• Cholelithiasis• Ethanol• Idiopathic• Microlithiasis/sludge• Medications

– 6MP/azathioprine– Hydrochlorothiazide– Pentamadine– Stavudine

• Hyperlipidemia

• ERCP• Trauma• Pancreas divisum• Hereditary• Hypercalcemia• Viral infections

– Mumps, coxsackie

• End-stage renal disease• Penetrating peptic ulcer• Sphincter of Oddi

80%

Biliary Sludge

Rajeev Jain, M.D.

Biliary SludgeDefinition

• 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;1979Ko CW et al. Ann Intern Med 130:301-11;1999

Biliary SludgeComposition

• Calcium bilirubinate• Cholesterol monohydrate• Mucus

Ko CW et al. Ann Intern Med 130:301-11;1999

Biliary SludgePathogenesis

• Similar to gallstones– Supersaturation

• Increased Chol:Bile ratio

– Nucleation factors– Gallbladder

dysmotility Sludge Microlithiasis Gallstones

Biliary SludgeAssociated Clinical Conditions

• Idiopathic• Nutrition/Weight

related– TPN, fasting, wt loss

• Pregnancy• Chronic illness

– AIDS– Cirrhosis– Sickle cell

• Acute illness– ICU– Spinal cord injury– Surgery

• Transplantation• Medications

– Ceftriaxone– Cyclosporine– Octreotide

Levy M. Gatrointest Endosc 55:286-93;2002

Biliary SludgeDiagnosis

• 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 SludgeDiagnosis

Test Sensitivity

Transabdominal ultrasound 50-60%

Bile microscopy 65-90%

Endoscopic Ultrasound ~95%

Levy M. Gatrointest Endosc 55:286-93;2002

Biliary SludgeDiagnosis - TUS

Biliary SludgeDiagnosis - EUS

Biliary SludgeDiagnosis - ERCP

Biliary SludgeClinical Presentation

• Asymptomatic• Biliary pain• Cholecystitis• Cholangitis• Pancreatitis

Biliary SludgeNatural History

50%

20%

15%

15%

ResolutionAsymptomaticGallstonesSymptoms

Lee SP et al. Gatroenterology 94:170-6;1988

Biliary SludgeNatural History

40%Resolution

40%Appear & Disappear

20%Gallstones

BiliarySludge

Levy M. Gatrointest Endosc 55:286-93;2002

Frequency of Microlithiasis in Idiopathic Acute Recurrent

PancreatitisStudy Frequency Percent

Venu 1989 8/116 7

Ros 1991 37/51 73

Lee 1992 21/29 72

Sherman 1993

7/13 54

Nash 1996 5/88 6

Kaw 1996 15/25 60

Overall 93/322 29

Levy M. Gatrointest Endosc 55:286-93;2002

Biliary SludgeTreatment Algorithm

Jain R. Curr Treat Options Gastroenterol. 7(2):105-9;2004

Biliary SludgeRecurrent Acute Pancreatitis

Jain R. Curr Treat Options Gastroenterol. 7(2):105-9;2004

Case Presentation

• EUS: gallbladder sludge• Laparoscopic cholecystectomy• 2 years without acute pancreatitis