Disorders of bile acid metabolism in cholesterol gallstone disease.

The aim of the study was to evaluate the metabolism of individual bile acids in patients with cholesterol gallstone disease. Therefore, we determined pool size and turnover of deoxycholic (DCA), cholic (CA), and chenodeoxycholic acid (CDCA) in 23 female gallstone patients classified according to their gallbladder function and in 15 healthy female controls. Gallstone patients had normal hepatic bile acid synthesis, but, depending on gallbladder function, differed with respect to turnover and size of the bile acid pools: Patients with well-emptying gallbladder (group A, n = 9) had enhanced turnover and reduced pools of CA (-46%; P less than 0.01 vs. controls) and CDCA (-24%; P less than 0.05), but normal input and size of the DCA pool. With reduced gallbladder emptying (less than 50% of volume; group B, n = 6), turnover and pools of CA, CDCA, and DCA were similar as in controls. Patients with loss of gallbladder reservoir (group C, n = 8) had increased input (+100%; P less than 0.01) and pool size of DCA (+45%; P = 0.07) caused by rapid conversion of CA to DCA, while the pools of CA (-71%; P less than 0.001 vs. controls) and CDCA (-36%; P less than 0.05) were reduced by enhanced turnover. Thus, in patients with cholesterol gallstones, the pools of primary bile acids are diminished, unless gallbladder emptying is reduced. Furthermore, in a subgroup of gallstone patients, who had completely lost gallbladder function, the CA pool is largely replaced by DCA owing to rapid transfer of CA to the DCA pool. This probably contributes to supersaturation of bile with cholesterol.

Effects of cholecystectomy on the kinetics of primary and secondary bile acids.

Removal of the gallbladder is thought to increase formation and pool size of secondary bile acids, mainly deoxycholic acid (DCA), by increased exposure of primary bile acids (cholic acid [CA], chenodeoxycholic acid [CDCA]) to bacterial dehydroxylation in the intestine. We have tested this hypothesis by simultaneous determination of pool size and turnover of DCA, CA, and CDCA in nine women before and at various intervals after removal of a functioning gallbladder. An isotope dilution technique using marker bile acids labeled with stable isotopes (2H4-DCA, 13C-CA, 13C-CDCA) was used. After cholecystectomy, concentration and output of bile acids relative to bilirubin increased (P less than 0.02) in fasting duodenal bile and cholesterol saturation decreased by 27% (P less than 0.05) consistent with enhanced enterohepatic cycling of bile acids. Three months after removal of the gallbladder bile acid kinetics were in a new steady state: pool size and turnover of CDCA were unchanged. Synthesis of CA, the precursor of DCA, was diminished by 37% (P = 0.05), probably resulting from feedback inhibition by continuous transhepatic flux of bile acids. The fraction of CA transferred after 7 alpha-dehydroxylation to the DCA pool increased from 46 +/- 16 to 66 +/- 32% (P less than 0.05). However, this enhanced transfer did not lead to increased input or size of the DCA pool, because synthesis of the precursor CA had decreased.

The predictive value of four scoring systems in liver transplant recipients.

OBJECTIVE: To compare 4 general severity classification scoring systems concerning prognosis of outcome in 123 liver transplant recipients. The compared scoring systems were: the mortality prediction model (admission model and 24 h model); the simplified acute physiology score; the acute physiology and chronic health evaluation (Apache II) and the acute organ systems failure score. DESIGN: Retrospective, consecutive sample. SETTING: Adult intensive care unit in a university hospital. PATIENTS: 123 adult liver allograft recipients after admission to the intensive care unit. MEASUREMENTS AND MAIN RESULTS: The scoring systems were calculated as described by the authors to classify the severity of illness after admission of the allograft recipients to the intensive care unit. The mean and median values of survivors and the group of patients, that died during hospital stay were compared. Receiver-operating characteristics were plotted for all scoring systems and the areas under the curves of receiver-operating characteristics were calculated. The predictive value of the 4 scoring systems was tested using a variety of sensitivity analyses. The mortality prediction model (24 h model) was found to have a high significance (p < 0.001) in predicting mortality and showed the greatest area under the curve (0.829). Simplified acute physiology score (p < 0.001) and acute physiology and chronic health evaluation (Apache II) (p < 0.01) had a high significance as well, but did not hit the level of prognosis of mortality prediction model, as shown in the area under the curves. Accordingly, sensitivity was highest in MPM-24 h (83%), followed by SAPS (72%) and Apache II (71%). MPM-24 h had a total misclassification rate of 22% (SAPS = 32%, Apache II = 33%). MPM-admission failed in predicting mortality (sensitivity = 52%). Organ systems failure score seemed not to be useful in liver transplant recipients. CONCLUSION: General disease classification systems, such as the mortality prediction model, simplified acute physiology score or acute physiology and chronic health evaluation are good mortality prediction models in patients after liver transplantation. We suggest that there is no need for improvement of a special scoring system.

[Percutaneous drainage of fistula-associated abscesses and biliary fistulas]. / Perkutane Drainagebehandlung fistelassoziierter Abszesse und biliärer Fisteln.

33 abdominal abscesses associated with fistulae in 31 patients were treated by percutaneous drainage. 19 of these patients had had surgery immediately preceding the drainage. In 64% the percutaneous drainage led to a diagnosis of an internal fistula. Additional therapeutic measures, because of the fistula, were necessary in 45% (operation, biliary drainage, repositioning of catheter). The average duration of drainage was 29 days. 77% of those abscesses which could be drained were treated successfully. Mortality in the entire series was 19%.

[Percutaneous cholecystostomy in treating acute cholecystitis in patients at risk]. / Perkutane Cholezystostomie in der Behandlung der akuten Cholezystitis des Risikopatienten.

Percutaneous cholecystostomy was performed in 17 poor surgical risk patients. 16 patients developed acute acalculous cholecystitis postoperatively in the intensive care unit, 1 patient had an acute cholecystitis with calculi. Diagnostic imaging using CT and US was specific for acute cholecystitis in 58% only. Percutaneous cholecystostomy was the definitive treatment in 69% of the patients. Additional cholecystectomy was required in 3 patients with complicated cholecystitis, in 1 patient with bile leakage after catheter dislocation and in 1 patient with gallbladder calculi. 3 patients died, 2 of them from reasons unrelated to the gallbladder disease. Radiology-guided percutaneous cholecystostomy performed by a transhepatic approach is a safe and effective procedure for acute cholecystitis in high-risk patients.

[Percutaneous drainage treatment of primary liver abscesses]. / Die perkutane Drainagebehandlung primärer Leberabszesse.

28 primary liver abscesses, including 9 amoebic abscesses, in 24 patients were drained percutaneously. Indication for drainage in amoebic abscesses was imminent rupture and clinical symptoms as pleural effusion, lung atelectasis and pain. 95% of the primary abscesses were cured by percutaneous drainage and systemic antibiotic treatment. There was one recurrence of abscess, which was managed surgically. Reasons for drainage failure were: tumour necrosis and tumour perforation with secondary liver abscess.

[The results of a long-term follow-up of patients with a percutaneous cholecystostomy]. / Ergebnisse einer Langzeitkontrolle von Patienten mit perkutaner Cholezystostomie.

19 out of 37 patients with percutaneous cholecystostomy were followed up for assessment of gallbladder function after percutaneous drainage. 17 out of 19 of the patients remained free from symptoms of gallbladder disease during a mean follow-up period of 25.8 months. Contractility of the gallbladder calculated by measurement of the sonographic diameter of the gallbladder with provocation tests was 62%. One patient was operated upon for choledocholithiasis three years after percutaneous cholecystostomy. Histology showed signs of chronic cholecystitis. It can be concluded that cholecystectomy is not routinely necessary after percutaneous cholecystostomy provided biliary excretion is normal.

Percutaneous cholecystostomy in acute acalculous cholecystitis.

Percutaneous cholecystostomy was performed in 8 poor-surgical-risk patients with acute acalculous cholecystitis. Seven patients had had previous laparotomy, 1 patient a coronary bypass operation. A transhepatic approach was used in all patients. Insertion of the drainage catheters was guided by ultrasound and fluoroscopy. Percutaneous drainage was successful in all patients, with no need for further surgical intervention. Two patients died, for reasons unrelated to the gallbladder disease. Percutaneous cholecystostomy may be definitive treatment for acute acalculous cholecystitis in the critically ill patient.

[Percutaneous drainage treatment of abscess and fluid retention following abdominal surgery]. / Percutane Drainagebehandlung von Abscessen und liquiden Retentionen nach abdominellen Eingriffen.

61 patients with abdominal abscesses and fluid collections as a postoperative complication underwent percutaneous drainage. 60 abscesses, 11 haematomas, 3 steril seromas and 3 bile collections were drained. The fluid collections were associated with biliary or enteric fistulae in 16 cases. The percutaneous drainage was successful in 69%, additional surgery was required in 15%. The overall mortality rate was 13%. Reasons for drainage failure were infected clots, phlegmonic abscesses and pancreas involvement of the abscesses.

[10 years' results following proximal selective vagotomy in duodenal ulcer disease. A prospective study]. / 10-Jahres-Ergebnisse nach proximal selektiver Vagotomie beim Ulcus duodeni-Leiden. Eine prospektive Studie.

The results 10 years after proximal gastric vagotomy for chronic duodenal ulcer disease in a prospective trial are presented. Among 76 patients 5 were lost to follow-up, 3 had died from causes unrelated of ulcer disease. 80.3% of the patients remained clinically free from recurrence. 92.2% had a Visick grade I or II. The symptomatic recurrence rate was 19.7%, total recurrence rate including asymptomatic recurrences having been 25.3%. 6 patients (8.4%) had to be reoperated, 12 (16.9%) were treated medically. 3/4 of the medically treated patients only had 1 recurrence throughout 10 years. The rate of mild dumping and diarrhea was 2% each. Patients with recurrence showed no more significant reduction of BAO or pentagastrin stimulated maximal acid output (MAO) 10 years postoperatively. Patients without recurrence had a significant reduction of BAO and MAO of 42%. Based upon the results presented, the indication for proximal gastric vagotomy for chronic duodenal ulcer is still justified.