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• W2158241915 abstract "Acute pancreatitis results most commonly from alcohol abuse or gallstone disease. When patients have more than one clinical episode of acute pancreatitis they are given the diagnosis of acute recurrent pancreatitis (ARP). The etiology of ARP is identified in 70% to 90% of patients after an initial evaluation that includes a thorough history, physical examination, routine laboratory tests, and transabdominal ultrasound (TUS) or CT.1Venu RP Geenen JE Hogan W Stone J Johnson GK Soergel K Idiopathic recurrent pancreatitis. An approach to diagnosis and treatment.Dig Dis Sci. 1989; 34: 56-60Crossref PubMed Scopus (157) Google Scholar, 2Ballinger AB Barnes E Alstead EM Fairclough PD Is intervention necessary after a first episode of acute idiopathic pancreatitis?.Gut. 1996; 38: 293-295Crossref PubMed Scopus (58) Google Scholar, 3Thomson SR Hendry WS McFarlane GA Davidson AI Epidemiology and outcome of acute pancreatitis.Br J Surg. 1987; 74: 398-401Crossref PubMed Scopus (121) Google Scholar, 4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 5Levy MJ Geenen J Idiopathic acute recurrent pancreatitis.Am J Gastroenterol. 2001; 96: 2540-2555Crossref PubMed Google Scholar For the 10% to 30% of patients in whom the initial evaluation fails to reveal an etiology, the diagnosis of “idiopathic” acute recurrent pancreatitis (IARP) is often applied.1Venu RP Geenen JE Hogan W Stone J Johnson GK Soergel K Idiopathic recurrent pancreatitis. An approach to diagnosis and treatment.Dig Dis Sci. 1989; 34: 56-60Crossref PubMed Scopus (157) Google Scholar, 2Ballinger AB Barnes E Alstead EM Fairclough PD Is intervention necessary after a first episode of acute idiopathic pancreatitis?.Gut. 1996; 38: 293-295Crossref PubMed Scopus (58) Google Scholar, 3Thomson SR Hendry WS McFarlane GA Davidson AI Epidemiology and outcome of acute pancreatitis.Br J Surg. 1987; 74: 398-401Crossref PubMed Scopus (121) Google Scholar, 4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 5Levy MJ Geenen J Idiopathic acute recurrent pancreatitis.Am J Gastroenterol. 2001; 96: 2540-2555Crossref PubMed Google Scholar The extent of the evaluation impacts the frequency with which an etiology can be found and how often the diagnosis of IARP is used.2Ballinger AB Barnes E Alstead EM Fairclough PD Is intervention necessary after a first episode of acute idiopathic pancreatitis?.Gut. 1996; 38: 293-295Crossref PubMed Scopus (58) Google Scholar, 6Geenen JE Nash JA The role of sphincter of Oddi manometry and biliary microscopy in evaluating idiopathic recurrent pancreatitis.Endoscopy. 1998; 30: A237-A241PubMed Google Scholar This diagnosis is most often used when a more limited evaluation, as detailed above, fails to reveal an etiology. A more extensive evaluation may include specialized laboratory tests, ERCP, EUS, and magnetic resonance cholangiopancreatography (MRCP). Inclusion of these additional tests usually leads to the diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum.1Venu RP Geenen JE Hogan W Stone J Johnson GK Soergel K Idiopathic recurrent pancreatitis. An approach to diagnosis and treatment.Dig Dis Sci. 1989; 34: 56-60Crossref PubMed Scopus (157) Google Scholar, 3Thomson SR Hendry WS McFarlane GA Davidson AI Epidemiology and outcome of acute pancreatitis.Br J Surg. 1987; 74: 398-401Crossref PubMed Scopus (121) Google Scholar, 7Steinberg W Tenner S Acute pancreatitis.N Engl J Med. 1994; 330: 1198-1210Crossref PubMed Scopus (859) Google Scholar If this more extensive evaluation fails to reveal an etiology, then the diagnosis of “true” IARP may be assigned. Determining the etiology is important because it helps to direct therapy, limits further unnecessary tests, and may improve a patient's long-term prognosis.Table 1Frequency of microlithiasis in patients with idiopathic acute recurrent pancreatitisFrequencyPercentStudies with low frequency Venu 19898/1167 Nash 19965/88613/2046Studies with high frequency Ros 199137/5173 Lee 199221/2972 Sherman 19937/1354 Kaw 199615/256080/11868 Open table in a new tab Definition and compositionMicrolithiasis is also referred to as sludge, biliary sand, biliary sediment, microcrystalline disease, pseudolithiasis, and reversible cholelithiasis. Most use the term microlithiasis or sludge, and although they are technically different, the terms are often used interchangeably. This may be the case because many consider sludge to be a precursor to microlithiasis with both having the same clinical significance. The interpretation and applicability of data obtained from prior studies are limited by the lack of a uniformly accepted definition.15Lee SP Hayashi A Kim YS Biliary sludge: curiosity or culprit?.Hepatology. 1994; 20: 523-525Crossref PubMed Scopus (37) Google Scholar, 16Cetta F Biliary sludge: necessity for a better distinction between crushable and noncrushable microconcrements. Sludge is responsible for symptoms not by itself, but also in relationship to the variability of the container, i.e., the bile tract wall.Hepatology. 1996; 23: 191-192Crossref PubMed Scopus (1) Google Scholar, 17Houssin D Castaing D Lemoine J Bismuth H Microlithiasis of the gallbladder.Surg Gyn Obstet. 1983; 157: 20-24PubMed Google Scholar, 18Block MA Priest RJ Acute pancreatitis related to grossly minute stones in a radiographically normal gallbladder.Am J Dig Dis. 1967; 12: 934-938Crossref PubMed Scopus (20) Google Scholar, 19Pfefferman R Luttwak EM Gallstone pancreatitis. Exploration of the biliary system in pancreatitis of undetermined origin.Arch Surg. 1971; 103: 484-486Crossref PubMed Scopus (6) Google Scholar Although the definition varies among investigators, most refer to microlithiasis as stones less than 3 mm in diameter,17Houssin D Castaing D Lemoine J Bismuth H Microlithiasis of the gallbladder.Surg Gyn Obstet. 1983; 157: 20-24PubMed Google Scholar, 20Sarva RP Farivar S Fromm H Poller W Study of the sensitivity and specificity of computerized tomography in the detection of calcified gallstones which appears radiolucent by conventional roentgenography.Gastrointest Radiol. 1981; 6: 165-167Crossref PubMed Scopus (24) Google Scholar, 21Sharma BC Agarwal DK Dhiman RK Baijal SS Choudhuri G Saraswat VA Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy.Gastroenterology. 1998; 115: 124-128Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar and biliary sludge is considered to be a suspension of crystals, mucin, glycoproteins, cellular debris, and proteinaceous material within bile.4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 22Ko CW Sekijima JH Lee SP Biliary sludge.Ann Intern Med. 1999; 130: 301-311Crossref PubMed Scopus (153) Google Scholar, 23Filly RA Allen B Minton MJ Bernhoft R Way LW In vitro investigation of the origin of echoes with biliary sludge.J Clin Ultrasound. 1980; 8: 193-200Crossref PubMed Scopus (72) Google Scholar, 24Allen B Bernhoft R Blanckaert N Svanvik J Filly R Gooding G et al.Sludge is calcium bilirubinate associated with bile stasis.Am J Surg. 1981; 141: 51-56Abstract Full Text PDF PubMed Scopus (106) Google Scholar, 25Lee SP Nicholls JF Nature and composition of biliary sludge.Gastroenterology. 1986; 90: 677-686Abstract Full Text PDF PubMed Scopus (180) Google Scholar The various types of crystals include cholesterol monohydrate, calcium bilirubinate, and other calcium salts (carbonate, phosphate and fatty acid complexes).Risk factors and pathogenesisTable 2Clinical conditions associated with the formation of microlithiasisNo identifiable risk factorNutrition/weight related Prolonged fasting Total parenteral nutrition (long-term) Rapid weight lossPregnancyChronic illness Acquired immunodeficiency syndrome Cirrhosis Sickle cell anemiaAcute illness Intensive care unit Spinal cord injury SurgeryTransplantation Bone marrow Solid organMedications Cefriaxone Cyclosporine Octreotide Open table in a new tab Most investigators believe that physical and chemical interactions of gallbladder contents together with altered gallbladder motility and mucosal function serve as a nidus for sludge and the formation of microlithiasis.55Johnston DE Kaplan MM Pathogenesis and treatment of gallstones.N Engl J Med. 1993; 328: 412-421Crossref PubMed Scopus (176) Google Scholar, 56Carey MC Cahalane MJ Whither biliary sludge?.Gastroenterology. 1988; 95: 508-523PubMed Google Scholar, 57Lee SP Pathogenesis of biliary sludge.Hepatology. 1990; 12: 200S-205SPubMed Google Scholar, 58Cahalane MJ Neubrand MW Carey MC Physical-chemical pathogenesis of pigment gallstones.Sem Liver Dis. 1988; 8: 317-328Crossref PubMed Scopus (99) Google Scholar It is thought that microlithiasis is preceded by the intermediary step of sludge formation, followed by microprecipitate aggregation and eventual stone formation.55Johnston DE Kaplan MM Pathogenesis and treatment of gallstones.N Engl J Med. 1993; 328: 412-421Crossref PubMed Scopus (176) Google Scholar, 57Lee SP Pathogenesis of biliary sludge.Hepatology. 1990; 12: 200S-205SPubMed Google Scholar, 58Cahalane MJ Neubrand MW Carey MC Physical-chemical pathogenesis of pigment gallstones.Sem Liver Dis. 1988; 8: 317-328Crossref PubMed Scopus (99) Google Scholar This theory is supported by the typical finding of sludge before stone recurrence in chemical dissolution studies.59Lee SP Maher K Nicholls JF Origin and fate of biliary sludge.Gastroenterology. 1988; 94: 170-176Abstract PubMed Scopus (0) Google Scholar Others refute this theory because of the infrequent development of gallstones in persons with sludge and the spontaneous resolution of sludge in most individuals.DiagnosisThe optimal method for detecting microlithiasis and the extent to which a diagnosis is sought largely depend on the clinical setting and prior evaluation. The two most widely used techniques are TUS and bile microscopy. Although CT and magnetic resonance imaging may detect microlithiasis, their cost and unproven utility should preclude their use solely for this purpose unless otherwise indicated.Fig. 2EUS images. A, Gallbladder sludge. B, Gallbladder sludge and microlithiasis. C, Gallbladder sludge and macrolithiasis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Bile microscopy is the standard for the diagnosis of microlithiasis with an overall sensitivity of about 65% to 90%.29Delchier JC Benfredj P Preaux AM Metreau JM Dhumeaux D The usefulness of microscopic bile examination in patients with suspected microlithiasis: a prospective evaluation.Hepatology. 1986; 6: 118-122Crossref PubMed Scopus (49) Google Scholar, 61Venu RP Geenen JE Toouli J Stewart E Hogan WJ Endoscopic retrograde cholangiopancreatography. Diagnosis of cholelithiasis in patients with normal gallbladder x-ray and ultrasound studies.JAMA. 1983; 249: 758-761Crossref PubMed Scopus (38) Google Scholar, 64Moskovitz M Min TC Gavaler JS The microscopic examination of bile in patients with biliary pain and negative imaging tests.Am J Gastroenterol. 1986; 81: 329-333PubMed Google Scholar, 65Neoptolemos JP Davidson BR Winder AF Vallance D Role of duodenal bile crystal analysis in the investigation of ‘idiopathic’ pancreatitis.Br J Surg. 1988; 75: 450-453Crossref PubMed Scopus (86) Google Scholar, 66Buscail L Escourrou J Delvaux M Guimbard R Nicolet T Frexinos J et al.Microscopic examination of bile directly collected during endoscopic cannulation of the papilla. Utility in patients with suspected microlithiasis.Dig Dis Sci. 1992; 37: 116-120Crossref PubMed Scopus (54) Google Scholar, 67Agarwal DK Choudhuri G Saraswat VA Negi TS Utility of biliary microcrystal analysis in predicting composition of common bile duct stones.Scand J Gastroenterol. 1994; 29: 352-354Crossref PubMed Scopus (7) Google Scholar Bile sampling should be performed only if less invasive studies are negative, the clinical suspicion of microlithiasis is high, and the results will be used to guide management. Techniques vary with respect to the site of bile aspiration, use of cholecystokinin, processing of samples, and criteria for a positive test.Bile may be collected from the duodenum (during or separate from endoscopy), bile duct (during ERCP), or the gallbladder itself (by percutaneous aspiration). The diagnostic yield of microscopy is greatest when bile is collected from the gallbladder, lower when collected from the bile duct, and lowest from the duodenum. Although the reported sensitivity of microscopy varies according to the site of bile aspiration, there is likely minimal difference between sampling techniques when “gallbladder” bile is collected.29Delchier JC Benfredj P Preaux AM Metreau JM Dhumeaux D The usefulness of microscopic bile examination in patients with suspected microlithiasis: a prospective evaluation.Hepatology. 1986; 6: 118-122Crossref PubMed Scopus (49) Google Scholar, 62Dahan P Andant C Levy P Amouyal P Amouyal G Dumont M et al.Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography.Gut. 1996; 38: 277-281Crossref PubMed Scopus (162) Google Scholar Cholecystokinin is typically administered before bile aspiration to enhance gallbladder contractility, improve the collection of “gallbladder” bile, and increase the diagnostic yield.4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 68Negro P Flati G Flati D Porowska B Tuscano D Carboni M Occult gallbladder microlithiasis causing acute recurrent pancreatitis. A report of three cases.Acta Chir Scand. 1984; 150: 503-506PubMed Google Scholar, 69Dill JE Hill S Callis J Berkhouse L Evans P Martin D Combined endoscopic ultrasound and stimulated biliary drainage in the diagnosis of cholecystitis and microlithiasis.Endoscopy. 1995; 27: 424-427Crossref PubMed Scopus (93) Google ScholarThe need to control the temperature of the bile sample and equipment is controversial.22Ko CW Sekijima JH Lee SP Biliary sludge.Ann Intern Med. 1999; 130: 301-311Crossref PubMed Scopus (153) Google Scholar Most investigators favor maintaining the temperature at 37°C because of the risk of precipitating cholesterol from the micellar form to crystalline phase that occurs with a drop in temperature.9Ros E Navarro S Bru C Garcia-Puges A Valderrama R Occult microlithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy.Gastroenterology. 1991; 101: 1701-1709Abstract PubMed Google Scholar, 21Sharma BC Agarwal DK Dhiman RK Baijal SS Choudhuri G Saraswat VA Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy.Gastroenterology. 1998; 115: 124-128Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 25Lee SP Nicholls JF Nature and composition of biliary sludge.Gastroenterology. 1986; 90: 677-686Abstract Full Text PDF PubMed Scopus (180) Google Scholar, 29Delchier JC Benfredj P Preaux AM Metreau JM Dhumeaux D The usefulness of microscopic bile examination in patients with suspected microlithiasis: a prospective evaluation.Hepatology. 1986; 6: 118-122Crossref PubMed Scopus (49) Google Scholar, 66Buscail L Escourrou J Delvaux M Guimbard R Nicolet T Frexinos J et al.Microscopic examination of bile directly collected during endoscopic cannulation of the papilla. Utility in patients with suspected microlithiasis.Dig Dis Sci. 1992; 37: 116-120Crossref PubMed Scopus (54) Google Scholar The bile is usually centrifuged at 2000g for 10 minutes.21Sharma BC Agarwal DK Dhiman RK Baijal SS Choudhuri G Saraswat VA Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy.Gastroenterology. 1998; 115: 124-128Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 62Dahan P Andant C Levy P Amouyal P Amouyal G Dumont M et al.Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography.Gut. 1996; 38: 277-281Crossref PubMed Scopus (162) Google Scholar, 67Agarwal DK Choudhuri G Saraswat VA Negi TS Utility of biliary microcrystal analysis in predicting composition of common bile duct stones.Scand J Gastroenterol. 1994; 29: 352-354Crossref PubMed Scopus (7) Google Scholar, 68Negro P Flati G Flati D Porowska B Tuscano D Carboni M Occult gallbladder microlithiasis causing acute recurrent pancreatitis. A report of three cases.Acta Chir Scand. 1984; 150: 503-506PubMed Google Scholar, 70Sharma BC Agarwal DK Baijal SS Negi TS Choudhuri G Saraswat VA Effect of endoscopic sphincterotomy on gall bladder bile lithogenicity and motility.Gut. 1998; 42: 288-292Crossref PubMed Scopus (21) Google Scholar The supernatant is discarded and the sediment transferred to a glass slide for immediate direct and polarizing microscopic examination.4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 21Sharma BC Agarwal DK Dhiman RK Baijal SS Choudhuri G Saraswat VA Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy.Gastroenterology. 1998; 115: 124-128Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 66Buscail L Escourrou J Delvaux M Guimbard R Nicolet T Frexinos J et al.Microscopic examination of bile directly collected during endoscopic cannulation of the papilla. Utility in patients with suspected microlithiasis.Dig Dis Sci. 1992; 37: 116-120Crossref PubMed Scopus (54) Google Scholar, 68Negro P Flati G Flati D Porowska B Tuscano D Carboni M Occult gallbladder microlithiasis causing acute recurrent pancreatitis. A report of three cases.Acta Chir Scand. 1984; 150: 503-506PubMed Google Scholar, 71Chebli JM Ferrari Junior AP Silva MR Borges DR Atallah AN das Neves MM Biliary microcrystals in idiopathic acute pancreatitis: clue for occult underlying biliary etiology [in Portugese with English abstract].Arq Gastroenterol. 2000; 37: 93-101Crossref PubMed Google Scholar If the sediment is negative, reanalyzing the sample after 24 hours may allow identification of cholesterol crystals unseen on the initial review.21Sharma BC Agarwal DK Dhiman RK Baijal SS Choudhuri G Saraswat VA Bile lithogenicity and gallbladder emptying in patients with microlithiasis: effect of bile acid therapy.Gastroenterology. 1998; 115: 124-128Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 70Sharma BC Agarwal DK Baijal SS Negi TS Choudhuri G Saraswat VA Effect of endoscopic sphincterotomy on gall bladder bile lithogenicity and motility.Gut. 1998; 42: 288-292Crossref PubMed Scopus (21) Google Scholar, 72Juniper K Burson EN Biliary tract studies II: the significance of biliary crystals.Gastroenterology. 1957; 32: 175-211PubMed Scopus (89) Google Scholar If a delayed examination is planned, whole bile should be stored in sterile tubes at 37°C and not frozen to avoid the risk of a false-positive study. Centrifuging and freezing the sediment for re-examination does not alter the results.Fig. 3Photomicrograph of cholesterol monohydrate crystals.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 4Photomicrograph of calcium-containing crystals.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Course/outcomeOur understanding of the clinical significance of sludge has been limited by short-term studies involving patients with known risk factors, many of whom have coexisting stones and gallbladder pathologic condition. However, studies have demonstrated complete resolution in approximately 40% of patients, a cyclic pattern of disappearing and reappearing in about 40%, and progression to stones in approximately 20%.4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 9Ros E Navarro S Bru C Garcia-Puges A Valderrama R Occult microlithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy.Gastroenterology. 1991; 101: 1701-1709Abstract PubMed Google Scholar, 13Janowitz P Kratzer W Zemmler T Tudyka J Wechsler JG Gallbladder sludge: spontaneous course and incidence of complications in patients without stones.Hepatology. 1994; 20: 291-294Crossref PubMed Scopus (58) Google Scholar, 17Houssin D Castaing D Lemoine J Bismuth H Microlithiasis of the gallbladder.Surg Gyn Obstet. 1983; 157: 20-24PubMed Google Scholar, 22Ko CW Sekijima JH Lee SP Biliary sludge.Ann Intern Med. 1999; 130: 301-311Crossref PubMed Scopus (153) Google Scholar, 59Lee SP Maher K Nicholls JF Origin and fate of biliary sludge.Gastroenterology. 1988; 94: 170-176Abstract PubMed Scopus (0) Google Scholar Potential outcomes of microlithiasis include remaining asymptomatic, developing biliary colic, or experiencing complications.17Houssin D Castaing D Lemoine J Bismuth H Microlithiasis of the gallbladder.Surg Gyn Obstet. 1983; 157: 20-24PubMed Google Scholar, 74Zinberg J Chernaik R Coman E Rosenblatt R Brandt LJ Reversible symptomatic biliary obstruction associated with ceftriaxone pseudolithiasis.Am J Gastroenterol. 1991; 86: 1251-1254PubMed Google Scholar Complications include cholecystitis, cholangitis, papillary stenosis, and acute pancreatitis.1Venu RP Geenen JE Hogan W Stone J Johnson GK Soergel K Idiopathic recurrent pancreatitis. An approach to diagnosis and treatment.Dig Dis Sci. 1989; 34: 56-60Crossref PubMed Scopus (157) Google Scholar, 4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 9Ros E Navarro S Bru C Garcia-Puges A Valderrama R Occult microlithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy.Gastroenterology. 1991; 101: 1701-1709Abstract PubMed Google Scholar, 17Houssin D Castaing D Lemoine J Bismuth H Microlithiasis of the gallbladder.Surg Gyn Obstet. 1983; 157: 20-24PubMed Google Scholar, 75Park HZ Lee SP Schy AL Ceftriaxone-associated gallbladder sludge. Identification of calcium-ceftriaxone salt as a major component of gallbladder precipitate.Gastroenterology. 1991; 100: 1665-1670PubMed Google Scholar, 76Jacobs RF Ceftriaxone-associated cholecystitis.Pediatr Infect Dis J. 1988; 7: 434-436Crossref PubMed Scopus (53) Google Scholar, 77Grier JF Cohen SW Grafton WD Gholson CF Acute suppurative cholangitis associated with choledochal sludge.Am J Gastroenterol. 1994; 89: 617-619PubMed Google Scholar Although the course cannot be reliably predicted, removal of the precipitating event correlates with resolution. Persistence of an underlying risk factor often leads to stone formation and complications such as pancreatitis.13Janowitz P Kratzer W Zemmler T Tudyka J Wechsler JG Gallbladder sludge: spontaneous course and incidence of complications in patients without stones.Hepatology. 1994; 20: 291-294Crossref PubMed Scopus (58) Google Scholar, 78Everson GT Pregnancy and gallstones.Hepatology. 1993; 17: 159-161Crossref PubMed Scopus (32) Google Scholar, 79Messing B Bories C Kunstlinger F Bernier JJ Does total parenteral nutrition induce gallbladder sludge formation and lithiasis?.Gastroenterology. 1983; 84: 1012-1019PubMed Scopus (361) Google ScholarMicrolithiasis may lead to pancreatitis through several mechanisms. Small stones may transiently impact at the papilla leading to pancreatic duct obstruction and eventual pancreatitis.80Opie EL The etiology of acute hemorrhagic pancreatitis.Bull Johns Hopkins Hosp. 1901; 12: 182-188Google Scholar Repeated exposure to microlithiasis may lead to papillary stenosis and sphincter of Oddi dysfunction, both of which are associated with pancreatitis.81Hernandez CA Lerch MM Sphincter stenosis and gallstone migration through the biliary tract.Lancet. 1993; 341: 1371-1373Abstract PubMed Scopus (88) Google Scholar The smaller size of stones comprising microlithiasis (vs. macrolithiasis) does not imply a lower likelihood of pancreatitis. In fact there are some data to suggest that smaller stones may correlate with a greater tendency for the development of pancreatitis.17Houssin D Castaing D Lemoine J Bismuth H Microlithiasis of the gallbladder.Surg Gyn Obstet. 1983; 157: 20-24PubMed Google Scholar However, there is also some uncertainty regarding the causal relationship between microlithiasis and pancreatitis. Some investigators believe that microlithiasis does not cause pancreatitis, but instead indicates the prior presence of larger stones that precipitated the pancreatitis. Pancreatitis itself may induce the formation of microlithiasis as a result of edema of the head of the pancreas that leads to biliary compression and gallbladder hypomotility.25Lee SP Nicholls JF Nature and composition of biliary sludge.Gastroenterology. 1986; 90: 677-686Abstract Full Text PDF PubMed Scopus (180) Google Scholar, 82Holzbach RT Gallbladder stasis: consequence of long-term parenteral hyperalimentation and risk factor for cholelithiasis.Gastroenterology. 1983; 84: 1055-1058PubMed Scopus (47) Google Scholar Gallbladder stasis also results from fasting, parenteral nutrition, and weight loss, all conditions commonly experienced in patients with pancreatitis. Also, gallbladder contents are modified and may become more lithogenic as a result of pancreatitis.TreatmentTherapeutic options include surgical intervention, endoscopic sphincterotomy (ES), and chemical dissolution. The benefit of therapy has been demonstrated by the significant decrease in recurrent episodes of pancreatitis after therapy (<10%) versus a recurrence rate of approximately 66% to 75% in untreated patients.4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 9Ros E Navarro S Bru C Garcia-Puges A Valderrama R Occult microlithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy.Gastroenterology. 1991; 101: 1701-1709Abstract PubMed Google Scholar, 71Chebli JM Ferrari Junior AP Silva MR Borges DR Atallah AN das Neves MM Biliary microcrystals in idiopathic acute pancreatitis: clue for occult underlying biliary etiology [in Portugese with English abstract].Arq Gastroenterol. 2000; 37: 93-101Crossref PubMed Google Scholar, 83Kaufman Z Shpitz B Dinbar A Microlithiasis of the cystic duct.Am J Gastroenterol. 1986; 81: 303-304PubMed Google ScholarLaparoscopic cholecystectomy offers the most definitive therapy and is generally considered the treatment of choice.4Lee SP Nicholls JF Park HZ Biliary sludge as a cause of acute pancreatitis.N Engl J Med. 1992; 326: 589-593Crossref PubMed Scopus (438) Google Scholar, 9Ros E Navarro S Bru C Garcia-Puges A Valderrama R Occult microlithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy.Gastroenterology. 1991; 101: 1701-1709Abstract PubMed Google Scholar Laparoscopic cholecystectomy is indicated in good operative candidates of almost any age because the risks of future gallbladder-related symptoms and complications outweigh the operative risks. ES is an effective alternative and may obviate the need for cholecystectomy in the very elderly or those with significant comorbid illness. The benefit of sphincter ablation occurs as a result of enhanced gallbladder motility (and reduced gallbladder stasis) as shown by a significant reduction in the mean gallbladder fasting volume and residual volume and by an increase in mean gallbladder ejection fraction.62Dahan P Andant C Levy P Amouyal P Amouyal G Dumont M et al.Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography.Gut. 1996; 38: 277-281Crossref PubMed Scopus (162) Google Scholar, 70Sharma BC Agarwal DK Baijal SS Negi TS Choudhuri G Saraswat VA Effect of endoscopic sphincterotomy on gall bladder bile lithogenicity and motility.Gut. 1998; 42: 288-292Crossref PubMed Scopus (21) Google Scholar, 85Tanaka M Ikeda S Yoshimoto H Matsumoto S The long-term fate of the gallbladder after endoscopic sphincterotomy. Complete follow-up study of 122 patients.Am J Surg. 1987; 154: 505-509Abstract Full Text PDF PubMed Scopus (70) Google Scholar, 88Rosseland AR Solhaug JH Primary endoscopic papillotomy (EPT) in patients with stones in the common bile duct and the gallbladder in situ: a 5-8-year follow-up study.World J Surg. 1988; 12: 111-116Crossref PubMed Scopus (57) Google Scholar, 89Agarwal DK Sharma BC Dhiman RK Baijal SS Choudhuri G Saraswat VA Effect of endoscopic sphincterotomy on gallbladder motility.Dig Dis Sci. 1997; 42: 1495-1500Crossref Pub" @default.
• W2158241915 created "2016-06-24" @default.
• W2158241915 creator A5077228556 @default.
• W2158241915 date "2002-02-01" @default.
• W2158241915 modified "2023-09-25" @default.
• W2158241915 title "The hunt for microlithiasis in idiopathic acute recurrent pancreatitis: Should we abandon the search or intensify our efforts?" @default.
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