A 73 year old man had two episodes of acute pancreatitis within 3 months (Amylase 800+, Bilirubin 37 umol/L, ALT 350, Alkaline Phosphatase 190). He had many co-mormidities including ischaemic heart disease, type 2 diabetes and saddle pulmonary embolus (9 months ago) for which he was taking Apixaban (a novel oral anticoagulant). An initial ultrasound scan showed a normal gallbladder and a 9mm common bile duct but no gall stones. A MRCP scan showed similar findings with a slightly dilated cBD but no ductal stones. He did not drink excess alcohol. After the second episode of pancreatitis, an endoscopic ultrasound scan was performed and this showed ?5mm stones in the proximal CBD and sludge. Hence an elective ERCP was performed (see video)…
A substantial number of patients with ‘idiopathic’ pancreatitis and unexplained biliary pain turn out to have small gallstones that are not detected by abdominal ultrasound or CT or MRCP. The term ‘biliary microlithiasis’ was coined to describe gallstones of less than 3 mm in diameter. In some of these patients, biliary sludge and/or gallstones can be detected by endoscopic ultrasound (EUS), with its high spatial resolution. Lasting relief is obtained in most patients after treatment with UDCA, cholecystectomy or sphincterotomy.