P. Scalon

Natural history of gallstones in non-insulin-dependent diabetes mellitus : a prospective 5-year follow-up

This prospective study was undertaken to assess the natural history of gallstones in patients with non-insulin-dependent diabetes. Four hundred forty outpatients with diabetes mellitus were studied; 81 of these had gallstones diagnosed by ultrasound. On the basis of the information they gave, they were divided into two groups: A, asymptomatic; and B, symptomatic (previous episode(s) of biliary pain) at recruitment. Five years after diagnosis, the patients were recalled and questioned about their symptoms. Three of 81 could not be traced and eight had died from diseases not related to gallstones. Seventy were finally evaluated, 47 belonging to group A, 23 to group B. The cumulative percentage of initially asymptomatic patients who presented with biliary pain or complications during the follow-up was 14.9% (4.2% for complications). Of group A patients, 17% underwent cholecystectomy (one prophylactic, six elective and two emergency). One patient (2.1%) died after operation of obstructive jaundice. Of group B patients, 47.8% had biliary symptoms or complications (8.7% cholecystitis); 21.7% were operated (17.4% elective, 4.3% emergency cholecystectomy). Since few patients with asymptomatic gallstones and non-insulin-dependent diabetes mellitus develop pain or complications over time, prophylactic cholecystectomy is probably not advisable.

Computed tomography in predicting gall stone solubility: a prospective trial.

This prospective study was undertaken to evaluate the correlation between densitometric values of gall stones assessed by computed tomography and the success rate of litholytic therapy in 28 patients eligible for oral treatment. A densitometric study of the stones was performed in all patients before treatment. A cut off point of 60 Hounsfield units (HU) was chosen to divide the subjects into two groups--group 1, 14 patients with low density stones (less than 60 HU) and group 2, 14 patients with high density stones (greater than 60 HU). All patients were treated with ursodeoxycholic acid (8-10 mg/kg/day) for 12 months and followed up by ultrasound. In group 1, dissolution was complete in 50% of the patients and partial in a further 20%. In group 2 patients, complete dissolution was not observed but 33% showed partial dissolution. The number of patients with total dissolution at 12 months was significantly higher in group 1 compared with group 2 (p less than 0.02). These results suggest that computed tomography can be used to select patients with a better likelihood of successful stone dissolution after bile acid therapy.

Are morphology and composition of gallstones related ? An X-ray diffraction study

Abstract An x-ray diffractometric technique was used to study the crystalline composition of gallstones removed during surgery from 106 patients. Monohydrate cholesterol was found in the stones of 70 (66%) patients, either alone (33%) or in association with calcium salts (33%). The anhydrous form of cholesterol was found in the stones of 28 (26%) patients, either alone (10%) or in association with calcium salts (16%). These salts (vaterite, aragonite, and calcite) were found in 50% of cases in varying amounts (from 12% to 15% of the stone weight). Eight stones contained no cholesterol: 4 showed an amorphous pattern and 4 were composed of calcium carbonate salts. In 7 of 8 patients with bile duct stones concomitant with gallbladder stones, results of the diffractograms of the stones from the two different sites were comparable, even in 4 cases in which the stones were macroscopically different. Neither the macroscopic appearance nor the chemical structure of the stones appeared to be influenced by the patients sex.

Does Serum CAR-3 Play a Role in Pancreatic Cancer Diagnosis?

A new tumour marker, CAR-3, was isolated using the monoclonal antibody technique and measured in the sera of 27 patients with pancreatic cancer, 25 chronic pancreatitis, 30 extra-pancreatic diseases and in that of 18 healthy controls in order (1) to evaluate the diagnostic role of CAR-3 in patients with pancreatic cancer and (2) to ascertain whether liver dysfunction influences CAR-3 serum levels. The increased levels were found in 12/27 patients with pancreatic cancer (sensitivity 44.4%). No increase was found in patients with chronic pancreatitis, whereas abnormal levels were found in patients with other gastrointestinal diseases, especially those of the liver and biliary tract. Correlations were found between serum CAR-3 and (1) total bilirubin and (2) alkaline phosphatase. In conclusion, CAR-3, an antigen structurally related to CA 19-9, does not appear to be accurate enough to be considered a tumour marker. Cholestasis seems to increase CAR-3 levels as well as those of other glycoproteic tumour markers, probably by interfering with the hepatic clearance of these substances.

Urinary Kallikrein Excretion in Chronic Pancreatic Diseases

Variations in urinary kallikrein in pancreatic diseases were ascertained, and possible influencing factors were investigated. Serum amylase and urinary excretion of glandular kallikrein, pancreatic ribonuclease (RNase), gamma-glutamyltransferase (GGT) and amylase were measured in 24 control subjects, 39 patients with pancreatic cancer, 49 with pancreatitis and 63 with extra-pancreatic diseases. Urinary kallikrein was found to be elevated in a substantial number of patients with pancreatitis. Higher levels were detected in patients with a relapse, which was diagnosed using clinical and biochemical examinations. RNase was also increased in a high number of patients with pancreatic diseases, but was not correlated with pancreatic damage. In patients with pancreatitis, a correlation was found between urinary kallikrein and RNase excretions. No correlations were found between kallikrein and serum or urinary amylase and GGT. We can conclude that urinary kallikrein excretion increases in pancreatitis, especially when a phlogistic involvement of the pancreas is present; this condition may lead to a release of this ultrafiltrable enzyme in the circulation. Renal tubular damage, which determines a reduced reabsorption of this enzyme, seems to play a concomitant but minor role in this process.

Disappearance of gallbladder wall lesions after oral bile acids treatment—A pilot study

Abstract Two main types of gallbladder wall lesions are detectable: cholesterol deposits and adenomas. Whereas cholesterol polyps have no potential for malignant transformation, adenomatous lesions can evolve into cancer. There are no instrumental techniques capable of differentiating between these lesions, yet indiscriminate cholecystectomy is often performed on this basis. The objectives of the present study were to evaluate whether ursodeoxycholic acid (UDCA) treatment can dissolve such lesions, and to help establish a differential diagnosis for these two conditions. Twelve patients with an ultrasonographic diagnosis of gallbladder wall lesions were given UDCA (8 to 10 mg/kg/day) for 6 months. Disappearance of polyps was evaluated ultrasonographically at 3 months and again at 6 months. Lesions were detected in all 12 patients: 8 had single, sessile lesions; 2 had multiple, sessile lesions; and 2 had multiple, pedunculated lesions. Size of lesions varied from 4 to 18 mm. The complete disappearance of the polyps was observed in 8 of 12 patients after 6 months, and in one patient after 3 months. Dissolution of the polyps occurred regardless of size and site. Thus, when a gallbladder wall lesion is detected, it is reasonable to attempt an oral bile acid therapy to avoid any unnecessary cholecystectomy.