The medical treatment of gallstones

Degradation of Bile Acids by Soil and Water Bacteria

Bile acids are surface-active steroid compounds with a C5 carboxylic side chain at the steroid nucleus. They are produced by vertebrates, mainly functioning as emulsifiers for lipophilic nutrients, as signaling compounds, and as an antimicrobial barrier in the duodenum. Upon excretion into soil and water, bile acids serve as carbon- and energy-rich growth substrates for diverse heterotrophic bacteria. Metabolic pathways for the degradation of bile acids are predominantly studied in individual strains of the genera Pseudomonas, Comamonas, Sphingobium, Azoarcus, and Rhodococcus. Bile acid degradation is initiated by oxidative reactions of the steroid skeleton at ring A and degradation of the carboxylic side chain before the steroid nucleus is broken down into central metabolic intermediates for biomass and energy production. This review summarizes the current biochemical and genetic knowledge on aerobic and anaerobic degradation of bile acids by soil and water bacteria. In addition, ecological and applied aspects are addressed, including resistance mechanisms against the toxic effects of bile acids.

Thermal behavior of ursodeoxycholic acid in urea: identification of anomalous peak in the thermal analysis

The objective of this study was to clarify the thermal behavior of ursodeoxycholic acid (UDCA) in mixtures with urea. Physical mixtures of UDCA and urea in various ratios were prepared, and the thermal analysis of these sample mixtures was investigated using conventional differential scanning calorimetry (DSC) and variable-temperature powder X-ray diffractometry (VTXRD). The hot-stage microscopy (HSM) and powder X-ray diffractometry (PXRD) were used as complementary techniques. From the DSC results of all sample mixtures, it was found that there was no endothermic peak at the melting temperature of intact UDCA crystals. The DSC thermograms of each ratio showed only the endothermic peak at about 136 degrees C due to the melt of urea and the anomalous endothermic peak at about 155 degrees C 157 degrees C. The VTXRD study revealed that the crystals of urea completely disappeared at a temperature of 140 degrees C. At this temperature, it was identified that the VTXRD pattern obtained was of UDCA crystals. The crystalline peaks gradually decreased in intensity at a temperature of 150 degrees C When the temperature was up to 160 degrees C, the identical crystalline peaks of UDCA crystals completely disappeared. It was concluded that the anomalous endothermic peak at 155 degrees C-157 degrees C was the peak due to the dissolution of UDCA crystals in the surrounding melted urea.

Physicochemical Properties of Ursodeoxycholic Acid Dispersed in Controlled Pore Glass

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.

Scanning electron microscope studies of human gallstones after plasma etching

The morphological relationship between cholesterol and the calcium carbonate polymorphs and other inorganic constituents in intact human gallstones was investigated with scanning electron microscopy (SEM) after plasma etching the specimen instead of chemical dissolution of the organic constituents. The technique allowed magnification of more than 22,000x without structural damage or distortion. A framework of inorganic material that also contained crystals of calcium carbonate, vaterite, aragonite, calcite, and apatite remained after plasma etching. All cholesterol monohydrate and bile pigment compounds had been removed. The plasma etching technique allowed SEM studies of intact gallstones. An inorganic framework matrix was found in all stones. Its possible role in their formation is discussed.

Effect of chenodeoxycholate feeding upon the biliary output of plasma membrane enzymes in the rat

In model experiments using human erythrocytes, glycochenodeoxycholate caused extensive membrane damage (as judged by release of membrane phospholipid and acetylcholinesterase and by cell lysis) at approximately 10-fold lower concentrations than glycocholate. Chenodeoxycholate feeding had no effect upon the total protein, bile salt or phospholipid concentration of rat bile, although evidence is presented to suggest an expansion of the bile salt pool occurred. Rats fed chenodeoxycholate showed a dose-dependent enrichment of this bile acid in bile; this occurred mainly at the expense of cholate. Chenodeoxycholate feeding resulted in an increased biliary output of the plasma membrane enzymes alkaline phosphatase and 5'-nucleotidase; the hepatic activities of these enzymes were also increased. In contrast, the biliary output and hepatic activities of two other plasma membrane enzymes, alkaline phosphodiesterase I and L-leucine-beta-naphthylamidase, were unaffected by chenodeoxycholate feeding. A greater proportion of all four plasma membrane enzymes studied existed in bile of chenodeoxycholate-fed rats in a "soluble" form (as judged by their remaining in the supernatant on centrifugation of bile). These results are discussed in relation to the origin of plasma membrane enzymes in bile and to the potential toxicity of chenodeoxycholate and its conjugates to the membranes of the hepatobiliary system.

Analysis of minor and trace elements in gallstones by induction of characteristic ionising radiation

In an investigation of the role of trace elements in gallstone formation and of minor and trace elements in gallstone and bile, samples from five patients were analysed using three different techniques for cross-verification: NAA, PIXE, and XRF. In addition, certified standards of bovine liver and oyster tissue from the NBS, Washington, were re-analysed using the different techniques to confirm the accuracy of the experimental procedures. NAA of five gallstones was used for the quantitative analysis of 19 elements with Z greater than 11. The concentrations of Cl, K + Ca, Mn, Fe and Cu + Zn were determined by PIXE and those of Mg, P, S, K and Ca by XRF. In most cases the concentrations were in the range of a few PPB to a few hundred PPM. The spatial distribution of the component elements was obtained using XRF with a scanning electron microscope and the results demonstrated that calcium was present centrally in all the stones. The analysis of gallbladder bile from four patients showed that the calcium concentration was much greater than normal, indicating that calcium and other elements play an important role in stone formation. Infrared spectroscopy showed that the calcium salts were present in gallstones in three compound forms: calcium carbonate, calcium phosphate and calcium bilirubinate. Reasons for the cause of calcium precipitation are discussed.

The effects of 3,5,5-trimethylcyclohexanol on hepatic cholesterol synthesis, bile flow and biliary lipid secretion in the rat

The chemical trimethylcyclohexanol (TMC) is closely related to menthol, the major component of a terpene preparation with known choleretic and cholelitholytic activity. Its effects on hepatic cholesterol synthesis and bile secretion were examined in the rat. In both acute and long-term dosing experiments TMC significantly inhibited hepatic S-3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase. TMC was a potent choleretic, with detectable effects on bile flow at low doses, which also reduced coupling of cholesterol secretion to bile salt secretion. Single large doses tended to lower biliary cholesterol output and caused significant reduction in cholesterol saturation index after biliary diversion for 1 h. TMC and its widely prescribed ester cyclandelate, which is rapidly degraded to TMC after ingestion, should be investigated further as potential cholelitholytic treatments in man.

Effect of taurochenodeoxycholate or tauroursodeoxycholate upon biliary output of phospholipids and plasma-membrane enzymes, and the extent of cell damage, in isolated perfused rat livers

Isolated perfused rat livers were used to study the effects of taurochenodeoxycholate (TCDC) and tauroursodeoxycholate (TUDC) upon some aspects of biliary composition. After depletion of the endogenous bile salt pool of the liver, introduction of either bile salt brought about increases in bile flow, bile salt output and biliary phospholipid output. Taurochenodeoxycholate needed a lower biliary concentration to produce phospholipid output than did tauroursodeoxycholate. TCDC perfusion caused a substantial output of plasma-membrane enzymes (5'-nucleotidase and alkaline phosphodiesterase) into the bile, whereas TUDC caused little output of either enzyme; this may represent a characteristic difference between the effects of the two bile salts on the hepatobiliary system. The results from TUDC perfusion indicate also that much of the output of biliary phospholipid promoted by bile salts, may be independent of the output of plasma-membrane enzymes promoted by bile salts.

[Relation between serum lipoprotein metabolism and biliary lipid metabolism]

This review concern with recent results regarding interrelationships between serum lipoprotein and bile acid metabolism. First, changes in bile acid metabolism in primary hyperlipoproteinaemia type II and type IV are described. In addition, influences of lipid-lowering drugs such as sitosterol, cholestyramine/colestipol, neomycin, nicotinic acid, clofibrate and thyroxin on serum lipoproteins and biliary lipid metabolism are discussed. Changes in lipoprotein metabolism in disorders of bile acid metabolism and effects of primary and secundary bile acids on lipoprotein metabolism, hepatic cholesterol metabolism and intestinal cholesterol absorption are described. In the final discussion interrelationships between very low density lipoprotein - triglycerides and cholic acid metabolism as well as low density lipoprotein and chenodeoxycholic acid metabolism are stressed. The positive correlation between serum triglycerides and lithogenicity of bile is underlined and the possible significance of high density lipoprotein-cholesterol as precursor of biliary cholesterol is discussed.

Gall stone dissolving agents

During the decade in which the medical dissolution of gall stones has become feasible several drugs have been introduced but only the two listed in the British National Formulary have been intensively evaluated and shown to be effective--chenodeoxycholic acid and the closely allied ursodeoxycholic acid. The dissolution of gall stones was last reviewed in the "BMF" in 1976, at which stage experience with chenodeoxycholic acid was limited. Since then the indications and potential for this bile acid in treating gall stones have become better understood, and data on the newly introduced ursodeoxycholic acid are being evaluated. Cholesterol, but not pigment, gall stones are amenable to oral dissolution treatment. This review will cover firstly, chenodeoxycholic acid, secondly, ursodeoxycholic acid, then a comparison of the two drugs, an assessment of the place of medical dissolution in the management of gall stones, and, finally, the dissolution of stones in the common bile duct.

Current status of medical treatment of gallstones

Medical dissolution of gallstones is feasible and has worked in clinical practice. Cholelithiasis is both common and a cause of significant morbidity nationally. Thus, to readdress the question posed in the introduction, should there be a more aggressive detection of populations at risk to consider prophylactic or early treatment of gallstones, one has to consider the following. Is it cost effective to treat people with asymptomatic stones when one half of gallstones detected at autopsy have not caused trouble in life? Will the reduction of one health hazard create other hazards, such as colonic cancer? Is it improving the quality of the patient's life after successful treatment to have the person return every year for ultrasound or radiologic check-ups for recurrence of gallstones? We feel that despite the low morbidity and mortality of elective surgery, medical dissolution of gallstones is a viable alternative, but, as with most medical decisions, the pros and cons of any therapy for cholelithiasis will ultimately be a decision based on the physician, the patient, and the situation. On the basis of what has been discussed in this review, the approach to treatment should involve a rational understanding of all alternatives.

Choleretic effect of valproic acid in the rat

Valproic acid (VPA) is an anticonvulsant agent which produced marked choleresis in the rat. Bile flow rate increased from 50 to 60 microliter per min per kg to 120 to 145 microliter per min per kg immediately after i.v. injection of VPA (37.5 to 150 mg per kg; 2 ml per kg) in male Sprague-Dawley rats. The duration of maximal bile flow was dose-dependent and increased from 30 min (37.5 mg VPA per kg) to approximately 2 hr (150 mg VPA per kg). Choleresis diluted the biliary concentrations of bile acids, Cl-, cholesterol, and phospholipids. VPA did not change the bile/plasma ratio for erythritol suggesting that the increased bile flow is of canalicular origin. VPA did not influence the excretion of bile acids or their osmotic activity, whereas bile salt-independent flow doubled in rats treated with 150 mg VPA per kg. The bile/plasma, bile/liver, and liver/plasma concentration ratios for VPA were 11.7, 1.6, and 7.3, respectively. Approximately 90% of VPA appearing in bile was biotransformed, primarily as a glucuronide. Bile flow correlated with VPA excretion; 16 microliter of bile was produced per micromole VPA which suggests that choleresis is primarily due to the osmotic activity of VPA metabolites in bile. VPA enhanced the excretion of inorganic ions which may also contribute to choleresis. Biliary excretion of phenol-3,6-dibromophthalein disulfonate and ouabain was unaffected. Thus, VPA is an effective choleretic which stimulates bile salt-independent flow of canalicular origin largely as a consequence of the osmotic properties of VPA conjugates in bile.