Milk of Calcium Bile

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 19/07/2015

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 Opacification of GB with high-density, radiopaque fluid

– Fluid-fluid level on upright film
image Rarely opacification of cystic duct or common bile duct (CBD)

– Exclamation sign: Coexisting milk of calcium bile and gallstones in CBD
– Occurs only in patients who also have milk of calcium bile in gallbladder
• CT: High-attenuation (> 150 HU) sediment
• MR: Low signal on T2WI and layers dependently

image Differentiate from gallstones which are discrete nodules with low T2WI signal
• Ultrasound

image Mixed echogenicity, layering material within GB which might cause acoustic shadowing
image Echogenicity slightly higher than typical sludge, but may be indistinguishable from sludge if no shadowing
image May have associated gallstones

TOP DIFFERENTIAL DIAGNOSES

• Vicarious excretion of contrast
• GB sludge
• Porcelain GB
• GB hemorrhage

PATHOLOGY

• Etiology: Chronic cystic duct obstruction with resultant biliary stasis

CLINICAL ISSUES

• Incidental finding which may be asymptomatic
• Most patients have symptoms of biliary colic 

image Symptoms may be due to either milk of calcium bile or concomitant gallstones
• Associated with complications similar to cholelithiasis

image Acute cholecystitis, pancreatitis, obstructive jaundice
• No treatment in asymptomatic patients
• Cholecystectomy only for symptomatic patients
image
(Left) Frontal radiograph demonstrates extensive milk of calcium bile filling the gallbladder (GB) image.

image
(Right) Specimen radiograph in the same patient after cholecystectomy demonstrates milk of calcium bile in both the GB image and cystic duct image.
image
(Left) Ultrasound shows diffuse low-level echo sludge image within the GB lumen with posterior acoustic shadowing image. Sludge and shadowing were not present on an ultrasound performed 6 months later.

image
(Right) Axial CECT shows high-density milk of calcium bile filling the GB lumen. The GB also demonstrates subtle wall calcification image and a gallstone image. There is a frequent association of gallstones and milk of calcium bile.

TERMINOLOGY

Synonyms

• Limy bile syndrome, calcium carbonate bile

Definitions

• High-density calcium carbonate precipitate within gallbladder (GB) lumen

IMAGING

General Features

• Best diagnostic clue

image High-density layering liquid/sediment within GB
• Location

image GB lumen

Radiographic Findings

• Radiography

image Opacification of GB with high-density, radiopaque fluid

– Fluid-fluid level on upright film
image 

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