Wechsler Jg

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.

The relationship between serum lipids, nucleation time, and biliary lipids in patients with gallstones

SummaryThe relationship between biliary lipids, cholesterol saturation index, nucleation time, and serum lipids was studied in a group of 45 gallstone patients (10 male, 35 female; age 50.1 ±14.5 years). Bile was obtained by direct fine-needle puncture of the gallbladder under local anesthesia and sonographic monitoring. No significant correlation between the serum lipids and either the cholesterol saturation index or total biliary cholesterol levels was observed. We found a positive correlation between the nucleation time and serum triglycerides content (r = 0.45, p = 0.0018) and a negative correlation between nucleation time and biliary cholesterol level (r = −0.38, p = 0.009). The fatty acids derived from the triglycerides are primarily resynthesized to phospholipids in the liver. When the supply of free fatty acids exhausts the metabolic capacity of the liver as, for example, in fat-rich diets, triglycerides accumulate in the liver cells and may possibly be excreted in the bile. Free fatty acids stimulate mucin hypersecretion in the gallbladder. This mucosal hypersecretion has been assigned a significant role in the formation of gallbladder stones. We also found a positive correlation between the total biliary bile acids and serum high density lipoprotein (HDL)-cholesterol in patients with a rapid nucleation time (r = 0.50, p = 0.0128). This supports the findings of other researchers, which suggests that HDL-cholesterol is devoted primarily to bile acid synthesis. In patients with a short nucleation time, the cholesterol saturation index, total lipid concentration, biliary cholesterol, mean age, and biliary bile acids were statistically different in comparison with patients with a prolonged nucleation time.

Computed tomography evaluation of radiolucent gallstones in vivo

Computed tomography facilitates an in vivo classification of gallstones and can aid in the identification of calcifications that escape detection with conventional radiologic procedures. Of patients with radiolucent stones, 54.8% exhibited calcifications either in the form of discrete rims (41.9%) or at the center of the stone (12.9%). Densities of the noncalcified areas of partially calcified stones averaged 40.68±6.8 Hounsfield units (HU), which was not significantly higher than the average of 31.85±3.19 HU for noncalcified stones. Calcified regions showed significantly higher densities (240.0±28.6 HU,p< 0.001,x ± SEM). Of the identified stones, 16.1% showed densities greater than 50 HU. These were primarily bilirubin stones, which cannot yet be treated successfully with conservative therapeutic modalities.

Transhepatic topical dissolution of gallbladder stones with MTBE and EDTA : results, side effects, and correlation with CT imaging

Forty-two patients with symptomatic gallstones (28 women, 14 men, mean age 49.8±13.2 years) were recruited for contact dissolution therapy. Pretreatment CT scans of the gallbladder were obtained in every patient under standard conditions. For contact dissolution treatment of heterogeneous gallstones or gallstones with attenuation values of more than 50 Hounsfield units, methyltert-butyl ether and bile acid ethylene diaminetetraacetic acid were used in alternating administration at time intervals and durations adapted to the individual tolerance of the patients. In the case of gallstones with mean attenuation values under 50 Hounsfield units, the dissolution therapy was performed with methyltert-butyl ether alone. In 12 (28.6%) patients a complete dissolution of gallbladder stones could be achieved; 11 patients (26.2%) revealed gallbladder sludge but no radiologically or sonographically visualized residual stone debris. The remaining 19 (45.2%) patients had residual gallstone debris. Shell fragments in three of five rimmed gallstones, seven of eight laminated gallstones, and all densely calcified stones were refractory to contact dissolution therapy. Dissolution rates correlated well with mean attenuation values, whereas no significant correlation was found between stone number and dissolution rates or between stone diameter and dissolution rates respectively. The mean instillation time required for stones with a mean density of more than 50 HU was 17.7±11.5 hr of bile acid ethylene diaminetetraacetic acid and 5.8±3.2 hr of methyltert-butyl ether. In the case of isodense stones, the average instillation time of methyltert-butyl ether was 12.3±4.7 hr. There was a statistically significant difference in methyltert-butyl ether instillation time between the both groups (P<0.001), but the total instillation time required for stones with a mean density of more than 50 HU was significantly longer (P<0.0001); consequently, in these patients the incidence of severe complications was higher without reaching statistical significance. Mild complications occurred in 95.2% of patients and severe complications were observed in 16.8% of cases. Posttreatment CT examinations after intravenous application of contrast media revealed gallbladder mural hyperemia followed by edematous swelling of the pericystic tissue layer in 96.3% of patients. Eight of eleven patients (72.7%) with gallbladder sludge revealed gallstone recurrence in the course of a 12-month observation period. In the successfully treated group, only one patient experienced gallstone recurrence (P=0.0066). In principle, the use of bile acid ethylene diaminetetraacetic acid dissolution medium made the dissolution of calcified or pigment stones possible, although the side effects are greater than with cholesterol stones. More effective and safer solvents for these more difficult to dissolve stones should be sought.

Gallstone recurrence after successful dissolution therapy

After successful dissolution therapy of cholesterol gallbladder stones bile again becomes supersaturated and recurrent gallstones may develop. Three different postdissolution treatments [500 mg ursodeoxycholic acid (UDCA) per day (N=14, group I), 100 mg aspirin per day (N=14, group II) and diet (N=15, group III) versus a control group (no treatment,N=15, group IV) aimed at preventing recurrence of gallstones were investigated in a prospective, randomized study in 58 gallstone patients (33 female, 25 male) after complete stone clearance. Bile samples (prior to dissolution therapy and at stone recurrence) were investigated for biliary cholesterol (C), phospholipids (PL), total bile acid concentration (BA), cholesterol saturation index (CSI), total lipid concentration (TLC), total biliary protein concentration (TP), and nucleation time (NT). In group IV multiple gallstones tended to recur more often than solitary stones (66.7% vs 16.7%) whereas in groups I–III only solitary stones recurred. Recurrent gallbladder stones were detectable in 10 patients (eight patients in group IV and one each in groups I and II, respectively) within one year after dissolution and in two patients (one each in groups III and IV, respectively) after 15 months. Furthermore, the probability of stone recurrence was significantly higher in untreated patients as compared to treated patients. In nine (group IV) of 12 patients with recurrent stones NT, C, CSI, PL, BA, TLC, TP, and bile acid spectrum remained nearly unchanged as compared to their pretreatment values, whereas in three (groups I–III) of 12 cases a decrease in C, CSI, and TP was observed during therapy. However, in each of these three patients, initial and after-treatment TP was significantly higher and NT shorter as compared to groups I–IV. Furthermore, in these cases (N=3) NT was prolonged, whereas no significant changes were found in PL, BA, TLC, and bile acid spectrum. Recurrence of gallstones, which seems to occur more likely in patients with multiple stones as compared to solitary stones, will happen in the early stage after stone clearance, again causing biliary pain. UDCA, aspirin or diet will reduce the probability for recurrent stones after complete gallstone dissolution.

Wirkung von Bezafibrat bei primären Hyperlipidämien

SummaryThe effect of long-term treatment over 40 weeks with Bezafibrate on lipids and lipoproteins was investigated in 27 patients with primary hyperlipoproteinemias (hlp) (12 patients with hlp type IV, 7 patients with type IIb, 3 patients with type IIa, 4 patients with type V and 1 patient with type III). Bezafibrate reduced total cholesterol by 16%, whereas HDL-cholesterol increased by 28% and 36% (p<0.05). Serumtriglycerides decreased by 59% (450 mg Bezafibrate daily) and by 66% (600 mg Bezafibrate daily) statistically significant (p<0.05). In hyperlipidemias type IV, IIb, IIa and V increases of HDL-cholesterol could be observed. The course of LDL-cholesterol was different in the various types of hlp. The postheparin-lipoprotein-lipase (PHLA) was activated by treatment with Bezafibrate from 10.5±0.7 to 14.7±0.7 and 15.5±0.8 µmol FFA/ml/h or by 30% (p<0.05). Only few side-effects during treatment with Bezafibrate could be ascertained.ZusammenfassungDie Wirkung von Bezafibrat auf Lipid- und Lipoproteinspiegel wurde in einer Langzeitstudie über 40 Wochen bei 27 Patienten mit primären Hyperlipoproteinämien untersucht (12 Patienten mit HLP Typ IV n.F., 7 Patienten mit Typ IIb, 3 Patienten mit Typ IIa, 4 Patienten mit Typ V und 1 Patient mit Typ III). Bezafibrat senkte in diesem Kollektiv das Gesamtcholesterin um 16%, während das HDL-Cholesterin um 28 bzw. 36% anstieg (p<0,05). Die Serumtriglyzeride fielen um 59% (450 mg Bezafibrat/die) bzw. 66% (600 mg Bezafibrat/die) statistisch signifikant ab (p<0,05). Bei Hyperlipidämien vom Typ IV, IIb, IIa und V waren Anstiege des HDL-Cholesterins feststellbar. Das LDL-Cholesterin verhielt sich typenspezifisch. Die Aktivität der Lipoproteinlipasen (postheparin) wurde durch Bezafibrat von 10,5±0,7 auf 14,7±0,7 bzw. 15,5±0,8 µmol FFA/ml/Stunde um ca. 30% gesteigert (p<0,05). Die Nebenwirkungen während Bezafibrat-Behandlung waren gering.The effect of long-term treatment over 40 weeks with Bezafibrate on lipids and lipoproteins was investigated in 27 patients with primary hyperlipoproteinemias (hlp) (12 patients with hlp type IV, 7 patients with type IIb, 3 patients with type IIa, 4 patients with type V and 1 patient with type III). Bezafibrate reduced total cholesterol by 16%, whereas HDL-cholesterol increased by 28% and 36% (p less than 0.05). Serumtriglycerides decreased by 59% (450 mg Bezafibrate daily) and by 66% (600 mg Bezafibrate daily) statistically significant (p less than 0.05). In hyperlipidemias type IV, IIb, IIa and V increases of HDL-cholesterol could be observed. The course of LDL-cholesterol was different in the various types of hlp. The postheparin-lipoprotein-lipase (PHLA) was activated by treatment with Bezafibrate from 10.5 +/- 0.7 to 14.7 +/- 0.7 and 15.5 +/- 0.8 mumol FFA/ml/h or by 30% (p less than 0.05). Only few side-effects during treatment with Bezafibrate could be ascertained.

Computed tomography after ESWL of gallbladder calculi

Computed tomography (CT) was performed on 88 patients before and after extracorporeal shock wave lithotripsy (ESWL) of gallstones to find the effects of ESWL on the gallbladder and surrounding liver tissue. Post-ESWL scans demonstrated a thickening of the gallbladder wall in 25 (28.4%) cases. In one patient an intrahepatic bilioma beside the gallbladder was seen 3 days after ESWL treatment. Hematoma of the gallbladder wall or the adjacent liver tissue was not seen, and neither a hydrops nor biliary-induced pancreatitis was observed. The authors conclude that while some patients undergoing ESWL will show some posttreatment abnormality on CT scans, the procedure is associated with a low frequency of serious gallbladder and liver trauma.

A neural network expert system to support decisions in diagnostic mapping

An expert system module has been integrated into clinical workstations used for report generation and the storage and retrieval of diagnostic images. The expert system works in the background and supports the physicians decisions. The system has been created for ultrasound examinations of the abdomen. The knowledge-based system has been implemented for the same knowledge segment using two different methods: a rule-based approach with the AI-tool Joshua on a Symbolics machine for prototyping and knowledge debugging and a neural network approach based on back propagation. The results show that the neural network is robust and flexible for the mainly associative knowledge found in this application; it performed well in general and, specifically, on subsets of findings entered during the course of an examination. It was therefore decided to combine both components.<<ETX>>

Fish oil, enriched with polyunsaturated fatty acids of the omega-3-type accelerates the nucleation time in healthy subjects

SummaryThe daily administration of fish oil, containing 1.5 g omega-3-fatty acids causes a significant decrease in nucleation time (12.1 ±7.3 vs. 2.0 ±1.2 days, p< 0.001), as well as in biliary cholesterol saturation and biliary cholesterol composition in 13 healthy subjects. The nucleation time, cholesterol saturation index and biliary lipids showed no significant differences in 11 cholesterol gallstone patients after a six-week treatment period with omega-3-fatty acids. Taurocholate percentage increased significantly in the gallstone group (10.4 ±3.9 vs 13.5 ±1.7%, p<0.05). The levels of the other bile acids remained unchanged during the treatment period. Therefore, the incidence of gallstones might be increased after treatment with fish oil, containing omega-3-fatty acids.

Ein elektronisches Tutorsystem zur Aus- und Weiterbildung für die medizinische Ultraschalluntersuchung

Der Medizinstudent sowie der in der Aus- und Weiterbildung stehende Arzt sehen sich heute mit einem explosionsartigen Anwachsen des medizinischen Wissens und einer kaum zu bewaltigenden Datenflut konfrontiert. Als eine Konsequenz werden neue, effektive Methoden der Wissensvermittlung gefordert, die nicht mehr auf reinem Auswendiglernen, sondern einer Organisation des Wissens im problemspezifischen Kontext basieren (Greenes, 1989).