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Antonio Pio Masciotra Campobasso Molise Italy Website www.masciotra.netwww.masciotra.net YouTube channel https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ Intrahepatic cholelithiasis in a 29 years old woman without symptoms

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Ultrasound images of intrahepatic hyperechoic foci. In this patient we can see hyperechoic foci with diffuse topography compatible with lipid deposits along the luminal surface of the intrahepatic biliary tree, here limited to segments 6 and 7. These multiple dots, less than 1 mm in diameter, cast short echogenic trail without acoustic shadows and sometimes look like comet tails. They are typically distributed along the portal arborizations in single line (end to end or in indian file) and may be associated with intrahepatic sludge or microlithiasis casting typical acoustic shadows. In this patient gallbladder has no stones. In the slides n. 3 and 4 you can see that the images were taken with patient in supine and orthostatic positions to exclude that hyperechoic foci were due to aerobilia (in which case their distribution would have been changed, going the air upward). In a young woman like in this case we could suppose a Low phospholipid associated cholelithiasis, sometimes associated to an ABCB4 gene mutation. Phospholipids are the major carrier and solvent of cholesterol and they exert a protective effect against bile saltinduced biliary mucosa injury. Mutations in the ABCB4 gene are thought to be responsible for progressive intrahepatic cholestasis type 3 and heterozygous mutations have been also reported in patients presenting with a history of intrahepatic cholestasis of pregnancy or with a cholangiopathy referred to as anti-mitochondrial antibody (AMA) negative primary biliary cirrhosis (PBC). Defect in ABCB4 function causes the production of bile with low phospholipid content, increased lithogenicity and high detergent properties leading to bile duct luminal membrane injuries and resulting in cholestasis with increased serum GGT activity.

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Antonio Pio Masciotra Campobasso Molise Italy Email antoniomasciotra@yahoo.it Website www.masciotra.net YouTube Channel https://www.youtube.com/ch annel/UCgCj21nKGAhR997I a3-QegQ Intrahepatic cholelithiasis in a 29 years old woman without symptoms