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Review Article

Biliary microlithiasis, sludge, crystals,


microcrystallization, and usefulness of
assessment of nucleation time
Vasitha Abeysuriya, Kemal I Deen and Navarathne MM Navarathne
Ragama, Sri Lanka

BACKGROUND: The process of microcrystallization, its sequel


and the assessment of nucleation time is ignored. This
systematic review aimed to highlight the importance of biliary
microlithiasis, sludge, and crystals, and their association with
gallstones, unexplained biliary pain, idiopathic pancreatitis,
and sphincter of Oddi dysfunction.
DATA SOURCES: Three reviewers performed a literature
search of the PubMed database. Key words used were "biliary
microlithiasis", "biliary sludge", "bile crystals", "cholesterol
crystallisation", "bile microscopy", "microcrystal formation
of bile", "cholesterol monohydrate crystals", "nucleation
time of cholesterol", "gallstone formation", "sphincter of
Oddi dysfunction" and "idiopathic pancreatitis". Additional
articles were sourced from references within the studies from
the PubMed search.

support. Bile microscopy is a useful method to detect


microcrystals and the assessment of nucleation time is a good
method of predicting the risk of cholesterol crystallisation.
(Hepatobiliary Pancreat Dis Int 2010; 9: 248-253)
KEY WORDS: biliary microlithiasis;
sludge;
crystals;
gallstones;
idiopathic pancreatitis;
sphincter of Oddi dysfunction

Introduction

he clinical value of biliary microscopy and the


related clinical significance of biliary microlithiasis,
microcrystals, and biliary sludge have been
neglected. Furthermore, it has been observed that the
demarcation of the definitions of biliary microlithiasis,
microcrystals, and biliary sludge is not clear in most
instances.
Microlithiasis refers to small gallstones. Biliary
sludge is an ultrasonographic diagnosis. Biliary crystals
are microscopic structures and include cholesterol
monohydrate and calcium bilirubinate crystals, as well
CONCLUSIONS: Biliary crystals are associated with gallstone
[1]
disease, idiopathic pancreatitis, sphincter of Oddi dysfunction, as clacium microspheroliths. These are known to
unexplained biliary pain, and post-cholecystectomy biliary have an association with the formation of gallstones,
pain. Pathways of cholesterol super-saturation, crystallisation, sphincter of Oddi dysfunction, unexplained biliary pain,
and gallstone formation have been described with scientific and idiopathic pancreatitis.[1, 2]
Rapid crystallisation of cholesterol in bile is a
key factor in cholesterol gallstone formation.[3-8]
The nucleation time and method of its assessment
Author Affiliations: Department of Clinical Anatomy (Abeysuriya V) is increasingly important in the understanding of
and Department of Surgery (Deen KI), Faculty of Medicine, University of the cholesterol nucleation process in cholesterol
Kelaniya, Ragama, Sri Lanka; Department of Gastroenterology, National
supersaturation, leading to cholesterol crystallization
Hospital of Sri Lanka, Colombo, Sri Lanka (Navarathne NMM)
and ultimately the formation of microlithiasis.[9-12] This
Corresponding Author: Dr. Vasitha Abeysuriya, MBBS, Lecturer/Surgical
Registrar, Department of Clinical Anatomy, Faculty of Medicine, University article aimed to systematically review the available
of Kelaniya, Ragama, Sri Lanka (Tel: 94-1-77-3528167; Email: vasitha76@ literature on biliary microlithiasis, sludge, and crystals
hotmail.com)
as well as the significance of biliary microscopy and
nucleation time and their clinical relevance.
2010, Hepatobiliary Pancreat Dis Int. All rights reserved.
RESULTS: We found that biliary microcrystals account for
almost all patients with gallstone disease, 7% to 79% with
idiopathic pancreatitis, 83% with unexplained biliary pain,
and 25% to 60% with altered biliary and pancreatic sphincter
function. Overall, the detection of biliary microcrystals in
gallstone disease has a sensitivity ranging from 55% to 87% and
a specificity of 100%. In idiopathic pancreatitis, the presence of
microcrystals ranges from 47% to 90%. A nucleation time less
than 10 days in hepatic bile or ultra-filtered gallbladder bile has
a specificity of 100% for cholesterol gallstone disease.

248 Hepatobiliary Pancreat Dis IntVol 9No 3 June 152010 www.hbpdint.com

Biliary microlithiasis, sludge and crystals

Data sources

contributes to gallstone formation in the extra-hepatic


biliary system, idiopathic pancreatitis, and sphincter of
Oddi dysfunction.[10, 13-18]
Biliary crystals are microscopic structures and
include cholesterol monohydrate and Ca bilirubinate
crystals, as well as Ca microspheroliths. Cholesterol
crystals may be either cholesterol monohydrate or nonhydrate.[1,4,9] Classically, cholesterol monohydrate crystals
are plates.[1,4,9] Crystal forms, filamentous, helical, arcs,
and tubular are known as non-hydrated cholesterol
crystals.[5,17-24] Data indicate that these atypical forms of
crystal morphology predominate in some patients with a
clinical diagnosis of acalculous gallbladder disease.[24-26]
Calcium bilirubinate is a major constituent of pigment
stones and consists of the calcium salts of unconjugated
bilirubin. Thus, calcium bilirubinate is the other
predominant constituent of biliary crystals, and appears
as black, brown, or light brown aggregates on light
microscopy.[5-7, 24, 27]
Biliary sludge is an ultrasonographic diagnosis
when there is echogenic material that layers in the
gallbladder and does not cast acoustic shadows; also it
is a mixture of particulate solids that have precipitated
from bile.[5, 16] Such sediment consists of cholesterol
crystals, calcium bilirubinate pigment, and other
calcium salts.[5, 21] According to the data, biliary sludge
is sediment composed of cholesterol monohydrate
crystals and bilirubin granules embedded in a matrix
of mucus gel.[5, 10, 16] Mucus hypersecretion and early
glandular metaplasia in the epithelium are observed in
gallbladders harboring sludge, indicating that in patients
with sludge, the gallbladder is abnormal, showing mucus
hypersecretion and glandular metaplasia.[5, 18, 21]

We performed a systematic review of the current evidence


on biliary microlithiasis, sludge, and crystals, and their
association with gallstones, unexplained biliary pain,
idiopathic pancreatitis, and sphincter of Oddi dysfunction.
Three qualified reviewers searched the PubMed
database to identify studies of biliary microlithiasis, bile
microscopy, and cholesterol nucleation time from 1983
to 2010. Within PubMed, the MeSH browser was used by
entering the key words: bile microscopy, microlithiasis,
biliary sludge, microcrystal formation of bile, cholesterol
monohydrate crystals, nucleation time of cholesterol,
gallstone formation, and idiopathic pancreatitis. Studies
were limited to those written in English. Agreement
among the investigators was essential for data inclusion
and few minor disagreements were resolved.
The abstracts of the studies found in the search were
analyzed to judge their relevance. Case reports, technical
reports, articles with insufficient clinical data, series
duplicating previously published data from the same
author or institution, and papers that did not contain
the data needed for this review were excluded. From
the references of the included papers, further relevant
articles that were not identified by the PubMed search,
were added to the review. Papers reporting the same
data were identified and those with the most detailed
information were selected.
The possibility of combining the results of the studies
was explored, but there were several obstacles. Lack of
prospective studies and randomization precluded a
formal meta-analysis. Moreover, a significant proportion
of the studies undertaken in the same institution did not
provide sufficient data even to attempt combination,
and those that provided such data were statistically
heterogeneous. Therefore, the results of the studies are
presented separately under different subheadings, since Detection, etiology, and clinical significance of
it was impossible to categorise the data into tables or biliary sludge
flow charts.
Sludge is usually detected by trans-abdominal ultra-sonography.[16, 21] Endoscopic ultrasonography is more sensitive
in the detection of biliary sludge.[10, 16, 21] Biliary sludge
Biliary microlithiasis, microcrystals, and
is associated with pregnancy, with rapid weight loss,
biliary sludge
particularly in the obese, and with critical illness involving
The term biliary microlithiasis denotes the presence of low or absent oral intake, use of total parenteral nutrition,
small stones in the gallbladder or biliary tree that is 3 or after gastric surgery. It is also associated with biliary
mm and is not imaged on conventional ultrasonography stones with common bile duct obstruction, with certain
or cholecystography.[4, 5, 10] The presence of biliary drugs such as ceftriaxone and octreotide, and with bone
crystals is not equivalent to microlithiasis but suggests marrow or solid organ transplantation.
The clinical course of biliary sludge varies. It often
that the bile is supersaturated with cholesterol and that
it has nucleated. Thus, the assumption is that if there disappears, particularly if the cause is removed. Other
are biliary crystals on microscopic examination, then cases wax and wane and some may eventually develop
there might be microliths.[10-12] Biliary microlithiasis gallstones. Complications caused by biliary sludge
Hepatobiliary Pancreat Dis IntVol 9No 3 June 152010 www.hbpdint.com 249

Hepatobiliary & Pancreatic Diseases International

include biliary colic, acute cholangitis, and acute


pancreatitis.[10, 16, 18, 22, 23]

Crystallization of cholesterol in bile and


gallstone formation
Cholesterol crystallization is the primary step in
the pathogenesis of cholesterol gallstone formation.
Although crystallization pathways have been studied
extensively in model bile, limited data are available
on crystallization pathways in human bile.[4, 24, 27]
Several pathways of cholesterol crystallization have
been described.[4, 17] Some studies have described five
crystallization pathways in model biles depending on
salt/lecithin ratio, bile salt hydrophobicity, temperature,
and total lipid concentration.[4, 27, 28]
It has been suggested that two putative pathways
of cholesterol nucleation in bile might involve
precipitation of classic plate-like cholesterol crystals
from multilamellar vesicles and nucleation of anhydrous
cholesterol occurring internally as a liquid core
within unilamellar vesicles, also known as internal
nucleation.[27, 28] Furthermore, recent data indicate that
solid cholesterol precipitates as crystal forms other than
plate-like structures.[4, 5, 12, 15]
The true micromolecular sequence of cholesterol
crystallization and stone formation has not been exactly
identified. According to studies, the proposed sequence
of events is that the cholesterol is carried out in mixed
micelles and vesicles.[4, 15, 28] The micelles are aggregates
of phospholipid, bile salts, and cholesterol, and the
vesicles are closed spherical bilayers of phospholipids
with associated cholesterol. In the micelles and vesicles,
polar groups such as hydroxyl and phosphate face
the aqueous solvent, whereas nonpolar, hydrophobic
groups are hidden inside. The vesicles have cholesterolrich areas that can, when they come into contact, form
cholesterol crystals. At higher cholesterol concentrations,
multilamellar vesicles of cholesterol crystals form on the
surfaces of these vesicles and grow within the mucin gel.
Cholesterol crystals are glued together by bile proteins
to make stones.[4, 5, 15, 17]

Bile nucleation time and assessment


Nucleation time is the terminal step in studies
examining bile lithogenicity. The number of days taken
for microscopic plate-like cholesterol monohydrate
crystals to appear in human bile has been referred to
as the crystal nucleation time. Most data agree that if
biliary microcrystals appear in less than 10 days, the

bile should be considered potentially lithogenic.[19, 29, 30]


Also, it has been shown that the nucleation time of
ultrafiltered bile has a specificity of 100% for cholesterol
stones.[11, 28] Also, in those with cholesterol stones,
nucleation time has been shown to be shorter in those
with multiple cholesterol stones than in those who have
a solitary stone.[6, 7, 28]
Most clinical studies have utilized duodenal bile
for microscopy for the simple reason that it is risky to
aspirate bile from the gallbladder and it is unethical
to operate on a patient for this purpose. Moreover,
surgeons do not prefer to aspirate bile from the
gallbladder for fear of a bile leak. The data suggest
that duodenal bile is less suitable for determination
of nucleation time because of contamination with
pancreatic enzymes, which may also contaminate
nasobiliary bile. Contamination of bile with pancreatic
enzymes is known to alter the nucleation time.
Therefore, the advocated approach of collecting bile for
assessment of nucleation time is either during bile duct
aspiration at surgery or by ERCP if possible.[14, 29, 31]
In 20 cases of biliary colic that had a normal oral
cholecystogram and ultrasound, 11 (55%) showed
microcrystals in the form of cholesterol monohydrate
crystals and/or calcium bilirubinate granules on
polarized light microscopy of the duodenal bile.[28]
Microcrystals were noted in gallbladder bile of all
cases of proven gallstones but not in the duodenal bile
samples from healthy subjects.[27, 28]
Another study, in which gallbladder bile was
collected by duodenal intubation or during surgery,
compared 16 patients who were free of stones with 17
patients with proven stones, and showed that none of
the 16 patients had cholesterol monohydrate crystals or
calcium bilirubinate granules compared with 13 of the
17 patients, who had cholesterol monohydrate crystals.
Only 2 of 4 patients with pigment stones in the study
had calcium bilirubinate granules.[14, 23]
Review of the data showed that according to a study
of 31 patients with idiopathic pancreatitis, 23 (74%) had
biliary sludge and microcrystals consisting of cholesterol
monohydrate and calcium bilirubinate microcrystals.
Also in the same study, biliary sludge was detected
only in 11 (47%) of these patients by trans-abdominal
ultrasonography.[26, 28]
According to a study of 72 patients to evaluate
the usefulness of microscopic examination of pure
bile directly collected from the biliary tract during
endoscopic retrograde cholangiopancreatogram without
hormonal stimulation, the presence of microcrystals
exhibited a sensitivity and specificity for cholelithiasis
recognition of 82.7% and 100%, respectively, with a

250 Hepatobiliary Pancreat Dis IntVol 9No 3 June 152010 www.hbpdint.com

Biliary microlithiasis, sludge and crystals

positive predictive value of 88%.[31]


According to the literature, the prevalence of biliary
microcrystals in patients with idiopathic pancreatitis
(75%) and gallstone pancreatitis (90%) is significantly
higher than in those with alcoholic pancreatitis (15%).[32]
In the identification of the etiology of gallstone
pancreatitis, the presence of microcrystals has a
sensitivity of 90%, specificity of 85%, positive predictive
value of 85.7%, and negative predictive value of 89.4%.
The overall accuracy is 87.5%.[32] Thus assessment of
bile microcrystals may provide a clue to the etiology
of idiopathic pancreatitis. Elaborating further, a study
revealed that cholesterol microcrystals help to identify
cholesterol gallstones (sensitivity, 87%; specificity, 97%;
positive predictive value, 97%), therefore the presence
of cholesterol crystals is significantly related to the
cholesterol content of gallstones.[33]

is a significant association between biliary microcrystals


and idiopathic pancreatitis.[21-28]
Although available data support an association of
biliary microcrystalization with post-cholecystectomy
biliary pain and sphincter of Oddi dysfunction, the
number of studies is small. However, cumulative data
indicate that biliary microcrystals are a causative factor
for post-cholecystectomy biliary pain and sphincter
of Oddi dysfunction.[18, 23, 29-36] Cholesterol crystals are
suggested to be able to cause a functional obstruction
at the sphincter of Oddi by inducing papillitis, papillary
spasm, or papillary stenosis.[23, 34, 35]
Disagreement in reports about the definition of
biliary sludge is minimal. According to some studies, the
definition of biliary microcrystals is based on both the
crystal morphology and morphometry but others consider
the definition based on only the crystal morphology, at
light and polarized microscopy. [1,4,9,16,17,21,27] There is
controversy over the sequence in pathways of cholesterol
microcrystal
and pigment stone formation. In general,
Clinical significance of microcrystals
most
studies
agree that cholesterol crystallization
Gallstone disease is a major health burden in the western
world with about 10% of the population affected, mainly pathways are dependent on salt/lecithin ratio, bile
by cholesterol stones.[5, 17, 18] According to the literature, salt hydrophobicity, temperature, and total lipid
biliary crystals are present in 95% of patients with concentration. The main drawback is that most of these
symptomatic gallstone disease.[5, 16-18] It has also been studies are undertaken in synthesized bile whereas
found that about 8% of individuals without gallstones studies of human bile are rare. Overall, all of the data
crystallization is the initial step in
harbor microliths.[11] It has been suggested that the agree that cholesterol[5-7,
gallstone formation. 27, 28] Even though the pathways
detection of cholesterol monohydrate crystals or calcium
of cholesterol crystallization are complex, the formation
bilirubinate granules in bile indicates either the presence
of gallstones from crystallized bile is well correlated and
of occult gallstones or biliary microlithiasis.[11-13] Biliary
the contributory factors of cholesterol supersaturation
microcrystals are present in the gallbladder or duodenal
and crystallization for stone formation have been agreed
bile in patients with detectable gallbladder calculi, in
upon.[6, 27, 37-39]
those with biliary sludge, and in a subset of patients
Since the majority of the data revealed that biliary
without gallstones.[14-16]
microcrystals are associated with gallstone formation,
It is also believed that in 25% to 60% of patients,
idiopathic pancreatitis, post-cholecystectomy biliary
biliary and pancreatic sphincter function might be
pain, and sphincter of Oddi dysfunction, microscopic
altered by mechanical irritation by microcrystals and
detection seems to be beneficial.[32, 40-42] The review
subsequent inflammation, which may enhance gallstone
shows that biliary microscopy for microcrystals
formation.[2, 11, 16, 20] Also, it is believed that microcrystals
is sensitive and specific for risk stratification of
are a chief contributory cause of unexplained biliary
microcrystal-associated disease conditions. Studies
pain in post-cholecystectomy patients. Smaller gallstones
have shown that microscopic examination of bile is
carry a higher risk of pancreatitis than larger ones and
more sensitive and specific than oral cholecystography
this supports the possible role of biliary microlithiasis in
or trans-abdominal ultrasonography in detection of
its etiology. The data reveal that between 7% and 79%
biliary sludge in patients with idiopathic pancreatitis,
of patients with "idiopathic pancreatitis" harbor biliary
unexplained
biliary pain, and acalculous gallbladder
microlithiasis.[2, 11, 16, 20]
disease.[4, 30, 32, 34, 40]
Universally there is no controversy over the
definition of nucleation time of bile. The value of bile
Discussion
nucleation time in predicting the risk of cholesterol
The review revealed that biliary microcrystals are a crystallization, which eventually leads to gallstone
causative factor for gallstone disease. Furthermore, there formation, has been well recognized. By definition,
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Hepatobiliary & Pancreatic Diseases International

phospholipids and bile acids on cholesterol nucleation time


and vesicular/micellar cholesterol in gallbladder bile of patients
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4 Portincasa P, van Erpecum KJ, Vanberge-Henegouwen GP.
Cholesterol crystallisation in bile. Gut 1997;41:138-141.
5 Johnston DE, Kaplan MM. Pathogenesis and treatment of
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partial characterization of mechanisms whereby infected bile
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2003;1632:48-54.
8 Gustafsson U, Sahlin S, Einarsson C. Biliary lipid composition
in patients with cholesterol and pigment gallstones and
gallstone-free subjects: deoxycholic acid does not contribute to
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9 Peled Y, Halpern Z, Baruch R, Goldman G, Gilat T. Cholesterol
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13 Ros E, Navarro S, Bru C, Garcia-Pugs A, Valderrama
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14 Petroni ML, Jazrawi RP, Ahmed HA, Finch PJ, Dormandy J,
Northfield TC. Cholesterol nucleation time measurement in
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15 Tudyka J, Kratzer W, Maier C, Mason R, Wechsler JG. The
Funding: None.
relation between biliary lipids, nucleation time, and number
Ethical approval: This study was approved by the Ethics Committee
of gallbladder stones after percutaneous gallbladder puncture.
of the Faculty of Medicine, University of Kelaniya, Ragama, Sri
Scand J Gastroenterol 1994;29:844-848.
Lanka.
Contributors: AV wrote the main body of the article under the 16 Lee SP, Nicholls JF, Park HZ. Biliary sludge as a cause of acute
pancreatitis. N Engl J Med 1992;326:589-593.
supervision of DKI. NNMM provided advice on medical aspects.
17 Sedaghat A, Grundy SM. Cholesterol crystals and the
AV is the guarantor.
formation of cholesterol gallstones. N Engl J Med 1980;302:
Competing interest: No benefits in any form have been received
1274-1277.
or will be received from a commercial party related directly or
18 Portincasa P, van de Meeberg P, van Erpecum KJ, Palasciano
indirectly to the subject of this article.
G, VanBerge-Henegouwen GP. An update on the pathogenesis
and treatment of cholesterol gallstones. Scand J Gastroenterol
Suppl 1997;223:60-69.
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