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Milk of Calcium in the Common Bile Duct: CT Identification

Winthrop-University Hospital Mineola, NY 11051

A 71-year-old woman with a history of hepatitis A and gallstones presented after experiencing symptoms of abdominal discomfort for 2 days. She had right-sided abdominal pain that radiated to the back, as well as nausea, anorexia, and elevated bilirubin levels. Abdominal sonography revealed gallstones and a common bile duct measuring 11 mm, but no evidence of cholecystitis; the distal common bile duct could not be visualized. In an attempt to discover the cause of the patient's abdominal pain, we performed abdominal CT with both orally and IV-administered contrast material (Figs. 4A and 4B). CT revealed calcium—fluid levels in the gallbladder as well as in the dilated distal common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed. Scout radiographs and the initial abdominal radiographs obtained in the emergency department revealed hyperdense material in the gallbladder, but no definite evidence of radiopaque material in the common bile duct. When contrast material was injected into the common bile duct, the duct was filled distally with a cast of material (Fig. 4C), correlating with the milk of calcium identified on CT, and a focal stone was also seen proximal to the milk of calcium. During the ERCP, some of the milk of calcium extruded from the ampulla and was seen by the endoscopist as a whitish discharge. At ERCP, the patient then underwent sphincterotomy and balloon-sweeping of the common bile duct.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —71-year-old woman with 2-day history of right-sided abdominal pain. Milk-of-calcium bile was found in gallbladder and common bile duct. CT scans of abdomen with oral and IV contrast material show calcium—fluid levels in gallbladder (large arrows) and common bile duct (small arrow). Attentuation of calcium was approximately 500 H in both locations.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —71-year-old woman with 2-day history of right-sided abdominal pain. Milk-of-calcium bile was found in gallbladder and common bile duct. CT scans of abdomen with oral and IV contrast material show calcium—fluid levels in gallbladder (large arrows) and common bile duct (small arrow). Attentuation of calcium was approximately 500 H in both locations.

View larger version (79K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C. —71-year-old woman with 2-day history of right-sided abdominal pain. Milk-of-calcium bile was found in gallbladder and common bile duct. Spot image from endoscopic retrograde cholangiopancreatography shows cast (long arrows) from milk of calcium in common bile duct in addition to more proximally located focal stone (short arrow).

The patient had a minor episode of bleeding from the ampulla that was diagnosed during a second endoscopy, but the bleeding spontaneously resolved. The patient's hemoglobin and hematocrit levels remained stable, and she was subsequently discharged several days later in stable condition with no residual symptoms.

In 1911, Churchman first described the findings of a white substance in the gallbladder as white "milky" bile, a substance also called "limy bile" by Knutsson in 1933 [1]. Although the exact etiology of milk-of-calcium bile is unknown, gallbladder stasis and lithiasis are believed to be the main prerequisites for its formation [2]. This radiopaque bile includes a mixture of calcium carbonate (34-92%) and calcium bilirubinate [1, 3]. Patients with milk-of-calcium bile in the gallbladder represent only about 0.3% of all those undergoing surgery for biliary lithiasis [2]. The age and sex distribution tends to be the same as those for gallstones alone; a few cases have also been reported in children [1]. Milk-of-calcium bile may adhere to the gallbladder wall, and, when identified in an obstruction in the common bile duct, is usually associated with concurrent discrete stones [1]. The presence of milk of calcium in the common bile duct is extremely rare and occurs in association with milk of calcium in the gallbladder [2]. Patients present with mild jaundice and right upper quadrant pain and usually require endoscopic or surgical intervention. Occasionally, patients may be asymptomatic or undergo a spontaneous resolution of symptoms that corresponds to the passage of the impacted material [1,2,3].

Many radiologic examinations can be used to identify stones in the common bile duct, including sonography (transabdominal and endoscopic), CT (with or without various types of contrast material), MR cholangiopancreatography, and ERCP [4]. MR cholangiopancreatography is now considered the noninvasive test of choice [4]; however, in our patient, despite her history, contrast-enhanced CT was requested by the referring physicians so that the right side of the abdomen could be globally scanned. The milk of calcium was readily apparent because of its high density. To our knowledge, only one other case of the identification of milk of calcium in the common bile duct on CT has been reported [3], and in that patient, the diagnosis was initially established using conventional radiographs.

References

1. Fowler C, Soriano H, Ferry G, Margraf L, Harberg F. Limy bile syndrome. J Pediatr Surg 1993;28:1568 -1569[Medline]
2. Moreaux J, Roux JM. Limy bile: a surgical experience in 16 patients. Gastroenterol Clin Biol 1994;18:550 -555[Medline]
3. Morehouse H, Roush G, Deshmukh S, Baker S. Milk of calcium in the common bile duct. J Comput Assist Tomogr 1984;8:177 -179
4. Soto JA, Alvarez O, Munera F, Velez SM, Valencia J, Ramirez N. Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography. AJR 2000;175:1127 -1134[Abstract/Free Full Text]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mazzie, J. P. Articles by Katz, D. S. Search for Related Content PubMed Articles by Mazzie, J. P. Articles by Katz, D. S. Social Bookmarking                      What's this?