Executive Summary of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management.

The Airway section of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.

Materials Science Toolkit for Carbon Footprint Assessment: A Case Study for Endoscopic Accessories of Common Use.

Ironically, healthcare systems are key agents in respiratory-related diseases and estimated deaths because of the high impact of their greenhouse gas emissions, along with industry, transportation, and housing. Based on safety requirements, hospitals and related services use an extensive number of consumables, most of which end up incinerated at the end of their life cycle. A thorough assessment of the carbon footprint of such devices typically requires knowing precise information about the manufacturing process, which is rarely available in detail because of the many materials, pieces, and steps involved during the fabrication. Yet, the tools most often used for determining the environmental impact of consumer goods require a bunch of parameters, mainly based on the material composition of the device. Here, we report a basic set of analytical methods that provide the information required by the software OpenLCA to calculate the main outcome related to environmental impact, greenhouse gas emissions. Through thermogravimetry, calorimetry, infrared spectroscopy, and elemental analysis, we proved that obtaining relevant data for the calculator in the exemplifying case of endoscopy tooling or accessories is possible. This routine procedure opens the door to a broader, more accurate analysis of the environmental impact of everyday work at hospital services, offering potential alternatives to minimize it.

Endoscopic treatment (endoscopic balloon dilation/self-expandable metal stent) vs surgical resection for the treatment of de novo stenosis in Crohn's disease (ENDOCIR study): an open-label, multicentre, randomized trial.

BACKGROUND: Stenosis is one of the most common complications in patients with Crohn's disease (CD). Endoscopic balloon dilation (EBD) is the treatment of choice for a short stenosis adjacent to the anastomosis from previous surgery. Self-expandable metal stents (SEMS) may be a suitable treatment option for longer stenoses. To date, however, there is no scientific evidence as to whether endoscopic (EBD/SEMS) or surgical treatment is the best approach for de novo or primary stenoses that are less than 10 cm in length. METHODS/DESIGN: Exploratory study as "proof-of-concept", multicentre, open-label, randomized trial of the treatment of de novo stenosis in the CD; endoscopic treatment (EBD/SEMS) vs surgical resection (SR). The type of endoscopic treatment will initially be with EDB; if a therapeutic failure occurs, then a SEMS will be placed. We estimate 2 years of recruitment and 1 year of follow-up for the assessment of quality of life, costs, complications, and clinical recurrence. After the end of the study, patients will be followed up for 3 years to re-evaluate the variables over the long term. Forty patients with de novo stenosis in CD will be recruited from 15 hospitals in Spain and will be randomly assigned to the endoscopic or surgical treatment groups. The primary aim will be the evaluation of the patient quality of life at 1 year follow-up (% of patients with an increase of 30 points in the 32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32). The secondary aim will be evaluation of the clinical recurrence rate, complications, and costs of both treatments at 1-year follow-up. DISCUSSION: The ENDOCIR trial has been designed to determine whether an endoscopic or surgical approach is therapeutically superior in the treatment of de novo stenosis in CD. TRIAL REGISTRATION: ClinicalTrials.gov NCT04330846. Registered on 1 April 1 2020. https://clinicaltrials.gov/ct2/home.

The characteristics of the stricture, but not the ongoing treatment, could influence the outcome of endoscopic dilation in recurrent Crohn's disease.

AIM: Stricture is one of the main complications of Crohn's disease (CD). Among the main conservative therapeutic alternatives, endoscopic balloon dilation (EBD) of the strictures stands out, which can improve the symptoms and delay or even avoid the need for more surgeries. The main aim of this study was to evaluate the efficacy of the EBD in CD patients with post-surgical anastomotic strictures from a previous surgery. PATIENTS AND METHODS: An observational study of a cohort of 32 patients with CD who underwent EBD due to uncomplicated strictures at a tertiary hospital, since 2009. Demographic, clinical and disease variables, medical treatments and previous surgeries and types, analytical variables at the time of dilation, number of dilations, complications and need for subsequent surgery were collected by searching data in clinical records. RESULTS: Thirty-two patients were included, performing a total of 63 endoscopic dilations. A technical success of 63.5%, a therapeutic success by dilation of 58.75% and a therapeutic success per patient of 62.5% were achieved. Regarding complications, the percentage of post-dilation adverse events was 3.2% and post-dilation incidents were 4.8%. Thirty EBD did not need any medical treatment modification, 9 EBD remained untreated and 12 EBD required further surgery. The length of the strictures, but not the ongoing treatment, was the only statistically significant factor of therapeutic success by dilation and per patient. CONCLUSIONS: EBD seems a safe technique in short post-surgical strictures, can avoid the need for new surgery and prevents unnecessary immunosuppression in patients with CD anastomotic strictures.

Self-expandable metal stents versus endoscopic balloon dilation for the treatment of strictures in Crohn's disease (ProtDilat study): an open-label, multicentre, randomised trial.

BACKGROUND: Endoscopic balloon dilation (EBD) is the established endoscopic treatment for short strictures in Crohn's disease. Fully covered self-expandable metal stents (FCSEMS) have been used for endoscopic treatment of patients for whom EBD was unsuccessful. We aimed to determine the efficacy and safety of the two endoscopic treatments in patients with Crohn's disease with stenosis and compare the mean cost of both treatments. METHODS: This multicentre, open-label, randomised trial was done in 19 tertiary and secondary hospitals in Spain. Patients with Crohn's disease with obstructive symptoms and predominantly fibrotic strictures of less than 10 cm in length were eligible for inclusion. We excluded patients with stenosis treated with SEMS or EBD in the previous year and stenosis not accessible to a colonoscope. Patients were randomly assigned (1:1) to receive either EBD (EBD group) or FCSEMS (FCSEMS group) using a digital en-block randomisation system (block size of four). In the EBD group, dilation was done with a CRE Boston Scientific (Marlborough, MA, USA) pneumatic balloon with the diameter set at the discretion of the endoscopist; a maximum of two sessions of dilation were allowed with a minimum interval of 15-30 days between them. In the FCSEMS group, a 20 mm diameter Taewoong (Gimpo-si, South Korea) fully covered metal stent was placed; stent length was set at the discretion of the endoscopist. The primary outcome was to assess the efficacy of the endoscopic treatment, defined by the proportion of patients free of a new therapeutic intervention (EBD, FCSEMS, or surgery) due to symptomatic recurrence at 1 year of follow-up. Patients were analysed according to the intention-to-treat principle. Adverse events were recorded for all the patients; events were considered associated to be with the procedure when a causal association was possible, probable, or definite. This trial is registered with ClinicalTrials.gov, NCT02395354. FINDINGS: From Aug 28, 2013, to Oct 9, 2017, we assessed the eligibility of 99 patients, of whom 19 (19%) patients were excluded. Thus, 80 (81%) patients were randomly assigned to treatment: 39 (49%) patients to the FCSEMS group and 41 (51%) patients to the EBD group. 33 (80%) of 41 patients in the EBD group and 20 (51%) of 39 patients in the FCSEMS group were free of a new therapeutic intervention at 1 year (odds ratio [OR] 3·9 [95% CI 1·4-10·6]; p=0·0061). Two (3%) of 80 patients had severe adverse events (one [2%] patient in the EBD group and one [3%] patient in the FCSEMS group); both patients had perforations. INTERPRETATION: EBD is more effective than FCSEMS for Crohn's disease strictures, with a good safety profile for both treatments. FUNDING: Spanish National Institute of Health, Foundation of Spanish Society of Digestive Endoscopy, Catalan Society of Gastroenterology, and Taweoong.

Monitoring of Caged Bluefin Tuna Reactions to Ship and Offshore Wind Farm Operational Noises.

Underwater noise has been identified as a relevant pollution affecting marine ecosystems in different ways. Despite the numerous studies performed over the last few decades regarding the adverse effect of underwater noise on marine life, a lack of knowledge and methodological procedures still exists, and results are often tentative or qualitative. A monitoring methodology for the behavioral response of bluefin tuna (Thunnus thynnus) when exposed to ship and wind turbine operational noises was implemented and tested in a fixed commercial tuna feeding cage in the Mediterranean sea. Fish behavior was continuously monitored, combining synchronized echosounder and video recording systems. Automatic information extracted from acoustical echograms was used to describe tuna reaction to noise in terms of average depth and vertical dimensions of the school and the indicators of swimming speed and tilt direction. Video recordings allowed us to detect changes in swimming patterns. Different kinds of stimuli were considered during bluefin tuna cage monitoring, such as noise generated by feeding boats, wind farm operational noise, and other synthetic signals projected in the medium using a broadband underwater projector. The monitoring system design was revealed as a successful methodological approach to record and quantify reactions to noise. The obtained results suggested that the observed reactions presented a strong relationship with insonification pressure level and time. Behavioral changes associated with noise are difficult to observe, especially in semi-free conditions; thus, the presented approach offered the opportunity to link anthropogenic activity with possible effects on a given marine species, suggesting the possibility of achieving a more realistic framework to assess the impacts of underwater noise on marine animals.

Correction: Relationship between weight and linear dimensions of Bluefin tuna (Thunnus thynnus) following fattening on western Mediterranean farms.

[This corrects the article DOI: 10.1371/journal.pone.0200406.].

Automatic Bluefin Tuna Sizing with a Combined Acoustic and Optical Sensor.

A proposal is described for an underwater sensor combining an acoustic device with an optical one to automatically size juvenile bluefin tuna from a ventral perspective. Acoustic and optical information is acquired when the tuna are swimming freely and the fish cross our combined sensor's field of view. Image processing techniques are used to identify and classify fish traces in acoustic data (echogram), while the video frames are processed by fitting a deformable model of the fishes' ventral silhouette. Finally, the fish are sized combining the processed acoustic and optical data, once the correspondence between the two kinds of data is verified. The proposed system is able to automatically give accurate measurements of the tuna's Snout-Fork Length (SFL) and width. In comparison with our previously validated automatic sizing procedure with stereoscopic vision, this proposal improves the samples per hour of computing time by 7.2 times in a tank with 77 juveniles of Atlantic bluefin tuna (Thunnus thynnus), without compromising the accuracy of the measurements. This work validates the procedure for combining acoustic and optical data for fish sizing and is the first step towards an embedded sensor, whose electronics and processing capabilities should be optimized to be autonomous in terms of the power supply and to enable real-time processing.

Quality of life during one year of postoperative prophylactic drug therapy after intestinal resection in Crohn's patients: Results of the APPRECIA trial.

BACKGROUND: In APPRECIA trial, Crohn's disease (CD) patients undergoing intestinal resection were randomized to postoperative adalimumab (ADA) or azathioprine (AZA). AIMS: To evaluate health-related quality of life (HRQoL) in APPRECIA trial. METHODS: HRQoL was evaluated using disease-specific shortened Spanish version of the IBDQ (SIBDQ-9) and generic European Quality of Life-5 Dimensions (EQ-5D) questionnaires, completed at baseline and at weeks 24 and 52. RESULTS: Sixty-one patients (37 ADA and 24 AZA) had evaluable data for HRQoL. Patients treated with ADA or AZA had significant improvement from baseline to weeks 24 and 52 in SIBDQ-9 and EQ-5D (p < 0.001 and p ≤ 0.006 for all comparisons, respectively). There were no differences between treatment arms in mean change in SIBDQ-9 and EQ-5D at weeks 24 and 52 vs baseline. Only patients without endoscopic recurrence had significant improvement in SIBDQ-9 (p < 0.001) and EQ-5D (p < 0.001) at week 52. At week 52, there was a high to moderate negative correlation between CDAI score with SIBDQ-9 score (Pearson's r: -0.768) and with EQ-5D index (r: -0.644). CONCLUSION: HRQoL improved after intestinal resection in CD, irrespective of the postoperative therapy used (ADA or AZA). Outcomes in HRQoL were associated with prevention of endoscopic recurrence, since improvements in HRQoL were only significant in patients with endoscopic remission at 1 year.

Relationship between weight and linear dimensions of Bluefin tuna (Thunnus thynnus) following fattening on western Mediterranean farms.

This study presents various models based on formulae relating weight and dimensions (length, height and width) of Bluefin tuna, Thunnus thynnus (L.), fattened in captivity. The main aim of establishing these expressions is to design tools for indirectly predicting the weight of a Bluefin tuna from measurements of one or more dimensions obtained using non-invasive methods such as stereoscopic cameras. Measurements of maximum length, height and width following slaughter were taken of fish fattened in captivity (n = 2078). Different relationships drawn from the dimensions of the tuna against their weight are fitted with part of the data collection and later checked against a reserved sample set. The resulting formulae are compared with the formulae most commonly used in the case of wild tuna. The results of this study confirm that, for tuna fattened in cages, the availability of more than one dimension to estimate weight improves the predictive power of the model and reduces error in the estimate.

Adalimumab vs Azathioprine in the Prevention of Postoperative Crohn's Disease Recurrence. A GETECCU Randomised Trial.

BACKGROUND AND AIMS: Postoperative recurrence of Crohn's disease [POR-CD] is almost certain if no prophylaxis is administered. Evidence for optimal treatment is lacking. Our aim was to compare the efficacy of adalimumab [ADA] and azathioprine [AZA] in this setting. METHODS: We performed a phase 3, 52-week, multicentre, randomised, superiority study [APPRECIA], in which patients with ileocolonic resection were randomised either to ADA 160-80-40 mg subcutaneously [SC] or AZA 2.5 mg/kg/day, both associated with metronidazole. The primary endpoint was endoscopic recurrence at 1 year [Rutgeerts i2b, i3, i4], as evaluated by a blinded central reader. RESULTS: We recruited 91 patients [median age 35.0 years, disease duration 6.0 years, 23.8% smokers, 7.1% previous resections]. The study drugs were administered to 84 patients. Treatment was discontinued owing to adverse events in 11 patients [13.1%]. Discontinuation was significantly less frequent in the ADA [4.4%] than in the AZA group [23.2%] (dif.: 18.6% [95% CI 4.1-33.2], p = 0.011). According to the intention-to-treat analysis, therapy failed in 23/39 patients in the AZA group [59%] and 19/45 patients in the ADA group [42.2%] [p = 0.12]. In the per-protocol analysis [61 patients with centrally evaluable images], recurrence was recorded in 8/24 [33.3%] patients in the AZA and 11/37 [29.7%] in the ADA group [p = 0.76]. No statistically significant differences between the groups were found for recurrence in magnetic resonance images, biological markers of activity, surgical procedures, or hospital admissions. CONCLUSIONS: ADA has not demonstrated a better efficacy than AZA [both associated with metronidazole] for prophylaxis of POR-CD in an unselected population, although tolerance to ADA is significantly better. ClinicalTrials.gov NCT01564823.

Incidence, clinical outcomes, and therapeutic approaches of capsule endoscopy-related adverse events in a large study population.

INTRODUCTION: Capsule endoscopy (CE) has become a first-line tool for small bowel (SB) examination. However, adverse events (AEs), such as CE retention or aspiration, may occur. The aims of this study were to evaluate incidence, clinical outcomes and therapeutic approaches of CE-related AEs in the largest series published to date. METHODS: Data from 5428 procedures performed at 12 institutions between August 2001 and January 2012 were retrospectively analyzed. Baseline patient characteristics; procedure; type, localization and symptoms before/after AEs; previous patency tests performed; therapeutic management and patient's outcome were recorded. RESULTS: The overall incidence of CE-related AEs was 1.9%: 2.0% for SB, 0.9% for esophageal and 0.5% for colon CE. The incidence of capsule retention was significantly higher than capsule aspiration (1.87% vs. 0.003%; p < 0.05), in patients suffering from inflammatory bowel disease (IBD) than in obscure GI bleeding (OGIB) (3.3% vs. 1.5%; p < 0.05) and in patients with the combination of nausea/vomiting, abdominal pain and distension. The SB was the most frequent localization of retention (88.2%). The use of patency tests -except for Patency© capsule- before CE was not a good predictor for AEs. Most of the patients with AEs developed no or mild symptoms (97%) and were managed by non-surgical methods (64.4%). CONCLUSIONS: CE-related AEs are uncommon and difficult to predict by imagiological examinations. SB retention, that is usually asymptomatic, is the most frequent AE. In absence of symptoms, non-surgical management of CE-related AEs is recommended.

Capsule endoscopy capture rate: has 4 frames-per-second any impact over 2 frames-per-second?

AIM: To compare the current capsule and a new prototype at 2 and 4 frames-per-second, respectively, in terms of clinical and therapeutic impact. METHODS: One hundred patients with an indication for capsule endoscopy were included in the study. All procedures were performed with the new device (SB24). After an exhaustive evaluation of the SB24 videos, they were then converted to "SB2-like" videos for their evaluation. Findings, frames per finding, and clinical and therapeutic impact derived from video visualization were analyzed. Kappa index for interobserver agreement and χ (2) and Student's t tests for qualitative/quantitative variables, respectively, were used. Values of P under 0.05 were considered statistically significant. RESULTS: Eighty-nine out of 100 cases included in the study were ultimately included in the analysis. The SB24 videos detected the anatomical landmarks (Z-line and duodenal papilla) and lesions in more patients than the "SB2-like" videos. On the other hand, the SB24 videos detected more frames per landmark/lesion than the "SB2-like" videos. However, these differences were not statistically significant (P > 0.05). Both clinical and therapeutic impacts were similar between SB24 and "SB2-like" videos (K = 0.954). The time spent by readers was significantly higher for SB24 videos visualization (P < 0.05) than for "SB2-like" videos when all images captured by the capsule were considered. However, these differences become non-significant if we only take into account small bowel images (P > 0.05). CONCLUSION: More frames-per-second detect more landmarks, lesions, and frames per landmark/lesion, but is time consuming and has a very low impact on clinical and therapeutic management.

A comparative study between two different suture materials in oral implantology.

OBJECTIVE: The prospective study compares, in split-mouth design, the use of two different suture materials, silk vs. Teflon-coated, multi-filament braided polyester threads suture. MATERIAL AND METHODS: Ten edentulous or partially edentulous patients were surgically treated for implant installation. Each side was sutured with either, randomly selected one or the other suture material. Seven days postsurgically, the sutures were removed and three knots per patient and side were collected for microbiological testing. Additionally, a piece of each suture thread was analysed before clinical use to test its susceptibility for bacterial adherence. To evaluate the patient's subjective opinion, a questionnaire based on Visual Analogue Scale had to be filled out by all included patients 1 week after the intervention. RESULTS: The results showed a more pronounced plaque accumulation for silk sutures but there was not a statistical difference. The intraoperative handling of the silk sutures was less comfortable and the patient comfort was worse than Teflon-coated polyester suture. CONCLUSION: The bacterial adherence on Teflon-coated polyester suture was slightly inferior than silk suture although it did not show the expected differences.

Effect on pocket depth and attachment level of manual versus ultrasonic scaling of lower second molars following lower third molar extraction: a randomized controlled trial.

OBJECTIVE: The objective of this study was to compare the effect on periodontal health of ultrasonic versus manual scaling of the lower second molar (L2M) root surface following surgical extraction of mesioangular lower third molars (L3M). STUDY DESIGN: Randomized single-blind clinical trial to compare the effectiveness of ultrasonic scaling of the L2M (experimental group) and manual scaling and root planing (control group) after surgical extraction of the corresponding L3M. RESULTS: Forty-three subjects were enrolled, 69.8% completing the study. The postoperative bony defect on the distal surface of the L2M was significantly reduced for both treatment groups (P = .001). Despite a higher reduction of intrabony defect being observed in the ultrasonic group, the difference was not significant (P = .17) at 6 months. Furthermore, there was also no statistically significant correlation (P > .05) between the postoperative pocket depth and the treatment group (ultrasonic or manual). CONCLUSIONS: Pocket depth and depth of the intrabony defect were similar in both experimental and control groups.

[Patient satisfaction in gastrointestinal endoscopy: results of a multicenter study]. / Satisfacción del paciente con la endoscopia digestiva: resultados de un estudio multicéntrico.

BACKGROUND AND AIM: The aim of this study was to determine the main quality problems perceived by patients in gastrointestinal endoscopy through a satisfaction survey. PATIENTS AND METHODS: A total of 321 patients from five gastrointestinal endoscopy units were included. Telephone interviews using a previously validated questionnaire on several aspects related to the procedure were carried out. Pareto analyses were performed to pinpoint the most common aspects among the vital few causes at each medical center. Based on the questionnaire, the satisfaction indicators were calculated for each center: the overall satisfaction score (the sum of the responses to the eight questions) and the rate of perceived problems (number of questions with a negative response divided by the number of questions asked). RESULTS: The most frequent aspects among the vital few were waiting time for an appointment and discomfort during the examination, since both factors were included in the vital few in four of the five medical centers. Significant differences were found among centers in the overall satisfaction score (questionnaire score) (p < 0.001) and for the rate of perceived problems (p < 0.001). CONCLUSION: According to the patients, the most problematic aspects were waiting time until the day of the appointment and discomfort during the examination. Perceived quality differed among the participating centers.

Variation among endoscopy units in the achievement of the standards of colonoscopic performance indicators.

BACKGROUND/AIMS: To assess the achievement of quality standards of colonoscopy at six endoscopy units. METHODOLOGY: Three indicators were used to assess the quality of 1056 colonoscopies performed at six hospitals: cecal intubation; adequate colon cleansing; and removal and recovery of all detected polyps. Analyses were performed on the total number of colonoscopies and on colonoscopies in which polyps were actually detected. The accomplishment of each indicator and a global compound index of all three indicators, named the Problem Rate, were analyzed. Results from each endoscopy unit were compared to previously established standards. RESULTS: Adequate colon cleansing was the most frequent problem for quality in all centers; adequate colon preparation was 67% (range 50 to 84%). The cecum was reached in 84% of all colonoscopies (range 76 to 90%). 75% of all patients (range 28. 79%) had all polyps excised and recovered. All centers had rates below standard for one or several indicators (p<0.01, all cases). Two of the participant hospitals had an overall problem rate above the estimated standard (p<0.01). CONCLUSIONS: There is a significant variation in the achievement of quality standards of colonoscopy between endoscopy units. Colon cleansing is the most frequent quality problem for colonoscopy.

Minor salivary gland tumors: A clinicopathological study of 18 cases.

INTRODUCTION: Minor salivary gland tumors (MSGTs) are infrequent, representing 10-15% of all salivary neoplasms. Despite this low frequency, MSGTs conform a heterogeneous group of neoplasms characterized by a broad range of histological types. PATIENTS AND METHOD: We identified cases of MSGT in a retrospective study of the biopsies made in the period 1997-2007 in the Service of Oral Surgery (Dental Clinic of the University of Barcelona, Spain). The data collected comprised patient age and sex, the clinical characteristics and location of the tumor, the duration of the lesion, its size, the treatment provided, and the histopathological findings. RESULTS: Of the 18 cases of MSGT studied, 12 corresponded to women (66.7%) and 6 to men (33.3%). The great majority (94.4%) were benign tumors. The preferential location was the posterior third of the hard palate (33.2%), followed by the soft palate (16.7%) and the mucosa of the upper lip (16.7%). The histopathological diagnoses of our MSGTs comprised 10 pleomorphic adenomas (55.3%), 2 cystadenomas (11.1%), 1 myoepithelioma (5.6%), 1 sialadenoma papilliferum (5.6%), 1 basal cell adenoma (5.6%), 1 Warthin's tumor (5.6%), 1 canalicular adenoma (5.6%), and 1 low-grade polymorphic adenocarcinoma (5.6%). DISCUSSION AND CONCLUSIONS: Coinciding with our own results, the literature describes a high recurrence rate for MSGTs (5-30%) when surgical removal is incomplete. Six percent of all benign minor salivary gland tumors are considered to relapse, versus 65% of all malignant lesions. Periodic clinical controls are required, since the possibility of malignant transformation must be taken into account.

Quantitative cholescintigraphy and bile abnormalities in patients with acalculous biliary pain.

Acalculous biliary pain has been related to gallbladder dysfunction that produces a gallbladder emptying defect-a condition which favours the development of lithiasis. It is therefore probable that microlithiasis is present in patients with gallbladder dysfunction. The aims of this study were to measure gallbladder emptying and investigate bile abnormalities in patients with acalculous biliary pain. In 92 consecutive patients, gallbladder emptying was assessed by quantitative cholescintigraphy (abnormal ejection fraction < or =40%). In 64 patients, a microscopic study was performed on duodenal bile, defining abnormality as the presence of cholesterol crystals in any amount and/or calcium bilirubinate granules and/or microspheroliths at a rate of >10 per slide. The ejection fraction was abnormal in 45 patients (49%) (median 25.1%, range 6.8-39.3%) and normal in the remaining 47 cases (median 71.3%, range 41.0-96.1%). Bile was abnormal in 32 of 64 patients (50%), the most frequent finding being calcium bilirubinate granules. In the patients with bile abnormalities, abnormal ejection fraction was more frequent (20 of 32) and the median ejection fraction was lower (30.9%, range 12.0-94.1%) than in the patients with normal bile (16 of 32 with an abnormal ejection fraction; median ejection fraction 50.7%, range 6.8-96.1%). Abnormal bile was frequent (55.5%) in patients with reduced ejection fraction, but was not uncommon in patients with normal ejection fraction (33.3%). Fewer patients showed no alteration (25%). It is concluded that in most patients, acalculous biliary pain coexists with gallbladder dysfunction or abnormal bile, the combination of both alterations being common.