Biliary Microlithiasis

[ Speculation based on our limited findings require more investigation ]

Our experience suggests a fat free diet in some reduces and may resolve RUQ. Foci seem to resolve spontaneously in some. Perhaps it is because there is patient recognition that fat reduction improves symptoms.
We speculate the best medical therapy for these foci is a gallstone dissolving drug (URSO), with a trial of at least one month. It takes three weeks to become symptom free from RUQ pain, some sooner and others longer. We believe foci are not dissolved but URSO prevents their formation. Symptoms of RUQ pain may or may not recur after URSO therapy. We observed thirty patients with RUQ pain and/or elevated liver enzymes treated with URSO which cleared the clinical findings, showing no foci on repeat rotational ultrasounds. One other patient had no relief from RUQ pain with lengthy URSO therapy.

None of the patients with pancreatitis were treated with URSO but we believe URSO will be used to prevent recurrent pancreatitis and perhaps to prevent initial pancreatitis when foci are found fortuitously. URSO will resolve elevated liver enzymes of unkown etiology. URSO might be effective if used prior to ERCP to prevent pancreatitis.

We believe a gallstone dissolving drug such as URSO will likely be used in some way to treat the “same pain” post cholecystectomy, to prevent recurrent pancreatitis, RUQ pain and elevated liver enzymes of unknown etiology.

ERCP ampullary sphincterotomy should resolve elevated liver enzymes and prevent recurrent pancreatitis and relieve ampullary induced RUQ pain. RUQ pain could still occur from foci obstructions in the cystic duct. Does sphincterotomy always increase the luminal diameter allowing free egress of the foci?
We believe cholecystectomy is not appropriate as the primary treatment for biliary microlithiasis. Cholecystectomy does not prevent recurrent pancreatitis nor does it cure RUQ pain as there is often the “same pain” post cholecytectomy. These facts support our view that the formation of foci persists after cholecystectomy and that foci most likely form in the cystic duct within corrugated valves of Heister. If cholecystectomy is used to treat foci with or without gallstones, then we speculate that cystic duct ablation or removal will be necessary. This is recognized as technically difficult and URSO therapy may be required instead. If our assumption is right about these foci, a rapid rotation study should be done prior to cholecystectomy to detect foci with or without gallstones. It is our belief that all patients with idiopathic pancreatitis may require extensive and even life time URSO if the cystic duct is still present. We believe the main pancreatic duct placement in relation to the ampulla will be nearly the same for everyone with pancreatitis.

For simplicity and precise clarification, intraluminal gallbladder echogenic foci with rapid rotation, should be called Heavy Gallbladder Densities (HGD). This clarifies the difference between biliary microlithiasis (ERCP aspirates) and intraluminal gallbladder microlithiasis (<2 mm, nonshadowing gallstones).