Pathogenesis of calcium bilirubinate gallstone: role of E. coli, beta-glucuronidase and coagulation by inorganic ions, polyelectrolytes and agitation

Bacteriological study of transhepatically aspirated bile. Relation to cholangiographic findings in 295 patients

The purpose of this study was to elucidate the frequency of bacterial infection of intrahepatic bile in relation to biliary tract pathology. Bile was aspirated during percutaneous transhepatic cholangiography, with or without combined biliary tract drainage, and subjected to bacteriological investigations in 295 patients with various hepatobiliary diseases. Bile was infected in 89% of the 92 patients who had high fever and were on antibiotics at the time of study. Positive cultures were obtained in 39% of the patients who were not so ill as to require antibiotics. The overall incidence of biliary infection was 90% in bile duct stones, particularly high in patients with primary intrahepatic stones, regardless of the presence of stones in the common bile duct, and in patients who had dilation of the common bile duct, presumably due to obstructive involvement of the ampulla of Vater. E. coli and Klebsiella were the most frequent among the aerobic species isolated, and mixed infection involving these organisms was common. Anaerobes were much less frequent, always mixed with aerobes, but positive cultures would increase with more rigorous anaerobic conditions for culture. Duodenal fluid collected simultaneously did not always grow the same microorganisms, but showed a 86-87% coincidence with intrahepatic bile in terms of positive or negative cultures. It is recommended that bile be cultured at the time of percutaneous transhepatic cholangiography.

Abnormal bile duct epithelium accompanying septicaemia

A 56-year-old female without previous hepatobiliary disease developed a severe obstructive cholestasis following E. coli urinary tract infection with septicaemia. Liver biopsy showed cholangitis and a unique abnormality of almost all the interlobular bile ducts; the epithelium was irregular with polymorphic, angular, and hyperchromatic or pyknotic nuclei. Some ducts were ectatic , others narrowed due to protrusion of proliferating epithelium. In some areas the ducts were blurred or completely destroyed. Cholangitis or granulomas were, however, not present. Abnormal interlobular bile ducts have to our knowledge not previously been described in septicaemia. The lesion is morphologically distinguishable from other types of abnormal bile ducts. It is considered to be caused by endotoxaemia and seems to be reversible. The cholestasis may be due to endotoxic alteration of biliary secretion, bacterially induced inspissation of bile, and/or mechanical obstruction to the bile duct lesions.

Cholelithiasis in a preterm infant

A case of cholelithiasis in a preterm infant is described. The baby survived for 105 days, during which time she received multiple blood transfusions. Three pigment stones were found in the gallbladder at necropsy. It is suggested that they were a consequence of an excessive bilirubin load, the result of maintaining the hemoglobin above physiological levels.

The fine structure of pancreatic stones as shown by scanning electron microscopy and X-ray probe microanalyser

To delineate the process of pancreatic stone formation, stones from four patients were studied with a scanning electron microscope and X-ray probe microanalyser. The stones consisted of a central core and surrounding shell. Two kinds of stones were demonstrated: one had a core composed of a calcium-rich amorphous substance and interlacing fibrils; the other had a core consisting of multiple cavities with smooth walls composed of a calcium-deficient amorphous substance. The shells showed a common structure: zones of layers or bands of a calcium-rich amorphous substance, network fibrils filled with a calcium-rich amorphous substance, and laminated parallelogrammic or polygonal plates of calcite parallel to the surface in one layer and oblique or perpendicular in the next layer. Calcium was in the crypto-crystalline state as well as crystalline state of calcite. Crystalline calcite showed spiral and epitaxial growth along with findings of dissolution, resembling cholesterol crystals of gall stones. Pancreatic stones are probably formed through central core formation and layered growth of a shell. Comparison of stones and protein plugs suggests that protein plugs can grow to stones with calcite deposition accompanied by precipitation of network fibrils and an amorphous substance.

Changes in serum and bile bilirubin induced by acute hemolysis

The association between chronic hemolysis and pigment gallstones is well known but not adequately understood. To define the source and quantity of insoluble pigment resulting from hemolysis, hepatic bile in miniature swine was studied during the intravenous infusion of distilled water. Concentrations of both total bilirubin and insoluble unconjugated bilirubin rose rapidly during the first 2 hr to levels more than seven times above control values. In the third hour, unconjugated pigment continued to increase while total bilirubin plateaued, suggesting that glucuronidation or transport maxima had been reached. Elevations in unconjugated bilirubin could not be accounted for by the intrabiliary hydrolysis of conjugated bilirubin. It is concluded that hemolysis results in the secretion of large quantities of insoluble bilirubin directly into bile. This process may represent an important step in the development of pigment polymers or precipitates.

[Experimental gallstone formation. Etiological significance of beta-glucuronidase producing bacteria and biliary obstruction]

Bile pigment gallstones were produced in six of six mongrel dogs by narrowing the cystic duct with ligature after a postoperative interval of seven days. beta-Glucuronidase producing group G Streptococcus and Staphylococcus aureus were found in the bile, the gallbladder wall, and the liver. In another trial similar gallstones were produced in four of eight dogs after mere injection of beta-glucuronidase producing Escherichia coli into the spleen resp. in six of eight dogs after injection of E. coli into the colon without ligature of the cystic duct. In an additional series gallstones were produced in six dogs after injection of beta-glucuronidase producing E. coli into the colon plus ligature of the cystic duct. The injected strain of E. coli was found in the bile, the gallbladder wall, the liver, and even within the produced gallstones. In a control group in none of six dogs gallstones were present. beta-Glucuronidase producing group G Streptococcus was found in the gallbladder of one dog, Pseudomonas aeruginosa was found in the gallbladder of another dog and Staphylococcus aureus in the liver and gallbladder wall of a third dog. We conclude from our experiments that merely bacterial infection of the biliary tract can lead to gallstone formation. The bacterial colonization of the liver and the biliary tract is promoted by biliary tract obstruction. beta-Glucuronidase producing bacteria increase the amount of beta-glucuronidase in the bile thus leading to calcium bilirubinate precipitation and gallstone formation by deconjugation of bilirubindiglucuronide.

Intrahepatic stones: the Taiwan experience

From 1970 to 1979, 95 patients with intrahepatic stones were seen. Since 1974, however, the annual rate of cases has been only half that of the previous decades. Patients with this disease are young; onset of symptoms in over a third of the patients occurred before 20 years of age and in 14 patients before 15 years. Average length of time between onset of symptoms and definitive diagnosis was 8.3 years. Southeast Asian stones are multiple, soft, muddy, pigmented, and located in the primary and secondary biliary radicles (particularly in the left hepatic lobe). Transhepatic cholangiography is the best diagnostic maneuver. Many procedures have been tried but no one procedure is entirely satisfactory. Previously unoperated patients (44) had cholecystectomy and exploration of the common bile duct. Patients whose stones recurred after exploration needed reoperation after an average of 2.5 years; patients whose stones recurred after cholecystectomy were seen an average of 5.7 years later, and 11 of 18 were treated medically. The mortality rate was surprisingly low.

Clostridium perfringens and other anaerobes isolated from bile

Clostridium perfringens was isolated from bile in 13 cases of 150 patients examined. The serotypes of C perfringens strains isolated from bile and faeces were investigated using antisera to Hobbs' type 1-17. Two or more serological types were often found in a single specimen, but in the same patient the serotypes of C perfringens strains isolated from the bile were identical with those from the faeces. Beta-glucuronidase production in these C perfringens serotypes was tested with the API-Strep system. Strains agglutinated with Hobbs' antisera produced beta-glucuronidase, but non-agglutinated strains did not.

Gallbladder epithelial acid hydrolases in human cholecystitis

The lysosomal enzymes beta-glucuronidase and acid phosphatase were studied in 112 patients with cholecystitis. Acid phosphatase activity was generally lower in patients with cholesterol stones compared with cases with pigment stones. beta-glucuronidase activity was higher in acalculous cholecystitis than in any other group, a fact compatible with the concept that in lithiasis the enzyme is secreted into the bile and therefore may participate in nidus formation. Histochemistry at light microscopical level clearly demonstrates the lysosomal distribution of these enzymes and their presence in the macrophages infiltrating lamina propria in cholesterolosis. Electron histochemistry in 45 patients showed acid phosphatase activity in lysosomes and some in mucous droplets. Thiamine pyrophosphatase activity, a marker for the Golgi system, showed a close association with these mucous droplets. The secretion of mucus will be accompanied by a secretion of acid phosphatase, and by implication other acid hydrolases, into the bile.

Pigment gallstone disease: Summary of the National Institutes of Health--international workshop

This report summarizes the proceedings of the first National Institutes of Health--International Workshop on Pigment Gallstone Disease. The meeting held at the University of Pennsylvania in May, 1981 consisted of eight sessions in which the following aspects of pigment gallstone disease were discussed: (a) classification; (b) epidemiology; (c) radiographic assessment; (d) gallstone composition; (e) composition of bile; (f) pathogenesis; (g) animal models, genetics, and computer analysis, and (h) medical treatment. The interaction of participants interested in various aspects of pigment stone disease was stimulating. This workshop should be a major stimulus for future studies in this relatively neglected, but important area of biliary tract lithiasis.

The composition of biliary calculi in patients with juxtapapillary duodenal diverticula

Biliar calculi from 32 patients with juxtapapillary duodenal diverticula were analyzed by quantitative infrared spectroscopy. In 22 of the patients the calculi were classified as pigment stones and in 10 as cholesterol stones. Calcium bilirubinate was the main component in the pigment stones, with a median value of 45%; the median cholesterol content was 7.5%. In the cholesterol stones median calcium bilirubinate content was 1% and median cholesterol content 95.5%. Calcium carbonate was found in small amounts in only nine of the calculi. The findings support our theory that the pigment calculi in patients with juxtapapillary diverticula are caused by ascending infections to the bile ducts with intestinal beta-glucuronidase-producing bacteria. Beta-glucuronidase will split the conjugated bilirubin in bile into glucuronic acid and unconjugated bilirubin, which in turn combine with calcium to form insoluble calcium bilirubinate.

Lipids of pigment gallstones

The lipids of pigment gallstones were analyzed. In contrast to previous reports, pigment stones were found to contain a wide variety of free fatty acids. In addition, pigment stones contained unhydrolyzed phospholipids. Both free fatty acids and phospholipids were present in much higher concentrations in a brown stone obtained from a patient with a biliary tract infection than in a black stone obtained from a patient with sterile bile and a long-standing hemolytic anemia. However, the phospholipids in both kinds of stone consisted primarily of phosphatidylcholine. Separation of stone and bile phosphatidylcholines into their individual molecular species by high performance liquid chromatography indicated that the phosphatidylcholines in stones closely resemble those in bile. The data suggest that both the free fatty acids and the phosphatidylcholine of pigment stones derive from bile phosphatidylcholine, but that the extent of bile phosphatidylcholine participation in pigment stone formation may be variable.

Recurrent biliary calculi: duodenal diverticula as a predisposing factor

Several studies indicate a causal relationship between duodenal diverticula and gallstone disease. The diverticula persist after biliary tract surgery, and it is therefore presumed that patients with diverticula have an increased disposition to develop new calculi in the bile ducts after cholecystectomy. To test this hypothesis, the occurrence of recurrent biliary calculi was studied in 101 patients who had cholecystectomy, all with an asymptomatic period of two years or more following the primary biliary surgery. All patients had symptoms, that indicated biliary tract or pancreatic diseases. The incidence of recurrent calculi in patients with diverticula was 87.5% (95% confidence interval, 66.9-95.8). In patients without diverticula, the incidence was 31.9% (95% confidence interval, 21.5-44.3). The difference is highly significant, and the results support the assumption tht diverticula in the area of the papilla of Vater dispose to gallstone disease.

Intrahepatic periductal glands and their significance in primary intrahepatic lithiasis

Resected hepatic tissues of 24 patients with primary intrahepatic lithiasis were examined histo-pathologically. Calcium bilirubinate stones, cellular debris and mucinous substances occupied the lumen of large dilated intrahepatic bile ducts. Numerous mucin secreting glands were seen within or around the wall of these bile ducts. Similar structures were demonstrated in two patients with non calculous congenital dilatation of the intrahepatic bile ducts. Cholestasis was often absent in the hepatic parenchyma. Production of intrahepatic gallstones may be caused by not only biliary stasis and infection, but also by intraductal mucin and slow flowing bile in combination with cellular debris, bile pigment and other bile components.

Bacteria and gallstones. Etiological significance

Two hundred consecutive gallstone cases have been subjected to bacteriological study employing improved anaerobic culture techniques. In addition to Clostridia species, species of anaerobes such as Bacteroides fragilis, Peptococcus, Veillonella, and Eubacterium are found to be present, some of which possessed beta-glucuronidase activity. This finding has a certain bearing on the etiology of bile pigment calcium stones. In addition to Escherichia coli, Bacteroides and Clostridium often found in the biliary tract may contribute to the formation of bile pigment calcium stones by producing beta-glucuronidase and thus deconjugating bilirubin diglucuronide to form free unconjugated bilirubin which in turn combines with calcium, leading to stone formation. In contrast, very low bacterial incidence was associated with cholesterol stones and so-called black stones--sometimes called pure pigment stones--and thus bacteria play little role, if any, in their formation. Therefore, bile pigment calcium stones and so-called black stones, which are often classified as pigment stones indiscriminately, should be differentiated not only because of their difference in their appearance and composition but also in their etiological background. Regardless of the kind of stones present in the common duct, the incidence of bacteria was found to be increased.

Sludge is calcium bilirubinate associated with bile stasis

Biliary sludge is a frequent finding on abdominal sonography. It is most often found after prolonged stasis of gallbladder bile associated with other illness or mechanical obstruction of the common duct, and seldom indicates primary gallbladder disease. In most cases, sludge is a suspension of pigment precipitates in bile, and is at least in part calcium bilirubinate. Sludge may disappear with the return of normal gallbladder contractility. The ease with which this precipitate forms during stasis of gallbladder bile suggests a role for this process in the pathogenesis of cholelithiasis.

Biliary pigment and cholesterol calculi in patients with and without juxtapapillary duodenal diverticula

The occurrence of pigment and cholesterol calculi was studied in 45 patients with concrements in the gallbladder but no calculi in the common or intrahepatic bile ducts. Twenty-one of the patients had juxtapapillary duodenal diverticula diagnosed by duodenoscopy. Twenty-four patients had no diverticula. The classification of the calculi as pigment stones or cholesterol stones was based on quantitative determination of the cholesterol contents. Calculi with a cholesterol content of less than 25% were classified as pigment stones; calculi with a cholesterol content of more than 25% were classified as cholesterol stones. All pigment stones had a cholesterol content of less than 20%. With the exception of four patients the cholesterol content was over 70% in all cholesterol stones. Twelve of the 21 patients with were classified as pigment stones; calculi with a cholesterol content of more than 25% were classified as cholesterol stones. All pigment stones had a cholesterol content of less than 20%. With the exception of four patients the cholesterol content was over 70% in all cholesterol stones. Twelve of the 21 patients with were classified as pigment stones; calculi with a cholesterol content of more than 25% were classified as cholesterol stones. All pigment stones had a cholesterol content of less than 20%. With the exception of four patients the cholesterol content was over 70% in all cholesterol stones. Twelve of the 21 patients with diverticula had pigment stones, whereas only 1 of the 24 patients without diverticula had pigment calculi, a difference that was statistically significant (p less than 0.01).

Surgical significance of dilatation of the common bile duct--with special reference to choledocholithiasis

Diameter of the common bile duct was measured in 3,119 patients who underwent primary operation for gallstones, during the period from 1975 to 1978. Although dilatation of the common bile duct was most marked in patients with bilirubin stones in the bile duct alone, dilatation was also observed in patients with cholesterol stones in the gallbladder alone. Drip infusion cholangiograms of 84 healthy patients showed that the common bile duct dilated in parallel with aging. A review of patients with congenital choledochal cysts reported in the literature in Japan revealed that few had gallstones. Thus, it was difficult to determine whether common bile duct dilatation was the cause or result of gallstones, and it was suggested that the so-called drainage operation such as choledochoenterostomy should be done only under strict indications.

Recurrent pyogenic cholangitis: a necropsy study

Forty-six necropsy cases of recurrent pyogenic cholangitis (RPC) among Chinese in Hong Kong were reviewed. Intrahepatic biliary pigment stones or bile sludge were present in all cases and liver abscesses were common (80%). Histologically the early lesion was marked by acute inflammation in portal tracts with frequent pylethrombophlebitis and the advanced chronic lesion by periductal fibrosis. Most patients died from chronic persistent hepatic suppuration or disseminated infection. The pathogenesis is not fully understood; the present study favours the view that a protein-deficient diet initiates intrahepatic stone or sludge formation with biliary obstruction; subsequent bacterial infection probably originates from the portal system.

Glucuronidation of bilirubin and the occurrence of pigment gallstones in patients with chronic haemolytic diseases

A group of thirty-seven patients with increased haem catabolism has been studied to gain insight in their bilirubin conjugating capacity. Bilirubin UDP-glucuronyl transferase activity (GlcATa) in the liver and bilirubin monoconjugates in bile were measured and the hepatic bilirubin clearance was calculated from the radio-chromium-survival data. In the present group, 41% of the patients clearly had a deficiency in bilirubin conjugation similar to what is classically found in Gilbert's syndrome. The association may facilitate detection of these patients as serum bilirubin levels were higher (65.8 microM +/- 19) (m +/- 1 SD) in the fifteen patients with associated Gilbert's syndrome versus thirteen having only haemolysis (43.6 microM +/- 15). A fair correlation was found between the percentage of monoconjugates in bile and the GlcATa levels in the liver as well as with the calculated hepatic bilirubin clearance, although some discrepancies exist. Using these determinations, a clearcut separation from normal values was not obtained, suggesting at least in the present group of patients that Gilbert' syndrome represents only one end of a continuum of bilirubin conjugation rates and not a separate entity. Pigment stones in the gall-bladder were documented in 51% of the patients and usually at an early age. There was no relationship towards sex, serum bilirubin, GlcATa in liver, total bilirubin or monoconjugates in bile. Age played some role as well as the type of haemolysis as all patients with congenital dyserythropoiesis (n = 4) or acquired haemolysis (n = 3) had lithiasis. Moderate chronic cholecystitis was present, whereas an accumulation of iron and bile pigment was evident in the liver.

Further observations in lincomycin-induced cholelithiasis in guinea-pigs

Further experiments are reported on Lincomycin-induced cholelithiasis in guinea-pigs. The biochemical events in the bile and blood, and the chemical composition of gallstones, have been studied. The gallstones resemble human pigment stones in chemical composition. The clear hepatic bile and the normality of the bile salt--phospholipid--cholesterol equilibrium, the rise in beta-glucuronidase and hexosamine levels with the gallbladder, have reaffirmed that epithelial injury is most probably the primary lithogenic factor. Ligation of the cystic duct and the construction of a common hepatic duct-duodenum bypass did not prevent the development of acute cholecystitis, suggesting the lithogenic factor was mediated through the blood circulation and not through the enterohepatic circulation of bile.

Hepatolithiasis in Japan: present status

Intrahepatic gallstone or hepatolithiasis is one of the most difficult conditions encountered by surgeons in daily practice. A nationwide survey was conducted recently to document the state of hepatolithiasis in Japan and to establish proper methods of treatment. Over 160 institutions participated and 1,590 cases were collected. The stones were mostly of the bile pigment calcium stone variety and were found mainly in the left hepatic duct. The incidence was found to differ considerably from area to area. Pathologic features, diagnostic procedures and treatments currently available for hepatolithiasis are discussed.

Studies of the choledocho-duodenal sphincter in patients with and without juxta-papillary duodenal diverticula

The function of the choledocho-duodenal sphincter was studied in 16 patients, 8 with juxta-papillary duodenal diverticula. All patients had calculi in the gallbladder. The common bile duct was normal. At cholecystectomy two catheters were introduced into the common bile duct through the stump of the cystic duct and fixed in place. The examinations were performed when the patients had recovered from the operation. One catheter was connected to a pressure transducer, the other was used for saline infusions. Pressure in the common duct was recorded before infusion and at constant infusion rates of 3,6, and 12 ml/min. The muscular tone, the contractile activity, and the total rhythmic variations of the sphincter during infusions were all significantly less in patients with diverticula than in the controls without diverticula. The findings indicate that there is a dysfunction of the choledochoduodenal sphincter in patients with juxta-papillary duodenal diverticula. This may in part be responsible for the high incidence of biliary calculi in patients with duodenal diverticula.

Correlation of cholesterol and bilirubin solubilization in bile salt solution

Not only cholesterol but also bilirubin were considered to be solubilized by bile salt micelles. The correlation of cholesterol and bilirubin solubilization in aqueous conjugated and unconjugated bile salts solution and the effect of calcium on their solubilization were studied in this report. Cholesterol solubilization was usually reduced to some extent with increasing amount of added bilirubin. Bilirubin solubilization was always reduced by the co-existence of solubilized cholesterol. It was found that the addition of calcium increased cholesterol solubilization in conjugated bile salts system. On the other hand, calcium reduced bilirubin solubilization due to the formation of insoluble calcium bilirubinate especially in a high pH range of unconjugated bile salts system. Cholesterol solubilization in conjugated bile salts system was relatively lower than unconjugated bile salts system with or without added calcium, however co-existing bilirubin minimized these differences. The pH-dependency of cholesterol and bilirubin solubilization was small in conjugated bile salts system. On the contrary, it was remarkably bigger in unconjugated bile salts-calcium system.

Cholelithiasis. Review of advances in research

Cholelithiasis is now known to result from multiple causes and to have distinct clinical correlates. New knowledge about its pathophysiology and relationship to altered hepatic metabolism, the enterohepatic circulation, and gallbladder function has led to theories of prevention and to medical methods of treatment, including dissolution of stones by bile acid therapy.

[Causes, shape and chemistry of gallstones]

Gallstones are precipitations of oversaturated bile fluid. They can develop in the gallbladder and in the efferent bile ducts; they are very often correlated with diseases of the gallbladder, bile ducts and neighboring organs. The gallstone disease (cholelithiasis) is increasing continually, especially in developed countries with overcaloric nourished population. Surgical interventions on the biliary tract are the most frequent abdominal operations at present.

Black pigment stone in a male child aged two years and seven months

A case of cholelithiasis is reported occurring in a boy aged two years and seven months. The patient presented with biliary colic, and cholecystectomy was performed. Detailed analysis of the stone, including electron-probe studies, showed it to be an example of a polybilirubinate stone, containing also calcium, carbonate, and phosphate, with some sulphur, sodium, and magnesium. There were also traces of chlorine, aluminium, copper, nickel, and manganese.

Recurrent common duct stones, with special reference to primary common duct stones

A series of 1,358 cholelithic patients operated on at 32 affiliated hospitals during the last year and 492 patients operated on at authors' hospital during the last 21 years were reviewed with special reference to the cases of recurrent common duct stones. Of the former series 15 patients and of the latter series 12 patients respectively were reoperated on for recurrent, but not for residual, common duct stones, and all of them had in the markedly dilated common duct bilirubin stones showing characteristics of stasis stone-primary in common duct. Two representative cases are presented briefly. Congenital hypotonia of the common duct and inflammatory choledochitis are condemned and bilioenterostomy is recommended for preventing stone recurrences.

Present features of gallstones in Japan. A collective review of 2,144 cases

A collective review of 2,144 patients operated on for cholelithiasis during the last twenty-two months has shown that younger Japanese adults have predominantly cholesterol stones in their gallbladders and that elderly persons still frequently have bilirubin stones not only in their gallbladders but also in their common bile ducts. Recent westernization of dietary habits in Japan is considered to be the most probable factor causing the increased incidence of cholesterol stones. The decreased incidence of bilirubin stones is considered to be caused by the decreased incidence of biliary infection and increased intake of proteins in food.

Bacterial contamination of the biliary tree after choledochostomy

Secondary exogenous contamination of bile after choledochostomy could be an important cause of long-term morbidity if infection persists after removal of the T tube. Surprisingly, documentation of the frequency of conversion of sterile to infected bile after choledochostomy has rarely been recorded. Patients undergoing exploration and T-tube drainage of the common bile duct between July 1966 and January 1975, in whom intraoperative and postoperative cultures of bile were available, were studied. Postoperative cultures were obtained from five to forty days after operation. Of ninety-five patients available for study, contamination developed postoperatively in previously sterile bile in 44 per cent. The common duct bile contained bacteria at operation in 42 per cent and remained sterile throughout in 14 per cent. The most common secondary contaminants were klebsiella group and Escherichia coli. The fate of the contaminating organisms in a biliary tree without anatomic abnormalities is unknown. Two cases are presented which suggest that persistent infection may linger in the biliary tree for many years and give rise to pigment calculi. Since bacterial cannot be eradicated so long as a foreign body remains in the common duct and because such bacteria may cause symptoms even in an anatomically normal biliary tree, we suggest that a closed system of biliary drainage be employed and that appropriate antibiotic therapy be instituted for seven to ten days after removal of the T tubes.

Congenital cystic dilatation of the common bile duct as a cause of primary bile duct stone

Of the 101 patients with congenital cystic dilatation of the common bile duct, eighty-eight with adult-type cysts are reported on. The association of primary bile duct stone and adult-type cyst of this anomaly is discussed and found to be higher than previously recognized. In the cases without calculi, abnormal arrangement of the pancreaticobiliary ductal system is indicated to play an important role in the manifestation of the symptom. The anatomic and clinical features and the results of treatment for this type of cyst are reviewed.

Pigment vs cholesterol cholelithiasis: clinical and epidemiological aspects

This prospective study demonstrated that among 92 consecutive patients who underwent cholecystectomy for gallstones at an urban university hospital, 27% had pigment stones and 73% had cholesterol stones. Age, sex, and weight, but not race, were significant determinants of stone type. The mean hemoglobin, direct and total serum bilirubin, and fasting glucose concentrations were similar for each group. The presence of alcoholism, diabetes, thyroid disease, or heterozygous hemoglobinopathy did not influence stone type. The average patient with pigment stones is a lean man or woman 63 years old; in contrast the composite patient with cholesterol stones is a modestly overweight woman 43 years old.

Regulation of cholesterol metabolism in the dog. II. Effects of complete bile diversion and of cholesterol feeding on pool sizes of tissue cholesterol measured at autopsy

In six adult pedigreed dogs the effects of high-cholesterol diets or bile diversion on the sizes of body cholesterol pools were studied at autopsy. Total body cholesterol was determined by measuring the cholesterol content of discrete organs and of the eviscerated carcass: neither cholesterol feeding nor bile diversion had altered total body cholesterol or the cholesterol content of individual organs and tissues. These results validated the conclusion based on sterol balance data obtained during life, that high-cholesterol feeding did not lead to substantial expansion of tissue cholesterol pools. THE TOTAL AMOUNT OF EXCHANGEABLE CHOLESTEROL IN THE ANIMALS WITH AN INTACT ENTEROHEPATIC CIRCULATION, WHEN ESTIMATED FROM ISOTOPIC DATA, WAS ESSENTIALLY THE SAME AS THAT MEASURED CHEMICALLY: this indicated that there was little or no nonexchangeable cholesterol in these dogs, except in skin and nervous tissue, regardless of the cholesterol content of the diet. This correspondence of estimates was not obtained in the bile-diverted dogs: we propose that the defect in the isotopic estimates was due to the accelerated rate of cholesterol synthesis in these animals. Gross and microscopic morphology of all organs and tissues was examined. Abnormal findings were limited to the biliary tract and the urinary collecting system of the two bile-diverted dogs: multiple bilirubinate gallstones were found, and mild pyelitis and ureteritis were present on the side of the bilio-renal shunt, but the urinary bladder was normal. Histologic evidence of moderate degree of cholangitis was found in one of the two bile-shunted dogs, but in neither dog was there evidence of impedance of bile flow.