Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Sludge
is a common term that is applied to an abnormality of bile that is seen with ultrasonography of the gallbladder. Specifically, the bile within the gallbladder is seen to be of two different densities with the denser bile on the bottom. The bile is denser because it contains microscopic particles, usually cholesterol or pigment, embedded in mucus. (The mucus is secreted by the gallbladder.) Over time, sludge may remain in the gallbladder, it may disappear and not return, or it may come and go. As discussed previously, these particles may be precursors of gallstones, and they occur often in some situations in which gallstones frequently appear, for example, rapid weight loss, pregnancy, and prolonged fasting.
Nevertheless, it appears that sludge goes on to become gallstones in only a minority of individuals. Just to make matters more difficult, it is not clear how often
- if at all - sludge alone causes problems. Sludge has been blamed for many of the same symptoms as gallstones-biliary colic, cholecystitis, and pancreatitis, but often these symptoms and complications are caused by very small gallstones that are missed by ultrasonography. Moreover, it is possible that these gallstone-like symptoms and complications are actually caused by small gallstones that have passed through the
bile ducts and into the intestine rather than the sludge itself. Thus, there is uncertainty about the
significance of sludge.
It is clear, however, that sludge is not the equivalent of gallstones. The practical implication of this uncertainty is that unless an individual's symptoms are typical of gallstones, sludge should not be considered
as the cause of the symptoms.
How are gallstones diagnosed?
Gallstones are diagnosed in one of two situations.
The first is when there are symptoms or signs that suggest the presence
of gallstones, and the diagnosis of gallstones is being pursued.
The second is coincidentally while a non-gallstone-related medical problem is being evaluated.
Ultrasonography is the most important means of diagnosing gallstones. Standard computerized tomography (CT or CAT scan) and
magnetic resonance imaging (MRI) may occasionally demonstrate gallstones; however, they are
not as useful compared to ultrasonography.
Ultrasonography
Ultrasonography is a radiological technique that uses high-frequency sound waves to produce images of the organs and structures of the body. The sound waves are emitted from a device called a transducer and are sent through the body's tissues. The sound waves are reflected by the surfaces and interiors of internal organs and structures as "echoes." These echoes return to the transducer and are transmitted electrically onto a viewing monitor.
On the monitor, the outline of organs and structures can be determined as well as their consistency, for example, liquid or solid.
There are two types of ultrasonography that can be used for diagnosing gallstones,
1) transabdominal ultrasonography and 2) endoscopic ultrasonography.
Transabdominal ultrasonography
For transabdominal ultrasonography, the transducer is placed directly on the skin of the abdomen. The sound waves travel through the skin and then into the abdominal organs. Transabdominal ultrasonography is painless, inexpensive, and without risk to the patient. In addition to identifying 97% of gallstones in the gallbladder, abdominal ultrasonography can identify many other abnormalities related to gallstones. It can identify:
the thickened wall of the gallbladder when there is
cholecystitis,
enlarged gallbladder and bile duct due to obstruction by gallstones,
pancreatitis, and
sludge.
Transabdominal ultrasonography also may identify diseases not related to gallstones that may be the cause of the patient's problem, for example, appendicitis. The limitations of transabdominal ultrasonography are that it can only identify gallstones larger than 4-5 millimeters in size, and it is poor at identifying gallstones in
the bile ducts.
Endoscopic ultrasonography (EUS)
For
endoscopic ultrasonography, a long flexible tube - the endoscope - is swallowed by
the patient after he or she has been sedated with intravenous medication. The tip of the endoscope is fitted with an ultrasound transducer. The transducer is advanced into the duodenum where ultrasonographic images are obtained.
Endoscopic ultrasonography can identify gallstones and the same abnormalities as
transabdominal ultrasonography; however, since the transducer is much closer to the structures of interest - the gallbladder, bile ducts, and pancreas - better images are obtained than with transabdominal ultrasonography. Thus, it is possible to visualize smaller gallstones with endoscopic than transabdominal ultrasonography.
EUS also is better in identifying gallstones in the common bile duct.
Although endoscopic ultrasonography is in many ways better than transabdominal ultrasonography, it is expensive, not available everywhere, and carries
a small risk of complications such as those associated with the use of intravenous sedation, and intestinal perforation by the endoscope. Fortunately, transabdominal ultrasonography usually gives
most of the information that is necessary, and endoscopic ultrasonography
needed only infrequently. Endoscopic ultrasonography also is a better way than transabdominal ultrasound to evaluate the pancreas.
Magnetic resonance cholangio-pancreatography (MRCP)
Magnetic resonance cholangio-pancreatography or MRCP is a relatively new modification of magnetic resonance imaging (MRI) that allows the bile and pancreatic ducts to be examined.
For MRCP, the patient is placed in a strong magnetic field that aligns (magnetizes) the protons in the molecules of water in the tissues. (Protons are parts of the atoms that make up water molecules. All tissues
in the body contain water though they contain different amounts of water.)
Energy-carrying radio waves are passed through the tissues, and the energy is absorbed by the water's protons.
The radio waves are turned off, and the protons release the energy they
had absorbed.
The released energy is used to form an image of the tissues and organs of the body.
The MRI separates tissues and organs based on their concentration of water. Since different tissues contain different amounts of water, MRCP is very good at providing images of organs and tissues.
Since bile is mostly water, MRCP gives an excellent image of bile within the gallbladder and bile ducts. The pancreatic duct, which, like the bile ducts, is filled with a watery fluid, also is seen
well.
Thus, the procedure is called cholangio- (referring to the bile ducts) pancreatography (referring to the pancreatic duct).
MRCP has in many instances replaced other procedures such as cholescintigraphy (HIDA scan) and endoscopic retrograde cholangiopancreatography (ERCP). It can identify gallstones in the bile ducts, obstruction of the ducts, and bile leaks. There are no risks to the patient with MRCP.
Cholescintigraphy (HIDA scan)
Cholescintigraphy is a procedure done by nuclear medicine physicians. It
also is is referred to as a HIDA scan or a gallbladder scan.
For a HIDA scan, a radioactive chemical is injected intravenously into the patient.
The radioactive chemical is removed from the blood by the liver and secreted into the bile.
The chemical then disperses everywhere that the bile goes-into the bile ducts, the gallbladder, the intestine, and any place else that bile goes.
A camera that senses radioactivity (like a
Geiger counter) is then placed over the patient's abdomen and a "picture" of the liver, bile ducts, and gallbladder is obtained which corresponds to where the radioactive chemical has traveled within, or outside of the bile-filled bile ducts, and gallbladder.
HIDA scans are used to identify obstruction of the bile ducts, for example, by a gallstone. They also may identify bile leaks and fistulas. There are no risks to the patient with HIDA scans.
Cholescintigraphy is also used to study the emptying of the gallbladder. Some patients with gallstones have had
gallbladder inflammation due to recognized or unrecognized episodes of cholecystitis. (There also are uncommon, non-gallstone-related causes of inflammation of the gallbladder.) The inflammation can result in scarring of the gallbladder's wall and muscle, which reduces the ability of the gallbladder to contract. As a result, the gallbladder does not empty normally. During cholescintigraphy, a synthetic hormone related to
cholecystokinin (the hormone the body produces and releases during a meal to cause the gallbladder to contract) can be injected intravenously to cause the gallbladder to contract and squeeze out its bile and radioactivity into the intestine. If the gallbladder does not empty the bile and radioactivity normally, it is assumed that the gallbladder is diseased as a result of gallstones or non-gallstone related inflammation.
The problem with interpreting a gallbladder emptying study is that many people with normal gallbladders have abnormal emptying of the gallbladder. Therefore, it is hazardous to base a diagnosis of a diseased gallbladder on abnormal gallbladder emptying alone.
ERCP is a combined
endoscope and X-ray procedure performed to examine the duodenum (the first portion of the small intestine), the papilla of Vater (a small nipple-like structure where the common bile and pancreatic ducts enter the duodenum), the bile ducts, the gallbladder and the pancreatic duct.
The procedure is performed by using a long, flexible, side viewing instrument (a duodenoscope, a type of endoscope) about the diameter of a fountain pen. The duodenoscope is flexible and can be directed and moved around the many bends of the stomach and intestine. The video-endoscope, the most common type of duodenoscope, uses a thin wire with a chip at the tip of the instrument to transmit video images to a TV screen.
First the patient is sedated with intravenous drugs.
The duodenoscope is inserted through the mouth, to the back of the throat, down the food pipe (esophagus), through the stomach and into the first portion of the small intestine (duodenum).
Once the papilla of Vater is identified, a small plastic catheter (cannula) is passed through a channel in the duodenoscope into the papilla of Vater, and into the bile ducts and the pancreatic duct.
Contrast material (dye) is injected, and x-rays are taken of the bile ducts, gallbladder and/or the pancreatic duct.
ERCP can identify 1) gallstones in the gallbladder (though it is not particularly good at this) and 2) blockage of the bile ducts, for example, by gallstones, and 3) bile leaks. ERCP also may identify diseases not related to gallstones that may be the cause of the patient's problem, for example, pancreatitis or pancreatic cancer.
An important advantage of ERCP is that instruments can be passed through the same channel as the cannula used to inject the dye to extract gallstones stuck in the common and hepatic ducts. This can save the patient from having an operation. ERCP has several risks associated with it, including the drugs used for sedation, perforation of the duodenum by the duodenoscope, and pancreatitis (due to damage to the pancreas). If gallstones are extracted, bleeding also may occur.
Liver and pancreatic blood tests
When the liver or pancreas becomes inflamed or their ducts become obstructed, the cells of the liver and pancreas release some of their enzymes into the blood. The most commonly-measured liver enzymes in blood are
aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The most commonly-measured pancreatic enzymes in blood are amylase and lipase. Many medical conditions that affect the liver or pancreas cause these
blood tests to become abnormal, so
their abnormalities cannot be used to diagnose gallstones. Nevertheless, abnormalities
of these tests that suggest there is a problem with the liver, bile ducts, or pancreas, and gallstones are a common cause of such abnormal tests, particularly during sudden obstruction of the bile or pancreatic ducts. Thus, abnormal liver and pancreatic blood tests direct attention to the possibility that gallstones may be causing the acute problem.
Duodenal biliary drainage
Duodenal biliary drainage is a procedure that occasionally can be useful in diagnosing gallstones, however, it is not often used. As previously discussed, gallstones begin as microscopic particles of cholesterol or pigment that grow in size. It is clear that some people who develop biliary colic, cholecystitis, or pancreatitis have only these particles in their gallbladders, yet the particles are too small to obstruct the ducts. There are two potential explanations for how obstruction might occur in this situation. The first is that a small gallstone
initially caused an obstruction before passing through the bile ducts into the intestine. The second is that particles passing through the bile ducts can "irritate" the ducts, causing spasm of the muscle within the walls of the ducts (which obstructs the flow of bile) or inflammation of the duct that causes the wall of the duct to swell (and also obstructs the duct).
For duodenal drainage, a thin plastic or rubber tube with several holes at its tip is passed through a patient's anesthetized nostril, down the back of the throat, through the esophagus and stomach, and into the duodenum where the bile and pancreatic ducts enter the small intestine. This is done with the help of x-ray (fluoroscopy).
Once the tube is in place, a synthetic hormone related to cholecystokinin is injected intravenously. The hormone causes the gallbladder to contract and squeeze out its concentrated bile into the duodenum.
The bile is sucked through the tube in the duodenum and examined for the presence of cholesterol and pigment particles under a
microscope.
The risks to the patient of duodenal drainage are minimal. (There have been no reports of reactions to the synthetic hormone.) Nevertheless, duodenal drainage is uncomfortable.
A modification of duodenal drainage involves collection of bile through an endoscope at the time of an upper gastrointestinal endoscopy-either esophago-gastro-duodenoscopy (EGD) or ERCP.
Oral cholecystogram (OCG)
The oral
cholecystogram or OCG is a radiologic (X-ray) procedure for diagnosing
gallstones.
The patient takes iodine-containing tablets for one or two nights in a row and then has an
X-ray of
the abdomen.
The iodine is absorbed from the intestine, removed from the blood by the liver, and excreted into bile.
In the gallbladder, the iodine becomes concentrated along with the bile.
On the X-ray, the iodine, which is dense and stops X-rays, fills the gallbladder and outlines the gallstones which are not dense, and allow
X-rays to pass through them. The ducts cannot be seen on the x-ray because the iodine is not concentrated in the ducts.
The OCG is an excellent procedure for diagnosing gallstones; it finds 95% of them. The OCG has been replaced, however, by ultrasonography because ultrasonography is slightly better at diagnosing gallstones and can be done immediately without waiting one or two days for the iodine to be absorbed, excreted, and concentrated.
Unlike ultrasonography, the OCG also cannot give information about the presence of non-gallstone related diseases. As would be expected, ultrasonography sometimes finds gallstones that are missed by the OCG. Less frequently, the OCG finds gallstones that are missed by ultrasonography. For this reason, if there is a strong suspicion that gallstones are present but ultrasonography does not show them, it is reasonable to consider doing an OCG. An OCG should not be done in individuals who are allergic to iodine.
Intravenous cholangiogram (IVC)
The
intravenous cholangiogram or IVC is a radiologic (X-ray) procedure that is used primarily for looking at the larger intrahepatic and the extrahepatic bile ducts. It can be used to locate gallstones within these ducts.
An iodine-containing dye is injected intravenously into the blood. The dye is removed from blood by the liver and excreted into bile. Unlike the iodine used in the OCG, the iodine in the IVC is concentrated
sufficiently enough in the bile ducts to outline the ducts and gallstones within them. The IVC is rarely used because it has been replaced by MRI cholangiography and endoscopic ultrasound . Moreover, occasional serious reactions to the iodine-containing dye can occur, which rarely may result in the death of the patient.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Crohn's disease is a chronic inflammatory disease,
primarily involving the small and large intestine, but which can
affect other parts of the digestive system as well. Abdominal pain, diarrhea, vomiting, fever, and weight loss are
common symptoms.
Cirrhosis of the liver refers to a disease in which normal liver cells are replaced by scar tissue caused by alcohol and viral hepatitis B and C. This disease leads to abnormalities in the liver's ability to handle toxins and blood flow, causing internal bleeding, kidney failure, mental confusion, coma, body fluid accumulation, and frequent infections. Symptoms include yellowing of the skin, itching, and fatigue.
Liver disease can be cause by a variety of things including infection (hepatitis), diseases such as gallstones, high cholesterol or triglycerides, blood flow obstruction to the liver, and toxins (medications and chemicals). Symptoms of liver disease depends upon the cause; however, common symptoms may include nausea, vomiting, upper right abdominal pain, and jaundice. Treatment depends upon the cause of the liver disease.
Nausea is an uneasiness of the stomach that often precedes vomiting. Nausea and vomiting are not diseases, but they are symptoms of many conditions. The causes of vomiting differ according to age, and treatment depends upon the cause of nausea and vomiting.
Pancreatitis is a rare disease in which the pancreas becomes inflamed, occurring when digestive enzymes are activated and begin attacking the pancreas causing damage to the gland. There are two types of pancreatitis, acute and chronic. Most commonly caused by alcohol or gallstones, it can lead to bleeding in the gland, serious tissue damage, infection, and cysts. Enzymes and toxins may then enter the bloodstream and seriously injure organs, such as the heart, lungs, and kidney.
Jaundice is a yellowish staining of the skin and whites of the eyes (sclerae) with bilirubin, the pigment found in bile. Jaundice can be an indicator of liver or gallbladder disease, or it may result from the rupture of red blood cells (hemolysis).
Alcoholism is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law.
Stool color is generally brown. When stool color changes, often, an individual becomes concerned. The presence of the bilirubin in bile is generally responsible for stool color. Bilirubin concentration can vary bile color from light yellow to almost black in color. Changes in bilirubin can cause stool to turn green, gray, or clay-like in color. Intestinal bleeding may turn stool black, tarry, red, maroon, or smelly stool. Medication and food may also affect stool color.
Dyspepsia (indigestion) is a functional disease in which the gastrointestinal organs, primarily the stomach and first part of the small intestine, function abnormally. It is a chronic disease in which the symptoms fluctuate infrequency and intensity. Symptoms of dyspepsia include upper abdominal pain, belching, nausea, vomiting, abdominal bloating, early satiety, and abdominal distention (swelling). These symptoms are most often provoked by eating.
Pleurisy, an inflammation of the lining around the lungs, is associated with sharp chest pain upon breathing in. Cough, chest tenderness, and shortness of breath are other symptoms associated with pleurisy. Pleurisy pain can be managed with pain medication and by external splinting of the chest wall.
Cystic fibrosis is a disease of the mucus and sweat glands. Cystic fibrosis is an inherited disease. The outcome of the disease leaves the body malnourished, bulky and fouls smelling stools, vitamin insufficiency, gas, painful or swollen abdomen, infertility, susceptible to heat emergencies, and respiratory failure. There is no cure for cystic fibrosis, treatment of symptoms is used to manage the disease.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
Sickle cell anemia (sickle cell disease), a blood disease which shortens life expectancy, is cause by an inherited abnormal hemoglobin. Symptoms may include bacterial infections, painful swelling of the hands and feet, fever, leg ulcers, fatigue, anemia, eye damage, and lung and heart injury. Treatment for sickle cell anemia aims to manage and prevent the worst manifestations of the disease and focuses on therapies that block red blood cells from stacking together, which can lead to tissue and organ damage and pain.
The liver is the largest solid organ in the body, and is actually an gland. The liver has a wide variety of critical functions such as manufacturing proteins and metabolizing fats and carbohydrates. The liver also eliminates harmful biochemical waste products from the body (alcohol, drugs, toxins). The liver secretes bile that aids in digestion. Examples of diseases of the liver include cirrhosis, hepatitis, cancer, and fatty liver. Symptoms of liver disease include bleeding, easy bruising, edema, fatigue, and jaundice.
Pancreatic cysts are collections of fluid within the pancreas. Some are benign, malignant, or pseudocysts. There are two major types of pancreatic cysts, inflammatory cysts and non-inflammatory cysts. Non-inflammatory cysts include: serous cyst adenomas, mucinous cyst adenomas, intraductal papillary mucinous neoplasm (IPMN), and solid pseudopapillary tumor of the pancreas. Symptoms of pancreatic cysts include abdominal pain, jaundice, fever, chills, and sepsis. Treatment depends on the type of cyst, and patient health.
Nausea and vomiting are symptoms that may be caused by many conditions. Antiemetics are drugs that treat nausea and vomiting. Though some antiemetics for motion sickness and mild nausea are available over the counter (OTC), most require a medical evaluation and prescription.
Beta Thalassemia is the most familiar type of thalassemia. Thalassemia is not just one disease but rather a complex series of genetic (inherited) disorders all of which involve underproduction of hemoglobin.
Gallbladder cancer is a rare form of cancer with symptoms that include jaundice, abdominal pain, fever, nausea and vomiting, abdominal lumps, and bloating. Risk factors include being female and Native American. Treatment of gallbladder cancer depends upon the stage of the cancer, the type of gallbladder cancer, and whether the cancer can be removed by surgery.
Alpha thalassemia is a disorder in which the alpha globin protein is underproduced. There are two pairs of genes that carry the code for the alpha chains of hemoglobin. When one gene is impaired, that person is in a carrier state and suffers no medical problems. When four genes are impaired, the production of fetal and adult hemoglobin is prevented, resulting in hydrops fetalis and leading to death before birth.
Pregnancy planning is important to help prevent exposure of the mother and fetus to potentially harmful medications and substances during the early days, and throughout the pregnancy. Nutritional planning, prevention of birth defects, conditions such as high blood pressure, heart disease, diabetes, and kidney disease need careful monitoring. Gestational diabetes, preeclampsia, and pregnancy induced hypertension are conditions that may arise during pregnancy. Immunizations, inherited disorders, exercise, air travel, intercourse, and birth control are important factors to consider when planning a pregnancy.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
Asbestos exposure lung disease is divided into three main types, asbestosis (lung scarring caused by asbestos fibers), disease of the lining of the lung (pleural plaques, scarring, or fluid accumulation), and lung cancer. Mesothelioma is cancer of the lining of the lung caused by asbestos exposure. Cancers of the larynx, throat, kidney, esophagus, and gallbladder have been linked to asbestos exposure. Treatment is dependant upon the type of condition related to asbestos exposure.
Duodenal diverticula (extramural or intramural), or duodenal diverticulum, is a pouch that is attached to the first part of the small intestine (duodenum). The cause of extramural diverticula is not clear, however, it may be congenital. Complications caused by duodenal diverticulum include rupture, gallstones, or pancreatitis. Extramural duodenal diverticula has no symptoms. Treatment is generally surgery.
Choledochal cysts are cysts of the bile ducts. There are several different types of choledochal cysts. These cysts are congenital, however, their cause is not known. Symptoms of choledochal cysts in infants include an enlarged liver and jaundice. In older people, the cysts cause abdominal pain, jaundice, cholangitis, gallstones, and pancreatitis. Treatment for choledochal cysts is surgery.
Fast food consumption and lack of exercise are just a couple of causes of childhood obesity. Health effects of childhood obesity include type 2 diabetes, heart attack, stroke, high cholesterol, asthma, sleep apnea, gallstones, fatty liver disease, GERD, depression, and eating disorders.
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