Transient Biliary Sludge in A Woman of 11 Weeks Gestation with Hyperemesis Gravidarum
Figure 1. Abdominal ultrasonography findings showed an enlarged and over-distended gallbladder of 6.25×3.91 cm, half of which showed the presence of low-level echogenic material without post-acoustic shadowing.
This is the second report of the appearance/disappearance of biliary sludge association with hyperemesis gravidarum (HG) and liver dysfunction. Matsubara et al. (2011) reported two cases of HG, jaundice (one case), liver dysfunction, and transient biliary sludge . Pregnancy itself has been reported to increase the incidence of biliary sludge. Pregnancy increases the cholesterol saturation of bile and the rate of secretion of cholesterol. Pregnancy also decreases gallbladder motility with a net result of increased bile precipitation. HG with dehydration caused viscous bile and increased precipitation of bile. Biliary sludge has been detected in up to a third of pregnant women but does not usually cause symptoms . It often vanishes, but sometimes progresses to gallstones . HG may further enhance the formation of sludge. Physical examination of women with hyperemesis gravidarum is usually unremarkable. Additional upper abdominal ultrasonography imaging studies to evaluate the pancreas and/or biliary trees may be warranted if the patient’s clinical presentation is atypical nausea and/or vomiting beginning after 9-10 weeks of gestation (as in this case). Both gallbladder stasis and stone/sludge formation can disappear after hydration and resumption of normal food intake, as in our and Matsubara’s case reports. Reinstitution of oral food intake releases the sphincter of Oddi and induces strong gallbladder contractions, which then pushes the biliary sludge into the duodenum. It is still unclear whether the presence of biliary sludge during pregnancy is a risk factorfor future gallstone formation.
In conclusion, HG with pregnancy-related physiologic changes might worsen the severity of hepatobiliary disease, such as cholecystitis. If a patient has HG with liver dysfunction and/ or jaundice, an ultrasound of the gallbladder should be performed. In the presence of biliary sludge without signs of biliary tract obstruction, further invasive examinations, such as ERCP or gallbladder drainage should be avoided. Complications caused by biliary sludge include biliary colic, acute cholangitis, and acute pancreatitis; therefore, close follow-up of the clinical course is mandatory.
5.Matsubara, S., Kamozawa, C. Tamada, K. Biliary sludge during hyperemesis gravidarum and later occurrence of gallstones. Journal of Obstetrics and Gynaecology Research. 2013, 39: 617..