Bile duct crystals do not contribute to sphincter of Oddi dysfunction

Microlithiasis has been proposed as a cause of both occult gallbladder disease and of idiopathic pancreatitis. Theoretically, microlithiasis could also cause postcholecystectomy pain by causing temporary biliary obstruction and may be more common in patients with sphincter of Oddi dysfunction. The frequency of crystals in bile duct aspirates was assessed from patients with symptoms after cholecystectomy with and without elevated baseline sphincter of Oddi pressures.

A prospective analysis was performed on all patients with recurrent biliary pain after cholecystectomy who presented for ERCP and manometry between January 1998 and June 2000. All patients had aspirates obtained from the common bile duct for crystal analysis by using the aspirating port of the manometry catheter before the injection of contrast. Four to 20 mL of bile was examined by microscopy for both cholesterol and bilirubinate crystals.

Sixty patients (83% women, mean age 44 years) were studied. Thirty-five had normal baseline biliary sphincter pressures and 25 elevated biliary baseline sphincter pressures (>40 mm Hg). Two patients in the normal pressure group and 1 in the elevated pressure group had cholesterol crystals present in their aspirate. No patient had bilirubinate crystals present. A 5% frequency of microlithiasis was identified overall.

Bile duct crystals occur infrequently in patients with symptoms after cholecystectomy and are found in patients with normal and abnormal biliary sphincter manometry. This study suggests that the presence of bile duct crystals, or microlithiasis, does not play a role in sphincter of Oddi dysfunction.