Gallbladder sludge is a pathological condition in which a suspension of cholesterol or other crystals is formed in the biliary system. Initially, it is asymptomatic, subsequently manifested by pain in the right hypochondrium and dyspepsia. It is diagnosed by ultrasound and dynamic scintigraphy of the biliary system, duodenal probing, ERCP and biochemical blood examination. Therapy involves the appointment of ursodeoxycholic acid, myotropic antispasmodics, choleretics, cholekinetics and herbal hepatoprotectors. When the biliary tract is obstructed, cholecystectomy is performed, and the bile ducts are booged.
Diagnosis of gallbladder sludge as an independent pathological condition became possible after the widespread introduction of ultrasound methods for examining the liver and biliary tract. The prevalence of the disorder in the population is 1.7-4%, in patients with diseases of the digestive tract — 7-8%, in patients with hepatobiliary pathology — 24.4-55%. The composition of the sludge includes cholesterol crystals, mucin, calcium bilirubinate and other pigments. The disease is most often detected in women over 55 years of age. Most gastroenterologists and hepatologists consider the presence of crystalline biliary suspension in a patient as a preclinical (pre-stone) form of gallstone disease.
Causes of gallbladder sludge
Gallbladder sludge is of polyethological origin, provoked by the same factors as cholelithiasis. A key role in the occurrence of the disease is played by a change in the chemical composition of bile and its stagnation in the biliary tract. In the development of pathology, there is a hereditary predisposition, the probability of gallbladder sludge formation in patients whose relatives suffer from cholelithiasis increases 2-4 times. Specialists in the field of gastroenterology and hepatology identify several groups of prerequisites that increase the risk of sludge in the biliary system:
- Dyskinesia of the biliary tract. With primary violations of the motility of the biliary tract, the evacuation of bile from the bladder and its outflow into the duodenum is disrupted. Biliary stasis is characteristic of dysfunction of the gallbladder, sphincter Oddi. The formation of sludge is noted in secondary dyskinesia caused by organic pathology.
- Obturation of the biliary tract. Sludge formation is accelerated when the patency of the biliary tract is impaired in patients with Oddi sphincter stenosis on the background of pancreatitis, tumors of the liver and head of the pancreas, traumatic injuries. In such cases, the change in the rheology of bile and the occurrence of sludge is usually aggravated by the symptoms of mechanical jaundice.
- Liver diseases. The formation of sludge is complicated by most liver diseases that occur with impaired bile formation and cholestasis, such as viral hepatitis, steatohepatitis, alcoholic cirrhosis of the liver. The disorder also develops in hepatic dysfunction caused by a graft-versus-host reaction after bone marrow transplantation.
- Eating disorders. Precipitation of cholesterol in the form of crystals accelerates with an increase in its concentration in bile in patients who consume a lot of food with cholesterol (meat, smoked meats, products with trans fats). Violation of the rheological properties of bile is observed in obesity, while its outflow slows down with rapid weight loss, fasting and low-calorie diets.
- Hormonal changes. The appearance of sludge in pregnant women and women suffering from hyperestrogenism is facilitated by an increase in the concentration of estrogens that increase the lithogenicity of bile. During pregnancy, the situation is aggravated by hyperprogesteronemia, which provokes stagnation of bile. The risk group also includes patients taking estrogen-progestogenic drugs and COCs.
- Taking some medications. A side effect in the form of sludge deposition is detected when taking cephalosporins, synthetic analogues of somatostatin and calcium preparations. With short-term courses of treatment, this effect is reversible, in many patients, normal bile characteristics are restored 2-3 weeks after the completion of pharmacotherapy.
The disorder can complicate the course of non-biliary pathology. Up to 8-16% of cases of the disease are diagnosed in patients suffering from sickle cell anemia. If the spinal cord is damaged above the 10th thoracic vertebra, the formation of sludge is caused by cholelithiasis hypokinesia. The starting point of gallbladder sludge formation is often surgical interventions on the gastrointestinal tract: gastric bypass surgery, gastrectomy. In the postoperative period, sludge is determined in 42% of patients.
The mechanism of formation of gallbladder sludge is based on the resulting imbalance between the content of lithogenic and anti-nucleating factors. At a high concentration of cholesterol, nucleation begins, precipitation of its crystals in bile. Subsequently, the precipitated particles aggregate into microliths, which increase in size, turning into gallstones. Accelerated deposition of cholesterol is facilitated by violations of bile secretion of functional or organic genesis. Depending on the causes of sludge formation, the composition of the biliary contents may include pigments, calcium and other components of bile.
According to the origin of the crystalline suspension, the disease is primary (essential) and secondary, associated with the action of established etiological factors. When systematizing variants of gallbladder sludge, the composition of crystals (with a predominance of cholesterol-mucin complex, calcium salts or bilirubin-containing pigments), the presence of cholelithiasis and contractile activity of the gallbladder are taken into account. To choose a therapeutic tactic, it is important to know the ultrasound form of the disease:
- Echo here. The initial stage of sludge formation. It is asymptomatic, it is detected accidentally during a routine examination of the patient. Requires dynamic observation.
- Gallbladder sludge clots. The classic variant of the disease with the presence of hyperechogenic formations on ultrasound. The appointment of active anti-lithogenic therapy is recommended.
- Special forms. Signs of microcholelithiasis, bile-bubble cholesterol polyps, the formation of putty-like bile are revealed. Surgical treatment may be indicated.
Gallbladder sludge symptoms
Often, the disease proceeds for a long time without obvious symptoms. The clinic is nonspecific and is caused by the underlying pathology, which led to the accumulation of cholesterol crystals in the ducts of the biliary tract. Most often, patients are concerned about pain on the right side of the hypochondrium associated with eating and radiating into the right shoulder blade. The intensity of the pain syndrome depends on the degree of damage to the biliary system. The pain becomes more severe with the migration of sludge and may remotely resemble a typical biliary colic. Dyspeptic symptoms are also observed: nausea and vomiting, bitterness in the mouth, abdominal discomfort after eating. Sometimes there is a change in the nature of the stool with a predominance of constipation. The general condition of patients with symptoms of gallbladder sludge is not disturbed.
Prolonged injury to the walls of the bile ducts by crystals and microliths leads to an inflammatory reaction — cholangitis. With bile-bubble stagnation of thick bile, chronic cholecystitis may occur. In the case of secondary infection, purulent cholangitis, empyema of the gallbladder develops. The most common complication of gallbladder sludge is the formation of large-sized concretions. The long course of the disease leads to scarring of the bile ducts, stenosing papillitis, which requires surgical intervention. When the pathological process spreads beyond the biliary system, duodenitis, cryptogenic pancreatitis occurs.
Diagnostics of gallbladder sludge
Diagnosis can be difficult because the clinic of gallbladder sludge is often combined with symptoms of another disease. Usually, the disorder complicates the course of other pathology of the biliary tract, which causes polymorphism and nonspecific manifestations. The diagnostic search is aimed at excluding other diseases with the help of a comprehensive examination of the hepatobiliary system. The most informative have:
- Ultrasound of the liver and gallbladder. Taking into account the type of sludge, sonographic examination may detect small hyperechoic inclusions without a clear shadow (microlithiasis), echoes in the gallbladder cavity or ducts. In rare cases, sonography allows you to determine cholesterol polyps.
- Retrograde cholangiopancreatography. With the help of ERCP with the introduction of a contrast agent, it is possible to identify the most frequent complications — stones in the choledochus, strictures of the sphincter of the Fater papilla and cicatricial changes in the bile ducts. Additionally, Oddi sphincter manometry is performed.
- Duodenal probing. The study with the receipt of several portions of bile is carried out to assess the contractile function of the sphincters, gallbladder, analysis of the composition of bile. With sugar, calcium salts, cholesterol crystals and bilirubin-containing pigments are found in large quantities.
- Dynamic scintigraphy of the hepatobiliary system. The radiological method is intended for a comprehensive assessment of bile formation and determination of motor-evacuation bile-bubble dysfunction. With sludge in most patients, the contractility of the organ is significantly reduced.
- Blood test. Pronounced laboratory changes are noted with the exacerbation of the process. It is characterized by an increase in the levels of alkaline phosphatase and cholesterol, a slight increase in total bilirubin due to the conjugated fraction and an increase in the concentration of hepatic transaminases (AST, ALT).
Leukocytosis and increased ESR in the general blood test indicates a complication of the disease. The coprogram reveals drops of neutral fat, an increased amount of bile acids. Additionally, the cholesterol index can be calculated, indicating an increase in the concentration of cholesterol in the cystic bile. To exclude possible oncological pathology, CT or MRI of the abdominal cavity is performed.
Gallbladder sludge treatment
Patients with newly identified signs of the disease without clinical symptoms are recommended dynamic monitoring and elimination of factors that provoked sludge formation — treatment of the underlying pathology, cancellation of lithogenic drugs and correction of diet. With the constant presence of ultrasound signs of pathological suspension, conservative anti-lithogenic therapy is prescribed for 3 months. The treatment regimen usually includes the following groups of drugs:
- Derivatives of ursodeoxycholic acid (UDCA). Belong to the category of basic drugs. The therapeutic effect is associated with inhibition of cholesterol synthesis in hepatocytes and improvement of rheological characteristics of bile. The binding of UDCA with cholesterol into liquid crystals contributes to the dissolution of the precipitates formed.
- Choleretics and cholekinetics. The lithogenicity of the biliary contents decreases with an increase in its composition of primary bile acids. Drugs that improve the excretion of bile, the contractility of the gallbladder, the motility of the biliary tract, contribute to a faster release of cholesterol into the lumen of the duodenum.
- Myotropic antispasmodics. Recommended for spastic dyskinesia of the biliary tract. Due to the effect on smooth muscle fibers, they simplify the emptying of the gallbladder and relax the sphincter of Oddi with its hypertonicity. Improvement of bile secretion reduces congestion and reduces the risk of precipitation of cholesterol crystals.
- Plant hepatoprotectors. The expediency of prescribing drugs is due to their complex effect on different links of sludge formation. Hepatoprotective agents have a choleretic and antispasmodic effect, by improving the function of hepatocytes, they reduce the cholesterol content in bile in steatosis and other biliary pathology.
For faster elimination of sludge, enterosorbents, lipase blockers and intestinal motility regulators are used, which complicate the absorption of cholesterol in the intestine. Surgical methods for the detection of biliary suspension are rarely used, mainly in the presence of therapeutically resistant spasm or stenosis of the sphincter of Oddi. In such cases, sphincteropapillotomy is performed to eliminate cholestasis. With the obturation of putty-like bile of the narrow places of the biliary tract, open or laparoscopic cholecystectomy, endoscopic bile duct augmentation can be performed.
Prognosis and prevention
The outcome of gallbladder sludge is determined by the degree of functional and organic changes in the bile ducts and gallbladder, the general condition of the patient, the presence of concomitant pathology. The prognosis is favorable with a known etiological factor, the elimination of which leads to a complete regression of symptoms. In other cases, there is a high risk of transformation of the disease into organic biliary pathology. To prevent sludge, it is necessary to reduce the amount of fatty and fried dishes in the diet, observe intervals between meals (no more than 3-4 hours), limit the intake of medications that can cause spasm of the Oddi sphincter. It is important to carry out timely diagnosis and treatment of diseases that lead to biliary stagnation.