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Oluboyede DO, Zafar M, Shirazi F, Dsouza K, Abdulkarim A, Hacikurt K, Whitehead M. The Conservative Management of Choledocholithiasis With Ursodeoxycholic Acid. Cureus 2023; 15:e43850. [PMID: 37736472 PMCID: PMC10510569 DOI: 10.7759/cureus.43850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/23/2023] Open
Abstract
Choledocholithiasis has been defined as the presence of stones within the common bile duct (CBD) with up to one-half of the cases remaining asymptomatic. We report a case of an 84-year-old frail male admitted for the treatment of pneumonia, pleural effusion, and bacteraemia with co-incidental deranged liver function tests (LFTs). Ensuing magnetic resonance cholangiopancreatography (MRCP) noted three CBD stones; however, the patient remained asymptomatic. After discussing the benefits and risks of treatment options with the gastroenterology team, the patient refused endoscopic retrograde cholangiopancreatography (ERCP) and opted for close monitoring in the community whilst taking ursodeoxycholic acid (UDCA). In the months following, his LFTs normalised, and repeat MRCP no longer showed stones. This case demonstrates that UDCA with close monitoring may be considered a non-invasive alternative treatment of CBD stones, particularly in elderly or frail patients with multiple comorbidities.
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Affiliation(s)
- Daniel O Oluboyede
- Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, GBR
| | - Mansoor Zafar
- Gastroenterology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, GBR
- Gastroenterology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, GBR
| | - Farah Shirazi
- Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, GBR
- Medicine, Jinnah Medical & Dental College, Karachi, PAK
| | - Kevin Dsouza
- Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, GBR
| | - Abdulmoen Abdulkarim
- Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, GBR
| | - Kadir Hacikurt
- Radiology, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, GBR
| | - Mark Whitehead
- Gastroenterology, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, GBR
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Muratori R, Mandolesi D, Pierantoni C, Festi D, Colecchia A, Mazzella G, Bazzoli F, Azzaroli F. Ductal stones recurrence after extracorporeal shock wave lithotripsy for difficult common bile duct stones: Predictive factors. Dig Liver Dis 2017. [PMID: 28625406 DOI: 10.1016/j.dld.2017.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND & PURPOSE Extra-corporeal shock wave lithotripsy (ESWL) can be considered in difficult common bile duct stones (DCBDS), with a success rate greater than 90% but data on stone recurrence after ESWL are limited. We performed a retrospective analysis to evaluate long-term outcomes in patients who underwent ESWL for DCBDS. METHODS From May 1992 to October 2012, patients who underwent ESWL treatment for DCBDS, not amenable to endoscopic extraction, were included. Data on long-term outcome were collected through phone interviews and medical records. RESULTS A total of 201 patients with a successful clearance of DCBDS after ESWL were included. During a median follow-up period of 4.64 years, 40 patients (20%) developed a recurrence of bile duct stones. Logistic regression analysis showed that the common bile duct diameter, gallstones presence and the maximum stone size were significantly associated with recurrence. CONCLUSIONS We observed a recurrence rate of 20% over a median follow-up of 4 years. Gallbladder stones, stone size and a dilated common bile duct diameter are risk factors for recurrent stone formation, while ursodeoxycholic acid treatment did not influence recurrence in our population.
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Affiliation(s)
- Rosangela Muratori
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Daniele Mandolesi
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy.
| | - Chiara Pierantoni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Giuseppe Mazzella
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Francesco Azzaroli
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
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3
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Hu KC, Chu CH, Wang HY, Chang WH, Lin SC, Liu CC, Liao WC, Liu CJ, Wu MS, Shih SC. How Does Aging Affect Presentation and Management of Biliary Stones? J Am Geriatr Soc 2016; 64:2330-2335. [PMID: 27676699 DOI: 10.1111/jgs.14481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Common bile duct (CBD) stones are common in elderly adults, but the effect of aging on the presentation of CBD stones remains to be evaluated. Recent studies have demonstrated that the clinical presentation of CBD stones may vary with age. Younger adults may present with classical biliary colic symptoms, whereas elderly adults may have no unapparent clinical features. Younger adults with CBD stones were significantly more likely to have abnormal liver function tests than those without. The sensitivity and accuracy of transabdominal ultrasound scans in screening for CBD stones increases with age. Antibiotic agents should be promptly administered to individuals with CBD stones complicated by cholangitis, but the effects of pharmacotherapy on renal function should be considered in elderly adults. Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be first-line treatment for CBD stones, and endoscopic biliary sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD) along with ERCP is an adequate biliary drainage method in individuals with CBD stones. EPBD has a lower bleeding risk but higher post-ERCP risk of pancreatitis than EST. Longer-duration (>1 minute) EPBD may be preferred over EST because it is associated with a comparable risk of pancreatitis but a lower rate of overall complications, although recurrent cholangitis or unfavorable outcomes will increase during CBD dilation or in the presence of residual CBD stones.
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Affiliation(s)
- Kuang-Chun Hu
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Healthy Evaluation Center, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Medical, Nursing, and Management College, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Hsin Chu
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Medical, Nursing, and Management College, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Medical, Nursing, and Management College, Taipei, Taiwan
| | - Wen-Hsiung Chang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Medical, Nursing, and Management College, Taipei, Taiwan
| | - Shee-Chan Lin
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Medical, Nursing, and Management College, Taipei, Taiwan
| | - Chuan-Chuan Liu
- Healthy Evaluation Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Jen Liu
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Shiang Wu
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shou-Chuan Shih
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Healthy Evaluation Center, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Medical, Nursing, and Management College, Taipei, Taiwan.,MacKay Medical College, Taipei, Taiwan
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4
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Hu KC, Chu CH, Wang HY, Chang WH, Lin SC, Liu CC, Liao WC, Liu CJ, Wu MS, Shih SC. How Does Aging Affect Presentation and Management of Biliary Stones? J Am Geriatr Soc 2016. [DOI: doi.org/10.1111/jgs.14481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Kuang-Chun Hu
- Division of Gastroenterology; Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- Healthy Evaluation Center; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medical, Nursing, and Management College; Taipei Taiwan
- Graduate Institute of Clinical Medicine; College of Medicine; National Taiwan University; Taipei Taiwan
| | - Cheng-Hsin Chu
- Division of Gastroenterology; Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medical, Nursing, and Management College; Taipei Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology; Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medical, Nursing, and Management College; Taipei Taiwan
| | - Wen-Hsiung Chang
- Division of Gastroenterology; Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medical, Nursing, and Management College; Taipei Taiwan
| | - Shee-Chan Lin
- Division of Gastroenterology; Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medical, Nursing, and Management College; Taipei Taiwan
| | - Chuan-Chuan Liu
- Healthy Evaluation Center; MacKay Memorial Hospital; Taipei Taiwan
| | - Wei-Chih Liao
- Department of Internal Medicine; National Taiwan University Hospital; College of Medicine; National Taiwan University; Taipei Taiwan
| | - Chun-Jen Liu
- Graduate Institute of Clinical Medicine; College of Medicine; National Taiwan University; Taipei Taiwan
- Department of Internal Medicine; National Taiwan University Hospital; College of Medicine; National Taiwan University; Taipei Taiwan
| | - Ming-Shiang Wu
- Graduate Institute of Clinical Medicine; College of Medicine; National Taiwan University; Taipei Taiwan
- Department of Internal Medicine; National Taiwan University Hospital; College of Medicine; National Taiwan University; Taipei Taiwan
| | - Shou-Chuan Shih
- Division of Gastroenterology; Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- Healthy Evaluation Center; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medical, Nursing, and Management College; Taipei Taiwan
- MacKay Medical College; Taipei Taiwan
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5
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Yamamoto R, Tazuma S, Kanno K, Igarashi Y, Inui K, Ohara H, Tsuyuguchi T, Ryozawa S. Ursodeoxycholic acid after bile duct stone removal and risk factors for recurrence: a randomized trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:132-6. [PMID: 26705893 DOI: 10.1002/jhbp.316] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/17/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Currently, no established pharmacologic treatment exists for the prevention of recurrent common bile duct (CBD) stones. METHODS Here, we present a multi-center randomized trial that compared the CBD recurrence rate after bile duct stone removal between patients given ursodeoxycholic acid (UDCA) and the untreated group. A total of 36 patients were randomly assigned to either the UDCA (n = 15) or the untreated group (n = 21). The primary end-point was the recurrence rate of CBD stones. RESULTS The recurrence rate of CBD stones was 6.6% in the UDCA group and 18.6% in the untreated group (P = 0.171). A multivariate analysis found that not receiving UDCA was an independent risk factor for stone recurrence. The recurrence rates of CBD stones did not differ by sex, past history of cholecystectomy, or the presence of gallstones. CONCLUSIONS Our findings indicate that UDCA may be a novel treatment strategy to prevent the recurrence of CBD stones. However, further evaluation of UDCA in a larger number of subjects will be required to confirm the applicability of these results.
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Affiliation(s)
- Ryuichi Yamamoto
- Department of General Internal Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Susumu Tazuma
- Department of General Internal Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Keishi Kanno
- Department of General Internal Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yoshinori Igarashi
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Kazuo Inui
- Department of Internal Medicine, Banbuntane Houtokukai Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Hirotaka Ohara
- Department of Community-Based Medical Educations, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toshio Tsuyuguchi
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shomei Ryozawa
- Saitama Medical University International Medical Center, Saitama, Japan
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6
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Abstract
It is imperative for gastroenterologists to understand the different formations of bile duct stones and the various medical treatments available. To minimize the complications of endoscopic retrograde cholangiopancreatography (ERCP), it is critical to appropriately assess the risk of bile duct stones before intervention. Biliary endoscopists should be comfortable with the basic techniques of stone removal, including sphincterotomy, mechanical lithotripsy, and stent placement. It is important to be aware of advanced options, including laser and electrohydraulic stone fragmentation, and papillary dilatation for problematic cases. The timing and need for ERCP in those who require a cholecystectomy is also a consideration.
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Affiliation(s)
- James Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, Los Angeles County Hospital, University of Southern California, Los Angeles, CA 90033-1370, USA.
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7
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The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc 2011; 74:731-44. [PMID: 21951472 DOI: 10.1016/j.gie.2011.04.012] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 12/15/2022]
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8
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Okonogi S, Yonemochi E, Oguchi T, Puttipipatkhachorn S, Yamamoto AK. Enhanced Dissolution of Ursodeoxycholic Acid from the Solid Dispersion. Drug Dev Ind Pharm 2008. [DOI: 10.3109/03639049709150502] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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9
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Mikov M, Fawcett JP, Kuhajda K, Kevresan S. Pharmacology of bile acids and their derivatives: Absorption promoters and therapeutic agents. Eur J Drug Metab Pharmacokinet 2006; 31:237-51. [PMID: 17136862 DOI: 10.1007/bf03190714] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The role of bile acids in pharmacotherapy is reviewed in this article. The therapeutic use of bile has been recognized since ancient times. Previously bile acids were the standard treatment for gallstones where chenodeoxycholic acid and ursodeoxycholic acid were effective in promoting the dissolution of cholesterol gallstones. Today their therapeutic role looks set to expand enormously. Bile acids as absorption promoters have the potential to aid intestinal, buccal, transdermal, ocular, nasal, rectal and pulmonary absorption of various drugs at concentrations that are non-toxic. Keto derivatives of cholic acid, such as 3a,7a,dihydroxy-12-keto-5alpha-cholic acid (sodium salt and methyl ester) are potential modifiers of blood-brain barrier transport and have been shown to promote quinine uptake, enhance the analgesic effect of morphine and prolong the sleeping time induced by pentobarbital. They have also been shown to be hypoglycaemic. Bile acids as therapeutic agents have the potential to produce beneficial effects in sexually transmitted diseases, primary biliary cirrhosis, primary sclerosing cholangitis, gallstones, digestive tract diseases, cystic fibrosis, cancer and diabetes.
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Affiliation(s)
- M Mikov
- School of Pharmacy, University of Otago, Dunedin, New Zealand.
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10
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Caddy GR, Tham TCK. Gallstone disease: Symptoms, diagnosis and endoscopic management of common bile duct stones. Best Pract Res Clin Gastroenterol 2006; 20:1085-101. [PMID: 17127190 DOI: 10.1016/j.bpg.2006.03.002] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Bile duct stones (BDS) are often suspected on history and clinical examination alone but symptoms may be variable ranging from asymptomatic to complications such as biliary colic, pancreatitis, jaundice or cholangitis. The majority of BDS can be diagnosed by transabdominal ultrasound, computed tomography, endoscopic ultrasound or magnetic resonance cholangiography prior to endoscopic or laparoscopic removal. Approximately 90% of BDS can be removed following endoscopic retrograde cholangiography (ERC)+sphincterotomy. Most of the remaining stones can be removed using mechanical lithotripsy. Patients with uncorrected coagulopathies may be treated with ERC+pneumatic dilatation of the sphincter of Oddi. Shockwave lithotripsy (intraductal and extracorporeal) and laser lithotripsy have also been used to fragment large bile duct stones prior to endoscopic removal. The role of medical therapy in treatment of BDS is currently uncertain. This review focuses on the clinical presentation, investigation and current management of BDS.
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Affiliation(s)
- Grant R Caddy
- Department of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland, UK.
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11
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Abstract
BACKGROUND Common duct calculi retained after gallbladder surgery continue to present a clinical challenge especially in the era of minimally invasive surgery. This review examines the strategy of dissolution therapy used throughout the history of biliary tract surgery and its use to the modern surgeon. DATA SOURCES Original journal articles and reviews were identified using standard surgical textbooks and MEDLINE. Keywords for searching included choledocholithiasis, dissolution, mono-octanoin, common duct stones, MTBE, cholic acid, and gallstones. CONCLUSIONS Dissolution therapy used initially as an alternative to open surgery is now used more effectively as an adjunct to laparoscopic or endoscopic biliary tract surgery. The current review demonstrates a majority of patients with retained choledocholithiasis respond to dissolution and can be safely managed without choledochotomy.
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Affiliation(s)
- E Kelly
- Department of Surgery, University of California, Davis-East Bay, Oakland, California, USA
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12
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Okonogi S, Oguchi T, Yonemochi E, Puttipipatkhachorn S, Yamamoto K. Physicochemical Properties of Ursodeoxycholic Acid Dispersed in Controlled Pore Glass. J Colloid Interface Sci 1999; 216:276-284. [PMID: 10421735 DOI: 10.1006/jcis.1999.6331] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The objective of this study was to reduce the crystallinity of ursodeoxycholic acid (UDCA) by solid dispersion with controlled pore glass (CPG). To evaluate the effect of pore diameter and pore volume of CPG on the crystalline properties of UDCA, we used powder X-ray diffractometry (PXRD) and differential scanning calorimetry (DSC). PXRD patterns and the DSC data indicated the presence of UDCA in a crystalline state in the physical mixtures. It was found that amorphous UDCA could be formed via solid dispersion with CPG obtained by a solvent method. The DSC thermograms of solid dispersions showed that there were two states of UDCA, amorphous and crystalline. The amount of crystalline fraction in the solid dispersions depended on the pore size, pore volume, and the specific surface area of CPG. When UDCA was mixed with different pore diameters of CPG, it was found that UDCA molecules preferentially interacted with pores of smaller size. Copyright 1999 Academic Press.
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Affiliation(s)
- S Okonogi
- Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
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13
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Abstracts from the 3rd Meeting of the Association of Endoscopic Surgeons of Great Britain and Ireland in association with the Royal College of Surgeons of Ireland, held on 9 and 10 November 1995, in Dublin, Ireland. MINIM INVASIV THER 1996. [DOI: 10.3109/13645709609153717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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14
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15
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Perissat J, Huibregtse K, Keane FB, Russell RC, Neoptolemos JP. Management of bile duct stones in the era of laparoscopic cholecystectomy. Br J Surg 1994; 81:799-810. [PMID: 8044588 DOI: 10.1002/bjs.1800810606] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The introduction of laparoscopic cholecystectomy has resulted in increased options for the management of bile duct stones and has stimulated a fundamental reappraisal of the situation before the laparoscopic era. This article reviews the natural history of bile duct stones and details the different ways in which they may now be treated. New areas of controversy are highlighted and the need for further studies is emphasized.
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Affiliation(s)
- J Perissat
- Clinique Chirurgicale du CHU, Bordeaux, France
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16
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Johnson GK, Geenen JE, Venu RP, Schmalz MJ, Hogan WJ. Treatment of non-extractable common bile duct stones with combination ursodeoxycholic acid plus endoprostheses. Gastrointest Endosc 1993; 39:528-31. [PMID: 8365601 DOI: 10.1016/s0016-5107(93)70164-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Despite widely available technology for removal of bile duct stones, endoscopists currently encounter approximately 3% of patients with stones that defy extraction. After sphincterotomy and unsuccessful attempts at extraction of "defiant" stones, biliary stents were placed in 22 patients. Ten patients were treated with ursodeoxycholic acid, and 12 patients treated only with stent served as control subjects. Ductal strictures preventing stone extraction were present in eight control patients and in six patients treated with ursodeoxycholic acid. The number of total calculi in the ursodeoxycholic acid group was slightly higher (4.2 per patient) than the number in the control group (3.3 per patient). Stone and bile duct dimensions were similar in each group. Nine of 10 patients in the ursodeoxycholic acid group had complete stone clearance, and 41 of 42 stones were removed during a follow-up period of 9 +/- 2 months; in contrast, no patient in the control group had complete clearance and only 6 of 40 stones were removed after a follow-up period of 31 +/- 6 months. Oral ursodeoxycholic acid facilitates extraction of defiant bile duct stones. This treatment is an effective alternative to high-tech extraction methods for large biliary stones.
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Affiliation(s)
- G K Johnson
- Digestive Disease Center, St. Luke's Hospital, Racine, Wisconsin
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17
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den Toom R, Nijs HG, van Blankenstein M, Laméris JS, Schröder FH, Terpstra OT. Extracorporeal shock wave treatment of common bile duct stones: experience with two different lithotriptors at a single institution. Br J Surg 1991; 78:809-13. [PMID: 1873707 DOI: 10.1002/bjs.1800780714] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Extracorporeal shock wave lithotripsy (ESWL) is a new treatment modality for retained common bile duct stones. Sixty-two patients (mean age 75 years, range 27-95 years) with retained common bile duct stones were treated with two different lithotriptors. One of the lithotriptors operated on the electrohydraulic principle (Dornier HM-3) (n = 13), the other on the electromagnetic principle (Siemens Lithostar) (n = 49). All HM-3 patients were treated under general anaesthesia, whereas with the Lithostar one patients was treated under general anaesthesia, 43 received analgesia and sedation and five had no analgesia at all. Patients treated with the Lithostar had more sessions (mean 1.9 versus 1.3, P less than 0.05) and needed more stock waves (mean 8611 versus 2534, P less than 0.001) than patients treated with the HM-3. Fragmentation was achieved in all patients treated with the HM-3 and in 42 (86 per cent) patients treated with the Lithostar. In this latter group ten patients underwent common bile duct exploration without complications. Eleven patients had transient haematuria after treatment with the HM-3 and two patients (one in each group) had a subcapsular haematoma of the right kidney, all without clinical sequelae. At follow-up (median: HM-3 43 months, Lithostar 18 months), none of the patients had biliary complaints. We conclude that ESWL of retained common bile duct stones in safe and effective with both lithotriptors and should be considered before surgery in the elderly or high-risk patient.
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Affiliation(s)
- R den Toom
- Department of Surgery, University Hospital Dijkzigt, Erasmus University Rotterdam, The Netherlands
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18
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Abstract
There are a variety of methods for dissolving gallstones in the biliary tree, which include oral therapy and direct contact dissolution. Cholesterol gallstones are most amenable to dissolution. Developments in non-operative physical methods to remove gallstones (particularly endoscopic papillotomy and extracorporeal shock-wave lithotripsy have diminished the use of chemical dissolution. However, in selected patients, there remains a place for chemical dissolution, but often in conjunction with the physical techniques.
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Affiliation(s)
- J A Summerfield
- Department of Medicine, St Mary's Hospital Medical School, London, UK
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19
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Roberts-Thomson IC. Non-surgical treatment of gallstones. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1987; 17:369-70. [PMID: 3435315 DOI: 10.1111/j.1445-5994.1987.tb00067.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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20
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21
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Abstract
Gallstone pancreatitis is a disease of high mortality (11%) and significant morbidity (42%). An analysis of 66 patients with this disease revealed the importance of an early aetiological diagnosis; 66% of our patients had evidence of previous biliary disease. Most patients were elderly and the severity of their disease could be predicted using Ranson's predictive indices. Surgery was immediate (within 48 hours) in 11 (17%) patients, early (two-14 days) in 16 (24%) and delayed in 27 (41%) patients. Some patients refused surgery. Our study suggests that very ill patients require immediate surgery--often cholecystostomy alone--and that although in the majority symptoms should settle on conservative treatment, definitive surgery should be carried out at the time of the initial admission. Further delay increases morbidity, mortality and expense.
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22
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Abstract
The common bile duct stones obtained from 148 patients were analysed chemically for cholesterol, calcium and bilirubin. When stones were present in both the common bile duct and gallbladder at the time of surgery, the common duct stones were similar in chemical composition to gallbladder stones in the majority of cases and were predominantly cholesterol-type stones. However, common bile duct stones from patients whose gallbladders had been removed at least one year before the detection of common duct stones contained less cholesterol and more bilirubin than common bile duct stones which were associated with gallbladder stones. Thirty per cent of these stones contained suture material in the centre of the stone. Overall, the results indicate that common bile duct stones are more likely to be pigment type than gallbladder stones, especially if the common duct stones are large, have formed in the duct and become symptomatic less than 12 years after cholecystectomy. Non-absorbable suture material should be avoided in surgery involving the common bile duct.
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Somerville KW, Ellis WR, Whitten BH, Balfour TW, Bell GD. Stones in the common bile duct: experience with medical dissolution therapy. Postgrad Med J 1985; 61:313-6. [PMID: 4022860 PMCID: PMC2418220 DOI: 10.1136/pgmj.61.714.313] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Thirty-one patients with radiolucent common bile duct stones received medical treatment. Nineteen had Rowachol, a terpene preparation, eight (42%) achieving complete stone disappearance within 3 to 48 months. Fifteen (including 3 of the above) took Rowachol with bile acid (chenodeoxycholic in 11, ursodeoxycholic in 4) for 3 to 60 months: 11 (73%) achieved complete dissolution within 18 months. Persistent symptoms and complications settled on conservative management: 8 (25%) patients required admission (2 biliary colic, 1 obstructive jaundice, 4 cholangitis, 1 pancreatitis). One patient died of a myocardial infarction during recovery from pancreatitis; the other continued treatment, 2 achieving complete dissolution/disappearance. Oral dissolution therapy with Rowachol and bile acids should be considered when endoscopic sphincterotomy or surgery is not feasible, but careful attention to potential complications is required while stones persist.
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24
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25
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Staritz M, Poralla T, Dormeyer HH, Ewe K, Meyer zum Büschenfelde KH. Nitroglycerine dilatation of sphincter of Oddi for endoscopic removal of bileduct stones. Lancet 1984; 1:956. [PMID: 6143882 DOI: 10.1016/s0140-6736(84)92405-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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26
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Heiss FW, Rossi RL, Scholz FJ, Shea JA, Braasch JW. Common bile duct calculi. 2. Nonsurgical therapy. Postgrad Med 1984; 75:109-17. [PMID: 6701108 DOI: 10.1080/00325481.1984.11698596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Several nonsurgical methods of therapy are available for treatment of retained common bile duct calculi. These include percutaneous extraction, endoscopic extraction, dissolution, and endoscopic sphincterotomy. The method chosen depends on location and size of calculi, size of sinus tract, patient age, surgical risks, and other factors. In most cases, procedures can be carried out safely and successfully with few or no complications.
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Ward A, Brogden RN, Heel RC, Speight TM, Avery GS. Ursodeoxycholic acid: a review of its pharmacological properties and therapeutic efficacy. Drugs 1984; 27:95-131. [PMID: 6365507 DOI: 10.2165/00003495-198427020-00001] [Citation(s) in RCA: 107] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Ursodeoxycholic acid is the 7 beta-hydroxy epimer of chenodeoxycholic acid and is normally present in only trace amounts in the bile. Oral administration of pharmacological doses markedly decreases biliary cholesterol saturation. Complete or partial dissolution of radiolucent gallstones located in a functioning gallbladder occurred in about 40 to 55% of patients treated with ursodeoxycholic acid in controlled studies of 6 months duration. Patients showing partial gallstone dissolution at that time are likely to continue improving possibly to complete gallstone dissolution with continued therapy. The success rate with ursodeoxycholic acid may be increased top about 80% if more stringent patient selection criteria are applied to include only those with non-calcified floating cholesterol stones of less than 10 to 15 mm diameter. Those with calcified stones or stones greater than 15 mm diameter or unlikely to respond to ursodeoxycholic acid therapy. The optimal dose in published studies was about 8 to 10 mg/kg/day, which is about half to two-thirds the dose of chenodeoxycholic acid (15 mg/kg/day) achieving approximately equivalent results. Ursodeoxycholic acid appears to be remarkably well tolerated, with diarrhoea occurring in only a very small proportion of patients. While surgery is clearly the preferred treatment in many patients with symptomatic gallstones, in a carefully selected subgroup of such patients gallstone dissolution therapy with ursodeoxycholic acid offers an important and worthwhile alternative.
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