Biliary sludge

Biliary sludge

Description, Causes and Risk Factors:

Biliary sludge is most commonly composed of cholesterol monohydrate crystals, calcium bilirubinate granules, or other calcium salts embedded in strands of gallbladder mucus. Proteins after extensive analysis, sludge contains a large proportion of undefined residue, protein-lipid complexes, and mucin. Calcium bilirubinate granules are almost invariably present, with bilirubin usually found in its unconjugated, least soluble form. The source of the unconjugated bilirubin is controversial. Bilirubin is excreted by the liver mainly in its diglucuronide form, but with small amounts of the monoglucuronide and unconjugated forms. The enzymes beta glucuronidase which deconjugates bilirubin may be important. Conditions in which activity of this enzymes is increased, such as chronic low grade biliary infection are associated with pigment gallstones. Beta glucuronidase has been also identified in uninfected bile, where it probably originates in the biliary epithelium. Non-enzymatic hydrolysis of bilirubin may occur.

Biliary sludge

The chemical composition of sludge varies with the specific clinic situation. In the general population, sludge is composed of calcium bilirubinate and cholesterol monohydrate crystals in different proportions. In patients on total parenteral nutrition, sludge consists primarily of calcium bilirubinate.

Sludge formation depends on the physical chemical interactions of all these constituents, abnormalities of gallbladder, mucosal function, and gallbladder dysmotility, together leading to precipitate formation. Gallstones are hypothesized to form from sludge is a necessary precursor to gallstones. For example, in patients followed after chemical gallstones dissolution, gallbladder sludge is usually seen ultrasonographically prior to stone recurrence. Thus, most investigators feel that the pathogenesis of sludge is similar to that of gallstones. However, controversy remains about the fact that sludge will resolve spontaneously is most and that gallstones form in only a small minority. This suggests to some that sludge is not a precursor to stones, and that the pathogenesis of the two entities differs. Nevertheless, it is difficult to imagine that stones could form from clear bile without intermediate formation of microprecipitates. How the microprecipitates aggregate and grow to form well-ordered, structured gallstones remains to be determined.

Biliary sludge has been reported to occur in many diverse clinical settings, including pregnancy, rapid weight loss, critical illness, prolonged fasting, and long-term administration of total parenteral nutrition. It has also been reported in patients receiving certain drugs after bone marrow transplant.

Epidemiological studies show a high prevalence of sludge in the peripartum period. The incidence of sludge is pregnancy is 26-31%, with stones forming in 2-5%.


Symptoms may include:

    Abdominal pain. Pain in the upper abdomen, particularly on the right side and experienced shortly after a meal, may be a symptom of biliary sludge.

  • Chest pain. Although pain related to a gallbladder problem is most typically reported in the abdomen, substernal (chest) pain, as well as right shoulder pain, may also be related to the gallbladder.

  • Nausea and vomiting — can be symptoms of a biliary sludge.

  • Changes in bowel movement. Stools with a clay-like appearance may also indicate a biliary sludge.


Clinically, sludge is most commonly diagnosed ultrasonographically. Other entities including blood, necrotic debris, multiple small gallstones, or pus can appear similar ultrasonographically. However, transabdominal ultrasonography is only about 55% sensitive for sludge and cannot define the chemical composition of the cholecystitis or acute pancreatitis.


Patients who do experience symptoms as a result of the buildup may be asked to consider a cholecystectomy, a surgical procedure in which the gallbladder is removed, to prevent the onset of more serious symptoms. For mild cases, your doctor may prescribe Urso™, which contains ursodeoxycholic acid. Ursodeoxycholic acid will help to break down the proteins present in your bile.

NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.


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