Biliary Microlithiasis
Patient A 'At Rest'

Fig. 1.1 :: Patient A 'At Rest'

Patient A 'Post Rotate'

Fig. 2.1 :: Patient A 'Post Rotate'

Patient B 'At Rest'

Fig. 1.2 :: Patient B 'At Rest'

Patient B 'Post Rotate'

Fig. 2.2 :: Patient B 'Post Rotate'

Patient C 'At Rest'

Fig. 1.3 :: Patient C 'At Rest'

Patient C 'Post Rotate'

Fig. 2.3 :: Patient C 'Post Rotate'

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Biliary Microlithiasis - Our Objective

We believe we detected Biliary Microlithiasis in the Gallbladder for the first time, using a simple unique Rapid Patient Rotation Ultrasound Protocol as part of a routine medical ultrasound.

Our objective is to attract medical research to validate this finding. 

Biliary microlithiasis is defined as particles aspirated at ERCP from the biliary system.  Biliary microlithiasis must be distinguished from  gallbladder microlithiasis defined as non shadowing gallbladder foci, < 2mm, seen on routine gallbladder ultrasound.

The Rapid Patient Rotation Ultrasound Technique visualizes dependent intraluminal gallbladder echogenic foci not previously recognized in the gallbladder.  Intraluminal gallbladder echogenic is a term to describe foci approximately .5 to 2 mm in size seen free falling in gallbladder bile at the end of a rapid patient rotation. We consider these foci seen in the gallbladder lumen to be biliary microlithiasis.  These foci are consistently detected in certain specific medical conditions of the gallbladder, pancreas and biliary system.  Current literature suggests biliary microlithiasis is a cause for pancreatitis. 

Dependent intraluminal gallbladder echogenic foci could obstruct in the cystic duct, pancreatic duct(s) and CBD ampulla.  They are consistently detected in the following medical conditions.

These foci associate with or could cause:

  1. RUQ pain of unknown etiology (with normal routine medical gallbladder ultrasound).
  2. Pancreatitis - idiopathic, with or without prior pain.  ERCP induced pancreatitis.
  3. Elevation of liver enzymes without a known etiology, with or without prior pain. 

Speculation foci could cause:

  1. Post Cholecystectomy “the same” RUQ pain.
  2. Cholangitis and CBD stones due to a partial prolonged foci obstruction in the CBD ampulla.
  3. Acute cholecystitis as they do associate with gallstones.
  4. Cause part of the intermittent pain when associating with gallstones.
  5. Acalculous Cholecystitis
  6. Primary Biliary Cirrhosis (which is often treated with URSO)

A small percentage of patients with foci were asymptomatic of biliary, gallbladder or pancreatic disease.  None were followed to determine if clinical conditions developed.

In this text, intraluminal gallbladder echogenic foci, are referred to as fociThis term describes 1 to 2 mm, non-shadowing, echogenic structures, free falling in gallbladder bile seen only when using a unique Rapid Patient Rotation Ultrasound TechniqueWe would like the ultimate term for these gallbladder foci to be HGD (Heavy Gallbladder Densities) in order to make a clear distinction between biliary microlithiasis (found only with ERCP aspirates) and gallbladder microlithiasis (<2 mm, nonshadowing gallstones seen on routine ultrasound).  Both structures are similar in size but we believe they may be very different in shape and texture.  We suspect biliary microlithiasis could be flat, lenticular or saucer shaped and are fragile.  Gallbladder microlithiasis are round and dense, therefore easier to see on routine ultrasound.

Intraluminal Gallbladder Echogenic Foci are depicted in each patient with two images, Fig. 1 and 2, as follows:

Figure 1   A normal routine gallbladder ultrasound image taken at rest with no abnormality seen in the lumen or against the gallbladder wall.

Figure 2   The same patient as Fig. 1 with immediate and instantaneous imaging after Rapid Patient Rotation showing intraluminal echogenic foci free falling in the bile.