Gallstones therapy

Gallstone therapy —Certain types of dietary fiber alter the composition of the bile by binding one or more of the bile salts that would otherwise be absorbed and recirculated. The altered bile is a better solvent for cholesterol (a major constituent of gallstones) than the unaltered bile. However, further tests of this dietary therapy are needed to confirm that it is both effective and safe. 

Despite our increased knowledge of the synthesis, secretion and enterohepatic circulation of bile salts, several aspects of the effects of these sterol metabolites on the physiology of the intestine itself have not been emphasized and are poorly understood. This becomes of greater significance when we consider that bile acids, particularly chenodeoxycholic acid and ursodeoxycholic acids, are employed for gallstone therapy there are several dietary influences on the enterohepatic circulation of bile acids and on bile acid excretion (e.g. fats and dietary fibers) increased colonic bile acid concentrations have been implicated in the promotion of colorectal cancer and there appears to be an inverse relationship between cholesterolemia and colon cancer. 

Another experimental approach to gallstone therapy is the use of phenobarbital. In Rhesus monkeys it increases bile salt and phospholipid secretion into bile without significantly changing cholesterol secretion.98 Furthermore, it has been reported to decrease cholesterol saturation in hepatic bile in man.99 Phenobarbital s ability to decrease the relative cholesterol content in bile may allow dissolution of cholesterol gallstones after long-term therapy. Neither lecithin nor cholestyramine are effective in human gallstone disease.100... 

The altered composition of bile increases the capacity for cholesterol uptake. Thus, gallstones can be dissolved in the course of a 1- to 2 y treatment, provided that cholesterol stones are pure and not too large (<15 mm), gall bladder function is normal, liver disease is absent, and patients are of normal body weight. UCDA is more effective (daily dose, 8-10 mg) and better tolerated than is CDCA (15 mg/d frequent diarrhea, elevation of liver enzymes in plasma). Stone formation may recur after cessation of successful therapy. 

Cholelithiasis If cholelithiasis is suspected, perform gallbladder studies. Discontinue therapy if gallstones are found. 

Adverse effects of octreotide therapy include nausea, vomiting, abdominal cramps, flatulence, and steatorrhea with bulky bowel movements. Biliary sludge and gallstones may occur after 6 months of use in 20-30% of patients. However, the yearly incidence of symptomatic gallstones is about 1%. Cardiac effects include sinus bradycardia (25%) and conduction disturbances (10%). Pain at the site of injection is common, especially with the long-acting octreotide suspension. Vitamin B12 deficiency may occur with long-term use of octreotide. 

The solubility of cholesterol in bile is determined by the relative proportions of bile acids, lecithin, and cholesterol. Although prolonged ursodiol therapy expands the bile acid pool, this does not appear to be the principal mechanism of action for dissolution of gallstones. Ursodiol decreases the cholesterol content of bile by reducing hepatic cholesterol secretion. Ursodiol also appears to stabilize hepatocyte canalicular membranes, possibly through a reduction in the concentration of other endogenous bile acids or through inhibition of immune-mediated hepatocyte destruction. 

Adverse effects of therapy include nausea with or without vomiting, abdominal cramps, flatulence, and steatorrhea with bulky bowel movements. Biliary sludge and gallstones may occur after 6... 

H-12) Gallstones. Most gallstones are composed mainly of cholesterol. Bile salts and phospholipids normally prevent the precipitation of cholesterol, but cholesterol stones may form when the cholesterol/bile salt-phospholipid ratio increases excessively. Cheno-deoxycholate may be used as oral therapy for cholesterol gallstones. It not only provides an extra recirculating source of bile acids but inhibits the rate-limiting step in cholesterol biosynthesis. 

Contraindications to oestrogen therapy include women who may have an oestrogen-dependent neoplasm, e.g. breast cancer, who may be pregnant, or have a disposition to thromboembolism. Hypertension, liver disease or gallstones, migraine, diabetes, uterine fibroids or endometriosis may all be made worse by oestrogen. These are not necessarily absolute contraindications, and HRT should not for instance be denied to a poly-symptomatic woman with mild hypertension. If necessary, it may be permissible to treat both the hypertension and the postmenopausal symptoms with separate drugs. 

Therapy Asymptomatic patients do not need any treatment. With symptomatic patients, it is important to use therapeutic strategies which are directed towards the predominant symptoms. These include removal of gallstones by means of sphincterotomy (beware of varices ), antibiotics, placement of a stent, cholagogue agents, TIPS and surgical techniques. (21, 36, 63,106,157)... 

Dowling RH. Chenodeoxycholic acid therapy of gallstones. Philadelphia WB Saunders Company, 1977. 

Gallstones containing glafenic acid have been reported in a patient taking long-term therapy (SEDA-14, 95). 

A healthy 21-year-old woman developed acute pancreatitis a day after an anesthetic that lasted 138 minutes, with propofol for induction (66). She recovered after supportive therapy for 6 days. There was no evidence of gallstones on abdominal imaging and there was no defect in lipid metabolism. 

A 53-year-old male patient with elevated levels of low-density lipoprotein (LDL) cholesterol, signs of premature cholesterol gallstone disease and substantially elevated triglycerides visited his physician for a follow-up to check his current status. The patient had received various statin, HMG-CoA-reductase inhibitors therapies for the past 2 years. However, after blood work done at this follow-up visit, complications had still not subsided. This patient has similar problems as two of his siblings. Which of the following best explains this patients dyslipidemia ... 

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