Hepatobiliary and pancreatic: Commentary

Abstract

Journal of Gastroenterology and HepatologyVolume 17, Issue 7 p. 811-811 Free Access Hepatobiliary and pancreatic: Commentary First published: 10 September 2009 https://doi.org/10.1046/j.1440-1746.2002.t01-1-02856.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat INTERPRETATION OF FIGURE 2 (SEE PAGE 806) On the plain abdominal radiograph (Fig. 2), a dilated bile duct and dilated left and right hepatic ducts are seen as radio-opaque structures. This may occur when the biliary system contains multiple stones or when bile has a high calcium content. In this patient, the radio-density of the biliary tree is homogeneous, suggesting the presence of bile with a very high calcium concentration. This finding is called ‘limy bile’ or ‘milk of calcium bile’. Diagnosis: limy bile ‘Limy bile’ is biliary sludge that contains precipitated calcium salts. Predisposing factors include fasting and wasting, as in this patient. It normally forms in the gallbladder and can resolve spontaneously.1 It may also pass into the bile duct and cause abdominal pain and/or changes in liver function tests. Thereafter, sludge may persist in the bile duct or pass through the ampulla of Vater into the duodenum.2 In the illustrated case, ‘limy bile’ was not detected in the gallbladder. The physicochemical conditions of bile that expedite formation of pigment stones and sludge are not established, but it is known that opaqueness of bile is a result of the presence of more than 4% calcium as carbonate and/or phosphate. If the concentration of calcium salts in bile is less than 4%, sludge tends to be brown (rather than black) and radiolucent.3 Images of interest Obviously, serum enzymes improved while ‘limy bile’ was still in the bile duct. Presumably, impaction of sludge was relieved, perhaps by the spontaneous passage of some sludge into the duodenum. A subsequent ultrasound study showed less dilatation of intrahepatic ducts (Fig. 3). Ultrasound studies are often unhelpful for bile duct sludge, but magnetic resonance imaging may show sludge as a gravitation-dependent material, as shown in Figure 4. Figure 3Open in figure viewerPowerPoint Intrahepatic ducts are no longer dilated. Figure 4Open in figure viewerPowerPoint T2-weighted magnetic resonance image of the liver. (→) Sludge as a sediment on the posterior aspect of the bile duct (different case). References 1 Nomura F, Suzuki Y, Suzuki K et al. Spontaneous disappearance of limy bile: report of a case with review of the literature. Am. J. Gastroenterol. 1984; 79: 884– 8. 2 Hokama A, Kinjo F. Biliary sludge extruding into the duodenum. N. Engl. J. Med. 1998; 339: 1210. 3 Trotman BW. Pigment gallstone disease. Semin. Liver Dis. 1983; 3: 112– 19. Volume17, Issue7July 2002Pages 811-811 FiguresReferencesRelatedInformation