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Ultrasound Mis-Diagnosis of Biliary Sludge As a Gall Bladder Neoplasm-A Cae Report

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Ultrasound Mis-Diagnosis of Biliary Sludge As a Gall Bladder Neoplasm-A Cae Report ULTRASOUND MIS-DIAGNOSIS OF BILIARY SLUDGE AS A GALL BLADDER NEOPLASM-A CAE REPORT *O.U Ogbeide (MBBS, FMCR), *O Asemota (MBBS) *Department of Radiology University of Benin Teaching Hospital, Benin-City, Nigeria Correspondence: Dr Ogbeide Osesogie Usuale Department of Radiology University of Benin Teaching Hospital, Benin-City, Nigeria SUMMARY bilirubinate granules and cholesterol Background: Cholecystosonography crystals, glycoproteins, calcium is the Ultrasound examination of the carbonate or phosphate or palmitate. gall bladder and ducts. It has the These crystals determine the degree advantage of not using ionising of radio-opacity and thus was initially radiation, but may be operator termed “limy-bile” or biliary sound, or dependent. Thus misinterpretation of milk of calcium bile when seen on plain the images may sometimes occur abdominal radiographs.1-3 Biliary especially in the untrained hands. sludge is formed frequently under Case Report: A 24 year old male normal conditions, but either dissolves student was admitted into the medical or is cleared by the gall bladder and ward of the University of Benin only in about 15% of patients does it Teaching Hospital (UBTH) with persist to form cholesterol stones.3 symptoms of weakness, fever, nausea, The mechanism of formation of biliary pruritus, passage of yellowish urine, sludge is unknown but there is an jaundice of about 4 weeks. Initial association with biliary stasis ultrasound examination done by a secondary to prolonged fasting, private practitioner interpreted the parenteral nutrition, hyper- image findings as gall bladder tumor. alimentation, haemolysis, cystic duct Subsequently, the patient was referred obstruction, acute and chronic to the UBTH, Nigeria. cholecystitis.4-6 There the repeat scan done revealed The possibility of biliary sludge the diagnosis of biliary sludge. Patient being mis-diagnosed as gallbladder was treated appropriately. tumour and the value of abdominal Conclusion: By this report, the ultrasonography in differentiating one possibility of misinterpretation of from the other is the rational for this ultrasound images is documented, case. especially by untrained personnel is highlighted. Case Report KEY WORDS: Cholecystosonography, CK, a 24 year old male student Biliary sludge, Interpretation, Mis- was admitted into the Medical Ward of diagnosis. the University of Benin Teaching Hospital with symptoms of weakness, BACKGROUND fever, nausea, pruritus, passage of The term biliary sludge described yellowish urine, jaundice of about 4 bile stones which are in a gel form or weeks duration. There was no history thick bile that contains numerous of intravenous drug administration or crystals or micro-spheroliths of calcium blood transfusion or use of native concoctions. He had an abdominal below the right costal margin. It also ultrasound scan done in a private revealed normal hepatic parenchyma hospital prior to presentation, and was and dilated intrahepatic biliary radicles. told that he had gall bladder The left hepatic duct measured about carcinoma. He was then given a 8mm, common hepatic duct about referral for expert surgical 15mm and common bile duct was management at the University of Benin 23mm in size. The gall bladder was Teaching Hospital. enlarged showing normal wall On examination, he was pale, thickness and an intrinsic non- severely icteric, and afebrile. There shadowing echogenic homogenous was no evidence of pedal oedema or mass measuring about 11.4 x 5.6 x peripheral lymphadenopathy. The 6.7cm which changed position very liver, spleen and both kidneys were not slowly with changes in the patient’s palpable. The urinalysis showed position. (Figures 1&2) There was no excess of urobilinogen and traces of evidence of gallstones within the ketones. The serum bilirubin total was intrahepatic biliary radicles / cystic duct elevated (34.6mg/dl), the direct serum or common bile duct. The diagnosis bilirubin about 27mg/dl, serum urea was that of sludge within the gall (27mg/dl) as Alkaline phosphatase (67 bladder. iu) was also elevated. The provisional Subsequently, the patient had diagnosis was obstructive jaundice. cholecytectomy and histology The differentials were chronic confirmed chronic cholecystits. His cholecystitis and infective hepatitis. clinical condition improved and was Abdominal ultrasound discharged for out-patient follow-up. examination showed moderate hepatomegaly measuring about 3.1cm Figure 1: Sonogram of longitudinal section of the distended gall bladder showing an intrinsic non-shadowing echogenic homogenous ‘soft-tissue’ mass. Liver Gall bladder Figure 2: Sonogram of oblique section of the distended gall bladder showing non-shadowing echogenic homogenous soft tissue mass with a fluid- fluid level. Liver Fluid – fluid level Biliary sludge DISCUSSION Gallbladder sonography has become the dorminant method of Gall bladder disease rank among the 7-9 common causes of abdominal pain in examining the gallbladder. This is so because sonography is a convenient adults, while approximately 500,000 cholecystectomies are performed in and safe examination as it does not each year in America.7 The traditional use ionizing radiation, patient method of detecting gallbladder preparation or administration of drugs. disease had been cholecystography, More importantly, sonographic examination can be easily extended to which has since been replaced by gallbladder sonography.7-9 The include the biliary ducts and adjacent organs of the upper abdomen as done prevalence of gall bladder disease in 7-10 sickle cell disease has been stated to in this study. The sensitivity for be between 4-29%, in studies carried detecting echogenic bile was about 65.7% with a specificity of about out independently in Nigeria. 7-9 Gallstones is also a disorder very 96%. common in the female gender.10-12 Although the diagnosis of an Gallstones are conveniently classified acute or chronic cholecystitis and into cholesterol or pigment stones. gallstones can easily be made Cholesterol stones are the commonest clinically, radiological demonstration is type and encountered in industrialized required to adequately classify them. countries, whereas pigment stones are Gall bladder sludge occurs often in found more frequently in developing patients with prolonged fasting, long- countries.3 standing extra-hepatic cholestasis, various intrinsic disorders of the gall bladder, sickle-cell disease and other CONCLUSION causes of haemolysis. A 24 year old male who developed Ultrasonographically, the term biliary obstructive jaundice secondary to sludge describes a collection of fine biliary sludge earlier mis-diagnosed as echoes of a lower intensity than those carcinoma is presented. The need for produced by a gallstone. These proper training in ultrasonography to echoes do not cast an acoustic minimize such errors recurring is shadow as seen in this patient and highlighted. they lie in the most dependent part of the gall bladder. The possibility of REFERENCES artefacts in particular those due to 1. Filly RA, Allen B, Minton MJ, reverberations have to be carefully Bernohoft R, Way LW.: In-vitro excluded. 2 investigation of the origin of Biliary sludge may become very echoes within biliary sludge. J thick and simulate a gall bladder Clin Ultrasound 1980: 8:193. tumor, termed “tumefactive biliary sludge”, which could mimic a gall 2. Calancy JT, Goddard J, bladder neoplasm,13-16 confusing the Pearson DC: In-vitro inexperienced sonographer as seen in demonstration of cholesterol this case.10 Biliary sludge moves crystals high echogenicity slowly when the patient changes relative to protein particles. J position and may show evidence of Clin Ultrasound 1980; 8:27. fluid-fluid levels especially in the dependent position. This was 3. Moreaux J, Roux JM. Limy bile. observed in this patient. This A surgical experience in 16 distinguishes it from small stones and patients. Gastrenterol Clin Biol. pus, although this sign is not 1994; 18: 550-555. completely reliable.4 Other causes of shadowing in the gall bladder on 4. Conrad MR, James JO, Dietahy ultrasonographically include pus 4, the J. Significance of low-level secretion of abnormal mucus 4, echoes within the gall bladder. haematobilia 5, parasites such as Am J Roentgen 1979; 132: 967. ascariasis and distomiasis. 6 The clinical course of biliary sludge 5. Baschi AJ, Norma A, 17 varies. It often disappears particularly Brenbridge AG, Cochrane JA: A if the causative event is treated. Other further observation on gall cases wax and wane, and some may bladder debris. J Clin go on to developing gall stones. ultrasound 1979: 7; 152. Complications of biliary sludge include biliary colic, acute cholangitis, and 6. Eisencher A, Sauget Y. Aspect acute pancreatitis. Asymptomatic ultrasonores des ascaridioses patients with biliary sludge require no et distomatoses des voices therapy. When patients are biliares. Am J Rad. 1980: 161: symptomatic as seen in this case 319. report, cholecystectomy is indicated. In the elderly or those at risk from 7. Wickbom IG, Rentzhog U. The surgery, endoscopic sphincterotomy reliability of cholecystography. can prevent recurrent episodes of Acta Radiol Diagn Stockh. pancreatitis. 1955; 44: 185-200. 8. Krook PM, Allen FH, Bush WH, 13. Fakhry J. Sonography of Maimer G, McLean MD. tumefactive biliary sludge. AJR Comparison of real time 1882; 139: 717-719. cholecystosonography and oral cholecystography. Arch Surg 14. Anastasi B, Sutherland GR. 1980; 115: 1096-1098. Biliary sludge- Ultrasonic appearance simulating 9.
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