© 2003 Indian Journal of Surgery www.indianjsurg.com Original Article The usefulness of microscopic bile examination in the evaluation of patients with upper abdominal pain K. Ramachandra Pai, Alfred J. Augustine, Rajeev Premnath P Department of General Surgery, Kasturba Medical College, Mangalore, India. ABSTRACT Background: Biliary microlithiasis is a collection of cholesterol and calcium bilirubinate crystals and is known to cause biliary colic, acute pancreatitis and acute cholecystitis. In some of these patients biliary microlithiasis has been found. Objectives: To estimate the incidence of biliary microlithiasis in patients with upper abdominal pain and negative imaging tests. Methods: A prospective analysis of bile was studied in 50 patients. A positive result was the identification of cholesterol crystals or calcium bilirubinate clumps. Results: In the 50 patients studied, 7 patients were found to have microlithiasis in bile. Conclusion: Microscopic examination of bile for biliary microlithiasis is a simple and safe technique and must be done in patients with upper abdominal pain who have normal blood tests, negative imaging tests and normal upper gastrointestinal endoscopy. Biliary microlithiasis is the probable cause of upper abdominal pain in some of these patients. KEY WORDS Biliary microlithiasis, Cholesterol crystals, Calcium bilirubinate clumps, Bile microscopy. How to cite this article: Pai KR, Augustine AJ, Premnath RP. The usefulness of microscopic bile examination in the evaluation of patients with upper abdominal pain. Indian J Surg 2004;66:28-30. INTRODUCTION MATERIAL AND METHODS Today we see patients who present with upper Fifty consecutive microscopic bile examinations were abdominal pain but with normal blood tests, negative performed between March 2001 and November 2002. imaging tests and a normal upper gastrointestinal The subject’s pain was located in the epigastric region endoscopy. In some of these patients biliary or right hypochondrium and occurred episodically with microlithiasis has been found which could be the cause. variable duration. There was no consistent pattern of Biliary sludge has been shown to play a prominent role pain related to meals or types of food. All patients in the pathogenesis of biliary colic, acute pancreatitis, underwent ultrasonography of the abdomen and an acute relapsing pancreatitis and cholecystitis for this upper gastrointestinal endoscopy. Bile was collected pain abdomen.1,2 from the second part of the duodenum for examination. Many investigators have been able to study gallbladder Technique of microscopic examination of bile 1,4 bile by various duodenal intubation methods and the The patients underwent a routine upper gastrointestinal finding of biliary sludge is being investigated. Debates endoscopy and with the scope at the second part of centre on its clinical significance: some believed that it the duodenum, bile was aspirated and collected using is a transient curiosity, and others believe that it is a a trap connected between the suction apparatus and precursor to gall stones. the endoscope. The bile drainage samples were taken Address for correspondence: Dr. Alfred J. Augustine, Department of Surgery, Kasturba Medical College Hospital, Attavar, Mangalore - 575001, India. E-mail: [email protected] Paper Received: April 2003. Paper Accepted: October 2003. Source of Support: Self. 28 Indian Jour nal of Surgery 2004 Volume 66 Issue 1 (Januar y-Febr uary) 28 CMYK © 2003 Indian Journal of Surgery www.indianjsurg.comBiliary microlithiasis for examination within 6 hours of collection. The bile samples were centrifuged at 2000 rpm for 10 minutes and the sediment was examined microscopically under high power direct microscopy for the presence of cholesterol crystals and bilirubinate clumps. Cholesterol crystals were recognized typically as thin, transparent square crystals with notched corners or as rhomboid plates. Bilirubinate granules were defined as granular precipitate or as reddish-brown clumps often grossly visible after centrifugation, ranging in colour from yellow through a brick red. A positive study was regarded as more than two crystals per 100X field or more than four crystals per sample as a positive test result. Micro-photographs Figure 3: Microphotograph of calcium bilirubinate clumps showing cholesterol monohydrate crystals and calcium (100 X) bilirubinate clumps are shown in Figures 1-3. RESULTS 50 patients were examined in this study between March 2001 and November 2002. All patients in the study gave a history of upper abdominal pain or dyspepsia or vomiting or a combination of these symptoms. Patients ranged from 9 years to 68 years. Mean age of the study group was 37.44 yrs. There were 36 male patients and 14 female patients in the study. The statistical analysis in the study was done using the Chi-square test. Of the 50 patients examined, 7 patients were found to have microlithiasis in bile. 3 patients had cholelithiasis on ultrasound examination with normal upper gastrointestinal endoscopy. 1 patient had Figure 1: Microphotograph of cholesterol monohydrate acute relapsing pancreatitis, gallbladder sludge on crystals (40 X) ultrasound examination and normal upper gastrointestinal endoscopy. 1 patient had normal ultrasound examination but antral gastritis on upper gastrointestinal endoscopy. 2 patients had normal upper gastrointestinal endoscopy and normal ultrasound examination. The findings of the study has been shown in Figure 4. DISCUSSION The study group consisted of 36 male and 14 female patients. Biliary microlithiasis was found in 4 males and 3 female subjects in the study. Delchier et al found that majority of patients in his study were males.3 Figure 2: Microphotograph of cholesterol monohydrate Microscopic bile examination in this study group crystals (100 X) showed biliary microlithiasis in 2 patients, which Indian Jour nal of Surgery 2004 Volume 66 Issue 1 (Januar y-Februar y) 29 CMYK29 Pai KR, et al A B C D CONCLUSIONS Biliary microlithiasis must be looked for in patients who present with upper abdominal pain with normal blood tests, negative imaging tests and normal upper gastrointestinal endoscopy. E Microscopic examination of bile for biliary microlithiasis is a simple and safe technique and can be done in any ABABCDEC D E medical laboratory without the need for expensive A, B, C, D = Patients with biliary microlithiasis = 7 additional equipment. Patients with symptomatic biliary E = Patients without biliary microlithiasis = 43 microlithiasis in whom no other cause for pain abdomen A Cholelithiasis 3 C Gall bladder sludge 1 B Antral gastritis 1 D Normal UGI & USG 2 has been found may be candidates for cholecystectomy. Figure 4: Pie-chart showing results of the study REFERENCES accounted for a rate of 14%. 1. KO CW, Sekijima JH, Lee SP. Biliary Sludge. Ann Intern Med 1999;130:4:301-11. 2. Lee SP, Nicholls JF. Nature and composition of biliary sludge. Gas- Morry Moskovitz et al found a rate of 9.5% in their troenter ology 1986;90:677-86. 4 study group of 189 patients over a 5year period. 3. Delchier JC, Benfredj P, Preaux AM, Metreau JM, Dhumeaux D. Juniper and Burson found a rate of 22% in their own The usefulness of microscopic bile examination in patients with series.5 Delchier et al found a rate of 33% in their study suspected microlithiasis: a prospective evaluation. Hepatology 1986;6:118-22. 3 of 46 patients. D. Houssin et al found a rate of 23% in 4. Moskovitz M, Min TC, Gavaler JS. The microscopic examination 731 patients.6 A Gogna et al found a rate of 55% of bile in patients with biliary pain and negative imaging tests. positive bile microscopy in 20 patients.7 Am J Gastroenterol 1986;81:329-33. 5. Juniper K Jr, Burson EN Jr. Biliary tract studies II: The significance of biliary crystals. Gastroenter ol. 1957;32:175-208. The accuracy of microscopic bile examination can 6. Houssin D, Castaing D, Lemoine J, Bismuth H. Microlithiasis of be improved by the use of Cholecystokinin. This was the gallbladder. Surg Gynaecol Obstet 1983;157:20-4. 7. Gogna A, Kar P, Acharya NR, Anand VJ, Kapoor R. Polarized light not used in this study due to its non-availabilty in microscopic examination of human bile in the diagnosis of micr o- India. lithiasis of the gallbladder. T rop Gastr oenterol 1989;10;167-72. 30 Indian Jour nal of Surgery 2004 Volume 66 Issue 1 (Januar y-Febr uary) 30 CMYK.