Use of ultrasonographic risk score in the timing of operative intervention for acute cholecystitis

Timing of operative intervention for acute cholecystitis has long been a subject of debate. However, actual or impending perforation constitutes an absolute indication for prompt operative intervention. To discriminate these cases from those undergoing observation with conservative treatment, clinical and ultrasonographic findings were reviewed and analyzed in 17 patients with acute cholecystitis. Specificity, sensitivity, and accuracy of ultrasonography in discriminating cases of acute cholecystitis, in terms of timing of operative intervention, were calculated retrospectively based on the operative findings. The risk score for each ultrasonographic finding was determined, and the total risk score was calculated for each patient. The calculated total risk score was found to be well correlated with the macroscopic appearance of the gallbladder at operation in cases of acute cholecystitis. Therefore, this score should be useful in determining the timing of operative intervention for acute cholecystitis. However, the usefulness of the variables should further be established prospectively in other patient populations.

Composition of intrahepatic calculi. Etiological significance

Gallstones in intrahepatic (N = 42) and extrahepatic (N = 22) bile ducts and gallbladder (N = 23) were subjected to chemical analysis modified to suit the analysis of brown pigment stones with the aim of determining if stone location at surgery influenced stone composition. Dimethylsulfoxide-acetone-1 N HCl (90:9:1, v/v/v) was used to dissolve gallstone specimens. Intrahepatic calculi were divided into two groups, ie, nine cholesterol stones and 33 brown pigment stones. Cholesterol stones in the intrahepatic bile ducts had a similar composition to those in the gallbladder and extrahepatic bile ducts, suggesting a similar pathogenesis wherever formed throughout the biliary tract. Intrahepatic brown pigment stones contained significantly less bilirubin (P less than 0.001) and more cholesterol (P less than 0.05) by chi-square analysis than brown pigment stones found in the extrahepatic bile ducts, suggesting that the site of formation affects stone composition and modifies stone pathogenesis.

Type of gallstones and deaths from stroke and coronary heart disease among cholecystectomized patients

A total of 841 Japanese patients who had undergone cholecystectomy for choleithiasis (550 for cholesterol stones and 291 for pigment stones) from 1951 to 1970 were investigated on death from stroke, coronary heart disease (CHD) and heart disease other than CHD in relation to the type of gallstones. Compared to patients with pigment stones, those having cholesterol stones had a 50% lower risk of dying from stroke which was statistically significant. The findings support the idea that westernization of Japanese diets may be responsible both for the decline in stroke mortality and for the changing pattern of gallstones in this country. The risk of CHD among cholesterol-stone patients was higher, but not significantly so, than that of pigment-stone patients whereas mortality from heart disease other than CHD did not differ much between the two groups. There were, however, few deaths from these diseases and the findings were therefore not conclusive.

Ki-1+ cutaneous lymphoma. Gene rearrangement analysis of tumor cells in tissue and short-term culture of a patient

Cutaneous malignant lymphomas developed in an 80-year-old man without any evidence of leukemic disseminations of lymphoma cells. Immunohistologic staining showed the expression of Leu-3a, Leu-4, Ki-1, Tac, and HLA-DR antigens on tumor cells in tissue and large lymphoid cells in long-term, interleukin 2-containing culture of tumor explants. DNA samples extracted from the skin tumors and cultured lymphoid cells showed a clonal rearrangement of T-cell receptor (TCR) gene C beta 1 with the molecular size of 9 kilobases. These findings suggested the T-cell origin of Ki-1+ cutaneous lymphoma cells and the occurrence of a clonal proliferation of tumor cells in culture.

[Local administration of recombinant interferon-beta to patients with cancer-associated body cavity fluids]

The effects of local administration of interferon-beta produced by recombinant DNA technology (GKT-beta, Kyowa Hakko) on malignant effusion were studied in cancer patients and evaluated on the basis of the Criteria for the Evaluation of the Clinical Effects of Solid Cancer Chemotherapy (effects on malignant effusion). Out of 13 cases of peritoneal effusion, the effects were evaluated in 9 cases. Four of these cases remained free from ascites for 4 weeks and were evaluated as complete response (CR). Administration of GKT-beta alone was performed in 4 of 7 cases of pleural effusion, and CR was obtained in 1 case each of breast cancer, gastric cancer and malignant mesothelioma. In cases of gastric cancer, CR was obtained in 5 of 10 cases. The above results suggest that GKT-beta is a very effective drug against malignant effusion.

Absorption of bile acids in dog as determined by portal blood sampling: evidence for colonic absorption of bile acid conjugates

The intestinal phase of enterohepatic circulation, such as site and state of bile acid absorption, along the length of the intestinal tract has been speculated but not directly quantitated. In order to gain insight into the actual state of intestinal absorption of bile acid, the bile acid composition of portal blood from various segments of the intestinal tract was studied in dogs after loading endogenous bile acid by injection of caerulein. Total and unconjugated bile acids were determined with and without enzymatic hydrolysis, respectively. The amount of conjugated bile acids was calculated by subtracting unconjugated from total bile acids. Quantitation of cholic, chenodeoxycholic, deoxycholic and lithocholic acids and their conjugates was carried out by gas chromatography/mass spectrometry/selected ion monitoring with deuterated bile acids as internal standards. The major site of absorption of taurine-conjugated bile acid, a major conjugate form in the dog, was the distal small intestine. In addition, a considerable amount of cholic acid was found to be absorbed from the distal large intestine, the majority of which was still in the conjugated form. The pronounced absorption of the unconjugated secondary bile acid from the large intestine suggests the very active formation of the secondary bile acid in situ.

Diagnosis and operative indications for polypoid lesions of the gallbladder

In 411 patients undergoing cholecystectomy, benign polyps were present in 32 gallbladders and malignant polyps were present in eight. Histologically, cholesterol polyps accounted for most of the benign lesions, and all the malignant lesions were adenocarcinomas. Gallstones coexisted in 50% of the malignant lesions and endoscopic retrograde cholangiography revealed anomalous pancreaticobiliary junctions in three of five patients with malignant lesions. Sixty-nine percent of patients with benign lesions were under 60 years of age, whereas 75% of those with malignant lesions were over 60. Ninety-four percent of the benign lesions were under 1.0 cm in diameter, while 88% of the malignant lesions exceeded this size. Spread and size of the tumor showed a close correlation. Therefore, size of the tumor is a vital indicator in the treatment of polypoid lesions of the gallbladder, and a malignancy should be considered when the tumor exceeds 1.0 cm in diameter.

New abdominal retractor for exposure of subphrenic region

A new abdominal retractor for good exposure of the subphrenic space is described. It can be used either with subcostal incision for extensive hepatic resection or with upper midline incision for total gastrectomy. Because of the centrally placed winch and simple design, it withstands strong pulling and is very reliable. In more than 100 laparotomies done, the retractor was used in extensive hepatic resection or total gastrectomy without complications.

Analysis of 3-sulfated and nonsulfated bile acids by one-step solvolysis and high performance liquid chromatography

A facile solvolysis procedure of 3-sulfated bile acid was devised using trifluoroacetic acid, tetrahydrofuran, and methanol. The sulfate esters were completely solvolyzed within only 2 hr by the present method. The clinical utility of the solvolysis procedure and high performance liquid chromatography using immobilized 3 alpha-hydroxysteroid dehydrogenase was demonstrated in the analysis of bile acids in serum of patients with obstructive jaundice. The quantities of 3-sulfated bile acids were calculated from the difference in the amount of bile acids before and after solvolysis. A significantly large proportion of 3-sulfated glycochenodeoxycholic acid, i.e., 21.9 to 31.3% of total glycochenodeoxycholic acid, was found in the serum of patients with obstructive jaundice. Thus, the present method permits simultaneous quantitation of 3-sulfated as well as nonsulfated bile acids in biological samples.

Effect of albumin on the solubility of cholesterol in bile

Despite the fact that a considerable amount of albumin is present in bile, little is known about the effect of albumin on micellar solubility of cholesterol. The effect of albumin on solubility of cholesterol in various micellar bile salt solutions was studied using Millipore filtration after equilibration. In addition, partitioning of cholesterol from micellar solution was studied using a polyethylene disc method. Decrease of the solubility of cholesterol by the presence of albumin was observed only in unconjugated bile salt solution. The lowering effect of albumin on the cholesterol solubility was found to be proportional to the hydrophobicity of bile salt. In contrast, albumin had almost no effect on cholesterol solubility, either in conjugated bile salt solution or in micellar bile salt solution containing phosphatidylcholine. Addition of albumin enhanced the partitioning of cholesterol out of the micelles in sodium chenodeoxycholate solution as a result of decreased micellar solubility and increased the aqueous solubility of cholesterol in the presence of albumin. Therefore, conjugated bile salt and phosphatidylcholine exert a buffering action on the albumin-induced adverse effect on cholesterol solubility, thus stabilising bile against inadvertent precipitation of cholesterol.

Electrohydraulic lithotripsy of intrahepatic stones during choledochoscopy

In two patients, electrohydraulic lithotripsy was used under direct vision during choledochoscopy to fragment intrahepatic calculi above bile duct strictures, which were difficult to remove by ordinary choledochoscopic methods. Choledochoscopy was performed after dilation of a percutaneous transhepatic tract in one patient and after intubation of the subcutaneous blind jejunal limb of a previous Roux-en-Y intrahepatic cholangiojejunostomy in the other. Both patients were treated without any complications. Electrohydraulic lithotripsy during choledochoscopy is a safe and effective method to fragment stones and facilitate their removal.

Bile acid metabolism in cirrhotic liver tissue--altered synthesis and impaired hepatic secretion

Bile acid analysis of mild and severe cirrhotic liver showed that with the advancement of cirrhosis the concentration of chenodeoxycholic acid in liver tissue becomes higher, resulting in the lower ratio of cholic to chenodeoxycholic acid probably due to the progressive alteration of cholic and chenodeoxycholic acid synthesis with the advancement of liver cirrhosis. Bile acid analysis of paired liver and bile of severe cirrhosis showed that the ratio of cholic to chenodeoxycholic acid in liver was lower than that in bile or even with that in bile. This can be explained by postulating the impaired hepatic secretion of bile acids, especially chenodeoxycholic acid. The impaired secretion together with the relatively well preserved chenodeoxycholic acid synthesis results in the accumulation of chenodeoxycholic acid in liver tissue with cirrhosis.

Altered metabolism of bile alcohol and bile acid in complete extrahepatic cholestasis: qualitative and quantitative aspects

Urinary excretion of bile alcohols and bile acids in patients with complete extrahepatic cholestasis before and after the release by external biliary drainage was studied. Following extraction, isolation, and hydrolysis, bile alcohols were determined by capillary gas-liquid chromatography-mass spectrometry as dimethylethylsilyl derivatives. During cholestasis, 8.89 mumol/day of bile alcohol and 140.4 mumol/day of bile acid were excreted in urine. The amount of bile alcohol excreted was 6.1% of that of bile acid. Positive correlation between excretion of bile alcohols and bile acids was observed. The major bile alcohols excreted were also present in urine from healthy individuals but in much smaller amounts. After the release of extrahepatic cholestasis, urinary excretion of bile acid decreased rapidly, but that of bile alcohol decreased only gradually. The latter often increased again and remained high. The results indicate that the increased excretion of bile alcohols in complete extrahepatic cholestasis may reflect the expansion of a normally existing pathway of bile alcohol synthesis and excretion leading to the modification of bile alcohols for their efficient urinary elimination. It is also suggested that the rate of synthesis of bile alcohols is determined partly by the size of the substrate pool available.

Nonbacterial transformation of bilirubin in bile

Bilirubin present in gallstones is mainly in the unconjugated form despite the frequent absence of bacteria in bile. The aim of the present study was to determine if nonbacterial beta-glucuronidase activity and/or nonenzymatic hydrolysis is responsible. Inflammatory cells such as polymorphonuclear leukocytes and lymphocytes appearing with the presence of brown pigment gallstones and inflammation in biliary tract was shown to effect deconjugation of bilirubin conjugates in bile and contribute to their formation in addition to that of bacterial beta-glucuronidase. Gallbladder bile (mean +/- SD, 4.0 +/- 1.6%, N = 29) contained more unconjugated bilirubin than hepatic bile (mean +/- SD, 2.7 +/- 1.1%). In vitro experiments showed the deconjugation to take place during incubation at 37 degrees C without the presence of bacteria. Therefore, transformation of conjugated to unconjugated bilirubin is likely to take place in vivo during the storage in gallbladder, and nonbacterial beta-glucuronidase activity and/or nonenzymatic hydrolysis may be responsible for such transformation.

Demonstration and maintenance of mucus secretion in cultured human gallbladder epithelial cells

The method of human gallbladder epithelial cell culture has been developed successfully with active mucus secretory function. Human gallbladder epithelial cells were dissociated by Dispase digestion from the specimens obtained by cholecystectomy for uncomplicated gallbladder stone cases. The dissociated cells formed a monolayer in Eagle's minimum essential medium supplemented with 10% fetal bovine serum within 24 h after the inoculation. These cells were maintained for at least 2 wk without fibroblastic overgrowth. Cultured cells contained periodic acid Schiff-positive material in cellular cytoplasm for 3 d. On transmission electron microscopy these materials were identified as mucous secretory granules. Mucous secretory function was determined by [3H]glucosamine incorporation. Sixty percent of the secreted glycoproteins labeled with [3H]glucosamine was eluted in excluded fractions of Sepharose 4B gel filtration, which were considered to be mucous glycoprotein, because they were found to be resistant to proteoglycan-specific enzymes such as hyaluronidase, chondroitinase ABC, heparitinase, and heparinase. The mucous glycoprotein secretion was maintained for 3 d and found to be inhibited in a dose-dependent manner by monensin (10(-7) to 10(-5) M) which is a known blocker of secretory function.

Bile acid metabolism in isolated rat hepatocytes: studied by gas-liquid chromatography-mass spectrometry-selected ion monitoring

Bile acid contents in isolated rat hepatocytes were determined by gas-liquid chromatography-mass spectrometry-selected ion monitoring with the use of deuterium-labeled internal standards. This allowed us first to monitor the actual amounts of not only major but also minor bile acid components present with sufficient sensitivity and specificity and to follow the changes of individual bile acids in cultured rat hepatocytes simultaneously. In freshly isolated rat hepatocytes, cholic and beta-muricholic acids were the major components, comprising 35 and 46% of the total bile acids, respectively. These two bile acids were found to be most actively synthesized during the first 2 h of incubation and continued to increase thereafter for up to 6 h (the end of the period studied). In contrast, chenodeoxycholic and alpha-muricholic acids, which are the precursors of beta-muricholic acid, showed slight increases only in the first hour of incubation and decreased thereafter. These results suggested that the conversion to beta-muricholic acid from chenodeoxycholic acid via alpha-muricholic acid occurred rapidly in cultured rat hepatocytes. The secondary bile acids such as deoxycholic, hyodeoxycholic, and 3 alpha, 12 beta-dihydroxy-5 beta-cholanoic acids declined steadily from the start of incubation, which supported the findings that further hydroxylation of these dihydroxy bile acids occurs in rat liver.