Hepatobiliary and pancreatic: Limy bile

Abstract

What abnormalities are shown on the computed tomography (CT) scan in Figure 1? The major abnormality is calcification in the lumen of the gallbladder. Dense calcification in the fundus probably reflects the presence of a calcified gallstone but calcification has also been shown in gallbladder 'sludge'. Other CT images showed calcified 'sludge' in a mildly dilated bile duct. The patient was an 86-year-old man who was admitted to hospital with abdominal pain, fever and jaundice. Endoscopic retrograde cholangiography confirmed mild dilatation of the bile duct and there was a vague filling-defect in the left hepatic duct. Endoscopic sphincterotomy was performed and a milky amorphous material was extracted from the bile duct using a balloon catheter (Fig. 2). Thereafter, his symptoms resolved and he was referred for laparoscopic cholecystectomy.Limy bile is a term that is used to describe calcified biliary sludge. The original reports were based on plain abdominal radiographs but similar changes can be found on ultrasound studies and CT scans. Reasons for the presence of high concentrations of precipitated calcium salts remain unclear but predisposing factors may include prolonged fasting and narrowing or obstruction of the cystic duct. However, in relation to cystic duct obstruction, case reports have described the presence of limy bile in the bile duct and the spontaneous clearance of limy bile from the gallbladder. Almost all patients with limy bile have coexisting gallbladder stones and chronic cholecystitis. At surgery, limy bile within the gallbladder has a white or off-white appearance with a consistency that varies from milk curd to a pasty mass. In the patient described above, limy bile was present in both the gallbladder and bile duct. Whether the presence of limy bile increases the risk of complications such as cholecystitis and cholangitis remains unclear.