W. Kurtz

Ursodeoxycholic acid in primary biliary cirrhosis: Results of a controlled double-blind trial

We studied the effect of ursodeoxycholic acid on 18 women and 2 men with primary biliary cirrhosis, mainly stages I and II. After a 3-mo observation period, patients were randomized to a 9-mo treatment period with ursodeoxycholic acid, 10 mg/kg.day, or placebo. Two patients on placebo left the study. In all patients on ursodeoxycholic acid, mean values of serum glutamate dehydrogenase, aspartate and alanine aminotransferases, alkaline phosphatase, and gamma-glutamyl transpeptidase fell significantly by 48%-79% after 18-24 wk; 7 of 10 showed a mean decrease of 35% in immunoglobulin M after 24 wk. Prothrombin time, serum bilirubin, albumin, the antipyrin breath test, and plasma disappearance of indocyanine green were normal initially and did not change. Total serum bile acid concentrations increased; ursodeoxycholic acid became the predominant bile acid. No significant improvement occurred in the placebo group. Hepatic histology improved in 6 patients of the ursodeoxycholic acid group but deteriorated in 4 patients receiving placebo. In studies with erythrocyte membranes, changes in electron spin resonance revealed that ursodeoxycholic acid was less toxic than chenodeoxycholic or deoxycholic acid, and coaddition of ursodeoxycholic acid prevented their toxic effect.

Gallstone dissolution with ursodeoxycholic acid in patients with chronic active hepatitis and two years follow-up. A pilot study.

Chemical dissolution of cholesterol gallstones using ursodeoxycholic acid (UDCA) in six patients with histologically confirmed HBsAg-negative chronic active hepatitis was started after a minimum of one year of therapy with steroids, azathioprine, or chloroquine and a treatment-free period of 8–15 months. The treatment with UDCA lasted 3–20 months with a daily dose of 8–11 mg/kg. Four patients served as controls. A decrease in transaminases (P<0.05) occurred in all patients during the UDCA therapy. After completion of the treatment, the figures rose again, but did not return to the initial value. The stones dissolved in five patients. A second liver biopsy was carried out in two patients after UDCA therapy, and this showed no detectable deterioration. Four patients refused biopsy because the laboratory parameters had improved under UDCA. A stone recurred in one patient six months after the end of therapy; the others have remained free of stones for up to 24 months.

Dissolution of Gallbladder Stones with Methyl tert-Butyl Ether and Stone Recurrence (A European Survey)

Since there are now several ways to treatsymptomatic gallstone disease, one is able to selecttreatment on the basis of the patients comfort, thepracticability, effectiveness, and side effects of the technique, and the relative costs. In order toassess the present status of contact dissolution withmethyl tert-butyl ether with regard to these aspects,the present enquiry reports the data of 21 European hospitals. Eight hundred three patients wereselected for contact litholysis of cholesterolgallbladder stones using methyl tert-butyl ether.Percutaneous transhepatic puncture of the gallbladderwas performed under x-ray or ultrasound guidance. Dissolutionrate, side effects, and treatment times of 268 patientsfrom one single center were compared to those of 535patients from the other 20 centers. Two hundred sixty-four patients were followed for fiveyears to assess stone recurrence. Physicians were askedhow they assessed the expenditure of the method, thediscomfort to the patients, and the staffing situation. Patients were asked to indicate theiracceptance on an analog scale. Puncture was successfulin 761 (94.8%) patients. Prophylactic administration ofantibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludgeremained in the gallbladder. The most severecomplication was bile leakage, which led 12 (1.6%)patients to have elective cholecystectomy. Toxicinjuries due to the ether were not reported.Methodrelated lethality amounted to 0%, 30-day-lethalityto 0.4%. Stone recurrence rate was about 40% in solitarystones and about 70% in multiple stones over five years. Patients with multiple stones developedrecurrent stones almost twice as often as those withsolitary stones. The probability of stone recurrence inpatients with sludge in the gallbladder after catheter removal was not statistically significantlydifferent from those without sludge. Seventy to 90% ofthe centers found the puncture to be simple and notdistressing for patients and the relation betweenexpenditure and therapeutic success to be acceptable. Theacceptance of contact litholysis by the patients wasexcellent. Contact litholysis when applied by anexperienced team provides real advantages in thetreatment of gallstone disease. The method is technicallysimple, well accepted by the patients, and can be easilyapplied in community hospitals. Contact litholysis maybe of particular value in patients who are not suitable for anesthesia orsurgery.

Les progrès diagnostiques de l'ultrasonographie endoscopique

RÉSUMÉLa tomographie endoscopique ð ultrasons (TEU) abolit les barrières classiques des ultrasons telles que les gaz et les os et procure un pouvoir de résolution supérieur grâce ð l’utilisation de hautes fréquences. Les données de l’anatomie sonographique sont complètement modifiées et elles nécessitent de plus une standardisation stricte des sections croisées et des positions. Le présent travail représente l’expérience de 110 patients examinés par TEU au niveau du tractus digestif supérieur et des organes environnants. Les maladies pancréatiques et les lésions des voies biliaires sont souvent mieux visualisées par TEU que par ultrasonographie conventionnelle. Les lésions tant bénignes que malignes de l’estomac et de l’œsophage sont décrites avec une précision jusqu’ici inconnue et la TEU est appelée ð devenir une méthode d’investigation d’importance primordiale au niveau des lésions du tractus digestif supérieur.SummaryEndoscopic ultrasound tomography (EUT) overcomes conventional ultrasound barriers like gas and bones and gives superior detail resolution due to the use of higher frequencies. The thoroughly changed sonoanatomy, however, exacts a strict standardization of cross sections and positions. In 110 patients we examined the upper GI tract and its surrounding organs by EUT. Pancreatic diseases and bile duct processes can often be better visualized by EUT than by conventional UT. The gastric and oesophageal wall with their benign and malignant lesions are depicted with hitherto unknown exactitude suggesting that EUT may become of primary importance in the diagnosis of lesions of the upper GI tract.

Diurnal Rhythm of Bile Lipid Composition after Cholecystectomy and Papillotomy: Postpapillotomy Biliary Lithogenicity

The influence of the gallbladder and the sphincter of Oddi on the diurnal rhythm of bile lipid composition was assessed by determining the lithogenic index at 4-h intervals over a period of 24 h in 29 cholecystectomized and papillotomized patients with a nasobiliary tube receiving a normal hospital diet and in 9 during 1-day fast. With a normal diet, biliary cholesterol concentrations dropped during the daytime (p less than 0.05), and total biliary lipid, bile acid, phospholipid, and cholesterol concentrations rose at night (p less than 0.05). During fasting, total biliary lipid, phospholipid, and cholesterol concentrations rose continuously (p less than 0.01). Even with loss of function of the gallbladder and sphincter of Oddi, a diurnal rhythm of biliary lithogenicity persisted, caused mainly by cholesterol increases during fasting. Concomitant increases in phospholipids and, to a lesser extent, bile acids modulated these changes.

Clinical examination, laparoscopy and histology in the diagnosis of liver diseases : A prospective study in 900 patients

SummaryThe prospective study performed in 900 patients has shown that histological examination of liver tissue is most important in the diagnosis of diffuse-parenchymatous disorders. The accuracy rate reaches over 90%.On the other hand laparoscopy is superior to histological examination in focal-nodular disorders. In this group of diseases the inspection of the peritoneum and the abdominal cavity may contribute valuable informations.Based on clinical examinations only the definite diagnosis may be established in only approx. 30%.The positive evidence of such prospective studies is considerably influenced by the degree of severity of the disorders examined. In classical cases all correlations are excellent.RésuméL’étude prospective effectuée sur 900 patients montre l’importance de la biopsie hépatique dans les affections parenchymateuses diffuses avec un taux de précision supérieur à 90%.La laparoscopie est supérieure à l’histologie dans les lésions focales. Dans ce groupe, l’inspection du péritoine et de la cavité abdominale peuvent être contributives.Sur des bases uniquement cliniques le diagnostic définitif n’est obtenu que dans environ 30% des cas.Le degré de positivité des résultats de ce type d’étude prospective est très influencé par la sévérité des affections explorées. Dans les cas classiques, toutes les corrélations sont bonnes.

Medical Treatment of Cholesterol Gallstones: Present and Future

For 15 years it has been possible to dissolve cholesterol gallstones with chenodeoxycholic acid or ursodeoxycholic acid. There are now about 30 different chenodeoxycholic and ursodeoxycholic acid preparations available worldwide [10].