Ninety-six patients treated successively for symptomatic cholelithiasis with extracorporeal shock wave lithotripsy (ESWL) and oral bile acid therapy consisting of ursodeoxycholic acid in daily dosages of 600 mg were prospectively followed for gallstone recurrence for a median of 13 months. Ultrasonography was performed to detect stone recurrence at 3, 6, and 12 months, and then yearly after the termination of therapy. Recurrent stones were found in 17 patients (18%). The cumulative probability of gallstone recurrence was 15.8% at 12 months, 26.1% at 24 months, and 30.7% at 36 months. The probability of stone recurrence over the entire period of observation was not dependent on stone number, whereas the median interval to detection of recurrence was significantly shorter in the patients with multiple stones (2 months) than in those with solitary stones (8 months) (p < 0.05). The rate of impaired gallbladder contractility was higher in patients with recurrence (8/15, 53.3%) when compared with those with no recurrence (15/72, 20.8%) (p < 0.01). Neither age, gender, or stone characteristics predicted stone recurrence. Only one patient with a recurrence reported biliary pain. Of the 15 patients with recurrent stones who opted for further nonsurgical treatment, complete stone disappearance was achieved in 10. Impaired gallbladder function may predict gallstone recurrence after ESWL.
Our data suggest that the reduced concentrating function of the gallbladder in elderly gallstone patients helps to counteract stone recurrence despite their abnormal gallbladder motility. Therefore, aged gallstone patients may be preferentially treated by a non-surgical strategy.
Cholesterol crystallization in bile is affected by phosphatidylcholine (PtdCho) hydrophobicity. The aim of the present study was to determine whether PtdCho species modulate the metastable-labile limit and equilibrium solubility of cholesterol in the micellar phase of bile, thereby altering the distribution of cholesterol to biliary lipid carriers and thus influencing cholesterol crystallization. Supersaturated model bile (with a cholesterol saturation index of 2.0 and a total lipid concentration of 10 g/dl) was prepared with various PtdCho/(bile salt+PtdCho) ratios (0.1-0.5) using egg yolk or soya bean PtdCho. Subsequently, the following features were determined: metastable-labile limit, equilibrium solubility of cholesterol, metastable zone, and cholesterol crystallization process. Less hydrophobic PtdCho species destabilized bile cholesterol to induce rapid crystallization, because of a broad integrated metastable zone, whereas more hydrophobic species stabilized bile cholesterol with a less integrated metastable zone and thus retarded cholesterol crystallization. Cholesterol crystallization was accelerated by a decrease in the PtdCho/(bile salt+PtdCho) ratio, whereas the final nucleated crystal mass was increased by an increase in this ratio. With decreasing hydrophobicity of the PtdCho species, the intermixed micellar/vesicular concentration of bile salts decreased in association with less formation of vesicles and increased formation of micelles, and a variety of crystal forms were detected. In conclusion, PtdCho species directly influenced the cholesterol crystallization process in model bile by remodelling the bile mesophase, and also had an indirect influence by altering the balance between bile salt micelles and vesicles.
Biliary components are transported by hepatic adenosine triphosphate-binding cassette (ABC) transporters that are located in canalicular membranes. Physiological transporter function is related to membrane fluidity, which is modulated by the phospholipid composition of the lipid bilayer. We hypothesized that cholestasis may alter transporter function by modifying phospholipid species to protect the cell from cholestatic damage. Therefore, we examined the expression of ABC transport proteins and their mRNA levels in canalicular membrane vesicles isolated from rat liver 6 hr or three days after bile duct ligation. Membrane lipid composition and membrane fluidity of both sinusoidal and canalicular membrane vesicles were also examined. By 6 hr after bile duct ligation, we found a clear increase of mdr2 and bsep mRNA. These changes were associated with an increase of mdr-Pgp and with a clear decrease of mrp2 protein, and small decrease of bsep protein. In addition, mdrlb mRNA showed a strong increase by three days after bile duct ligation. Canalicular membrane fluidity decreased in a marked time-dependent manner, whereas sinusoidal membranes showed biphasic changes: increased fluidity at 6 hr and a decrease at three days. These changes were closely related to the changes of membrane lipid constitution; the saturated/unsaturated fatty acid ratio increased for phosphatidylcholine in canalicular membrane and the reverse occurred in sinusoidal membrane, and those for sphingomyelin showed the opposite pattern. We conclude that cholestasis causes modulation of ABC transporters as well as that of the lipid constitution in lipid bilayer. These may confer cytoprotective resistance to hepatocytes against cholestatic stress.
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