Cholecystolithiasis: Lithotherapy for the 1990s

Abstract

Cholelithiasis afTects from 10% to 15% of the adult population in industrialized Western countries, with higher prevalence in women, in women with high parity, in the obese, in patients with hypertriglyceridemia and in older patients (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13). In the United States, it has been estimated that 20 to 25 million people have gallstones, and more than 500,000 cholecystectomies are performed annually. Cholecystectomy is the most frequently performed surgical procedure, after cesarean section in this country (141, with an annual cost estimated at $4 to 5 billion. About a quarter of all women will experience cholelithiasis by age 60 in industrialized Western societies; the prevalence in men is about half that of womenThe fist effective treatment for cholelithiasis was cholecystostomy (15, 161, a procedure that was abandoned in the early decades of this century because of the high incidence of stone recurrence. Open cholecystectomy (OC) was introduced more than 100 yr ago (17) and remained the sole effective treatment of this disease for about 90 yr. During this period, the only decision that was required for a patient with cholelithiasis was whether treatment was indicated or not. In the last two decades several new treatments, such as oral bile acid therapy (BAT), extracorporeal shock wave lithotripsy (ESWL) and, more recently, laparoscopic cholecystectomy (LC) have become available. Therefore, it is now not only necessary for physicians to decide whether to treat gallstones but also to recommend the most suitable type of treatment. The purpose of this work is to present an evaluation of the newer therapies (mainly in comparison with OC) including the basis for selection of therapy in individual patients. CLINICAL STAGES OF CHOLELITHIASISCholelithiasis has three clinical stages: the asymptomatic and symptomatic stages and the stage of complications. Complicated forms of cholecystolithiasis include acute cholecystitis and its complications, choledocholithiasis and its complications, gallstone ileus and gallbladder cancer. These complications are much 31/1/40081 more serious than symptomatic cholelithiasis and usually require prompt and invasive treatment. Treatment of the complicated forms of cholelithiasis will not be considered in this work, but it should be noted that it is the avoidance of such complications that constitutes an important rationale for therapy in the symptomatic stage or even under special circumstances in the asymptomatic stage (18)(19)(20)(21)(22)(23)(24)(25).Of critical importance in making recommendations about treatment is knowledge of the natural history of cholelithiasis (i.e., the rate of conversion from the asymptomatic stage to the other stages). Such information is necessary to weigh the risk of expectant management against the hazards of treatment. Historical series on the natural history of gallstones have yielded controversial results, mainly because of the inclusion of many patients with biliary symptoms at the start of the study; this distorts the resu...

Management of cholelithiasis in Italian children: A national multicenter study

“…As for diagnostic approach, abdominal X-ray was not performed in all cases; in fact, radiographic aspect of gallstones in a third of patients was not evaluated. As for treatment, although in adults UDCA therapy is recommended only for a specific subset of patients [15] , in the present study this drug was used in about two third of cases and only in half of cases the gallstones were radiolucent. Our study confirmed that UDCA was ineffective in dissolution of gallstones in the vast majority of the cases.…”

“…The non-surgical approach is based on the use of ursodeoxycholic acid (UDCA); UDCA can reduce cholesterol saturation in bile and progressively dissolve cholesterol gallstones [13,14] . Treatment of radiolucent gallstones with UDCA has been well documented in adults [15][16][17] ; on the contrary, little information is available for children [18,19] . Another approach to pediatric cholelithiasis is represented by expectant management, in which the patients are not treated with medical or surgical therapies but are followed up with periodical clinical and ultrasound controls.…”

Apolipoprotein E4 genotype and gallbladder motility influence speed of gallstone clearance and risk of recurrence after extracorporeal shock-wave lithotripsy

“…At recurrence, 48% of patients had solitary gallstones while 52% had multiple gallstones. The number of recurrent gallstones (i.e., solitary or multiple) was concordant with the initial gallstone number only in 44% and 46% of the cases Table 1 for previous criteria, 27 was higher in patients with than without the definition of the two apoE groups. recurrence (53% vs. 13%, P Å .001).…”

Increased activity in the biliary con A–binding fraction accounts for the difference in crystallization behavior in bile from Chilean gallstone patients compared with Dutch gallstone patients

“…Symptomatic gallstone disease was defined according to accepted criteria as a clinical history with typical biliary pain. 15 In Chile some gallbladder bile from nongallstone patients (n ϭ 6) was also obtained. These patients underwent surgery because of resectable gastric cancer.…”