Hepatolithiasis in East Asia. Retrospective study

Intrahepatic peribiliary glands of humans. II. Pathological spectrum

The pathological spectrum of intrahepatic peribiliary glands is reviewed here. Several categories of histopathological changes such as necro-inflammation, cystic dilatation, hyperplasia and neoplasia have been identified in this glandular system. Necro-inflammation is associated with biliary tract diseases and chronic advanced liver diseases and may also appear in the livers of subjects with extrahepatic diseases such as sepsis. Cystic changes of microscopic sizes are not uncommon in autopsy livers of chronic advanced liver diseases, portal hypertensive diseases and also polycystic liver of adult type. Grossly recognizable cysts are, however, infrequent and occasionally cause compression of the adjoining bile ducts. Hyperplasia of these glands, which occurs consistently in hepatolithiasis and more variably in other conditions (e.g. biliary tract infection and submassive hepatic necrosis), may be associated with hypersecretion of seromucinous substances. Hyperplasia of peribiliary glands may then lead to mucin-related biliary diseases. In addition, these glands, particularly the hyperplastic ones, could be a precursor of cholangiocarcinoma. The pathological spectrum of the intrahepatic peribiliary glands is being expanded, although a clinical pathological correlation remains uncharted. Furthermore, age-related variations and non-specific reactive changes of these glands remain unexplored.

Alterations of bile acid composition in gallstones, bile, and liver of patients with hepatolithiasis, and their etiological significance

A detailed comparison was made of the bile acid composition in gallstones (brown pigment stones) and paired bile and liver from both affected and unaffected lobes by gallstones, which were taken at operation from 16 patients with hepatolithiasis, with the aim of elucidating whether stone formation is derived from possible local disturbances limited to intrahepatic bile ducts. Brown pigment stones in the intrahepatic bile ducts, most of which were accompanied by bile with high cholesterol saturation, had significantly more cholesterol, and less calcium bilirubinate and bile acid than those found in the extrahepatic bile ducts. Intrahepatic gallstones had significantly lower amounts of secondary and unconjugated bile acids, the bile acids modified by bacterial intervention, than extrahepatic stones. Bile specimens from both affected and unaffected lobes showed significantly increased molar percentages of cholesterol and decreased percentages of bile acids than bile from controls. In contrast, liver specimens from both lobes showed significantly higher concentrations of total bile acids. Secondary bile acids were present in a much lower proportion in bile and liver from both lobes than in bile and liver from controls. On the other hand, unconjugated bile acids were present in a much higher proportion in bile and liver from patients and only in negligible amounts in bile from controls. Furthermore, the plasma levels of mevalonate and those of 7 alpha-hydroxy-4-cholestene-3-one were found to be significantly higher and lower in patients than in controls, respectively, indicating that in hepatolithiasis cholesterol synthesis might increase and bile acid synthesis might decrease in the liver. These findings suggested that alterations of bile acid composition in gallstones, bile, and liver of patients with hepatolithiasis may be attributed to not only secondary changes resulting from local disturbances limited to intrahepatic bile ducts but also possible primary alterations of hepatocyte metabolism, such as bile acid conjugation and primary defects in cholesterol and bile acid synthesis.

Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis

Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. Acute cholecystitis is treated by surgery in most cases. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy may become more common in the future for treatment of acute cholecystitis as well as in cases of acute cholangitis and pancreatitis if the bile ducts are cleared of gallstones. Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.

The management of complicated hepatolithiasis with intrahepatic biliary stricture by the combination of T-tube tract dilation and endoscopic electrohydraulic lithotripsy

Hepatolithiasis with intrahepatic biliary strictures, more common in Southeast Asia than elsewhere, remains a difficult problem to manage. Retention of stones behind strictures after surgery is a frequent and troublesome complication. Post-operative duct dilation with percutaneous transhepatic cholangioscopy tube stenting through a matured T-tube tract was performed in 15 patients. Choledochoscopic electrohydraulic lithotripsy was applied in six patients when impacted or large stones were encountered. Complete clearance of stones was achieved in 12 patients (80%). Two patients had fevers develop after ductal dilation and recovered after conservative treatment. These 12 successfully treated patients remain well, with a mean follow-up of 18 months. Post-operative T-tube tract dilation, selectively combined with endoscopic electrohydraulic lithotripsy, is an effective and safe method for complicated hepatolithiasis with biliary strictures.

Bile duct stents in the management of hepatolithiasis with long-segment intrahepatic biliary strictures

Biliary stricture represents a challenging problem in the treatment of hepatolithiasis because of its association with treatment failure and stone recurrence. The long-segment type of stricture is difficult to manage and is likely to recur. To investigate the necessity for biliary stenting after balloon dilatation therapy, 20 consecutive patients with long-segment strictures who had 22 stents (group 1) were compared with ten patients who refused stenting (group 2). The long-segment strictures in group 1 were located on the right side in 80 per cent of patients, on the left side in 10 per cent, and were bilateral in 10 per cent. The stents, varying from 8 to 12 Fr, were retained for at least 6 months. They were inserted through the routes of a matured T tube track (five cases), percutaneous transhepatic track (14 cases), a jejunal limb (two cases) and a fistula (one case). Complications of stenting consisted of dislodgement (one case), haemobilia (two cases), cholangitis (two cases) and intrahepatic abscess (one case). The cumulative probability of stricture recurrence in group 1 was 10 per cent, 15 per cent and 21 per cent at 2, 3 and 4 years, respectively, whereas in group 2 it was 80 per cent at 2 years (P less than 0.003). The results suggest that intrahepatic biliary stenting after balloon dilatation appears necessary and helpful in the management of hepatolithiasis with long-segment biliary strictures.

Complications of hepatolithiasis

Hepatolithiasis or intrahepatic stone is associated with a variety of complications of which biliary sepsis is one. Left untreated, infection results in formation of micro-abscesses, portal thrombophlebitis and fistulation into adjacent structures. With repeated infection, biliary strictures and severe destruction of liver parenchyma occur. Biliary cirrhosis, portal hypertension and bleeding varices are the terminal manifestations. Early recognition and proper treatment are essential for the prevention of severe complications and functional deterioration.

Choledocholithiasis treated by ethylenediaminetetraacetic acid infusion through an endoscopic nasobiliary catheter

A 64 year old man was admitted to the National Cheng Kung University Hospital for obstructive jaundice. He had received cholecystectomy 5 years previously. Sonography revealed common bile duct stones. He was treated with endoscopic nasobiliary drainage (ENBD) for 5 days for concomitant cholangitis. The muddy pigment stones disappeared completely after 10 days of infusion of ethylenediaminetetraacetic acid (EDTA) via the ENBD tube. There were no adverse effects, and he was stone-free 4 months later.

Relative prevalence of gallstone diseases in Taiwan. A nationwide cooperative study

For many years, it has been said that Taiwan has the highest relative prevalence of hepatolithiasis among the Asian countries. To confirm this, and to reevaluate the chronological changes regarding gallstone disease in Taiwan, a retrospective nationwide cooperative study was conducted in this country. A total of 17,182 patients from 28 medical centers are included in this survey. A gradual increase during the past 20 years in gallstone prevalence with a concomitant decrease of choledocholithiasis and hepatolithiasis are well demonstrated. Both nutritional and environmental factors are involved in these changes. With respect to hepatolithiasis, Taiwan continues to have the highest prevalence among Asian countries, and 20% may be the average figure for the whole country.

Risk factors for perforation of gallbladder. A combined hospital study in a Chinese population

The composition and location of gallstones differ in Western and Eastern people. This has been documented in the literature. The difference in the clinical manifestations of biliary calculous disease has been postulated to be based on ethnic or environmental factors. In an effort to improve our management of patients with gallbladder perforations, a combined hospital study in a Chinese population during 11 years was conducted to study the clinical profiles at risk. Seventy-one patients were studied. The perforations were categorized as either acute (type I) in 14 (19.7%), subacute (type II) in 25 (35.2%), or chronic (type III) in 32 (45.1%). The incidence of severe underlying disease was significantly greater (p = 0.02) in patients with acute and subacute perforation as compared with chronic perforation. Multiple stones in the biliary tree and the gallbladder are very common and may mask the presentation of gallbladder perforation when patients with either biliary colic or biliary tract infection. A history suggestive of chronic gallstone disease is common, especially in patients with chronic perforation. The clinical manifestations of gallbladder perforation are similar to those of acute cholecystitis without perforation. On the basis of these data, clinical profiles have been developed for patients at risk of developing acute versus chronic gallbladder perforation. Awareness of these groupings forms the basis for early recognition and treatment of acute gallbladder perforation.

Microanalysis of bile acid composition in intrahepatic calculi and its etiological significance

Brown pigment stones in the intrahepatic bile ducts were compared with those found in the extrahepatic bile ducts with special reference to the bile acids modified by bacterial intervention, that is, unconjugated, glucuronidated, secondary, and ketonic bile acid fractions. The former showed significantly lower amounts of total bile acids (P less than 0.01) and lower proportions of unconjugated bile acid fraction (P less than 0.01), secondary bile acid fraction (P less than 0.05), and ketonic bile acid fraction (P less than 0.05) to total bile acids than the latter. The discriminant analysis using these bile acid parameters led to complete separation between intrahepatic and extrahepatic stones in the case of brown pigment stones. In contrast, cholesterol stones in the intrahepatic bile ducts showed the bile acid composition close to those found in the extrahepatic ducts and gallbladder. The above data show that the bacterial infection plays a less important role in the formation and ensuing growth of most intrahepatic brown pigment stones than in extrahepatic stones, and that factors other than or in addition to bacterial infection are involved.

Intrahepatic cholangiocarcinoma in hepatolithiasis: A frequently overlooked disease

Five cases of intrahepatic cholangiocarcinoma were found among 101 cases of hepatolithiasis. There was no definite sign of cholangiocarcinoma in ERCP and image studies of four cases. The possibility of the existence of occult cholangiocarcinoma should be kept in mind, especially when unusual presentations, such as body weight loss, anemia, palpable abdominal mass, and intractable pain, appear. An intraoperative frozen-section examination should be considered under the following circumstances: (1) whitish nodular mass over liver, (2) mucinous substance within bile duct, and (3) enlarged, firm lymph nodes clustered along the hepatic arteries and/or celiac arteries.

Hepatolithiasis in East Asia: comparison between Japan and China

The incidence of hepatolithiasis is high throughout East Asia compared with the West, but the marked difference in the relative proportion of hepatolithiasis to all cholelithiasis cases exists even among countries of similar ethnic backgrounds. A retrospective study of cases was conducted in two areas in China with the aim of clarifying the presence of such regional difference in China itself. The relative proportion of hepatolithiasis was 21.2% in Shenyang, 9.2% in Beijing and 4.1% in Fukuoka, Japan. A significant difference in the location of stones was also found between Shenyang, Beijing and Fukuoka. Intra- and extrahepatic hepatolithiasis in all hepatolithiasis cases was 95% in Shenyang and 75% in Beijing. Involvement of both hepatic lobes was found in 73% in Shenyang and less than 60% in the other two, suggesting that hepatolithiasis of the old form or of an advanced stage still lingers in Shenyang. In conclusion, regional differences in the proportion and the type of hepatolithiasis exist in China itself, as well as in the Chinese population in Taiwan, Hong Kong and Singapore, as previously reported. The possible contribution of environmental factors to the occurrence of hepatolithiasis is again emphasized.

Intrahepatic cholesterol stones: a rationale for dissolution therapy

A case of primary cholesterol hepatolithiasis is reported. Stone composition was documented by infrared spectroscopy, and the presence of cholesterol saturated bile was demonstrated using standard biochemical techniques. The patient was treated with operative stone extraction, choledochoscopy, biliary enteric anastomosis, and oral dissolution therapy. The administration of oral dissolution agents has altered the composition of the patient's bile and may prevent further stone formation. We advocate the use of both stone and biliary biochemical analysis for patients with primary hepatolithiasis to facilitate optimal therapy.

Pathogenesis of gallstones

The many developments in nonoperative methods for the treatment of gallstone disease underscore the importance of understanding the pathogenesis of these stones. Elucidation of the factors responsible for nucleation of crystals and the mechanism by which it occurs would appear to be the challenge if we are to define the cascade of events that results in gallstone formation.

Dilatation of intrahepatic biliary strictures in patients with hepatolithiasis

To investigate the role of balloon dilatation in the management of complicated hepatolithiasis with intrahepatic biliary stricture, 57 consecutive patients who received 208 sessions of dilatation in addition to the usual treatment were analyzed. The strictures were located in the right intrahepatic ducts (84.2%), left intrahepatic ducts (12.3%), or both (3.5%). Dilatation began 3-4 weeks after surgery. The routes of dilatation included the matured T-tube tract (3 cases), percutaneous transhepatic biliary drainage tracts (42 cases), and both (12 cases). The immediate overall success rate of complete stone clearance increased significantly from 0% predilatation to 94.7% postdilatation. The main complications of dilatation therapy consisted of septicemia (10.5%), hemobilia (10.5%), and mild diarrhea (80%). Eight patients (14%) with long-segment strictures received 11 postdilatation biliary stentings. Complications were 1 patient with occlusion and 2 patients with "spontaneous" hemobilia. Severe multiple strictures and coexistent secondary biliary cirrhosis were the contributing factors to complications. During the follow-up of 3.4 +/- 1.2 years, recurrence of strictures was found in 4 patients. Two of them belonged to the stenting group. The cumulative probability of restricture was low: 4% at 2 years, 6% at 2.5 years, and 8% at 3 years. We conclude that in complicated cases of hepatolithiasis with intrahepatic biliary stricture, dilatation and stenting are good adjuvant therapies.

Current management of intrahepatic stones

A high incidence of intrahepatic stones occurs in East Asia. The surgical management of intrahepatic stones is problematic because it is difficult to locate and remove all the stones and relieve the accompanying biliary strictures. Consequently, the rate of recurrent cholangitis is high. Many new techniques have been introduced to locate, fragment, and retrieve gallstones. Operative procedures to relieve biliary strictures have also undergone development. These new procedures and techniques have been applied to intrahepatic stones. The initial results are good. Whether these good results can be maintained in the long-term remains to be seen.

Limitations of percutaneous transhepatic cholangioscopy in the removal of complicated biliary calculi

To investigate the limitations of percutaneous transhepatic cholangioscopic lithotomy (PTCSL) in the management of retained or reformed biliary calculi, we conducted a retrospective study of 50 patients who had received PTCSL for complicated biliary calculi during a period of 32 months. The calculi were located in the common bile duct (24%), the intrahepatic bile ducts (60%), and in both the common bile duct and intrahepatic bile ducts (16%). The adjunctive techniques in PTCSL included balloon dilatation for the biliary stricture, electrohydraulic lithotripsy (EHL) for crushing large impacted stones, and flushing techniques, biliary spoons, and basket catheters for stone fragmentation and grasping. The overall percutaneous manipulations totaled 221 procedures, including 124 sessions of PTCS. In each patient, the number of sessions of PTCS varied from 1 to 7. In our series, the main complications of PTCS therapy, rarely reported in the literature, included pain intolerance in 7 cases (14%), minor bleeding in 7 cases (14%), and massive bleeding which needed angiographic diagnosis and therapy for hemostasis in 5 cases (10%). Secondary biliary cirrhosis, severe biliary stricture and angulations, previous shunt surgery, neovascularization surrounding the chronic inflammatory stenotic intrahepatic bile ducts, pseudoaneurysm formation, and coexistent cholangiocarcinoma contributed to the vulnerability of bleeding during manipulations. The complications resulted in treatment failure in 11 patients (22%). We conclude that PTCS is a useful alternative treatment to surgery for biliary calculi, but it has limitations that obviate complete stone clearance.

Pathophysiology and treatment of gallstones

Spurred on by the discovery of "lithogenic bile" as a precursor, there has been much attention focused on the pathophysiology and treatment of gallstones. The article reviews the progress to date regarding the epidemiology, pathophysiology, diagnosis, therapy, and recurrence/prevention of gallstones.

Primary cholesterol hepatolithiasis

Stones extracted from patients with hepatolithiasis were analysed by infrared spectrophotometry. Cholesterol stones containing 70% or more cholesterol were found in 12 out of 55 cases. Judging from the lodging site of the stones, the degree of dilatation of the cystic duct, and the presence of cholecystitis, five of the cases were considered to be cholesterol stones produced in the liver. Two out of the five cases were a 44-year-old female and a 46-year-old female, respectively, with normal bifurcation of intrahepatic ducts, and stones were found in the lateral branches of dilated cystic bile ducts. The other three were 2 males and 1 female with an average age of 33. In these cases, the posterior descending branch bifurcated from the left hepatic duct, and stones were lodged in the dilated bile ducts distal to the junction of the left hepatic duct and the posterior descending branch. It is our conclusion that at least the former two were cases of "primary cholesterol hepatolithiasis" in view of the shape of the stones conforming to the hepatic duct, their easy morcellation, and the high cholesterol contents.

Composition of intrahepatic calculi. Etiological significance

Gallstones in intrahepatic (N = 42) and extrahepatic (N = 22) bile ducts and gallbladder (N = 23) were subjected to chemical analysis modified to suit the analysis of brown pigment stones with the aim of determining if stone location at surgery influenced stone composition. Dimethylsulfoxide-acetone-1 N HCl (90:9:1, v/v/v) was used to dissolve gallstone specimens. Intrahepatic calculi were divided into two groups, ie, nine cholesterol stones and 33 brown pigment stones. Cholesterol stones in the intrahepatic bile ducts had a similar composition to those in the gallbladder and extrahepatic bile ducts, suggesting a similar pathogenesis wherever formed throughout the biliary tract. Intrahepatic brown pigment stones contained significantly less bilirubin (P less than 0.001) and more cholesterol (P less than 0.05) by chi-square analysis than brown pigment stones found in the extrahepatic bile ducts, suggesting that the site of formation affects stone composition and modifies stone pathogenesis.

Hepatic fibrosis and cirrhosis in tropical countries (including portal hypertension)

The spectrum of diseases seen in patients from certain 'tropical areas' requires that a physician be aware of some of the syndromes discussed here. A high index of suspicion for less usual causes of cirrhosis is imperative when evaluating such patients presenting with hepatocellular disease. The differential must be expanded and the work-up complete. Liver biopsy should be performed as early in the course of disease as is feasible and will often provide valuable diagnostic information. It will not only facilitate treatment but allow for needed clinical trials and may help to increase our understanding of the various disease processes.