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PubMed1983

Drug and treatment efficacy of chenodeoxycholic acid in 97 patients with cholelithiasis and increased surgical risk.

Patients with symptomatic cholelithiasis who represent higher than normal surgical risks may be the most suitable candidates for medical dissolution of gallstones. Chenodeoxycholic acid was given to 97 patients in a dosage of 15 mg/kg of body weight per day for a period of two years. Complete gallstone dissolution occurred in 27 of 97 patients (28%). If dropouts are excluded then the success rate is 27 of 64 patients (42%). Diarrhea was a common but manageable side effect for most. Thirty-two percent of patients developed chemical liver test abnormality; however, in only 13% was the degree of abnormality sufficient to require temporary (3%) or permanent (10%) cessation of therapy. Although better chemotherapeutic agents are needed, chenodeoxycholic acid is a reasonable choice for patients with non-calcified cholelithiasis in a functioning gallbladder if the patient is a heightened surgical risk. Because of the prolonged treatment period and the possibility of hepatotoxicity this treatment program requires a substantial commitment on the part of both the patient and the physician.

Chenodeoxycholic Acid↗
PubMedDate not supplied

Laparoscopic cholecystectomy: treatment of choice for cholelithiasis in children.

Laparoscopic cholecystectomy is rapidly replacing traditional cholecystectomy as the standard treatment for cholelithiasis and cholecystitis in adults. Over a period of 16 months, 14 children with a clinical diagnosis of cholelithiasis, ranging in age from 4 to 15 years (mean 12.2), were treated. All had symptoms of abdominal pain or vomiting; one had jaundice and recurrent cholecystitis. Five children (35%) had associated metabolic or hemolytic diseases. The 14 children were operated on using the laparoscopic cholecystectomy technique. No operation was converted to open cholecystectomy, but two patients required laparotomy: one because of suspected injury to the common duct, and the other because of nonvisualization of the gallbladder during laparoscopy. The mean post-operative hospital stay for the 11 children who underwent only laparoscopic cholecystectomy (one patient also had a simple mastectomy) was 50 hours (range 48-72 hours). All children resumed their normal activities almost immediately after discharge from hospital. No long-term biliary or other complications were seen in any patient throughout an average follow-up period of 6.2 months (range 3-16 months). The benefits of this operation in children are obvious: It is safe, effective, and well tolerated.

Adolescent↗
PubMed1996

Prevention of cholesterol cholelithiasis by dietary unsaturated fats in hormone-treated female hamsters.

We examined the effect of diet on gallstone incidence and the composition of biliary phosphatidylcholines in methyltestosterone-treated female hamsters. These hamsters were fed a nutritionally adequate purified lithogenic diet containing 2% corn oil, 4% butterfat, 0.3% cholesterol, and 0.05% methyltestosterone, resulting in a cholesterol gallstone incidence of 86%. This incidence was lowered when mono- and polyunsaturated fats or fatty acids were added to the diet: 2.5% oleic acid resulted in total prevention of cholesterol cholelithiasis, 2.5% linoleic acid, and 4% safflower oil (78% linoleic acid content) reduced gallstone incidence to 26 and 8%, respectively. An additional 4% butterfat (29% oleic acid content) produced gallstones in 50% of the animals. At the end of the 6-wk feeding period, the bile of all hamsters was supersaturated with cholesterol. The major biliary phosphatidylcholine species in all groups were (sn-1-sn-2): 16:0-18:2, 16:0-18:1, 18:0-18:2, 16:0-20:4, and 18:2-18:2. The safflower oil- and linoleic acid-fed hamsters exhibited an enrichment of 16:0-18:2 (16-18%); added butterfat or oleic acid increased the proportion of 16:0-18:1 (9 and 25%, respectively). We conclude that the phosphatidylcholine molecular species in female hamster bile can be altered by dietary fats/fatty acids and that mono- and polyunsaturated fatty acids play a role in suppressing the induced cholelithiasis.

Animal Feed↗
PubMed1995

Hydrophilic bile acids: prevention and dissolution experiments in two animal models of cholesterol cholelithiasis.

The effects of beta-muricholic acid and hyocholic acid on cholesterol cholelithiasis were examined in two animal models. The following experiments were carried out: A) In a gallstone prevention study, prairie dogs were fed the lithogenic diet with or without 0.1% beta-muricholic or 0.1% hyocholic acid for eight weeks. B) In a second prevention study, hamsters were fed the lithogenic diet with or without 0.1% beta-muricholic acid or 0.1% hyocholic acid for six weeks. C) In a gallstone dissolution study, hamsters were fed the lithogenic diet for six weeks to induce stones; stone dissolution was examined during administration of a cholesterol-free purified diet with or without 0.1% beta-muricholic acid or 0.1% hyocholic acid. In the prevention study in prairie dogs (A), both bile acids failed to prevent stone formation, the cholesterol saturation index of bile was 0.89 in the lithogenic controls, remained unchanged with hyocholic acid and increased to 1.52 in the beta-muricholic acid group. In the prevention study in hamsters (B), beta-muricholic acid completely inhibited the cholesterol cholelithiasis (0% stone incidence); the cholesterol saturation index of bile was 1.78 (compared to lithogenic controls, 1.37). Hyocholic acid reduced stone incidence to 16% with a cholesterol saturation index of 0.98. In the dissolution study in hamsters (C), preexisting cholesterol gallstones were not dissolved by either hydrophilic bile acid after feeding these bile acids for an additional six weeks; at the end of the experiment, the cholesterol saturation indices were below unity.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of Variance↗
PubMed1983

The influence of chenodeoxycholic acid on cholesterol and bile acid turnover in humans with cholelithiasis.

The in vivo dynamics of cholesterol were determined in 8 individuals who were part of a national double-blind study testing the efficacy of chenodeoxycholic acid ingestion on the dissolution of gallstones. Despite the ingestion of this bile acid in amounts in excess of its normal endogenous flux, the conversion of neutral sterol to chenodeoxycholic acid continued. The flux of neutral sterol to endogenous chenodeoxycholate was lower for the patients ingesting bile acid than for one of the patients on placebo, but was similar to that of the other control and similar to previously published chenodeoxycholate flux in patients with cholesterol cholelithiasis. The remaining flux was on the basis of the very efficiently absorbed dietary chenodeoxycholate. The total cholesterol fractional catabolic rate and flux were not appreciably diminished by the administration of either high or low dose chenodeoxycholate to these individuals with cholesterol cholelithiasis.

Adult↗
PubMed1992

Dietary fat and fatty acids modulate cholesterol cholelithiasis in the hamster.

We tested two hypotheses, i) whether the type and the amount of fat in the diet will affect the formation of cholesterol gallstones in the hamsters, and ii) whether palmitic acid, a major fatty acid component of butterfat, can act as a potentiator of cholesterol cholelithiasis in the hamster. Young, male golden Syrian hamsters (Sasco) were fed a semipurified diet containing casein, corn starch, cellulose and cholesterol (0.3%) to which various types and amounts of fat (butterfat, olive oil, menhaden oil, corn oil) were added. All diets contained 2% corn oil to supply essential fatty acids to the growing hamsters. No deaths or illness occurred during the experiment. Animals fed the semipurified diet plus 4% butterfat (group 1) had a gallstone incidence of 63%. Replacement of butterfat with either olive oil, corn oil or menhaden oil prevented the formation of cholesterol gallstones entirely (groups 2-4). When total butterfat was increased from 4% to 8% (group 8), the incidence of cholesterol gallstones increased to 80%. Substitution of 4% olive oil (group 5), corn oil (group 6), or menhaden oil (group 7) for the additional 4% butterfat significantly reduced gallstones to 35%, 45% and 30%, respectively. The replacement of 4% butterfat with 1.2% palmitic acid gave the highest incidence of cholesterol gallstones (95%). These results suggest that butterfat (and one of its components, palmitic acid) intensifies gallstone formation in this model whereas mono- and polyunsaturated fats act as inhibitors of cholesterol cholelithiasis. A fatty acid, possibly palmitic acid, appears to act as lithogen in our model.

Animals↗
PubMed1999

Recanalization of a portal-vein thrombosis and partial resolution of biliary cirrhosis following cholecystectomy for cholelithiasis in an infant.

Cholelithiasis in infants and children is unusual and is reputedly associated with underlying hemolytic disorders, total parenteral nutrition, ileal disease, and congenital anomalies of the biliary tree. We report a case of cholecystitis with pigmented stones in a 3-month-old infant associated with portal vein thrombosis (PVT) and biliary cirrhosis without the above-mentioned causes. Recanalization of the PV and partial resolution of the cirrhosis was observed following cholecystectomy. To our knowledge, cholelithiasis associated with PVT and cirrhosis in an infant has not been reported in the literature.

Biopsy, Needle↗
PubMed2005

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis.

BACKGROUND: The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging. METHODS: We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD. RESULTS: Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality. CONCLUSION: We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

Adult↗
PubMed1998

Cholelithiasis following Escherichia coli O157:H7-associated hemolytic uremic syndrome.

Sequelae of Escherichia coli O157:H7-associated hemolytic uremic syndrome (HUS) 2-3 years following an outbreak in Washington State have been prospectively studied to identify predictors of adverse sequelae. Logistic regression analysis was used to examine associations between findings in the acute course and long-term renal and gastrointestinal outcomes. Twenty-one percent of patients had gastrointestinal sequelae, which included cholelithiasis resulting in cholecystectomy (3/29), persistent pancreatitis (2/29), late colon stricture (1/29), and/or glucose intolerance (1/29). Logistic regression analysis found long-term gastrointestinal sequelae were higher in patients who, during HUS, had hypertension [odds ratio (OR) = 21.2, 95% confidence interval (CI) = 1.9-164.4, P = 0.01] or gastrointestinal complications (OR = 21.2, 95% CI = 1.9-164.4, P = 0.01). Renal sequelae were seen in 35% of patients. One patient (4%) had persistent hypertension and 9 (31%) had minor urinary findings (hematuria or proteinuria). Thrombocytopenia lasting longer than 10 days during the acute illness was associated with a risk for subsequent renal sequelae (OR = 15.0, 95% CI = 1.98-1,703.0, P = 0.009). We conclude a high incidence of gastrointestinal sequelae, especially cholelithiasis presenting long after the acute illness, may be seen with HUS. The short follow-up period may underestimate the extent and severity of eventual renal sequelae.

Child↗
PubMed2000

Management of cholelithiasis in combination with cardiovascular surgery.

A retrospective review of the perioperative management of patients with cardiovascular surgical disorders and cholelithiasis was conducted, and the surgical strategies employed are discussed. Between 1988 and 1998, 18 patients having cardiovascular surgical disorders underwent cholecystectomy. These patients were divided into three groups: group I, given a one-stage operation (n = 9); group II, given a two-stage operation (n = 3); and group III, given cholecystectomy during follow-up after cardiovascular surgery (n = 6). In group I, a median laparotomy was adopted for patients with an abdominal aortic aneurysm (AAA) to allow both disorders to be treated through the same incision, whereas a right subcostal approach was employed to separate the incisions for patients who underwent cardiac operations. In group II, one patient underwent cholecystectomy before cardiac surgery, and two patients underwent cholecystectomy for postoperative cholecystitis after cardiovascular operations. One patient from group II and all from group III were on preoperative anticoagulant therapy, two of whom underwent laparoscopic cholecystectomy. No fatal complications such as prosthetic infection, intraperitoneal hemorrhage, or cerebral attack were encountered. In conclusion, we consider that performing cholecystectomy during AAA repair may be safe and prevents the risk of postoperative cholecystitis; it is preferable to treat cholelithiasis coexisting with cardiac disorders concomitantly with or before cardiac operations; and laparoscopic cholecystectomy can be safely performed under anticoagulant therapy.

Adult↗
PubMed1991

Frequent occurrence of asplenism and cholelithiasis in patients with autoimmune polyglandular disease type I.

PURPOSE: This study assesses the occurrence of asplenism and gallstones in patients with autoimmune polyglandular disease type I (APG I). PATIENTS AND METHODS: Nine patients with APG I (ages 14 to 48) were studied at the National Institutes of Health. Each patient received endocrine testing, a careful examination of his or her peripheral blood smear, lymphocyte immunophenotyping, a liver-spleen scan, and either an upper abdominal ultrasound or a computer-assisted tomogram to evaluate the spleen and gallbladder. RESULTS: We documented asplenism in four patients and cholelithiasis in four patients, with two patients having both conditions. The patients with asplenism had Howell-Jolly bodies on peripheral blood smears, lack of splenic uptake by liver-spleen scan, and absent spleens by abdominal computed tomographic scan or ultrasound evaluation. The clinical presentation of the patients with cholelithiasis ranged from acute symptoms requiring surgery to asymptomatic gallstones. Lymphocyte immunophenotyping did not reveal consistent changes in either B- or T-cell subpopulations in the patients studied. CONCLUSION: Asplenism and gallstones occur frequently in patients with APG I. In addition to careful examination of the peripheral blood smear for Howell-Jolly bodies to screen for asplenism, we recommend an abdominal ultrasound to detect asplenism and/or gallstones in all patients with APG I. Appropriate immunizations and antibiotic coverage may be helpful in those patients with absent spleens.

Adolescent↗
PubMed1980

Chronic cholelithiasis and decreased bile salt pool size: cause or effect?

The hypothesis that the decreased bile salt pool size observed in humans with chronic cholelithiasis is a result rather than a cause of gallstones was tested in a prairie dog gallstone model. A decrease in bile salt pool size was observed in cholesterol-fed prairie dogs only after the chronic presence of stones had induced physiologic, anatomic and microscopic changes typical of human chronic cholecystitis. These data suggest that the decreased bile salt pool size associated with chronic cholelithiasis is a result rather than a cause of gallstones and that the link between the hepatic secretion of cholelithogenic bile and gallstones is altered gallbladder function.

Animals↗
PubMed1981

The differing effects of early and chronic cholelithiasis on hepatic bile lithogenicity.

The hypothesis that increasing chronicity of cholelithiasis is associated with a progressive alteration of the enterohepatic circulation, resulting in a decrease in bile salt pool size and reversion of hepatic bile composition to a less lithogenic state, was tested in the prairie dog gallstone model. During the early phases of cholesterol cholelithiasis, both hepatic and gallbladder bile were saturated with cholesterol, and the bile salt pool size was normal. As stones became more chronic, the gallbladder was increasingly removed from the enterohepatic circulation, bile salt recycling increased and the pool size decreased. Despite this decrease in pool size and persistence of lithogenic gallbladder bile, hepatic bile composition reverted to a less lithogenic state. These data suggest that the sequelae of functional cholecystectomy are analogous to those of cholecystectomy, In addition, it appears that the liver and gallbladder interact in a dynamic manner, continually influencing the function of each other.

Animals↗
PubMed1984

Operative management of incidental cholelithiasis.

Incidental cholelithiasis was encountered at the time of celiotomy in 56 patients. Thirty-three of the patients underwent concomitant cholecystectomy. The overall morbidity and mortality were 27 and 3 percent, respectively, but only one complication (3 percent) was clearly related to the cholecystectomy. Cholecystectomy was not performed in 23 patients. Within 6 months of primary celiotomy, acute cholecystitis developed in 11 patients, 3 had attacks of biliary colic, and 2 became jaundiced. Fifteen patients (65 percent) underwent cholecystectomy and 6 of the 15 (40 percent) required common bile duct exploration. Concomitant cholecystectomy adds minimal morbidity to the operation and should be performed unless specific contraindications exist. Left untreated, cholelithiasis becomes symptomatic and leads to subsequent operation in most patients, which may require a more extensive procedure producing greater morbidity.

Adolescent↗
PubMed1985

Human beta-glucuronidase. Studies on the effects of pH and bile acids in regard to its role in the pathogenesis of cholelithiasis.

Human bile contains a considerable amount of endogenous beta-glucuronidase. The effects of pH and bile acids on its activity have been studied in regard to its role in the pathogenesis of cholelithiasis. beta-Glucuronidase, purified from human liver to homogeneity, was structurally stable between pH 4 and 10, but was active only over a much narrower range of pH, with a pH optimum of 5.2. The inactivation below pH 4 was due to its irreversible denaturation, whereas the inactivation at higher pH was due to a true reversible pH effect on the enzyme velocity. Kinetic studies revealed that hydrogen ion acted as a substrate-directed activator of the free enzyme, but not the enzyme-substrate complex, with a molecular dissociation constant of 4 X 10(-6). The enzyme activity was not affected by unconjugated bile acids, primarily due to their extremely low water solubility. Conjugated bile acids, on the other hand, exerted heterogeneous and pH-dependent effects on the enzyme. At pH 5.2, taurocholic acid and glycocholic acid were substrate-directed activators of the enzyme; taurochenodeoxycholic acid and taurodeoxycholic acid, competitive inhibitors; and glycochenodeoxycholic acid and glycodeoxycholic acid, mixed inhibitors. At pH 7.0 all taurine and glycine conjugates behaved as substrate-directed activators. Though beta-glucuronidase activity at pH 7 was only 23% of its maximal activity at pH 5.2, conjugated bile acids tended to restore its activity to a certain extent at pH 7. Thus, endogenous beta-glucuronidase could play a significant role in pigment cholelithiasis.

Bile Acids and Salts↗
PubMed1991

Cholelithiasis in patients with variegate porphyria.

Four patients with variegate porphyria (VP) who developed symptoms attributable to cholelithiasis are described. Elective cholecystectomy was performed uneventfully in two of these patients in whom the diagnosis of porphyria had previously been made. The third patient was not known to have porphyria at the time of surgery and developed a fulminating attack which proved fatal. The major haem precursor overproduced in VP is protoporphyrinogen and protoporphyrin was present in the gallstones available for analysis. Our experience suggests that patients with VP have an increased risk of cholelithiasis which may be related to the overproduction of protoporphyrinogen and increased bile concentration of protoporphyrin.

Adult↗
PubMed1999

The laparoscopic management of appendicitis and cholelithiasis during pregnancy.

BACKGROUND: Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy remains controversial. We report the single largest series of laparoscopic cholecystectomies and appendectomies during pregnancy. METHODS: Medical records of all pregnant patients who underwent open or laparoscopic management of appendicitis/cholelithiasis at LDS Hospital from 1990 to 1998 were reviewed. RESULTS: Eighteen open appendectomies (OA) and 13 open cholecystectomies (OC) were performed. Forty-five laparoscopic cholecystectomies (LC) and 22 laparoscopic appendectomies (LA) were performed without birth defects, fetal loss or uterine injury. Preterm delivery rates (PTD) in the LA and OA groups were similar (15.8% versus 11.8%, P>0.9). The PTD rate in the LC group was not significantly different than in the OC group (11.9% versus 10.0%, P>0.9). Neither birth weights nor Apgar scores were significantly different across groups. CONCLUSIONS: Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy can be performed with minimal fetal and maternal morbidity when accepted management guidelines are followed.

Adult↗
PubMed2005

[Acute cholecystitis secondary to recurrent cholelithiasis after subtotal cholecystectomy].

Subtotal cholecystectomy is a well-established procedure for complicated acute cholecystitis. Short-term safety is good and few complications have been described during follow-up. However, residual gallbladder mucosa can produce new calculi, which can provoke the same symptoms and complications as those in non-operated patients and which require a high index of suspicion. Surgical treatment can be indicated. We report the case of a man who underwent subtotal cholecystectomy for complicated cholecystitis. Postoperative follow-up did not reveal residual cholelithiasis. The patient developed obstructive jaundice 8 years later. Initial studies (computed tomography and ultrasonography) showed no complications. Endoscopic retrograde cholangiopancreatography revealed residual gallbladder with recurrent cholelithiasis. Conservative management was initiated but gallbladder stump cholecystectomy was required for acute cholecystitis.

Acute Disease↗