From the Guidelines
Biliary sludge should be managed by maintaining or resuming oral nutrition to prevent its formation, and cholecystectomy and/or endoscopic procedures should be performed in case of biliary complications. The management of biliary sludge is crucial to prevent its progression to gallstones and potential complications. According to the ESPEN practical guideline on clinical nutrition in chronic intestinal failure 1, maintaining or resuming oral nutrition is suggested for the prevention and treatment of gallbladder sludge. This approach is based on the fact that patients on parenteral nutrition (PN) are at risk of developing biliary sludge or cholelithiasis due to nil or negligible ingesta.
Key Considerations
- The use of narcotics or anticholinergics should be limited as much as possible to prevent gallbladder stasis and promote oral nutrition 1.
- Cholecystectomy and/or endoscopic procedures are recommended for the treatment of gallbladder sludge and stones in case of biliary complications, similar to the general population 1.
- Regular follow-up with ultrasound imaging is essential to monitor for progression to gallstones in patients managed conservatively.
- Dietary modifications, such as reduced fat intake and increased fiber consumption, may help in the management of biliary sludge.
- The ESPEN guideline also emphasizes the importance of addressing disease-related complications, including liver disease, gallbladder sludge and stones, renal disease, and bone disease, in patients with chronic intestinal failure 1.
From the Research
Definition and Composition of Biliary Sludge
- Biliary sludge is defined as a mixture of particulate matter and bile that occurs when solutes in bile precipitate 2
- It is composed of calcium bilirubinate and cholesterol monohydrate crystals, as well as other calcium salts 3, 2, 4
- Synonyms for biliary sludge include microlithiasis, biliary sand or sediment, pseudolithiasis, and microcrystalline disease 3
Diagnosis of Biliary Sludge
- Biliary sludge can be detected on transabdominal ultrasonography as low-level echoes that layer in the dependent portion of the gallbladder without acoustic shadowing 3
- Microscopy of aspirated bile and endoscopic ultrasonography are more sensitive methods for detecting biliary sludge 4
- Ultrasonography can be used to classify biliary sludge into different types, with different treatment approaches for each type 5
Clinical Significance and Complications of Biliary Sludge
- Biliary sludge can cause complications such as biliary colic, acute cholangitis, and acute pancreatitis 2, 4
- Asymptomatic patients with biliary sludge can be managed expectantly, while symptomatic patients may require cholecystectomy or other treatments 3, 2, 4
- Biliary sludge is associated with various risk factors, including pregnancy, rapid weight loss, and certain medications 2, 4
Treatment of Biliary Sludge
- Ursodeoxycholic acid (UDCA) can be used to treat biliary sludge, with daily doses of 600 mg divided into two postprandial times for a six-month period 6
- UDCA has been shown to be effective in dissolving gallstones and biliary sludge, with minor adverse effects such as acidism and diarrhea 6
- The duration of treatment with UDCA depends on the type of biliary sludge, with type 1 requiring a minimum of 1 month, type 2 requiring at least 3 months, and type 3 requiring 6-12 months or more 5