Gall stone recurrence and its prevention: the British/Belgian Gall Stone Study Group's post-dissolution trial

The British/Belgian Gall Stone Study Group (BBGSG) post-dissolution trial was a prospective, multicentre, randomised, double blind trial of: (i) low dose ursodeoxycholic acid, (ii) placebo, and (iii) a high fibre, low refined carbohydrate diet in the prevention of gall stone recurrence in patients with complete gall stone dissolution. Further aims included establishing the timing and frequency of recurrence and its association with biliary symptoms, a comparison of the sensitivity of ultrasonography v oral cholecystectography in detecting recurrent stones, and a search for risk factors predicting recurrence. Ninety three patients entered the study, and 82 were followed up for up to five years (mean (SEM) 28 (1.5) months) with six monthly ultrasonography and yearly oral cholecystectography. There were 21 recurrences (26 by oral cholecystectography or ultrasonography, or both), only two of which were symptomatic, which were detected between 12 and 42 months after trial entry. This corresponded to an actuarial recurrence rate of 33.9 (7.0%) by lifetable analysis at 42 months and subsequently. There were four recurrences in the ursodeoxycholic acid, six in the placebo, and 11 in the diet groups, corresponding to 21.9 (9.9)%, 27.4 (10.1)%, and 45.8 (12.4)% respectively at 42 months by lifetable analysis (NS). Variables including age, obesity, menopausal state, pregnancy, and oestrogen containing drugs were not shown to affect recurrence rate. Men had more frequent recurrence than women (NS). Patients who had had multiple stones experienced more recurrences than did those with single stones (NS). Recurrence did not occur in patients who took non-steroidal anti-inflammatory drugs (NSAIDs) (p < 0.02). The stone free interval between stone dissolution and trial entry proved to be important--those stone free > nine months had a recurrence rate of only 12.7 (6.0)% at 42 months compared with 55.4 (12.5)% in those stone free < nine months (p < 0.01). There was imbalance between the ursodeoxycholic acid and placebo groups for this factor, and after applying a statistical correction, the adjusted recurrence rate in the ursodeoxycholic acid group was 15% compared with 30% in both placebo and diet groups (NS). These data suggest that after medical dissolution, the risk of gall stone recurrence is not reduced by a high fibre, low refined carbohydrate diet: it may be lowered, but not abolished, by low dose ursodeoxycholic acid.

Final outcome of ursodeoxycholic acid treatment in 126 patients with radiolucent gallstones

One hundred and twenty-six patients with radiolucent gallstones in 'functioning' gallbladders were treated with 8-10 mg ursodeoxycholic acid (UDCA) kg/day and followed to a treatment conclusion. Complete or partial gallstone dissolution was achieved in 74 (59 per cent). However, only 22 achieved complete gallstone dissolution, as judged by two normal oral cholecystograms; ultrasonograms were performed in 16 of these patients, and all were normal. UDCA was stopped in 76 patients: because of cystic duct obstruction (n = 12), severe biliary pain (n = 13), non-response (n = 25) or partial stone dissolution with arrested progress (n = 26). Life-table analysis showed that complete gallstone dissolution rates at four years were 25-30 per cent (two normal oral cholecystograms) and 17-19 per cent (two normal oral cholecystograms plus one ultrasonogram). All patients with complete gallstone dissolution had shown partial stone dissolution at 6-12 months; of those with partial stone dissolution at six months, only 25 per cent went on to complete gallstone dissolution, and then always within two years. Efficacy correlated inversely with stone size but not with age, sex, obesity or on-treatment saturation indices. Acquired surface gallstone calcification developed in 13 patients (life-table analysis 22 +/- 7 per cent at four years); none of these patients achieved complete gallstone dissolution and only five achieved partial stone dissolution. Thus, despite relatively high partial gallstone dissolution rates, the ultimate efficacy of UDCA in achieving complete gallstone dissolution is low.

Prevention of gallstone recurrence by non-steroidal anti-inflammatory drugs

In laboratory animals, non-steroidal anti-inflammatory drugs (NSAIDs) are reported to inhibit diet-induced gallstone formation. To see if these drugs had a similar effect in man, 82 patients who had taken part in a comparison of ursodeoxycholic acid, placebo, and diet for prevention of gallstone recurrence were sent questionnaires about their use of NSAIDs during the period of the trial. 75 replied. After a mean follow-up of 33 (SEM 4) months none of the 12 regular users of NSAIDs had had gallstone recurrences, compared with 20 of the 63 who never or rarely used these drugs (p less than 0.02).

Gall stone disease without gall stones--bile acid and bile lipid metabolism after complete gall stone dissolution

Although bile acid and bile lipid metabolism have been studied in established cholelithiasis, little is known about them in patients destined to develop gall stones, but in whom the stones have not yet appeared (prestone gall stone disease). After confirmed complete gall stone dissolution and withdrawal of treatment, gall stones recur frequently. Before the stones reappear, these patients have 'poststone gall stone disease'. In 13 such patients we confirmed complete gall stone dissolution with two normal cholecystograms and in 11 of the 13 by normal ultrasonography, measured bile acid and bile lipid composition in fasting duodenal bile, bile acid synthesis from marker corrected three day faecal bile acid excretion, bile acid pool size using an abbreviated isotope dilution technique, 'steady-state' bile lipid secretion using a duodenal amino acid perfusion system and then calculated the enterohepatic cycling frequency of the bile acid pool and the relationship between pool size and body weight. The results confirm that after withdrawal of treatment the biliary cholesterol saturation index reverts to levels (1.6 +/- SEM 0.4) comparable with those before dissolution therapy first began (1.6 +/- 0.2; NS). The mean bile acid pool size in the 13 patients of 4.4 +/- 0.5 mmol was comparable with that in untreated gall stone patients. Pool size was significantly smaller in the nine non-obese patients (3.5 +/- 0.3), than in the four obese (6.0 +/- 0.8; p less than 0.05). It also correlated significantly with body weight (r = 0.72) and with %IBW (r = 0.79). The coefficients of variation for biliary bile acid, phospholipid and cholesterol secretion were high, but the mean hourly secretion rates were of the same order as those seen in untreated gall stone patients studied with the amino acid duodenal perfusion stimulus. These results provide a baseline for assessing the response to postdissolution treatment and may indicate metabolic events leading to gall stone formation.

Discrepancies between cholecystography and ultrasonography in the detection of recurrent gallstones

As part of the British Gallstone Study Group's multi-centre post-dissolution trial of different treatment regimes designed to prevent recurrence after complete gallstone dissolution, the frequency of concordance and discordance between oral cholecystography (OCG) and ultrasonography (U/S), and between repeat U/S studies, in diagnosing recurrent stones was recorded. Before entering the trial, all patients had had complete gallstone dissolution, confirmed by 2 normal OCGs 3 months apart during continued bile acid treatment; and all but three had also had at least 1 normal U/S examination of the gallbladder. During 6-24 months follow-up, from a total of 129 U/S examinations, gallstone recurrence was detected on 25 occasions (19 definite and 6 probable) in 14 patients, and from a total of 71 OCGs, recurrent stones were detected on 11 occasions in 10 patients. All the presumed recurrences developed in the absence of symptoms. On 67 occasions, the OCG and U/S studies were performed within 8 weeks of each other and of these, there was discordance in 15 (22%). On 11 occasions (6 patients), ultrasound suggested recurrent stones despite a normal OCG whilst on 4 occasions (4 patients) stones diagnosed on OCG were not confirmed by ultrasound. Of the 25 instances of U/S recurrence, a further U/S examination was performed on 17 occasions in 11 patients which failed to confirm the initial findings on 8 occasions (7 patients). After 1 year's follow-up, the predicted recurrence rates (pooled data from all 3 treatment groups), as calculated by life table analysis, were 29.3 +/- 7.1%, when the diagnosis was based on 1 U/S; 15.4 +/- 5.8% on 1 OCG; 14.9 +/- 5.6% on 2 successive U/S studies, and 8.1 +/- 4.5% on 1 U/S plus 1 OCG. At 24 months, the corresponding values were 37.2 +/- 8.3, 31.5 +/- 8.6, 18.3 +/- 6.3, and 22.4 +/- 8.6%. These results show that following complete gallstone dissolution by bile acid treatment, there is both intra- and inter-technique variation in the detection of recurrent stones.

Cimetidine reduces the risk of rebleeding from duodenal ulcers displaying signs of recent haemorrhage

The presence of endoscopic signs of recent haemorrhage (SRH) greatly increases the risk of rebleeding from peptic ulcers. Fifty-five patients with acute bleeding from chronic duodenal ulcers with SRH completed a randomized double-blind trial to assess the effect of administration of cimetidine (800 mg daily intravenously for 2 days, then 1000 mg daily orally for 10 days in divided doses) versus placebo on rebleeding and need for emergency surgery. In the cimetidine group (n = 29), 5 rebled, compared with 11 receiving placebo (n = 26) (p less than 0.05; relative risk, 0.28, 95% confidence interval, 0.08-0.97). This reduction in rebleeding rate in the cimetidine-treated patients was observed only in subjects over 60 years of age. Fifteen patients receiving cimetidine required blood transfusion (mean, 2.3 +/- 0.6 (SEM) units per patient) compared with 19 receiving placebo (3.5 +/- 0.5) (p greater than 0.1). Emergency surgery to arrest bleeding was required in three patients receiving cimetidine and four receiving placebo (p greater than 0.5). Cimetidine therapy should be considered in patients more than 60 years old who present with haemorrhage from a chronic duodenal ulcer with SRH and who are at high risk of rebleeding.

Value of serum gamma-glutamyltransferase activity in the diagnosis of hepatobiliary disease

Serum gamma-glutamyltransferase activity (GGT) has been measured in 150 patients with a variety of hepatobiliary disorders. GGT concentration was significantly higher in patients with "cholestatic" liver disease than in those with "hepatic" disorders, although there was considerable overlap. Measurement of GGT alone did not allow differentiation of intrahepatic cholestasis from extrahepatic cholestasis. However, GGT/serum bilirubin ratios were significantly higher in patients with intrahepatic cholestasis when compared with patients with extrahepatic biliary obstruction. Estimation of serum concentration of GGT appears to be a sensitive screening test both for alcohol consumption and for hepatobiliary disease. However, measurement of GGT concentration has only limited value in the differential diagnosis of hepatobiliary disease, although it may help in the differentiation of "hepatitic" and "cholestatic" liver disease.

Is recurrence inevitable after gallstone dissolution by bile-acid treatment?

Gallstone dissolution was observed on 60 occasions in 54 patients; in 6, recurrent stones were dissolved by a second course of medical treatment. When complete gallstone dissolution was confirmed (by two consecutive cholecystograms, 3 months apart) bile-acid treatment was stopped, and the patients were followed for up to 71/2 years with oral cholecystograms taken annually (or sooner if symptoms suggested early recurrence). Recurrence was detected 30 times after the 60 episode of gallstone dissolution (50%), in 25 of the 54 patients (46%), and in 25 of 46 patients who had had at least one post-dissolution X-ray before recurrence (54%). In 21 of these 25 patients (84%) the recurrence was observed within 2 years of treatment being stopped. There were no significant differences in clinical details and pre-treatment gallstone characteristics between the 25 gallstone-recurrent (at any time) and the 29 gallstone-free (at the time of study) patients, nor between a subgroup of patients in whom recurrent stones developed rapidly (less than or equal to 1 year) and a subgroup who remained gallstone-free for 3 years. It is concluded that long-term follow-up is advisable and that post-dissolution treatment will be necessary to prevent gallstone recurrence.