Biliary stones

Investigations into gallstone pathogenesis this year continue to emphasize kinetic factors that determine whether gallstones form once supersaturation of bile occurs. Studies of biliary phospholipid and cholesterol vesicles show two peaks that may be important in cholesterol precipitation. The larger void-volume peak is present in bile from most patients with cholesterol gallstones, whereas the smaller peak's eluting just before micelles correlates with nucleation time in bile. Evidence is presented showing that much of the promoting activity in fractions separated on concanavalin A columns is due to biliary immunoglobulins. In addition, alterations in gallbladder absorptive function, gallbladder contractility, and secretion of mucin, which might contribute to gallstone formation, are examined. Results of dissolution therapy with ursodeoxycholate and chenodeoxycholate are reviewed. Nucleation time in bile and volume of stones in the gallbladder are good predictors of gallstone dissolution in patients with 'pure' cholesterol gallstones. A combination of ursodeoxycholate and chenodeoxycholate seems to be superior to either agent alone, but ursodeoxycholate is superior in treating obese patients undergoing rapid weight loss. A relatively new contact dissolution agent, D-limonene, was tested in 200 patients with retained common duct stones. Forty-eight percent of stones were completely dissolved by this agent, but 84% of patients experienced some degree of abdominal pain during treatment. The incidence of gallstones was reexamined in several groups of patients. The high incidence of gallstone disease in elderly patients emphasizes the increasing risk of gallstones with increasing age, and high incidences of gallstones with hemolytic anemia and cirrhosis were again supported. Finally, a high incidence of common duct stones in immigrants from southeast Asia, compared with Americans and Europeans, warrants routine cholangiography in this population.