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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

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case presentation
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 presentation2
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

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

Acute PancreatitisAssociated Conditions

80%

biliary sludge

Biliary Sludge

Rajeev Jain, M.D.

biliary sludge definition
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;1979

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

biliary sludge composition
Biliary SludgeComposition
  • Calcium bilirubinate
  • Cholesterol monohydrate
  • Mucus

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

biliary sludge pathogenesis
Biliary SludgePathogenesis
  • Similar to gallstones
    • Supersaturation
      • Increased Chol:Bile ratio
    • Nucleation factors
    • Gallbladder dysmotility

Sludge  Microlithiasis  Gallstones

biliary sludge associated 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

Biliary SludgeAssociated Clinical Conditions

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

biliary sludge diagnosis
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 sludge diagnosis10
Biliary SludgeDiagnosis

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

biliary sludge clinical presentation
Biliary SludgeClinical Presentation
  • Asymptomatic
  • Biliary pain
  • Cholecystitis
  • Cholangitis
  • Pancreatitis
biliary sludge natural history
Biliary SludgeNatural History

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

biliary sludge natural history16
Biliary SludgeNatural 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
Frequency of Microlithiasis in Idiopathic Acute Recurrent Pancreatitis

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

biliary sludge treatment algorithm
Biliary SludgeTreatment Algorithm

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

biliary sludge recurrent acute pancreatitis
Biliary SludgeRecurrent Acute Pancreatitis

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

case presentation20
Case Presentation
  • EUS: gallbladder sludge
  • Laparoscopic cholecystectomy
  • 2 years without acute pancreatitis