Biliary sludge: curiosity or culprit?

Role of EUS at high risk for choledocholithiasis without severe cholangitis and visible stone on cross-sectional imaging: A multicenter randomized clinical trial

Background and Objectives:

The prevalence of choledocholithiasis in the high-risk group of choledocholithiasis has been reported to be slightly more than 50% when there is no definite cholangitis. Replacement of diagnostic endoscopic retrograde cholangiography (ERC) with an EUS-first approach may be beneficial in these patients.

Materials and Methods:

In this prospective, multicenter study, patients with dilated common bile duct and serum total bilirubin levels of 1.8–4 mg/dL were randomly allocated to undergo either EUS first, followed by subsequent ERC if necessary (EUS group) or ERC only (ERC group). The primary endpoint was the incidence of negative outcomes associated with a false-negative diagnosis of the choledocholithiasis or the endoscopic procedure. The secondary endpoints were the rate of diagnostic ERC and hospital stay length related to the endoscopic procedure.

Results:

Of 90 patients who were randomly assigned, the final analysis involved 42 in the EUS group and 44 in the ERC group. The negative outcomes were not significantly different between the EUS and ERC groups (2.4% vs. 6.8%; P = 0.62). The rate of diagnostic ERC was significantly lower in the EUS group (2.4% vs. 47.7%; P < 0.001). The hospital stay length related to the endoscopic procedure was significantly shorter in the EUS group (1.8 ± 1.0 vs. 2.5 ± 1.2 days; P = 0.001).

Conclusion:

In selected high-risk choledocholithiasis patients, an EUS-first strategy significantly decreased the rate of diagnostic ERC and hospital stay but did not achieve a significant reduction in negative endoscopic procedure outcomes.

Similarities and differences between biliary sludge and microlithiasis: Their clinical and pathophysiological significances

The terms biliary sludge and cholesterol microlithiasis (hereafter referred to as microlithiasis) were originated from different diagnostic techniques and may represent different stages of cholesterol gallstone disease. Although the pathogenesis of biliary sludge and microlithiasis may be similar, microlithiasis could be preceded by biliary sludge, followed by persistent precipitation and aggregation of solid cholesterol crystals, and eventually, gallstone formation. Many clinical conditions are clearly associated with the formation of biliary sludge and microlithiasis, including total parenteral nutrition, rapid weight loss, pregnancy, organ transplantation, administration of certain medications, and a variety of acute and chronic illnesses. Numerous studies have demonstrated complete resolution of biliary sludge in approximately 40% of patients, a cyclic pattern of disappearing and reappearing in about 40%, and progression to gallstones in nearly 20%. Although only a minority of patients with ultrasonographic demonstration of biliary sludge develop gallstones, it is still a matter of controversy whether microlithiasis could eventually evolve to cholesterol gallstones. Biliary sludge and microlithiasis are asymptomatic in the vast majority of patients; however, they can cause biliary colic, acute cholecystitis, and acute pancreatitis. Biliary sludge and microlithiasis are most often diagnosed ultrasonographically and bile microscopy is considered the gold standard for their diagnosis. Specific measures to prevent the development of biliary sludge are not practical or cost-effective in the general population. Laparoscopic cholecystectomy offers the most definitive therapy on biliary sludge. Endoscopic sphincterotomy or surgical intervention is effective for microlithiasis-induced pancreatitis. Ursodeoxycholic acid can effectively prevent the recurrence of solid cholesterol crystals and significantly reduce the risk of recurrent pancreatitis.

Inspissated bile syndrome; Safe and effective minimally invasive treatment with percutaneous cholecystostomy in neonates and infants

PURPOSE

Inspissated bile syndrome (IBS) is a rare cause of obstructive jaundice in neonates and infants with several treatment options reported. We present our experience with the use of minimally invasive ultrasound-guided percutaneous cholecystostomy drain catheter placement with ongoing saline lavage in neonates and infants.

METHODS

Retrospective chart review of patients treated with percutaneous cholecystostomy, from February 2010 till June 2015. We reviewed the technical and clinical success along with complications of the procedure.

RESULTS

There were 6 patients, mean age 17weeks (range 4-40). Most had significant risk factors for IBS presenting with biliary obstruction. A total of 7 procedures performed on the 6 patients, with a technical success rate of 6/7. One patient required cannulation of the intrahepatic biliary system. Drains were flushed for a median of 26days (10-70). Clinical success was achieved in all patients. 3 had displacement of the drain, one of which required re-insertion. Another developed a small sub-hepatic collection post procedure with pyrexia. On long term follow up one was found to have a forme fruste choledochal cyst.

CONCLUSION

Centers with suitable interventional radiology services ultrasound-guided percutaneous cholecystostomy drain catheter placement with ongoing saline lavage is a safe and effective minimally invasive treatment for IBS in neonates and infants.

Roles of infection, inflammation, and the immune system in cholesterol gallstone formation

Cholesterol gallstone formation is a complex process mediated by genetic and environmental factors. Until recently, the role of the immune system in the pathogenesis of cholesterol gallstones was not considered a valid topic of research interest. This review collates and interprets an extensive body of basic literature, some of which is not customarily considered to be related to cholelithogenesis, describing the multiple facets of the immune system that appear to be involved in cholesterol cholelithogenesis. A thorough understanding of the immune interactions with biliary lipids and cholecystocytes should modify current views of the pathogenesis of cholesterol gallstones, promote further research on the pathways involved, and lead to novel diagnostic tools, treatments, and preventive measures.

Utility of endoscopic ultrasound in pancreatitis: A review

The close proximity of the endoscopic ultrasound probe to the pancreas results in superior spatial resolution compared to CT scan and MRI. In addition, endoscopic ultrasound (EUS) is a minimally invasive procedure that does not share the relatively high complication rate of ERCP. Due to these advantages, EUS has evolved into an important technique to assess pancreatobiliary disease. This review will discuss the role of EUS in patients with pancreatitis. The indications can be divided into acute pancreatitis and chronic pancreatitis. In acute pancreatitis, EUS is used to determine the etiology; in suspected chronic pancreatitis it is helpful to establish the diagnosis. Lastly, this review will discuss biliary pancreatitis with suspicion for persistent choledocholithiasis.

Comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the diagnosis of pancreatobiliary diseases: a prospective study

OBJECTIVES

To compare the diagnostic value of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in: (a) patients with a dilated biliary tree unexplained by ultrasonography (US) (group 1), and (b) the diagnosis of choledocholithiasis in patients with nondilated biliary tree (group 2).

METHODS

Patients were prospectively evaluated with EUS and MRCP. The gold standard used was surgery or EUS-FNA and ERCP, intraoperative cholangiography, or follow-up when EUS and/or MRCP disclosed or precluded malignancy, respectively. Likelihood ratios (LR) and pretest and post-test probabilities for the diagnosis of malignancy and choledocholithiasis were calculated.

RESULTS

A total of 159 patients met one of the inclusion criteria but 24 of them were excluded for different reasons. Thus, 135 patients constitute the study population. The most frequent diagnosis was choledocholithiasis (49% in group 1 and 42% in group 2, P= 0.380) and malignancy was more frequent in group 1 (35%vs 7%, respectively, P < 0.001). When EUS and MRCP diagnosed malignancy, its prevalence in our series (35%) increased up to 98% and 96%, respectively, whereas it decreased to 0% and 2.6% when EUS and MRCP precluded this diagnosis. In patients in group 2, when EUS and MRCP made a positive diagnosis of choledocholithiasis, its prevalence (42%) increased up to 78% and 92%, respectively, whereas it decreased to 6% and 9% when any pathologic finding was ruled out.

CONCLUSIONS

EUS and MRCP are extremely useful in diagnosing or excluding malignancy and choledocholithiasis in patients with dilated and nondilated biliary tree. Therefore, they are critical in the approach to the management of these patients.

The clinical significance of bile duct sludge: is it different from bile duct stones?

BACKGROUND

Some patients with suspected common bile duct (CBD) stones are found to have sludge and no stones. Although sludge in the gallbladder is a precursor of gallbladder stones, the significance of bile duct sludge (BDS) is poorly defined. This study aimed to compare BDS with bile duct stones in terms of frequency, associated risk factors, and clinical outcome after endoscopic therapy.

METHODS

The study enrolled 228 patients who underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis. The patients were divided into two groups: patients with BDS but no stones on ERCP and patients with CBD stones. The presence of risk factors for bile duct stones (age, periampullary diverticulum, ductal dilation or angulation, previous open cholecystectomy) were assessed at ERCP. Follow-up data (36 +/- 19 months) were obtained from medical records and by patient questioning.

RESULTS

Bile duct sludge occurred in 14% (31/228) of patients and was more common in females. After endoscopic clearance, CBD stones recurred in 17% (33/197) of the patients with CBD stones, and in 16% (5/31) of the patients with BDS (p = 0.99). Common bile duct dilation was less common in the sludge group. The other known risk factors for recurrent CBD stones (age, previous open cholecystectomy, bile duct angulation, and the presence of a peripampullary diverticulum) were not statistically different between the two groups.

CONCLUSIONS

The findings indicate that the clinical significance of symptomatic BDS is similar to that of CBD stones. Bile duct sludge seems to be an early stage of choledocholithiasis.

Recurrent symptomatic common bile duct stones after endoscopic stone extraction in elderly patients

BACKGROUND

Endoscopic sphincterotomy (EST) and stone extraction are established therapeutic procedures for common bile duct (CBD) stones. Little is known about the outcomes of EST for CBD stones among elderly patients.

OBJECTIVES

To examine the rate and the risk factors (CBD dilation and/or angulation, periampullary diverticulum, and past open cholecystectomy) for recurrent symptomatic CBD stones after EST in the elderly.

DESIGN AND PATIENTS

A total of 228 patients who underwent EST for CBD stones in the period 1997 to 2004 were included. Follow-up data were obtained from medical records and by questioning all the patients. The correlation between age and stone recurrence, as well as between age and the prevalence of risk factors for recurrence was calculated. In addition, a subgroup of 45 elderly patients aged > or =80 years was compared with a control subgroup of 51 young patients aged < or =50 years, in terms of stone recurrence and associated risk factors.

SETTING

Single-center, retrospective study.

INTERVENTIONS

Endoscopic sphincterotomy.

MAIN OUTCOME MEASUREMENTS

Symptomatic CBD stone recurrence rate and frequency of risk factors for it.

RESULTS

In the group of all patients, a correlation was found between the age and stone recurrence, as well as between age and the known risk factors for recurrent stones. In analyzing the 2 subgroups, CBD stones recurred in 20% of the elderly patients compared with 4% of the young patients. Risk factors for recurrent CBD stones were more common in the elderly, and so was the presence of multiple risk factors in the same patient.

CONCLUSIONS

Recurrence of symptomatic CBD stones after endoscopic therapy was more frequent in the elderly patients because of an increased frequency of risk factors.

Biliary sludge: When should it not be ignored

Biliary sludge is usually seen on transabdominal sonography as low-level echoes that layer in the dependent portion of the gallbladder without acoustic shadowing. Synonyms for biliary sludge include microlithiasis, biliary sand or sediment, pseudolithiasis, and microcrystalline disease. In most patients, biliary sludge is composed of calcium bilirubinate and cholesterol monohydrate crystals. A variety of predisposing factors are associated with biliary sludge formation. In most of these patients, removal of the risk factor can lead to resolution of sludge. In asymptomatic patients, biliary sludge can be managed expectantly. In patients who develop biliary-type pain, cholecystitis, cholangitis, or pancreatitis, the treatment of choice is cholecystectomy for those who can tolerate surgery. In patients who are not operative candidates, endoscopic sphincterotomy can prevent further episodes of cholangitis and pancreatitis, whereas medical therapy with ursodeoxycholic acid can prevent sludge formation and recurrent acute pancreatitis.

Approach to idiopathic recurrent pancreatitis

Acute pancreatitis is caused by acute or chronic alcohol intake or choledocholithiasis in approximately 80% of cases. In the absence of alcohol abuse or gallstones, a variety of established and putative factors must be considered, any of which can cause a single or recurrent attacks of acute pancreatitis. When the underlying cause eludes detection following an initial thorough search and leads to a second attack, the term idiopathic acute recurrent pancreatitis (IARP) is applied. This article discusses IARP and its work-up.

Gastrointestinal disorders of the critically ill. Biliary sludge and cholecystitis

Biliary sludge develops commonly in critically ill patients and may be associated with biliary colic, acute pancreatitis or acute cholecystitis. Sludge often resolves upon resolution of the underlying pathogenetic factor. It is generally diagnosed on sonography. Treatment of sludge itself is unnecessary unless further complications develop. Acute acalculous cholecystitis also develops frequently in critically ill patients. It may be difficult to diagnose in these patients, manifesting only as unexplained fever, leukocytosis or sepsis. Sonography and hepatobiliary scintigraphy are the most useful diagnostic tests. Management decisions should take into account the underlying co-morbid conditions. For many patients, percutaneous cholecystostomy may be the best management option. Cholecystostomy may also provide definitive drainage as patients recover and underlying critical illness resolves.

Second harmonic imaging improves trans-abdominal ultrasound detection of biliary sludge in 'idiopathic' pancreatitis

BACKGROUND

Recently, biliary sludge has been strongly correlated with 'idiopathic pancreatitis'. It is often diagnosed by trans-abdominal ultrasonography, despite the low sensitivity of this investigation. New scanners, using second harmonic imaging, may improve the quality of the echographic picture.

AIM

To verify the impact of this methodology on the detection of biliary sludge in patients with 'idiopathic' pancreatitis.

METHODS

Fifty patients with 'idiopathic' pancreatitis observed over a 18-month period entered the study. Exclusion criteria were gall-bladder stones, polyps, clinical conditions related to biliary sludge development and haemolytic disorders. Patients were assessed blind by two operators using either conventional ultrasonography or second harmonic imaging. The parameters of diagnostic quality of both examinations were evaluated using, as the gold standard, microscopic examination of the gall-bladder content collected at endoscopy after cholecystokinin infusion.

RESULTS

An improvement in sensitivity, specificity, efficiency and negative predictive value was obtained by second harmonic imaging compared with conventional ultrasonography.

CONCLUSIONS

Second harmonic imaging, in our experience, is a reliable non-invasive tool for the diagnosis and follow-up of biliary sludge in the course of 'idiopathic' pancreatitis.

Magnetic resonance cholangiography versus ultrasound in the evaluation of the gallbladder

Ultrasonography (US) is currently the reference technique for evaluating gallbladder pathology. The aim of this study was to prospectively determine the diagnostic efficacy of magnetic resonance cholangiography (MRCP) in evaluating the gallbladder, as compared with US. The study included 80 patients (mean age, 69.3 years; male-to-female ration, 1.3:1) who underwent prospective US and MRCP; 5 patients in whom MRCP was contraindicated were excluded. In all cases, US was performed before MRCP. Ultrasound was the reference technique for evaluating MRCP sensitivity and specificity. Magnetic resonance cholangiopancreatography provided good image quality in 65 patients (81.2%) and poor image quality in 15 (mostly because of poor patient cooperation). Artefacts did not influence visualization of the gallbladder or evaluation of the background pathology. The sensitivity of MRCP in diagnosing gallbladder stones (43 patients; 97.7%) was comparable to US (44 patients). In contrast, MRCP diagnosed biliary sludge or microlithiasis in 13 patients, versus 5 in the case of US. Magnetic resonance cholangiopancreatography is a good technique for diagnosing cholelithiasis and biliary sludge. However, its high cost, contraindications, and the need for patient cooperation limit the use of the technique in routine clinical gallbladder studies. Magnetic resonance cholangiopancreatography could contribute to the diagnosis of microlithiasis, provided that future studies confirm its greater sensitivity versus US.

Dissolution of cholesterol gallstones in mice by the oral administration of a fatty acid bile acid conjugate

Gallstones, mostly cholesterol stones, affect some 15% of the population. Oral bile salts dissolve human cholesterol gallstones, but with low efficacy, and surgery remains the main therapeutic option. Fatty acid bile acid conjugates (FABACs) were shown to prevent formation of cholesterol gallstones in experimental animals. The aim of this study was to test whether these compounds could dissolve preexisting cholesterol gallstones via oral administration. Inbred, gallstone-susceptible C57J/L mice were given a lithogenic diet for 2 months, and the presence of gallstones was ascertained. The mice were then switched to a regular diet while part of them were given in addition C20-FABAC, by gavage, at a dose of 0.5 or 3 mg per animal per day. All mice tested had cholesterol gallstones after 2 months on the lithogenic diet. In study I, after 2 months on the regular diet, 3 of 4 (75%) of the controls had gallstones, whereas none of the 6 FABAC-fed animals (3 mg/d) had stones (P =.033). In study II, evaluating 2 FABAC doses, after 2 months on the regular diet, 8 of 8 (100%) of the controls had gallstones, which were found in 2 of 7 (28%) and 1 of 8 (12%) of the mice supplemented with 0.5 mg/d (P =.007) or 3 mg/d (P =.001) FABAC, respectively. On a molar basis, the dose of 0.5 mg FABAC is equivalent to 14 mg/kg/d of a bile acid. In conclusion, FABACs given orally can dissolve preexisting cholesterol gallstones in mice. This was accomplished with a dose of FABAC equivalent to the dose of bile acids used in human gallstone dissolution.

Prevalence and laparoscopic ultrasound patterns of choledocholithiasis and biliary sludge during cholecystectomy

A prospective study of laparoscopic ultrasound (LUS) for evaluation of the common bile duct during laparoscopic cholecystectomy was started in October 1993. LUS during cholecystectomy was performed routinely to preoperatively identify unsuspected stones. Three-hundred thirty patients with symptomatic cholelithiasis were included in the study. The preoperative work-up included endoscopic retrograde cholangiopancreatography in 49 patients. Common bile duct (CBD) stones were found in 22 cases; in 19 cases the stones were removed successfully by endoscopic sphincterotomy. LUS successfully visualized the CBD in all but 10 patients (3%). CBD stones were found in 17 patients and confirmed by preoperative cholangiography and/or CBD exploration. There were two false-negative and one false-positive result for LUS. In 47 patients (14.2%) LUS detected CBD sludge as low-amplitude echoes without acoustic shadowing. The presence of CBD sludge was correlated with some biochemical and clinical variables. A significant correlation was identified between the absence or presence of CBD sludge and endoscopic retrograde cholangiopancreatography, acute pancreatitis, gallbladder sludge, age, and the levels of serum bilirubin and alkaline phosphatase. A significant difference was recorded between CBD diameter and the presence or absence of stones or sludge (p = 0.00001). In our experience, LUS allowed good diagnosis of CBD stones during laparoscopic cholecystectomy. The clinical significance of CBD sludge remains to be elucidated.

Prevalence and laparoscopic ultrasound patterns of choledocholithiasis and biliary sludge during cholecystectomy

A prospective study of laparoscopic ultrasound (LUS) for evaluation of the common bile duct during laparoscopic cholecystectomy was started in October 1993. LUS during cholecystectomy was performed routinely to preoperatively identify unsuspected stones. Three-hundred thirty patients with symptomatic cholelithiasis were included in the study. The preoperative work-up included endoscopic retrograde cholangiopancreatography in 49 patients. Common bile duct (CBD) stones were found in 22 cases; in 19 cases the stones were removed successfully by endoscopic sphincterotomy. LUS successfully visualized the CBD in all but 10 patients (3%). CBD stones were found in 17 patients and confirmed by preoperative cholangiography and/or CBD exploration. There were two false-negative and one false-positive result for LUS. In 47 patients (14.2%) LUS detected CBD sludge as low-amplitude echoes without acoustic shadowing. The presence of CBD sludge was correlated with some biochemical and clinical variables. A significant correlation was identified between the absence or presence of CBD sludge and endoscopic retrograde cholangiopancreatography, acute pancreatitis, gallbladder sludge, age, and the levels of serum bilirubin and alkaline phosphatase. A significant difference was recorded between CBD diameter and the presence or absence of stones or sludge (p = 0.00001). In our experience, LUS allowed good diagnosis of CBD stones during laparoscopic cholecystectomy. The clinical significance of CBD sludge remains to be elucidated.

MDR3 gene defect in adults with symptomatic intrahepatic and gallbladder cholesterol cholelithiasis

BACKGROUND & AIMS

Many studies indicate that gallstone susceptibility has genetic components. MDR3 is the phosphatidylcholine translocator across the hepatocyte canalicular membrane. Because phospholipids are a carrier and a solvent of cholesterol in hepatic bile, we hypothesized that a defect in the MDR3 gene could be the genetic basis for peculiar forms of cholesterol gallstone disease, in particular those associated with symptoms and cholestasis without evident common bile duct stone.

METHODS

We studied 6 adult patients with a peculiar form of cholelithiasis. MDR3 gene sequence was determined by reverse-transcription polymerase chain reaction amplification of mononuclear cell RNAs followed by direct sequencing. Hepatic bile was analyzed in 2 patients.

RESULTS

All patients shared the following features: at least 1 episode of biliary colic, pancreatitis, or cholangitis; biochemical evidence of chronic cholestasis; recurrence of symptoms after cholecystectomy; presence of echogenic material in the intrahepatic bile ducts; and prevention of recurrence by ursodeoxycholic acid therapy. Hepatic bile composition showed a high cholesterol/phospholipid ratio and cholesterol crystals. In all patients, we found MDR3 gene mutations involving a conserved amino acid region.

CONCLUSIONS

These preliminary observations suggest that MDR3 gene mutations represent a genetic factor involved in this peculiar form of cholesterol gallstone disease in adults. They require further studies to assess the prevalence of MDR3 gene defects in symptomatic and silent cholesterol gallstone disease.

[Biliary microcrystals in idiopathic acute pancreatitis: clue for occult underlying biliary etiology]

The main causes of pancreatic inflammation worldwide are biliary lithiasis and alcoholism. However, 10 to 30% of patients have been considered to have "idiopathic" acute pancreatitis. Recently, some studies showed that a significant rate of the so called idiopathic pancreatitis are caused by microlithiasis and/or biliary sludge, identified by the presence of cholesterol monohidrate and/or calcium bilirubinate microcrystals in the biliary sediment. In the present study, the analysis of microcrystals from bile obtained during endoscopic retrograde cholangiopancreatography was done in patients with pancreatitis (idiopathic, biliary or alcoholic--20 in each group). Patients with idiopathic pancreatitis and microcrystals in the bile underwent cholecystectomy whenever possible. Those who refused or were inapt to surgery underwent endoscopic sphincterotomy or received continuous therapy with ursodeoxycholic acid. Patients with idiopathic pancreatitis without biliary crystals did not receive any specific treatment. The prevalence of biliary microcrystals in patients with idiopathic pancreatitis (75%) and biliary pancreatitis (90%) was significantly higher than in those with alcoholic pancreatitis (15%). In the identification of the etiology of biliary pancreatitis, the presence of microcrystals had a sensitivity of 90%, specificity of 85%, positive predictive value of 85.7%, negative predictive value of 89.4% and accuracy of 87.5%. In the patients with recurrent idiopathic pancreatitis, with biliary crystals, there was an statistically significant reduction in the number of pancreatitis episodes after specific treatment. In the follow-up of this group during 23.3 +/- 4.8 months, recurrence of pancreatitis occurred only in patients with "persistent biliary factor" (choledocholithiasis and/or persistence of cholesterol monohidrate). All patients with idiopathic pancreatitis who underwent cholecystectomy had chronic cholecystitis. Moreover, cholelithiasis was present in one case. In the ultrassonographic follow-up of the patients with idiopathic acute pancreatitis with microcrystals in the bile, cholelithiasis was detected in one case. In the subgroup of five patients with idiopathic pancreatitis without biliary microcrystals recurrence occurred in one case. Ultrassonographic study during follow-up did not reveal biliary stones in any of these patients. We concluded that the detection of biliary microcrystals in "idiopathic" pancreatitis suggested an underlying biliary etiology, even if occult. What's more, early specific therapeutic procedure (cholecystectomy, endoscopic sphincterotomy or ursodeoxycholic acid) in patients with recurrent idiopathic pancreatitis with microcrystals in the bile reduced significantly the recurrence during the follow-up. Finally, acute pancreatitis (specially recurrent) should not be called idiopathic before the microscopic analysis of the bile, aiming to detect or exclude the presence of microcrystals.

Apolipoprotein E genotype and the risk of gallbladder disease in pregnancy

The E4 allele of apolipoprotein E (apoE4) has previously been associated with symptomatic gallstone disease. The aim of this study was to determine if apoE4 is associated with the development of gallbladder sludge and/or stones during pregnancy. We conducted a nested case-control study based on an ongoing cohort study of gallbladder disease in pregnancy. Women in this study receive gallbladder ultrasounds in each trimester of pregnancy. Cases (n = 52) were defined as women with incident gallbladder sludge or stones diagnosed at the third trimester ultrasound. Controls (n = 104) were defined as women without gallbladder sludge or stones on any of 3 study ultrasounds. ApoE genotyping was performed from stored white blood cell pellets. Data were analyzed by stratified analysis and multivariate logistic regression. Cases and controls were similar in baseline characteristics. Forty-two women had sludge, 6 had gallstones, and 4 had both sludge and stones. After adjusting for risk factors such as age, parity, and body mass index, the odds ratio (OR) for the association between heterozygosity or homozygosity for the apoE4 allele and incident gallbladder sludge or stones was 0.91 (95% confidence interval [CI], 0.41-2.02). Further adjustment for family medical history and serum lipid levels did not substantially change these results (OR, 0.73; 95% CI, 0.29-1.82). In conclusion, apoE4 appears to have little or no overall association with the development of new gallbladder sludge or stones in pregnancy. However, an effect could not be ruled out in certain subgroups, such as blacks or women who are homozygous for apoE4.

Cholestasis after hematopoietic cell transplantation

Cholestasis and jaundice are common after hematopoietic cell transplantation and may have multiple causes. Specific disorders that may contribute to cholestasis in this setting include sepsis, hemolysis, cyclosporine administration, drug toxicity, parenteral nutrition, graft versus host disease, viral infection, and extrahepatic obstruction.