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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

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Case Presentation

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  1. 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

  2. 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

  3. 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%

  4. Biliary Sludge Rajeev Jain, M.D.

  5. 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

  6. Biliary SludgeComposition • Calcium bilirubinate • Cholesterol monohydrate • Mucus Ko CW et al. Ann Intern Med 130:301-11;1999

  7. Biliary SludgePathogenesis • Similar to gallstones • Supersaturation • Increased Chol:Bile ratio • Nucleation factors • Gallbladder dysmotility Sludge  Microlithiasis  Gallstones

  8. 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

  9. 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)

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

  11. Biliary SludgeDiagnosis - TUS

  12. Biliary SludgeDiagnosis - EUS

  13. Biliary SludgeDiagnosis - ERCP

  14. Biliary SludgeClinical Presentation • Asymptomatic • Biliary pain • Cholecystitis • Cholangitis • Pancreatitis

  15. Biliary SludgeNatural History Lee SP et al. Gatroenterology 94:170-6;1988

  16. Biliary SludgeNatural History 40% Resolution Biliary Sludge 40% Appear & Disappear 20% Gallstones Levy M. Gatrointest Endosc 55:286-93;2002

  17. Frequency of Microlithiasis in Idiopathic Acute Recurrent Pancreatitis Levy M. Gatrointest Endosc 55:286-93;2002

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

  19. Biliary SludgeRecurrent Acute Pancreatitis Jain R. Curr Treat Options Gastroenterol. 7(2):105-9;2004

  20. Case Presentation • EUS: gallbladder sludge • Laparoscopic cholecystectomy • 2 years without acute pancreatitis

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