Acute and relapsing pancreatitis caused by bile pigment aggregates and diagnosed by biliary drainage

Over a three-year period 10 patients were observed with acute and relapsing pancreatitis for which no conventional cause could be identified. In all 10 patients the gallbladders visualized on oral cholecystography and no stones were identified by cholecystography or ultrasonography but biliary drainage revealed aggregates of bile pigment granules. In eight of the 10 patients, cholecystectomy was eventually performed, recommended on the basis of the abnormal findings on biliary drainage. None of the eight patients who underwent cholecystectomy and followed for up to two years have had further bouts of pancreatitis. It is proposed that: 1. aggregates of bile pigment granules in the passage from gallbladder to duodenum can cause acute and relapsing pancreatitis; 2. preoperative identification of such aggregates can only be made by biliary drainage; 3. aggregates of pigment granules and cholesterol crystals should be looked for in the bile of all patients with pancreatitis without a clearcut etiology and 4. in the absence of other overt causes, the presence of crystals and pigment granules in bile of patients with pancreatitis justifies therapeutic cholecystectomy with a realistic expectation that pancreatitis will not recur after this operation.