Alok Anand Ashley Davidoff MD
Milk of calcium bile, also known as Limey Bile Syndrome, is a term used to describe bile secretions that appear radioopaque or “milky” on radiographic imaging of the gallbladder and occasionally the common bile duct. This bile is rich in calcium carbonate and calcium bilirubinate, from which the term calcium bile originates. It is a rare finding, believed to cocur in 0.3% of all cholecystectomies.
The cause of this phenomenon is unknown, although it does appear to occur in the presence of bilary stasis and cholelithiasis.
Clinically the presentation of patients is similar to chronic cholecystitis, with intermittent RUQ pain lasting several months to several years. Patients may present more emergently with fever, RUQ pain and obstructive jaundice.
The diagnosis is made by finding high density sedimented fluid layering below normal bile lying dependently in the gallbladder.
Surgical treatment is not indicated unless patients are symptomatic.
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Typically the gallbladder and bile ducts are dilated, as with cholecystitis.
Changes in character include the presence of a thick, paste-like, radio-opaque material in the gall bladder and/or common bile duct lumen. It is usually accompanied by the presence of discrete gallstones as well. On imaging, particularly ultrasound, this may appear similar to a porcelain gallbladder.
Structural changes may include an inflamed and distended gallbladder with a hyperemic wall usually due to chronic inflammation.
Functionally, receiving of bile is believed to be relatively normal, whereas the formation of Calcium bile occurs in processing, and impaired exporting leading to stasis and precipitation of inorganic calcium salts.
Mazzie, J. P.; Gold, B. M.; Bartolomeo, R. & Katz, D. S. Milk of Calcium in the Common Bile Duct: CT Identification Am. J. Roentgenol., 2002, 179, 804-805.
Ballas, K. D.; Alatsakis, M. B.; Rafailidis, S. F.; Psarras, K. & Sakadamis, A. K. Limy bile syndrome: review of seven cases. ANZ J Surg, Second Propedeutical Department of Surgery, Aristotelian University of Thessaloniki, Hippokration General Hospital of Thessaloniki, Greece., 2005, 75, 787-789