Resistance to chenodeoxycholic acid (CDCA) treatment in obese patients with gall stones

In most patients with radiolucent gall stones who were given chenodeoxycholic acid (CDCA) in doses of 13-15 mg/kg body weight/day the bile became unsaturated in cholesterol, and their gall stones dissolved. The patients whose stones did not dissolve were significantly heavier and fatter than the responders, which suggested that obese patients might be “resistant” to the effects of CDCA. To test this hypothesis, 32 consecutive patients presenting for medical treatment of gall stones had their ideal body weight (IBW) and estimated body fat mass calculated. The eight most obese and the eight least obese patients were then selected, and their fasting bile lipid responses to CDCA 13-15 mg/kg/day were measured. The very obese patients were also given larger doses, and any changes in bile lipid composition were studied in relation to subsequent gall-stone dissolution.Before treatment the obese patients had a higher mean biliary cholesterol saturation index than the non-obese patients, and this difference was maintained during treatment with the normal dose of CDCA: the bile in the obese patients remained supersaturated while that in the non-obese became unsaturated with cholesterol. When the obese patients were given larger doses of CDCA their bile ultimately became unsaturated in cholesterol. Gall stones dissolved partially or completely in five of the eight non-obese patients after 6-18 months of 13-15 mg CDCA/kg/day, but none of the obese patients showed any response after comparable periods of treatment with this standard dose. With increased doses and unsaturated bile, however, three of the obese patients showed partial gall-stone dissolution after 3-12 months'' treatment and one showed complete gall-stone dissolution after three years'' treatment.These results suggest that when giving CDCA to patients with gall stones, larger than normal doses (some 18-20 mg/kg/day) should be prescribed. Alternatively the lipid composition of the patients'' bile should be monitored by duodenal intubation and the CDCA dose increased until the bile becomes unsaturated in cholesterol.     

Migration of gall stones.

The factors influencing the migration of gall stones are ill understood. Altogether 331 patients undergoing cholecystectomy were studied prospectively. The diameters of the cystic and common bile ducts and of stones in the gall bladder and bile ducts were measured. Increasing pressure was applied to the freshly excised gall bladder in an attempt to evacuate stones through the cystic duct. Stones passed in 33 (60.0%) of patients with choledocholithiasis, 45 (67.2%) of patients with pancreatitis, and 7 (3.2%) of patients without either pancreatitis or choledocholithiasis. Stones migrated in 6 (3.0%) who had a normal cystic duct diameter (less than or equal to 4 mm) and in 46 (32.5%) with a duct over 4 mm diameter. Common bile duct stones were often larger than the diameter of the cystic duct and when reintroduced into the gall bladder would not migrate. The passage of debris (less than or equal to 1 mm) through the cystic duct bore no relation to the presence or absence of choledocholithiasis or a dilated cystic duct. Small stones (1-4 mm diameter) must migrate to initiate and facilitate further migration; some must increase in size in the common bile duct. Increased biliary pressure consequently dilates the duct system retrogradely, allowing larger stones to follow. Patients at risk of stone migration and thereby pancreatitis and jaundice have large ducts that can be detected by ultrasound assessment.     

Bile acids of a 3200-year-old Egyptian mummy.

The bile acids of the gall bladder and hepatic tissue of a 3200-year-old Egyptian mummy were isolated by thin-layer chromatography and identified by combined gas-liquid chromatrography and mass spectrometry. Except for complete deconjugation and extensive dehydration, the bile acids were found to correspond in their qualitative and quantitative composition to the gall bladder bile acids of modern man. The secondary bile acids constituted about 50% of the total and were identified as the normal bacterial oxidoreduction products of the primary bile acids and their dehydration products. In addition a series of unsaturated bile acids were identified, which corresponded to the dehydration products of cholic and chenodeoxycholic acids. It is suggested that both bile acid deconjugation and the limited oxidoreduction were probably brought about by the Clostridium organisms identified in the tissue. On the basis of the bile acid composition it is concluded that the ancient man metabolized cholesterol along the same pathways as modern man.     

A relation between high-density-lipoprotein cholesterol and bile cholesterol saturation.

The association of cholesterol gall stones with coronary artery disease is controversial. To investigate this possible relation at the biochemical level, bile cholesterol saturation and the plasma concentrations of triglycerides, total cholesterol, and high-density-lipoprotein cholesterol (HDL cholesterol) were measured in 25 healthy, middle-aged women. Bile cholesterol saturation index was negatively correlated with HDL cholesterol. It was positively correlated with plasma triglycerides and with total cholesterol minus HDL cholesterol. These findings provide a biochemical basis for a positive association in women between cholesterol gall stones and coronary artery disease.     

Regulation of Bile Salt Pool Size in Man

When the enterohepatic circulation is intact the size of the bile salt pool is largely determined by the frequency of its enterohepatic circulation. This hypothesis, derived from studies of cholate kinetics in coeliac, cholecystectomy, and gall stone patients, represents the simplest interpretation of the data. A corollary is that daily cholate secretion is likely to be normal in these conditions and that therefore the propensity of bile to form cholesterol gall stones is not likely to be directly related to bile salt pool size.     

Low-cholesterol diet: enhancement of effect of CDCA in patients with gall stones.

Fifteen patients with gall stones who were taking chenodeoxycholic acid(CDCA) 15 mg/kg at bedtime participated in two separate experiments to investigate the effects of altering sterol intake on the cholesterol saturation index (SI) of fasting gall-bladder bile. In experiment I the 15 patients on an unrestricted diet had a SI of 0.87 +/- 0.04 (mean +/- SE of mean), which fell to 0.75 +/- 0.04 after one week in hospital on a diet of 100 mg cholesterol daily. In experiment II seven of the patients were given four different dietary regimens lasting one month each in random order as outpatients. On a diet of 600 mg of cholesterol daily the mean SI was 0.72 +/- 0.05, which fell to 0.67 +/- 0.05 when the patients were put on a 100 mg cholesterol diet. The addition of plant sterols (3 g daily) to both diets raised the mean SIs to 0.80 +/- 0.05 and 0.77 +/- 0.05 respectively. The percentage CDCA in bile was unaffected by alterations in the cholesterol and plant sterol intakes. We conclude that a low-cholesterol diet but not a high intake of plant sterols enhances the effect of CDCA in patients with gall stones.     

Biliary proteins: assessment of quantitative techniques and comparison in gallstone and nongallstone subjects

Although protein is the third most abundant solid in bile and is important in cholesterol crystal formation, methods for quantitating the concentration of total protein in bile have not been systematically evaluated. To establish a reliable protein assay for bile, we evaluated three protein assays (Lowry's method and the fluorescamine and Coomassie blue methods), and employed amino acid analysis as a reference technique. Large protein-to-protein variations were observed with the fluorescamine and Coomassie blue methods. Although all assays were affected by interfering substances, Lowry's method and the fluorescamine technique (after trichloroacetic acid precipitation and delipidation of bile) and the Coomassie blue method with native bile showed excellent correlations (P less than 0.0001) with those obtained by amino acid analysis. Using these reliable protein assays, we examined gallbladder bile obtained at surgery from subjects with and without gallstones. No differences in the concentrations of total biliary proteins were observed among patients with cholesterol (n = 23) or pigment (n = 7) gallstones and subjects without gallstones (n = 10). Protein values obtained by amino acid analysis also did not differ among groups. As expected, bile from patients with cholesterol gallstones was supersaturated with cholesterol while bile from nongallstone subjects and those with pigment stones was unsaturated. These results indicate that it is not possible to separate patients with and without gallstones on the basis of the total protein concentration of gallbladder bile.     

Proteins of guinea-pig bile: selective resorption in the gall bladder

We have examined and compared the proteins present in guinea-pig bile as collected either from the common hepatic duct or from the gall bladder. Guinea-pig bile, collected from the common bile duct, has a rather low concentration of protein. Detailed examination shows that the concentrations of actively transported proteins such as immunoglobulin A and haptoglobin.haemoglobin complexes are markedly lower than in rats although the concentrations of proteins which, like albumin, leak non-specifically into bile are similar in the two species. We also find that the protein composition of guinea-pig bile is extensively and selectively modified by resorp-tion of protein in the gall bladder.     

Measurement of cholesterol gallstone growth in vitro

Methods to study growth of gallstones in the laboratory have not been reported. We here present such a method. Human cholesterol gallstones were harvested from patients with multiple nearly identical stones. The gallstones were washed and added to supersaturated model biles and the formation of cholesterol crystals and the increases in mass of human cholesterol gallstones were studied concurrently, over a period of weeks, using nephelometry and a microbalance, respectively. All stones incubated in model biles supersaturated with cholesterol increased in mass. Increases in the degree of supersaturation of cholesterol in the model biles resulted in increased growth of stones. The mass increases, the growth rates, and the spatial orientation of accreted crystalline cholesterol differed among various stone types. The kinetics and structures of stone growth were similar when the stones were incubated in supersaturated, native, human gallbladder biles. The structure of accreted cholesterol was the same as found on the surface of some human gallstones that were harvested during apparent active growth in situ. This simple method allows accurate measurements of stone growth in vitro, in patterns that mimic stone growth in vivo, and is useful for studies on the relationships of gallstone growth and the kinetics of cholesterol crystallization.     

Gall stone dissolving agents.

During the decade in which the medical dissolution of gall stones has become feasible several drugs have been introduced but only the two listed in the British National Formulary have been intensively evaluated and shown to be effective--chenodeoxycholic acid and the closely allied ursodeoxycholic acid. The dissolution of gall stones was last reviewed in the "BMF" in 1976, at which stage experience with chenodeoxycholic acid was limited. Since then the indications and potential for this bile acid in treating gall stones have become better understood, and data on the newly introduced ursodeoxycholic acid are being evaluated. Cholesterol, but not pigment, gall stones are amenable to oral dissolution treatment. This review will cover firstly, chenodeoxycholic acid, secondly, ursodeoxycholic acid, then a comparison of the two drugs, an assessment of the place of medical dissolution in the management of gall stones, and, finally, the dissolution of stones in the common bile duct.     

Taurocholic acid synthesis in dogs maintained on a high cholesterol diet

Labeled 35S-taurocholic acid synthesis was studied in dogs with gall bladder fistulae, fed high cholesterol diet. During the first period (1--2 months) dietary cholesterol caused a significant increase in the 35S-taurocholic acid synthesis. In 5--6 months, at the period of development of the pathological process in the liver, there was a decrease of synthesis and secretion of bile acids, and of cholesterol sediment in the bile. The level of plasma cholesterol in these dogs increased only slightly.     

The gall of subordination: changes in gall bladder function associated with social stress

Diverse physiological and behavioural mechanisms allow animals to effectively deal with stressors, but chronic activation of the stress axis can have severe consequences. We explored the effects of chronic social stress on agonistic behaviour and gall bladder function, a critical but widely neglected component of stress-induced gastrointestinal dysfunction. Prolonged cohabitation with dominant individuals elicited behavioural modifications and dramatically increased bile retention in subordinate convict cichlid fish (Archocentrus nigrofasciatum). The key predictor of gall bladder hypertrophy was social subordination rather than status-related differences in food intake or body size. Stress-induced inhibition of gall bladder emptying could affect energy assimilation such that subordinate animals would not be able to effectively convert energy-rich food into mass gain. These results parallel changes in gall bladder function preceding cholesterol gallstone formation in humans and other mammals. Thus, social stress may be an important diagnostic criterion in understanding pathologies associated with gall bladder dysfunction.     

Cephalexin Levels in Human Bile in Presence of Biliary Tract Disease

Cephalexin was given to 24 patients before and after operation on the bile ducts and gall bladder. Two patients had obstructive jaundice. Samples of the bile were taken either directly from the gall bladder at operation or via the T-tube. Cephalexin was excreted in the bile, peak levels being obtained after two to three hours. These levels could be raised if probenecid was given concurrently. Higher levels were found in patients with functioning gall-bladders. A trial of cephalexin seems justified for the treatment of typhoid carriers.     

Prevalence of gall stones in Dundee: a necropsy study.

Necropsy records from two large general hospitals in Dundee showed short-term fluctuations in the prevalence of gall stones that had not previously been described. There was no evidence of a rise in the standardised prevalence rate between 1902-9 and 1953-73. A spurious increase was apparent from the crude prevalence rates for these periods, which resulted simply from the increased age of the patients in the later period. Since there was no real increase in prevalence no conclusions can be drawn about dietary or other changes. Patients with stones in the common bile duct were likely to die from an associated cause. This related mainly to a high mortality rate in women. In patients with established epilepsy the prevalence of gall stones was greater than expected, which suggests that phenobarbitone does not diminish the likelihood of gall stones.     

Contribution of vesicular and micellar carriers to cholesterol transport in human bile

A nonmicellar, bile salt-independent mode of cholesterol transport in human bile involving phospholipid vesicles was recently reported by our group. In the present study, we have investigated the relative contribution of the phospholipid vesicles and mixed bile salt-phospholipid micelles to cholesterol transport in human hepatic and gallbladder biles. The vesicles (ca 800 A diameter) were demonstrated by quasi-elastic light scattering (QELS) in fresh bile and after chromatography. Gel filtration under conditions that preserved micellar integrity demonstrated that biliary cholesterol was associated with both vesicles and micelles. At low bile salt concentration, the vesicular phase was predominant and most of the cholesterol was transported by it. With increasing bile salt concentrations, a progressive solubilization of the vesicles occurred with a concomitant increase in the amount of cholesterol transported by micelles. The vesicular carrier may be of particular biological significance for cholesterol solubilization in supersaturated biles.     

Gall Stones in Patients with Disorders of the Terminal Ileum and Disturbed Bile Salt Metabolism

In a combined historical and radiological survey gall stones were found in 23 out of 72 patients with disorders of the terminal ileum (31·9%). This is four to five times the expected incidence of cholelithiasis. In these patients the incidence of gall stones was not related to age, but did, however, increase with increased duration of the ileal disorder. Glycine/taurine conjugation ratios of bile salts in the bile were abnormally high in 10 out of 11 patients with ileal disorders. Both impaired bile salt recirculation and absorption of poorly soluble bacterially degraded bile salts are possible causes of cholelithiasis in these patients.     

Percutaneous cholecystolithotomy

A percutaneous method was used to remove stones from otherwise normal gall bladders, as assessed by cholecystography and ultrasonography. The procedure was performed in a single stage under general anaesthesia, adopting the method and instruments used for one stage percutaneous nephrolithotomy. A Foley catheter was left in the gall bladder and the system checked with contrast at 10 days to ensure free drainage and exclude residual calculi. Seven out of eight patients had a successful percutaneous cholecystolithotomy. An adequate track could not be secured in one man; he had an uneventful cholecystectomy under the same anaesthetic. Follow up at three months of the seven patients showed no calculi and no complications.Percutaneous cholecystolithotomy may prove complementary to extracorporeal shockwave lithotripsy in patients in whom there is difficulty focusing the shock waves on the gall bladder or who have had incomplete disintegration of stones.     

Increases in biliary cholesterol-to-bile acid ratio in pregnant hamsters fed low and high levels of cholesterol

Gallstones develop when the secretion of cholesterol is elevated compared with the secretion of bile acids into bile. One of the risk factors for the formation of gallstones is pregnancy. Because the pregnancy-induced increase in hepatic cholesterol synthesis rates could play a critical role in the development of cholesterol stones, the aim of the present study was to determine whether stone formation, as assessed by the ratio of cholesterol to bile acids in bile, could be ablated by blocking the pregnancy-induced increase in hepatic sterol synthesis rates. Golden Syrian hamsters were fed either ground chow or chow supplemented with 0.5% cholesterol for 3 wk and studied in the nonpregnant state or in late gestation. In chow-fed animals, a 1.6-fold increase in the ratio of cholesterol to bile acids occurred simultaneously with a sevenfold increase in hepatic sterol synthesis rate and a ninefold increase in the amount of newly synthesized cholesterol secreted into the bile in late gestation. In the cholesterol-fed dams, an increase in the ratio of cholesterol to bile acids occurred even with the lack of induction of hepatic sterol synthesis rates during pregnancy. Thus it appears that the marked induction of hepatic sterol synthesis rates during gestation is not essential for the pregnancy-induced cholesterol saturation of bile when cholesterol is fed to animals.     

Ampicillin Levels in Human Bile in the Presence of Biliary Tract Disease

Ampicillin levels were measured in the serum and in the bile from both the gall bladder and the common bile duct in patients undergoing surgery for biliary tract diseases. In patients with radiologically non-functioning gall bladders ampicillin was either not present or its concentration was lower than normal. Therapeutic levels were present in the common bile duct of all patients except those with obstruction of the common bile duct. Hence ampicillin fails appreciably to penetrate the obstructed viscus in obstructive biliary tract disease, and it is unlikely to be effective in treating infection associated with this.     

Gall-bladder sensitivity to cholecystokinin in patients with gall stones.

Gall-bladder sensitivity to cholecystokinin (CCK) was determined by dynamic cholescintigraphy in 18 patients with radiolucent gall stones and 18 matched controls during an infusion of CCK in which the rate of infusion was increased. In 10 of the matched pairs the patient was more sensitive than the control, in one the control was more sensitive, and in seven no difference was detected (p = 0.012). It is concluded that patients with cholesterol gall stones have increased gall-bladder sensitivity to CCK, and that this may be important in the pathogenesis of this disease.