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

Layering hyperintensity in T1-weighted magnetic resonance imaging predicts gallbladder sludge: a retrospective cohort and diagnostic accuracy study in patients with significant liver disease

BACKGROUND

Layering hyperintensity in the gallbladder is frequently observed on T1-weighted (T1w) magnetic resonance imaging (MRI), but its association with hepatobiliary disorders is not well understood.

OBJECTIVE

This study aimed to evaluate the prevalence of T1w layering in the gallbladder and its correlation with ultrasound (US) findings and patient characteristics in a cohort with significant liver disease.

METHODS

A single-center study from 2015 to 2022 included patients who underwent MRI and abdominal US within one week. Exclusion criteria were poor imaging quality and prior cholecystectomy. MRI findings were correlated with US and analyzed against patient characteristics.

RESULTS

Among 415 patients (mean age 58.3 ± 14.8 years; mean BMI 28.0 ± 4.5 kg/m²), 67% had abnormal liver function tests, with high prevalences of cirrhosis (n = 260), transjugular intrahepatic portosystemic shunt (TIPS) (n = 233), and choledocholithiasis (n = 106). T1w layering was observed in 56% (n = 232) and associated with higher BMI (p = 0.001) and with cholecystolithiasis (p < 0.001), but not with age, sex, or liver disease indicators. T1w layering was predictive of gallbladder sludge on US (odds ratio 17.2, 95% confidence interval 9.87-31.44, p < 0.001), with a sensitivity of 92.7% but moderate specificity (57.9%).

CONCLUSION

T1w layering on MRI strongly predicts gallbladder sludge detected on US and is associated with increased BMI in this cohort of patients with liver disease. However, the moderate specificity requires cautious interpretation, and our findings suggest that T1w layering may serve as a complementary diagnostic tool.

Time from drainage to surgery is an independent predictor of morbidity for moderate-to-severe acute cholecystitis: a multivarirble analysis of 259 patients

BACKGROUND

Acute cholecystitis (AC) is an acute inflammatory disease of the gallbladder and one of the most frequent causes of acute abdominal pain. Early cholecystectomy is recommended for mild cholecystitis. However, the optimal surgical timing for moderate-to-severe cholecystitis requiring percutaneous transhepatic gallbladder drainage (PTGBD) remains unclear. We hypothesized that early elective surgery after PTGBD would reduce surgical morbidity.

METHODS

A retrospective analysis was performed on adult patients who underwent elective surgery for AC after PTGBD at our hospital between January 2011 and December 2020. Patient demographics, perioperative findings, and postoperative morbidity and mortality rates were also investigated. The patients were divided into two groups based on postoperative morbidity, and univariable analysis was performed for preoperative factors. Multivariable logistic regression analysis was performed for the potential independent variables.

RESULTS

A total of 891 patients were screened for eligibility, and 259 were included in the analysis. Among these patients, 32 developed postoperative morbidity; however, there was no postoperative mortality. Multivariable analysis revealed that the time from PTGBD to surgery was an independent predictor of surgical morbidity (odds ratio, 1.05; 95% confidence interval: 1.01-1.10).

CONCLUSION

In early elective surgery for moderate-to-severe AC requiring PTGBD, a shorter interval from biliary drainage to surgery may decrease surgical morbidity.

Practical approach to linear endoscopic ultrasound examination of the gallbladder

The gallbladder (GB) is a susceptible organ, prone to various pathologies that can be identified using different imaging techniques. Transabdominal ultrasound (TUS) is typically the initial diagnostic method due to its numerous well-established advantages. However, in cases of uncertainty or when a definitive diagnosis cannot be established, computed tomography (CT) or magnetic resonance imaging may be employed to provide more detailed information. Nevertheless, CT scans may sometimes offer inadequate spatial resolution, which can limit the differentiation of GB lesions, particularly when smaller yet clinically relevant abnormalities are involved. Conversely, endoscopic ultrasound (EUS) provides higher frequency compared to TUS, superior spatial resolution, and the option for contrast-enhanced harmonic imaging, enabling a more comprehensive examination. Thus, EUS can serve as a supplementary tool when conventional imaging methods are insufficient. This review will describe the standard EUS examination of the GB, focusing on its endosonographic characteristics in various GB pathologies.

Predictive modeling of postoperative gastrointestinal dysfunction: the role of serum bilirubin, sodium levels, and surgical duration in gynecological cancer care

OBJECTIVE

To elucidate the role of preoperative serum bilirubin and sodium levels, along with the duration of surgery, in predicting postoperative gastrointestinal dysfunction (POGD) following gynecological cancer surgery, informing tailored perioperative strategies.

METHODS

We conducted a retrospective analysis of 281 patients undergoing gynecological cancer surgery between 2018 and 2023. This analysis focused on preoperative serum bilirubin and sodium levels and intraoperative factors (surgical duration) as potential predictors of POGD. Logistic regression models were utilized for analysis, controlling for relevant confounders.

RESULTS

Elevated preoperative serum bilirubin was associated with a reduced risk of POGD (mean level in non-POGD cases: 14.172 ± 4.0701, vs. POGD cases: 9.6429 ± 3.5351; p <  0.001), suggesting a protective role. Lower preoperative sodium levels were identified in the POGD group (136.26 mEq/L [IQR: 135.2-137.63]) compared to the non-POGD group (139.32 mEq/L [IQR: 137.7-140.75]; p <  0.001), highlighting its predictive value. Additionally, longer surgical duration was associated with increased POGD incidence, with POGD cases experiencing surgeries lasting 6.1547 ± 1.9426 hours compared to 4.5959 ± 1.5475 hours in non-POGD cases (p <  0.001).

CONCLUSION

Our findings underscore the importance of serum bilirubin, sodium levels, and surgical duration as significant predictors of POGD in patients undergoing gynecological cancer surgery. These indicators should be integrated into a predictive model, aiding clinicians in identifying high-risk patients, allowing for personalized perioperative care adjustments, potentially mitigating POGD risks.

Natural Course of Common Bile Duct Microlithiasis

BACKGROUND

Common bile duct microlithiasis (CBDM) with a diameter of ≤ 3 mm can pass spontaneously without causing any symptoms, but in some cases, it can also cause severe cholangitis and pancreatitis. The optimal strategy for managing CBDM is yet to be determined.

METHODS

Data of 154 patients with CBDM were collected and divided into two groups: with endoscopic retrograde cholangiopancreatography (with ERCP, n = 82) and without ERCP (n = 72). Clinical outcomes, including the incidence of unfavorable outcomes (UOs), such as cholangitis and pancreatitis, were observed and compared between the two groups.

RESULTS

The incidence of UOs was significantly lower in the ERCP group than in the without ERCP group (3.7% vs. 23.6%, respectively, p < 0.001). Moreover, the total number of readmissions was also lower in the ERCP group than in the without ERCP group (p < 0.001). A multivariate analysis adjusted for age, sex, and the American Society of Anesthesiologists (ASA) class revealed that endoscopic sphincterotomy (EST) and cholecystectomy were associated with a lower risk of UOs.

CONCLUSION

The high rate of UOs in CBDM patients without ERCP suggests that its natural clinical course may not be as favorable as previously suggested. This finding implies that efforts should be made to clear the bile ducts.

Evaluating approaches to diagnosis and management of idiopathic acute pancreatitis

INTRODUCTION

Idiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence.

METHODS

Patients diagnosed with IAP from 2015-21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines.

RESULTS

A total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence.

CONCLUSION

Complete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.

Microbiome analysis of bile samples in patients with choledocholithiasis and hepatobiliary disorders

Introduction

The involvement of bacteria in the pathogenesis of biliary tract disease is largely unknown. In this study, we investigated the microbiota of the biliary tissue among adult patients with choledocholithiasis during endoscopic retrograde cholangiography (ERCP).

Methods

16S rDNA sequencing of bile samples, culture, and data of the medication history, underlying diseases, and liver function tests were used for the interpretation of differences in the composition of detected bacterial taxa.

Results

The four most common phyla in the bile samples included Proteobacteria, Firmicutes, Actinobacteria, and Bacteroidetes. Infection with anaerobic and microaerophilic bacteria showed host specificity, where Fusobacterium, Prevotella, Veillonella, Propionibacterium, Gemella, and Helicobacter coexist in the same patients. Clostridium and Peptoclostridium spp. were detected in 80% and 86% of the patients, where the highest relative abundance rates were detected in patients with elevated alkaline phosphatase (ALP) levels and leukocytosis, respectively. Higher diversity in the bacterial population was detected in patients with common bile duct (CBD) stone, in which the richness of an unclassified member of Alphaproteobacteria plus Helicobacter, Enterobacter/Cronobacter spp., Sphingomonas, Prevotella, Fusobacterium and Aeromonas were detected.

Conclusions

Our findings suggested correlations between the presence and relative abundance of several bacterial taxa and CBD stone formation and the effect of medication and underlying diseases on the bile microbial communities. A study on a higher number of bile samples from patients compared with the control group could reveal the role of these bacteria in the pathogenesis of biliary tract disease.

Treatment of asymptomatic gallstones in children with hereditary spherocytosis requiring splenectomy

BACKGROUND

Gallstones are common in hereditary spherocytosis (HS) and other chronic hemolytic diseases, with most affected patients being asymptomatic. Whether and how asymptomatic gallstones should be treated is controversial.

METHODS

We conducted a retrospective cohort study of pediatric patients with HS and asymptomatic gallstones to compare the clinical outcomes between the observation group (followed up with gallstones in situ) and the intervention group (cholecystectomy or cholecystolithotomy). The primary outcome was the composite of adverse outcomes, including gallstone-associated, gallbladder surgery-associated, and splenectomy-associated events. Secondary outcomes included the changes in the size and number of gallstones and the recurrence of gallstones.

RESULTS

Fifty-two patients were included (38 in the observation group and 14 in the intervention group), with a mean follow-up length of 5.2 years. Patients in the intervention group had a lower incidence of primary outcomes (7.1% vs. 42.1%) than patients in the observation group (OR, 0.12; 95%CI, 0.01-0.99). Patients with gallstones >5 mm in diameter had the highest risk of adverse events (47.4%). In the observation group, gallstone growth, disappearance, and stability were observed in 19.4%, 29.0%, and 51.6% of splenectomized HS patients, respectively. Small gallstones (diameter ≤5 mm) or sludge were more likely to be associated with disappearance (P = 0.04).

CONCLUSIONS

Most asymptomatic gallstones grow or persist in splenectomized HS patients for an extended period. Surgical treatment of asymptomatic gallstones in HS patients requiring splenectomy is associated with a lower risk of adverse outcomes.

LEVELS OF EVIDENCE

III (retrospective comparative study).

Postpartum Idiopathic Pancreatitis Complicated by Acute Necrotizing Pancreatitis

Acute pancreatitis (AP) is a common medical condition with a wide variety of etiologies. One of the common but frequently undetected causes of acute pancreatitis is microlithiasis, which can appear as biliary "sludge" in the gallbladder on imaging. While a broad workup should be initiated, endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the diagnosis of microlithiasis. In this case, we present a severe presentation of acute pancreatitis in a teenager within the postpartum period. A 19-year-old woman presented with severe 10 out of 10 right upper quadrant (RUQ) pain with episodes of nausea that radiated to her back. She had no history of chronic alcoholism, illicit drug use, or over-the-counter supplement use, and no familial history of autoimmune disease, or pancreatitis. The patient was diagnosed with necrotizing acute pancreatitis with gallbladder "sludge" using contrast-enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP). She followed up with gastroenterology and had a great clinical recovery. Therefore, it is important to consider acute pancreatitis in patients with idiopathic pancreatitis in their postpartum period as they are prone to forming gallbladder "sludge" which can precipitate and cause a variation in gallbladder pancreatitis which can be difficult to detect on imaging.

Does "Sludge" Require Cholecystectomy?

Biliary sludge is a subjective, ill-defined term. Surgery is often consulted for laparoscopic cholecystectomy, regarded as a low risk procedure.After IRB approval, a word search was used to identify "sludge" in all ultrasounds performed in 2016. The number of patients undergoing cholecystectomy, complications, pathologic findings, and risk factors were identified. Non-operative patients were evaluated for subsequent symptoms and studies or procedures related to biliary pathology.2769 patients underwent RUQ US; 253 patients were found to have sludge. Of 48 (19%) cholecystectomy patients, 9 had cholelithiasis. No deaths occurred in the cholecystectomy group. Two surgical complications occurred. Fifty (24.4%) of the 205 non-operative patients underwent subsequent US imaging: 44% residual sludge, 28% normal, 18% stones, and 10% other.Sludge may resolve 28% of the time. Repeat ultrasound is prudent before proceeding with cholecystectomy. If an abnormality is seen on repeat imaging and risk factors persist, cholecystectomy may be reasonable.