Brides of quietness: silent gall stones

Contribution of silent gallstones in gallbladder cancer

Silent (asymptomatic) gallstones are detected frequently with the widespread use of abdominal ultrasonography. The presence of gallstones is found strongly associated with gallbladder carcinoma. Studies on the natural history and most decision analysis studies do not favor prophylactic cholecystectomy for patients with silent gallstones. Gallbladder carcinoma is known to be highly aggressive and lethal disease with a poor outcome. It is rarely diagnosed early and only 10-30% patients are offered radical surgery on presentation. This has lead to a dilemma leading most surgeons to opt for an expectant management of silent gallstones. It thus raises the important question of the implications of leaving asymptomatic gallstones untouched. In this paper the author has reviewed the current understanding on silent gallstones and gallbladder carcinoma.

Effects of cholecystectomy on gastric emptying and myoelectrical activity in man

To investigate the effects of cholecystectomy on gastric motor function, 13 patients with symptomatic gallstones were studied before and 8-12 months after surgery. Twelve healthy subjects entered the study as control group. The cutaneous electrogastrography and ultrasound examination of gastric emptying were simultaneously performed at pre- and post-prandial states. The dominant gastric frequency and its coefficient of variation were not affected by surgery. After cholecystectomy, an increase in normal 3 cpm wave percentage and a decrease in power ratio were found (P < 0.05 and P < 0.01, respectively). Gastric emptying recorded after cholecystectomy was faster than before surgery (306.9 +/- 15.9 min vs 336.9 +/- 11.8 min, respectively; P < 0.05). Such changes were associated with the relief of symptoms, and the comparison between patients and controls showed a normalization of the gastric electrical activity and gastric emptying after surgery. In conclusion, in symptomatic patients, gallstones are associated with motor dysfunctions, and cholecystectomy seems to induce a normalization of gastrointestinal motility.

Appropriateness of cholecystectomy in the United Kingdom--a consensus panel approach

A consensus development approach was used to assess the extent to which doctors in the UK agreed about the appropriate indications for cholecystectomy. Two panels, one composed entirely of surgeons and one containing a mix of relevant specialists, were asked to rate a series of possible indications. A consensus was achieved for 61% (surgical panel) and 67% (mixed panel) of indications considered. The surgical panel considered more indications as being appropriate for cholecystectomy (29% v 13%) and fewer indications as being inappropriate (27% v 50%) than the mixed panel. For between one third and a half of all indications, the panels were unable to reach agreement, partly as a result of differences in views as to the role of endoscopic sphincterotomy.

Influence of cholecystectomy on symptoms

A group of 292 consecutive patients underwent cholecystectomy for gallstones with presumed biliary pain over a 4-year period and all completed a self-assessment questionnaire before operation. Over the following 2 years 18 patients died but no others were lost to follow-up. The remaining 274 patients completed a further questionnaire 1 and 2 years after operation. Demographic characteristics and abdominal symptoms have been compared with an age- and sex-matched control group using the same questionnaire. Before operation symptoms of flatulent dyspepsia were far more frequent in patients with gallstones but operation markedly reduced these symptoms to an incidence which almost matched that of the control group. However, 1 year after cholecystectomy 34 per cent of patients still suffered some abdominal pain and of 35 patients referred back to hospital for investigation none has been shown to have a retained bile duct stone at a minimum follow-up of 5 years. A multivariate analysis indicated that preoperative flatulence together with long duration of attacks of pain are risk factors for postoperative dissatisfaction as judged by a linear analogue scale. However, both these factors are common and neither is a good discriminator of a poor outcome. The prediction of a poor symptomatic outcome after cholecystectomy from preoperative symptoms or patient characteristics had only limited success and all patients should be warned of this risk.

Do cholecystectomy rates correlate with geographic variations in the prevalence of gallstones?

Two fold variations in the age and sex standardised post mortem prevalence of gallstones have been demonstrated between nine British towns by Barker and his colleagues. We have examined the rates of cholecystectomy in the Districts serving seven of these towns to discover whether the incidence of operation bears any relation to this variation in morbidity. The opportunity to compare independent measurements of morbidity with the supply of health services and their use is rare, and in this example a plausible association is demonstrated. Variations in cholecystectomy rates between countries is, however, more difficult to explain by variations in relevant morbidity.

Ursodeoxycholic acid: a review of its pharmacological properties and therapeutic efficacy

Ursodeoxycholic acid is the 7 beta-hydroxy epimer of chenodeoxycholic acid and is normally present in only trace amounts in the bile. Oral administration of pharmacological doses markedly decreases biliary cholesterol saturation. Complete or partial dissolution of radiolucent gallstones located in a functioning gallbladder occurred in about 40 to 55% of patients treated with ursodeoxycholic acid in controlled studies of 6 months duration. Patients showing partial gallstone dissolution at that time are likely to continue improving possibly to complete gallstone dissolution with continued therapy. The success rate with ursodeoxycholic acid may be increased top about 80% if more stringent patient selection criteria are applied to include only those with non-calcified floating cholesterol stones of less than 10 to 15 mm diameter. Those with calcified stones or stones greater than 15 mm diameter or unlikely to respond to ursodeoxycholic acid therapy. The optimal dose in published studies was about 8 to 10 mg/kg/day, which is about half to two-thirds the dose of chenodeoxycholic acid (15 mg/kg/day) achieving approximately equivalent results. Ursodeoxycholic acid appears to be remarkably well tolerated, with diarrhoea occurring in only a very small proportion of patients. While surgery is clearly the preferred treatment in many patients with symptomatic gallstones, in a carefully selected subgroup of such patients gallstone dissolution therapy with ursodeoxycholic acid offers an important and worthwhile alternative.

Should cholecystography or ultrasound be the primary investigation for gallbladder disease?

The conclusions drawn from a prospective survey of 500 patients examined by cholecystography (OCG) and ultrasound (UCG) are presented. First, both procedures were found to be highly accurate in detecting calculi, with false-negative rates of 1%. Secondly, if OCG is abandoned in favour of UCG, most acalculous adenomyomatosis (and many polyps) will not be diagnosed. If acalculous as well as calculous disease is regarded as clinically important, fluoroscopic OCG is the examination of choice. However, if a clinician wishes solely to find or exclude stones the investigations are equally accurate. Thirdly, since some calculi and some acalculous disease will be missed by either technique, serious consideration should be given to the further investigation of all gallbladders considered normal by either examination. A protocol is described which, though unorthodox, enables a decision on the status of the gallbladder to be made on a single visit to the radiology department.

Management of stones in the biliary tree

Images