case presentation cc: recurrent abdominal pain hpi: 52 yo man 1 yr ago was admitted with...
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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 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 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 SludgeRecurrent Acute Pancreatitis
Jain R. Curr Treat Options Gastroenterol. 7(2):105-9;2004