Case Presentation CC Recurrent abdominal pain HPI 52

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. Et. OH 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. Et. OH 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 – – 6 MP/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

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<3 mm) 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 dysmotility Sludge Microlithiasis Gallstones

Biliary Sludge Associated Clinical Conditions • Idiopathic • Nutrition/Weight related – TPN, fasting, wt loss • Acute illness – ICU – Spinal cord injury – Surgery • Pregnancy • Chronic illness • Transplantation • Medications – AIDS – Cirrhosis – Sickle cell – 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 Sensitivity Transabdominal ultrasound 50 -60% Bile microscopy 65 -90% Endoscopic Ultrasound ~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 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 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