Combination therapy with oral ursodeoxycholic and chenodeoxycholic acids: pretreatment computed tomography of the gall bladder improves gall stone dissolution efficacy.

Abstract

In a five year study, 55 patients with radiolucent gall stones were treated with the combination of 7*5 mg chenodeoxycholic acid (CDCA) and 5 0 mg ursodeoxycholic acid (UDCA)/kg/daythat is, half the monotherapeutic doses. Side effects were few but four patients could not tolerate the prescribed bile acids because of diarrhoea or nausea. Analysis of fasting duodenal bile confirmed that CDCA+UDCA converted supersaturated into unsaturated bile but the saturation indices did not predict the dissolution response. By actuarial analysis, the confirmed (by ultrasound x 2) complete gail stone dissolution rates in all 55 patients were mean (SEM) 29 (7)% at 12 and 44 (8)% at 24 months. The advent of routine computed tomography before treatment enabled comparison of dissolution efficacy in those screened by computed tomography (n=24), whose maximum gail stone attenuation was <100 Hounsfield units, with that in those ndt screened (n=29). Although stone size and number were comparable, patients screened by computed tomography had significantly better dissolution rates (p<0025) than those not screened in this way. At 12 months, partial or complete gall stone dissolution rates were 93 (7)% in the screened and 55 (11%) in the nonscreened patients. At 18 months, complete dissolution rates were 64 (12%) and 20 (9)% respectively. Computed tomography before treatment is cost effective in selecting those patients likely to achieve gall stone dissolution on treatment with UDCA+CDCA.

Long-term ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute cholecystitis in patients with gallbladder stones: A cohort analysis

“…Several reports have suggested additional use of more sensitive CAT. 38,39 These reports cannot be directly compared with ours, because they did not include data of plain x-ray, US, or OCG, while we did not perform pretreatment CAT examination in many patients. Our selection criteria not including CAT gave us high accuracy (92%) for predicting the outcome.…”

“…22,25 Furthermore, since the introduction of highly effective laparoscopic cholecystectomy, more strict indication of BAT has been proposed, [1][2][3] because of the low successful dissolution rates (30%-40%) with the high recurrence rates. Multiple characteristics of GS and gallbladder (GB) on either plain x-ray, [33][34][35] oral cholecystography (OCG), 33,34 ultrasound (US), [35][36][37] computer-assisted tomography (CAT) 38,39 or GB function, 40 have been independently compared with the primary outcome of BAT. These examinations, however, have not been simultaneously tested on multivariate analysis.…”

Gallstones during Octreotide Therapy

“…dissolvable stones from those which contain too much calcium for complete GBS dissolution. How ever, in our experience a score of <90-100 HU predicts cholesterol-rich stones which will dissolve well with oral bile acid treatment [94], At this conference, Hussaini et al [95] report the results of a CT study in 11 acromegalic patients with octreotide-associated GBS. The maximum gallstone HU score in these patients ranged from 23 to 490 with a median of 58 and a mean of 136 ± (SEM) 41.…”

“…Indeed, approximately 50% of GBS which appear lucent by traditional X-ray, are visibly dense by CT and are either non-cholesterol stones or stones which contain calcium in amounts likely to ren der complete dissolution with either oral bile acids or con tact solvents (see below), unlikely [91]. Moreover, local ised CT screening of the GB provides a simple non-invasive way of predicting GBS composition [92,93] and dissolvability both in vitro [91,92] and in vivo [94], Thus in patients scheduled for elective cholecystectomy, when the maximum GBS attenuation value was measured in Hounsfield Units (HU) before surgery and correlated with the composition of the stones harvested at the time of operation, there was a strong linear correlation between the HU score and gallstone: (1) total calcium (2) calcium carbonate (positive relationships), and (3) cholesterol (a negative relationship) [91], There is still controversy about the cut-off point in HU score which divides choles terol-rich. dissolvable stones from those which contain too much calcium for complete GBS dissolution.…”

Composition of gall bladder stones associated with octreotide: response to oral ursodeoxycholic acid.

“…Three patients were shown to be free of stones by ultrasound before octreotide treatment began. They were found to have developed gall stones three, 12, and 15 months after starting octreotide, and their stones were therefore classified as octreotide induced. In the remaining 11, no imaging studies of the gall bladder had been carried out before octreotide treatment to exclude preexisting stones: they were, therefore, described as octreotide associated gall stones.…”