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Biliary Sludge
- Cynthia W. Ko, MD; and
- Sum P. Lee, MD, PhD
- University of Washington; Seattle, WA 98195 (Ko) Veterans Affairs Puget Sound Health Care System; Seattle, WA 98108 (Lee)
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IN RESPONSE:
We thank the readers for their insightful and constructive comments on our review. Biliary sludge, or microlithiasis, is an evolving field and therefore generates different and controversial viewpoints. Dr. Baron raises the question of the appropriateness of endoscopic biliary sphincterotomy for patients with biliary sludge. We agree that sphincterotomy is useful as an alternative treatment in selected patients. It is a valid treatment option in patients with sludge and complications, including biliary colic and recurrent pancreatitis, who are not candidates for cholecystectomy. Just like asymptomatic gallstones, asymptomatic biliary sludge should not trigger an automatic response of surgical (or endoscopic) treatment. In addition, sphincterotomy itself is associated with a high risk for complications and should be used cautiously (1). Therefore, patients with biliary sludge who do not have symptoms or complications should not be subjected to the risks of sphincterotomy.
Dr. Dill asks about the appropriate use of endoscopic EUS in the diagnosis of biliary sludge. We agree that EUS is a promising technique for this indication. However, few studies of the relative diagnostic yield and cost of EUS in the management of upper abdominal pain and biliary sludge have been published. We believe that further studies of this technique are needed before it can be widely recommended for patients with undiagnosed abdominal pain or suspected biliary sludge. The use of ERCP in patients with recurrent acute pancreatitis is well accepted, and this procedure should remain in the diagnostic algorithm for patients with this problem. In addition to providing a means to collect bile for microscopy, it allows evaluation for anatomic abnormalities of the bile ducts or pancreas, such as pancreas divisum, which may lead to recurrent pancreatitis (2). It also allows for endoscopic therapy in appropriate candidates. Such therapy includes endoscopic sphincterotomy in patients with sludge who are not candidates for cholecystectomy (as mentioned by Dr. Baron), as well as dilatation of strictures and stenting of ruptured ducts.
Sum P. Lee, MD, PhD
Veterans Affairs Puget Sound Health Care System; Seattle, WA 98108
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
