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Case Presentation CC: Recurrent stomach torment HPI: 52 yo man 1 yr prior was conceded with pancreatitis epigastric torment emanating 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 prior outpt – ordinary labs, sono

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Case Presentation PMHx: hypertension, pancreatitis PSHx: none All: NKDA Meds: ACE-I FHx: (- ) SHx: Married. No tobacco. EtOH 2-3/wk PE: AF-VSS gentle epigastric tend Labs: Lipase > 1,000 NL-LFTs, Ca, Tri Radiology: Sono – no stones; CT – peripanc edema

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Cholelithiasis Ethanol Idiopathic Microlithiasis/muck Medications 6MP/azathioprine Hydrochlorothiazide Pentamadine Stavudine Hyperlipidemia ERCP Trauma Pancreas divisum Hereditary Hypercalcemia Viral contaminations Mumps, coxsackie End-organize renal illness Penetrating peptic ulcer Sphincter of Oddi Acute Pancreatitis Associated Conditions 80%

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Biliary Sludge Rajeev Jain, M.D.

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Biliary Sludge Definition Low-level echoes that layer in the needy part of the gallbladder w/o acoustic shadowing Microlithiasis (stones<3mm) Biliary sand or silt Pseudolithiasis Microcrystalline malady Conrad MR et al. Am J Roentgen 132:967-72;1979 Ko CW et al. Ann Intern Med 130:301-11;1999

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

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Biliary Sludge Pathogenesis Similar to gallstones Supersaturation Increased Chol:Bile proportion Nucleation elements Gallbladder dysmotility Sludge ��  Microlithiasis ��  Gallstones

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Idiopathic Nutrition/Weight related TPN, fasting, wt misfortune Pregnancy Chronic sickness AIDS Cirrhosis Sickle cell Acute ailment ICU Spinal string harm Surgery Transplantation Medications Ceftriaxone Cyclosporine Octreotide Biliary Sludge Associated Clinical Conditions Levy M. Gatrointest Endosc 55:286-93;2002

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Biliary Sludge Diagnosis Transabdominal ultrasound (TUS) Bile microscopy Duodenal desire after CCK implantation Endoscopic Nasogastric tube Endoscopic retrograde cholangiography (ERCP) Endoscopic ultrasound (EUS) Magnetic reverberation cholangiography (MRCP)

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Biliary Sludge Diagnosis Levy M. Gatrointest Endosc 55:286-93;2002

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Biliary Sludge Diagnosis - TUS

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Biliary Sludge Diagnosis - EUS

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Biliary Sludge Diagnosis - ERCP

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Biliary Sludge Clinical Presentation Asymptomatic Biliary agony Cholecystitis Cholangitis Pancreatitis

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

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

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Frequency of Microlithiasis in Idiopathic Acute Recurrent Pancreatitis Levy M. Gatrointest Endosc 55:286-93;2002

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

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Biliary Sludge Recurrent Acute Pancreatitis Jain R. Curr Treat Options Gastroenterol. 7(2):105-9;2004

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Case Presentation EUS: gallbladder slop Laparoscopic cholecystectomy 2 years without intense pancreatitis

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