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: NKDAMeds: ACE-IFHx: (-) 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. 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 80%

4. Biliary Sludge Rajeev Jain, M.D.

5. Biliary Sludge Definition 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 Sludge Composition Calcium bilirubinate Cholesterol monohydrate Mucus Ko CW et al. Ann Intern Med 130:301-11;1999

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

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

9. 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)

10. Biliary Sludge Diagnosis TestSensitivity Transabdominal ultrasound50-60% Bile microscopy65-90% Endoscopic Ultrasound~95% Levy M. Gatrointest Endosc 55:286-93;2002

11. Biliary Sludge Diagnosis - TUS

12. Biliary Sludge Diagnosis - EUS

13. Biliary Sludge Diagnosis - ERCP

14. Biliary Sludge Clinical Presentation Asymptomatic Biliary pain Cholecystitis Cholangitis Pancreatitis

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

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

17. Frequency of Microlithiasis in Idiopathic Acute Recurrent Pancreatitis StudyFrequencyPercent Venu 19898/1167 Ros 199137/5173 Lee 199221/2972 Sherman 19937/1354 Nash 19965/886 Kaw 199615/2560 Overall93/32229 Levy M. Gatrointest Endosc 55:286-93;2002

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

19. Biliary Sludge Recurrent 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