Digestive Diseases and Sciences

, Volume 55, Issue 3, pp 836–841 | Cite as

Are the Echogenicities on Intraductal Ultrasonography Really Biliary Microlithiasis?

  • Beom Jin Kim
  • Pung Kang
  • Jong Kyun Lee
  • Dong Hyun Sinn
  • Kwang Hyuck Lee
  • Kyu Taek Lee
  • Jong Chul Rhee
  • Jae Hoon Lim
Original Article


Background Intraductal ultrasonography (IDUS) is a useful procedure for diagnosing microlithiasis in the bile duct but it is not easy to differentiate between tiny echogenicity and real microlithiasis. We compared the echogenicity seen on IDUS and the findings of bile microscopy (BM) of bile that was collected in the common bile duct (CBD) to determine whether the echogenicity seen on IDUS is real microlithiasis. Methods This prospective study involved a total of 30 patients who experienced biliary pain (n = 11), acute cholecystitis (n = 11) or indeterminate pancreatitis (n = 8) without a filling defect or obstruction in the bile duct. IDUS was performed during endoscopic retrograde cholangiopancreatography (ERCP), followed by bile aspiration for BM. Endoscopic sphincterotomy (EST) was performed if definite echogenic materials were observed on IDUS. Results Of the 30 patients, 23 (77%) had echogenic materials visible in the CBD on IDUS. Of these 23 patients, 13 (57%) were found to have biliary crystals by BM. The size of the echogenic materials was the only significant factor associated with BM positivity. Using the receiver operating curve, the optimal size of the echogenicity to differentiate real microlithiasis was 1.4 mm. Conclusions Optimal concordance between IDUS and BM was observed when the size of the microlithiasis was greater than 1.4 mm; under these conditions the sensitivity and specificity were 71% and 75%, respectively. This information may be useful when deciding whether to perform endoscopic sphincterotomy.


Microlithiasis Intraductal ultrasonography Bile microscopy Echogenicity 



Intraductal ultrasonography


Bile microscopy


Endoscopic retrograde cholangiopancreatography


Endoscopic sphincterotomy


Cholesterol monohydrate crystals


Calcium bilirubinate granules


  1. 1.
    Houssin D, Castaing D, Lemoine J, Bismuth H. Microlithiasis of the gallbladder. Surg Gynecol Obstet. 1983;157:20–24.PubMedGoogle Scholar
  2. 2.
    Sarva RP, Farivar S, Fromm H, Poller W. Study of the sensitivity and specificity of computerized tomography in the detection of calcified gallstones which appears radiolucent by conventional roentgenography. Gastrointest Radiol. 1981;6:165–167.CrossRefPubMedGoogle Scholar
  3. 3.
    Saraswat VA, Sharma BC, Agarwal DK, Kumar R, Negi TS, Tandon RK. Biliary microlithiasis in patients with idiopathic acute pancreatitis and unexplained biliary pain: response to therapy. J Gastroenterol Hepatol. 2004;19:1206–1211.CrossRefPubMedGoogle Scholar
  4. 4.
    Ko CW, Sekijima JH, Lee SP. Biliary sludge. Ann Intern Med. 1999;130:301–311.PubMedGoogle Scholar
  5. 5.
    Lee SP, Nicholls JF, Park HZ. Biliary sludge as a cause of acute pancreatitis. N Engl J Med. 1992;326:589–593.PubMedGoogle Scholar
  6. 6.
    Lee SP, Maher K, Nicholls JF. Origin and fate of biliary sludge. Gastroenterology. 1988;94:170–176.PubMedGoogle Scholar
  7. 7.
    Ohara N, Schaefer J. Clinical significance of biliary sludge. J Clin Gastroenterol. 1990;12:291–294.CrossRefPubMedGoogle Scholar
  8. 8.
    Takahashi T, Yamamura T, Utsunomiya J. Pathogenesis of acute cholecystitis after gastrectomy. Br J Surg. 1990;77:536–539.CrossRefPubMedGoogle Scholar
  9. 9.
    Zinberg J, Chernaik R, Coman E, Rosenblatt R, Brandt LJ. Reversible symptomatic biliary obstruction associated with ceftriaxone pseudolithiasis. Am J Gastroenterol. 1991;86:1251–1254.PubMedGoogle Scholar
  10. 10.
    Ros E, Navarro S, Bru C, Garcia-Puges A, Valderrama R. Occult microlithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology. 1991;101:1701–1709.PubMedGoogle Scholar
  11. 11.
    Tseng LJ, Jao YT, Mo LR, Lin RC. Over-the-wire US catheter probe as an adjunct to ERCP in the detection of choledocholithiasis. Gastrointest Endosc. 2001;54:720–723.CrossRefPubMedGoogle Scholar
  12. 12.
    Das A, Isenberg G, Wong RC, Sivak MV Jr, Chak A. Wire-guided intraductal US: an adjunct to ERCP in the management of bile duct stones. Gastrointest Endosc. 2001;54:31–36.CrossRefPubMedGoogle Scholar
  13. 13.
    Varadarajulu S, Eloubeidi MA, Wilcox CM. Prospective evaluation of indeterminate ERCP findings by intraductal ultrasound. J Gastroenterol Hepatol. 2007;22:2086–2092.CrossRefPubMedGoogle Scholar
  14. 14.
    Stavropoulos S, Larghi A, Verna E, Battezzati P, Stevens P. Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography. Endoscopy. 2005;37:715–721.CrossRefPubMedGoogle Scholar
  15. 15.
    Catanzaro A, Pfau P, Isenberg GA, Wong RC, Sivak MV Jr, Chak A. Clinical utility of intraductal US for evaluation of choledocholithiasis. Gastrointest Endosc. 2003;57:648–652.CrossRefPubMedGoogle Scholar
  16. 16.
    Palazzo L, Girollet PP, Salmeron M, et al. Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP. Gastrointest Endosc. 1995;42:225–231.CrossRefPubMedGoogle Scholar
  17. 17.
    Tamada K, Kanai N, Ueno N, et al. Limitations of intraductal ultrasonography in differentiating between bile duct cancer in stage T1 and stage T2: in vitro and in vivo studies. Endoscopy. 1997;29:721–725.CrossRefPubMedGoogle Scholar
  18. 18.
    Tamada K, Ueno N, Tomiyama T, et al. Characterization of biliary strictures using intraductal ultrasonography: comparison with percutaneous cholangioscopic biopsy. Gastrointest Endosc. 1998;47:341–349.CrossRefPubMedGoogle Scholar
  19. 19.
    Delchier JC, Benfredj P, Preaux AM, Metreau JM, Dhumeaux D. The usefulness of microscopic bile examination in patients with suspected microlithiasis: a prospective evaluation. Hepatology. 1986;6:118–122.CrossRefPubMedGoogle Scholar
  20. 20.
    Ramond MJ, Dumont M, Belghiti J, Erlinger S. Sensitivity and specificity of microscopic examination of gallbladder bile for gallstone recognition and identification. Gastroenterology. 1988;95:1339–1343.PubMedGoogle Scholar
  21. 21.
    Dahan P, Andant C, Levy P, et al. Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography. Gut. 1996;38:277–281.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Beom Jin Kim
    • 1
  • Pung Kang
    • 1
  • Jong Kyun Lee
    • 1
  • Dong Hyun Sinn
    • 1
  • Kwang Hyuck Lee
    • 1
  • Kyu Taek Lee
    • 1
  • Jong Chul Rhee
    • 1
  • Jae Hoon Lim
    • 2
  1. 1.Department of Medicine, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
  2. 2.Departments of Medicine and RadiologySungkyunkwan University School of MedicineSeoulKorea

Personalised recommendations