[Obstructive jaundice du to sludge in the common bile duct]

A 21-year-old woman developed increasing jaundice with severe pruritus and weight loss after a bout of dyspepsia. She had been taking contraceptives for 4 years (ciproteronacetate 2 mg, ethinylestradiol 0.035 mg).

Laboratory tests at first suggested cholestatic hepatitis (serum bilirubin > 5 mg/dl, predominantly indirect bilirubin, SGOT 77 U/l, SGPT 154 U/l, gamma-GT 138 U/l, alcaline phosphatase 630 U/l). Ultrasonography showed a gall bladder filled with biliary sludge and dilatation of the common bile duct and the smaller biliary passages. A tumour-like space-occupying lesion was noted near the papilla: it was not fixed and had no vascular supply. Endoscopic retrograde cholangiopancreatography (ERCP) also demonstrated a mobile space-occupying lesion in the common bile duct near the papilla and markedly dilated biliary passages.

The tumour-like obstruction was removed by balloon catheter after papillotomy. It consisted of several jelly-like viscous streaky bile without calculi. The procedure was complicated by subsequent pancreatitis which, however, soon subsided. Within a few days the jaundice disappeared and the pruritus ceased. At the same time the liver functions returned to normal. Ultrasonography no longer showed obstructed biliary passages and sludge.

Obstructive jaundice may be due not only to strictures gall stones and benign or malignant tumours but also to thickened sludge in the biliary tract in women on oral contraceptives. The obstruction can be demonstrated by ERCP and removed by interventional procedures (i.e. endoscopic papillotomy).