Biliary sludge

Case contributed by Assoc Prof Frank Gaillard


Right upper quadrant pain

Patient Data

Age: 80 years
Gender: Female

The gallbladder is markedly distended and contains a large volume of mobile echogenic material in keeping with sludge. This extends into the neck of the gallbladder and the cystic duct. Cholelithiasis is demonstrated. The gallbladder wall is thickened measuring 6 mm. There is a small volume of pericholecystic free fluid. Murphy's sign positive.

The common bile duct is dilated measuring up to 13 mm at the head of pancreas. No choledocholithiasis detected. There is also intrahepatic biliary dilatation.


Markedly distended, tender gallbladder with cholelithiasis and a large amount of sludge. The appearances are in keeping with acute cholecystitis.

The patient was treated conservatively with antibiotics and symptoms improved, but then represented. 

3 weeks later


The gallbladder is markedly distended (measuring up to 17cm) and contains a large volume of sludge and mobile gallstones. There is small volume pericholecystic free fluid. No gallbladder wall thickening. Sonographic Murphy's sign is however positive. Intrahepatic duct dilation is present.

The common bile duct measures up to 6.4 mm. No choledocholithiasis detected.

Case Discussion

Gallbladder sludge (also known as biliary sludge) is a mixture of particulate matter and bile.   It may occur in isolation or not infrequently along with gallstones. A liquid-liquid level is usually identified due to the interface to normal bile and sludge inside the gallbladder, as in this case.

Two key elements on ultrasound to observe:

1.  On prolonged observation one can usually identify to-and-fro movement of the sludge

2.  On moving the patient the sludge will move in position - with dependency.

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