ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Overview of nonsurgical management of gallbladder stones

Overview of nonsurgical management of gallbladder stones
Author:
Salam F Zakko, MD, FACP, AGAF
Section Editor:
Sanjiv Chopra, MD, MACP
Deputy Editor:
Shilpa Grover, MD, MPH, AGAF
Literature review current through: Jan 2024.
This topic last updated: Jan 31, 2023.

INTRODUCTION — The majority of patients with asymptomatic (incidental) gallstones do not require treatment. Patients with symptomatic gallstone disease who are unable or unwilling to undergo cholecystectomy may be candidates for nonsurgical management. (See "Overview of gallstone disease in adults", section on 'Symptomatic gallstones'.)

For patients with symptomatic gallstones who are surgical candidates, cholecystectomy is the treatment of choice in order to prevent future attacks of biliary colic and complications of gallstone disease [1-3]. While the nonsurgical approaches are hypothetically safer, requiring no abdominal incision or general anesthesia, they all suffer from three inherent disadvantages. They are labor-intensive, they are mainly suited for primarily cholesterol stones, and they have high rates of recurrence.

The main modalities for nonsurgical treatment of gallbladder stones include oral dissolution therapy with bile acids, and percutaneous cholecystostomy and stone extraction. Extracorporeal shock wave lithotripsy (ESWL) is used in rare situations. Historically, topical solvent dissolution was widely used but it is labor-intensive, expensive, and requires a complex apparatus for safe solvent delivery that is not readily available [4-7]. This topic will review nonsurgical management for gallbladder stones. Nonsurgical management of bile duct stones (choledocholithiasis) and cholangitis, including endoscopic sphincterotomy without subsequent cholecystectomy, are discussed separately. (See "Endoscopic management of bile duct stones" and "Laparoscopic cholecystectomy".)

TYPES OF GALLSTONES

Composition — Gallstones are composed of a mixture of cholesterol, calcium salts of bilirubinate or palmitate, proteins, and mucin. Based upon the predominant constituents, gallstones are broadly classified into the following (picture 1):

●Cholesterol stones – Cholesterol stones usually form in individuals with a genetic or environmental predisposition to bile that is supersaturated with cholesterol. Most "cholesterol" stones have a mixed composition with small amounts of calcium, palmitate, and bilirubinate salts.

●Black pigment stones – Black pigment stones result from hemolysis and consist primarily of calcium bilirubinate.

●Brown pigment stones – Brown pigment stones are associated with a bacterial infection or parasitic infestation of the biliary system. They are also often found in the bile ducts in association with prior biliary manipulation. They may also occur as de novo common bile duct stones following cholecystectomy.

Gallstones in an individual patient are usually similar in composition.

Prevalence by composition — The prevalence of pigment stones is dependent primarily upon the frequency of hemolytic disorders in the community. In industrialized countries, cholesterol gallstones account for approximately 75 percent of stones, black pigment stones for 20 percent, and brown pigment stones for 5 percent [8-12].

PRETREATMENT IMAGING — Pretreatment imaging of the gallbladder is required to guide the choice of nonsurgical management options. Imaging is needed to evaluate:

●Composition of the gallstones

●Number and size of stones within the gallbladder

●Patency of the cystic duct

●The concentrating ability of the gallbladder

We use a noncontrast thin slice computed tomography (CT) limited to the gallbladder to evaluate gallstone composition. We use an oral cholecystogram or HIDA scan to assess cystic duct patency. An oral cholecystogram can also assess gallbladder wall concentrating ability. We do not assess gallbladder motor function with cholecystokinin-stimulated imaging (HIDA scan/oral cholecystogram/ultrasound) in patients with known gallstones as this can lead to biliary colic.

Transabdominal ultrasonography is often the first test for the diagnosis of gallstones. It should be interpreted with caution as it may not accurately determine the number or size of stones in the gallbladder. Smaller stones might be missed (1 or 2 mm in diameter) and, when present in large numbers, can appear on transabdominal ultrasound as one large stone, which would erroneously lead to the conclusion that the patient is not an ideal candidate for dissolution therapy. Hence, we use it in combination with the CT scan findings for this purpose. When available, the oral cholecystogram is the most accurate test for evaluating stone size and number. (See "Overview of gallstone disease in adults", section on 'Transabdominal ultrasound'.)

Computed tomography — A limited noncontrast CT scan without oral or intravenous contrast and of only the liver and gallbladder can assess stone composition by evaluating buoyancy (relative physical density of the stones to bile) and CT image density in Hounsfield units (image 1) [13-16]. The presence of floating stones (gallstone buoyancy) is indicative of high cholesterol gallstone content and relatively more rapid dissolution. Stones with a high concentration of cholesterol have a very low CT density and appear as black holes within gallbladder bile (image 1). Stones with an average CT density of <75 Hounsfield units are the most susceptible to dissolution, whereas stones with an average CT density of >100 Hounsfield units dissolve poorly [13].

The pattern of calcification and the stone's morphologic appearance on CT scan may also be predictive of dissolution success [14]. Highly calcified stones and stones with dense surface calcification are unlikely to dissolve. The majority of gallstones are not visualized on abdominal CT because they are isodense with bile. However, assessing the CT density of bile in the gallbladder in this case can help predict outcomes. (See 'Efficacy' below.)

Oral cholecystography — Oral cholecystography can accurately assess the number of gallstones, their size, buoyancy, cystic duct patency, and the gallbladder's concentrating ability (image 2) [17,18]. Cholecystography involves administration of an oral contrast agent (eg, iopanoic acid, sodium tyropanoate, or calcium ipodate) the night before the test. It is absorbed through the intestine, taken up by the liver, secreted into bile, and concentrated in the gallbladder. Successful visualization of the gallbladder on abdominal upright radiographs the next day is based on all these steps being intact. Oral cholecystography can also indirectly assess gallbladder motor function. A reduction in gallbladder size on serial radiographs after ingestion of a fatty meal suggests that the gallbladder is functioning normally.

On plain radiographs, gallstones appear as filling defects within the contrast. Gallstone buoyancy, which is indicative of high cholesterol contention, can be seen in the upright position (image 2). Non-opacification of the gallbladder can occur due to poor absorption from the intestine, liver disease with impaired hepatic clearance of iminodiacetic acid compounds, impaired gallbladder concentration due to mucosal fibrosis, or extrahepatic biliary obstruction. The availability of the contrast agents for this test has been sporadic. When not available, we rely on the other imaging studies from which we can derive adequate, although slightly less accurate, information.

Cholescintigraphy (HIDA scan) — We perform cholescintigraphy using 99mTc-hepatic iminodiacetic acid (generically referred to as a HIDA scan) to assess cystic duct patency only if an oral cholecystogram is not available. Unlike oral cholecystography, the HIDA scan cannot assess mucosal concentration function of the gallbladder, as the tracer will enter the gallbladder, leading to its visualization without the need for concentration. A stimulated HIDA scan with cholecystokinin should not be performed in patients with known gallbladder stones, as a forceful gallbladder contraction may lead to an attack of biliary colic or other complications. (See "Acute calculous cholecystitis: Clinical features and diagnosis", section on 'Cholescintigraphy (hepatic iminodiacetic acid [HIDA] scan)'.)

MANAGEMENT

Choice of therapy — The goal of nonsurgical management is to reduce the severity of symptoms, clear the gallbladder of stones, and/or decrease the risk of gallstone-related complications. The choice of non-surgical options is based on the clinical presentation and stone/gallbladder characteristics as assessed by imaging and patient preferences. (See 'Pretreatment imaging' above and "Overview of gallstone disease in adults", section on 'Symptomatic gallstones'.)

In symptomatic patients with uncomplicated gallstone disease, manifested by biliary colic, who are unable/unwilling to undergo cholecystectomy and have small noncalcified stone(s) in a functioning gallbladder, we suggest oral bile acid dissolution therapy with ursodeoxycholic acid. Ideal candidates for oral bile acid dissolution therapy have all the following characteristics [19-24]:

●Small stone size (<1 cm)

●Minimal stone calcification and high cholesterol concentration

●Mild symptoms of uncomplicated gallstone disease (biliary colic)

●Patent cystic duct

●Good gallbladder mucosal concentration function

In symptomatic patients with uncomplicated gallstone disease who are unable/unwilling to undergo cholecystectomy but who do not have small noncalcified stones, the decision to use oral dissolution therapy is made on an individual basis, taking into account patient preferences and success rates for dissolution therapy. As an example, patients with larger stones may be treated with oral dissolution therapy but will require several years of therapy for dissolution. (See 'Efficacy' below.)

In patients with unremitting biliary colic that is unresponsive to oral bile acid therapy, percutaneous extraction via a cholecystostomy tube can be performed if they are unable/unwilling to undergo cholecystectomy. In patients with acute cholecystitis who require percutaneous gallbladder drainage, percutaneous gallstone extraction can be performed in patients who continue to be high risk for surgery. (See "Treatment of acute calculous cholecystitis", section on 'Percutaneous' and "Approach to the management of gallstones", section on 'Alternatives to cholecystectomy'.)

Oral bile acid dissolution therapy

Mechanism of action — Ursodeoxycholic acid (ursodiol) dissolves gallstones by solubilizing cholesterol from the surface and center of the gallstone. In addition, ursodiol has been shown to inhibit and reduce intestinal absorption of cholesterol and improve gallbladder emptying [20,25-29]. When the cholesterol portion of stones that have limited amounts of calcium salts dissolve, the remainder of the stone disintegrates into sand that is expelled over time by a functioning gallbladder.

For ursodiol to be effective, a patent cystic duct is required for it to enter the gallbladder. The absorptive capacity of the gallbladder is important to the successful stone dissolution, as bile acid entering the gallbladder needs to be concentrated in order for it to dissolve the cholesterol. Good gallbladder motor function (ie, filling and emptying) is theoretically desirable to ensure that bile that has become saturated with the dissolved cholesterol is emptied into the duodenum and fresh, unsaturated hepatic bile containing the administered bile acid can mix with the stones and affect their dissolution. Good motor function is also needed to expel gallstone debris and minimize stone recurrence. (See 'Gallstone recurrence' below.)

Dose and administration — Ursodiol is typically given at a dose of 10 mg/kg daily in two to three divided doses [30-32]. Administration in divided doses helps maintain hepatic bile acid secretion overnight, reduces secretion of supersaturated bile, and increases stone dissolution rates [33,34].

Monitoring and duration — We perform an abdominal ultrasound every 6 to 12 months to assess the response to oral dissolution treatment. However, it is important to note that because most stones dissolve from the inside out, they do not appear to be decreasing in size on yearly follow-up exams before they disappear when the external shell disintegrates. Ursodiol is continued for at least six months after ultrasonography demonstrates clearance of the gallstones. In patients in whom high surgical/anesthetic risk precludes cholecystectomy, we continue long-term therapy. (See 'Prevention of recurrence' below.)

The rate of gallstone dissolution in patients taking ursodiol at a standard dose is approximately 1 mm per month [35]. Multiple small stones dissolve faster than a few larger stones due to their larger surface area. If only patients with ideal characteristics were selected (small, noncalcified, high cholesterol stones in a functioning gallbladder), dissolution rates may exceed 90 percent [36]. Unfortunately, less than 10 percent of patients fall into this category. The response to treatment is slow and treatment may be required for two or more years. However, in most cases, recurrent uncomplicated biliary colic will subside within a few weeks of bile acid administration even though the stones are still present [23,24].

Efficacy — The results of oral dissolution therapy correlate with the size and composition of the gallstones. The overall success rate for ursodiol in dissolving gallstones up to 20 mm in diameter ranges from 30 to 50 percent [20]. A meta-analysis of 23 randomized trials found a 37 percent dissolution rate with ursodiol, with higher dissolution rates in patients with small buoyant stones [37]. Incomplete dissolution has been attributed to insoluble components of the gallstones as well as a process referred to as "rim calcification," in which calcium is laid down upon the surface of the stone, preventing the bile acid from reaching the cholesterol portion of the stones. Rim calcification has been reported in 10 to 12 percent of patients treated with bile acids [38,39].

In most cases, episodes of biliary pain decrease in frequency within a few weeks of bile acid administration even though gallstones are still present [21,23,24,30,40-42]. This observation was supported by a cohort study that included 527 patients with uncomplicated gallstones of whom 181 received ursodiol who were followed for up to 18 years [21]. The use of ursodiol was associated with a significantly reduced risk of gallstone-related symptoms at up to 10 years of follow-up (62 versus 92 percent in those with a history of gallstone-related symptoms, and 6 versus 12 percent in those without a prior history of symptoms). This benefit was independent of stone dissolution. Although this study is limited by its nonrandomized design, it suggests a potential benefit of long-term bile acid therapy in symptomatic patients even if complete gallstone dissolution cannot be accomplished. (See 'Monitoring and duration' above.)

Percutaneous cholecystostomy and gallstone extraction — In patients with a percutaneous cholecystostomy tube for gallbladder drainage but who remain at high risk for surgery, gallstones can be extracted percutaneously. This is typically performed two or more weeks after placement of the cholecystostomy thereby, allowing time for the development of an epithelialized percutaneous tract that extends into the gallbladder [43]. The tract is dilated under fluoroscopic guidance using graded percutaneous dilators followed by basket extraction of the stones and irrigation of the debris to the outside using saline [44]. Percutaneous cholecystoscopy has been used to monitor and aid this procedure [45-47]. (See "Treatment of acute calculous cholecystitis", section on 'Nonsurgical candidates'.)

THERAPIES WITH LIMITED OR UNCERTAIN BENEFIT

Extracorporeal shock wave lithotripsy (ESWL) — Solitary, radiolucent stones are technically amenable to fragmentation with ESWL. However, the use of ESWL is limited by high rates of biliary colic (30 to 50 percent) and high rates of gallstone recurrence (up to 60 percent at 5 years) after treatment [48-50]. ESWL employs shock waves produced by electrical discharge. These shock waves generated outside the body are focused on the gallstones, using acoustic reflectors, to fragment the stone. Stone fragments are then ejected into the duodenum through the biliary system [16,51]. The success rates of ESWL decrease in the presence of multiple stones, impaired gallbladder motor function, and the presence of gallstone calcifications [52]. The use of oral bile acids as an adjunctive measure to ESWL does not appear to be superior to ESWL alone in providing symptom relief [53]. (See 'Oral bile acid dissolution therapy' above.)

Statins — There is insufficient evidence to recommend the use of statins for the treatment of gallstones. Statins reduce biliary cholesterol secretion and long-term use of statins is associated with a reduction in gallbladder disease [54-61]. However, the efficacy of statins in gallstone dissolution has not been demonstrated [62]. Results from randomized trials combining statins with ursodiol have also been conflicting [63,64].

Ezetimibe — Ezetimibe is a lipid-lowering drug that acts by inhibiting intestinal cholesterol absorption. Animal models suggest that it may be effective for the treatment or prevention of gallstones [65,66]. It lowers biliary cholesterol secretion but does not decrease the bile salt content in bile. In humans it has been shown to reduce the cholesterol saturation index of bile and slow cholesterol crystallization [65]. Clinical trials are needed to determine if it is effective for gallstone prevention or dissolution.

Monoterpenes — Monoterpenes stimulate bile production and increase the solubility of cholesterol, calcium carbonate, and calcium phosphate. A preparation of six monoterpenes has been used in combination with chenodeoxycholic acid dissolution therapy for radiolucent and some radio-opaque gallstones [67,68]. While it appears to be well tolerated, its efficacy has not been evaluated in randomized trials.

GALLSTONE RECURRENCE

Incidence — Gallstone recurrence following successful medical therapy remains a major concern because patients frequently remain poor surgical candidates. Gallstone recurrence rates at five years in patients treated with oral dissolution or extracorporeal shockwave lithotripsy are 45 and 60 percent, respectively [48,49,69-73]. However, recurrent stones are usually asymptomatic and appear to follow the natural history of asymptomatic stones. In patients treated with oral bile acid dissolution therapy, the risk of recurrence appears to be highest in those with multiple stones and in whom the time to complete dissolution was longest [69].

Recurrent gallstones are often cholesterol rich and not necessarily the same composition as the initial gallstones. Even in the case of previous calcified gallstones, recurrent gallstones are usually rich in cholesterol, and may be suitable for oral bile acid dissolution therapy [74]. However, recurrent stones are usually asymptomatic and may not need therapy unless they cause symptoms. (See "Overview of gallstone disease in adults", section on 'Natural history and disease course'.)

Prevention of recurrence — In addition to dietary and lifestyle modification, we continue long-term oral bile acid dissolution therapy in patients who are unable or unwilling to undergo cholecystectomy and are at risk for recurrent gallstones. Long-term bile acid therapy is likely to prevent further gallstone recurrence and the development of symptoms [20,75,76]. (See "Gallstones: Epidemiology, risk factors and prevention", section on 'Risk factors'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gallstones".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Gallstones (The Basics)" and "Patient education: Choosing surgery to treat gallstones (The Basics)")

●Beyond the Basics topics (see "Patient education: Gallstones (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●The majority of patients with asymptomatic (incidental) gallstones do not require treatment. Patients with symptomatic gallstone disease or those at high risk for developing symptomatic gallstone disease, but are unable or unwilling to undergo cholecystectomy, may be candidates for nonsurgical management. (See 'Introduction' above.)

●Gallstones are composed of a mixture of cholesterol, calcium salts of bilirubinate or palmitate, proteins, and mucin. Based upon the predominant constituents, gallstones are broadly categorized into cholesterol, brown pigment, and black pigment stones. (See 'Composition' above.)

●Dedicated imaging of the gallbladder is required to evaluate the number and size of stones within the gallbladder and their composition, the patency of the cystic duct, and the concentrating ability of the gallbladder. This can usually be achieved by a combination of computed tomography and oral cholecystography/cholescintigraphy of the gallbladder. (See 'Pretreatment imaging' above.)

●The goal of nonsurgical management is to reduce the severity of symptoms, clear the gallbladder of stones, and decrease the risk of gallstone related complications. The choice of nonsurgical therapy is based the clinical presentation and stone/gallbladder characteristics as assessed by imaging and patient preferences. (See 'Choice of therapy' above.)

●Ideal candidates for oral bile acid dissolution therapy have all the following characteristics:

•Small stone size (<1 cm)

•Minimal stone calcification and high cholesterol concentration

•Mild symptoms of uncomplicated gallstone disease (biliary colic)

•Patent cystic duct

•Good gallbladder mucosal concentration function

●We suggest oral bile acid dissolution therapy with ursodeoxycholic acid (ursodiol) in patients with mild symptoms who have non-calcified small stone(s) in a functioning gallbladder and are not candidates for cholecystectomy (Grade 2B). The decision to use oral bile acid dissolution therapy in symptomatic patients with uncomplicated gallstone disease who are unable/unwilling to undergo cholecystectomy but do not have small noncalcified stones is made on an individual basis taking into account patient preferences. (See 'Choice of therapy' above.)

●We perform an abdominal ultrasound every 6 to 12 months to assess the response to oral dissolution treatment. Ursodiol is continued for at least six months after sonographic clearance of the gallstones. In patients at high surgical/anesthetic risk for cholecystectomy, we continue long-term therapy. (See 'Monitoring and duration' above and 'Prevention of recurrence' above.)

●We reserve percutaneous stone extraction in patients with a cholecystostomy tube either for recurrent symptoms of biliary colic despite oral dissolution treatment or complicated gallstone disease (acute cholecystitis) who cannot undergo surgery. Solitary, radiolucent stones are technically amenable to fragmentation with extracorporeal shock wave lithotripsy (ESWL). However, the use of ESWL is limited by high rates of biliary colic and gallstone recurrence after treatment. (See 'Percutaneous cholecystostomy and gallstone extraction' above and 'Extracorporeal shock wave lithotripsy (ESWL)' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff thank Dr. David Nunes, MD, FRCPI, for his contributions as author to prior versions of this topic review.

  1. Darzi A, Geraghty JG, Williams NN, et al. The pros and cons of laparoscopic cholecystectomy and extracorporeal shock wave lithotripsy in the management of gallstone disease. Ann R Coll Surg Engl 1994; 76:42.
  2. Portincasa P, van de Meeberg P, van Erpecum KJ, et al. An update on the pathogenesis and treatment of cholesterol gallstones. Scand J Gastroenterol Suppl 1997; 223:60.
  3. Yamashita Y, Takada T, Kawarada Y, et al. Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14:91.
  4. Zakko SF, Hofmann AF. Microprocessor-assisted solvent-transfer system for gallstone dissolution. In vitro and in vivo validation. Gastroenterology 1990; 99:1807.
  5. Thistle JL, May GR, Bender CE, et al. Dissolution of cholesterol gallbladder stones by methyl tert-butyl ether administered by percutaneous transhepatic catheter. N Engl J Med 1989; 320:633.
  6. Zakko S, Srb S. Chemical contact dissolution of cholesterol gallbladder stones. One hundred years later. Recenti Prog Med 1992; 83:416.
  7. Zakko SF.. Topical contact dissolution of gallbladder and biliary tract. In: Diseases of the gallbladder, Afdhal NH (Ed), NY 2000.
  8. Diehl AK. Epidemiology and natural history of gallstone disease. Gastroenterol Clin North Am 1991; 20:1.
  9. Attili AF, Carulli N, Roda E, et al. Epidemiology of gallstone disease in Italy: prevalence data of the Multicenter Italian Study on Cholelithiasis (M.I.COL.). Am J Epidemiol 1995; 141:158.
  10. Attili AF, Capocaccia R, Carulli N, et al. Factors associated with gallstone disease in the MICOL experience. Multicenter Italian Study on Epidemiology of Cholelithiasis. Hepatology 1997; 26:809.
  11. Sherlock S, Dooley J. Diseases of the liver and biliary system, Blackwell Science, Oxford 2002.
  12. Trotman BW, Soloway RD. Pigment vs cholesterol cholelithiasis: clinical and epidemiological aspects. Am J Dig Dis 1975; 20:735.
  13. Caroli A, Del Favero G, Di Mario F, et al. Computed tomography in predicting gall stone solubility: a prospective trial. Gut 1992; 33:698.
  14. Petroni ML, Jazrawi RP, Grundy A, et al. Prospective, multicenter study on value of computerized tomography (CT) in gallstone disease in predicting response to bile acid therapy. Dig Dis Sci 1995; 40:1956.
  15. Walters JR, Hood KA, Gleeson D, et al. Combination therapy with oral ursodeoxycholic and chenodeoxycholic acids: pretreatment computed tomography of the gall bladder improves gall stone dissolution efficacy. Gut 1992; 33:375.
  16. Pereira SP, Veysey MJ, Kennedy C, et al. Gallstone dissolution with oral bile acid therapy. Importance of pretreatment CT scanning and reasons for nonresponse. Dig Dis Sci 1997; 42:1775.
  17. Malet PF, Baker J, Kahn MJ, Soloway RD. Gallstone composition in relation to buoyancy at oral cholecystography. Radiology 1990; 177:167.
  18. Dolgin SM, Schwartz JS, Kressel HY, et al. Identification of patients with cholesterol or pigment gallstones by discriminant analysis of radiographic features. N Engl J Med 1981; 304:808.
  19. Fromm H, Malavolti M. Bile acid dissolution therapy of gallbladder stones. Baillieres Clin Gastroenterol 1992; 6:689.
  20. Rubin RA, Kowalski TE, Khandelwal M, Malet PF. Ursodiol for hepatobiliary disorders. Ann Intern Med 1994; 121:207.
  21. Tomida S, Abei M, Yamaguchi T, et al. Long-term ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute cholecystitis in patients with gallbladder stones: a cohort analysis. Hepatology 1999; 30:6.
  22. Paumgartner G, Pauletzki J, Sackmann M. Ursodeoxycholic acid treatment of cholesterol gallstone disease. Scand J Gastroenterol Suppl 1994; 204:27.
  23. Bachrach WH, Hofmann AF. Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. part I. Dig Dis Sci 1982; 27:737.
  24. Bachrach WH, Hofmann AF. Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. Part II. Dig Dis Sci 1982; 27:833.
  25. Guarino MP, Cong P, Cicala M, et al. Ursodeoxycholic acid improves muscle contractility and inflammation in symptomatic gallbladders with cholesterol gallstones. Gut 2007; 56:815.
  26. Hardison WG, Grundy SM. Effect of ursodeoxycholate and its taurine conjugate on bile acid synthesis and cholesterol absorption. Gastroenterology 1984; 87:130.
  27. Uchida K, Akiyoshi T, Igimi H, et al. Differential effects of ursodeoxycholic acid and ursocholic acid on the formation of biliary cholesterol crystals in mice. Lipids 1991; 26:526.
  28. Wang DQ, Tazuma S, Cohen DE, Carey MC. Feeding natural hydrophilic bile acids inhibits intestinal cholesterol absorption: studies in the gallstone-susceptible mouse. Am J Physiol Gastrointest Liver Physiol 2003; 285:G494.
  29. van de Heijning BJ, van de Meeberg PC, Portincasa P, et al. Effects of ursodeoxycholic acid therapy on in vitro gallbladder contractility in patients with cholesterol gallstones. Dig Dis Sci 1999; 44:190.
  30. Tint GS, Salen G, Colalillo A, et al. Ursodeoxycholic acid: a safe and effective agent for dissolving cholesterol gallstones. Ann Intern Med 1982; 97:351.
  31. Guarino MP, Cocca S, Altomare A, et al. Ursodeoxycholic acid therapy in gallbladder disease, a story not yet completed. World J Gastroenterol 2013; 19:5029.
  32. Di Ciaula A, Wang DQ, Wang HH, et al. Targets for current pharmacologic therapy in cholesterol gallstone disease. Gastroenterol Clin North Am 2010; 39:245.
  33. Kupfer RM, Maudgal DP, Northfield TC. Gallstone dissolution rate during chenic acid therapy. Effect of bedtime administration plus low cholesterol diet. Dig Dis Sci 1982; 27:1025.
  34. Lanzini A, Facchinetti D, Northfield TC. Maintenance of hepatic bile acid secretion rate during overnight fasting by bedtime bile acid administration. Gastroenterology 1988; 95:1029.
  35. Senior JR, Johnson MF, DeTurck DM, et al. In vivo kinetics of radiolucent gallstone dissolution by oral dihydroxy bile acids. Gastroenterology 1990; 99:243.
  36. Maton PN, Iser JH, Reuben A, et al. Outcome of chenodeoxycholic acid (CDCA) treatment in 125 patients with radiolucent gallstones. Factors influencing efficacy, withdrawal, symptoms and side effects and post-dissolution recurrence. Medicine (Baltimore) 1982; 61:86.
  37. May GR, Sutherland LR, Shaffer EA. Efficacy of bile acid therapy for gallstone dissolution: a meta-analysis of randomized trials. Aliment Pharmacol Ther 1993; 7:139.
  38. Bazzoli F, Festi D, Mazzella G, et al. Acquired gallstone opacification during cholelitholytic treatment with chenodeoxyholic, ursodeoxycholic, and tauroursodeoxycholic acids. Am J Gastroenterol 1995; 90:978.
  39. Bateson MC, Bouchier IA, Trash DB, et al. Calcification of radiolucent gall stone during treatment with ursodeoxycholic acid. Br Med J (Clin Res Ed) 1981; 283:645.
  40. Ward A, Brogden RN, Heel RC, et al. Ursodeoxycholic acid: a review of its pharmacological properties and therapeutic efficacy. Drugs 1984; 27:95.
  41. Petroni ML, Jazrawi RP, Pazzi P, et al. Ursodeoxycholic acid alone or with chenodeoxycholic acid for dissolution of cholesterol gallstones: a randomized multicentre trial. The British-Italian Gallstone Study group. Aliment Pharmacol Ther 2001; 15:123.
  42. Frigerio G. Ursodeoxycholic acid in the treatment of dyspepsia; Report of a multicenter controlled trial. Curr Ther Res 1979; 26:214.
  43. Davis CA, Landercasper J, Gundersen LH, Lambert PJ. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg 1999; 134:727.
  44. Burhenne HJ, Stoller JL. Minicholecystostomy and radiologic stone extraction in high-risk cholelithiasis patients. Preliminary experience. Am J Surg 1985; 149:632.
  45. Zakko S, Rashid S, Ramsby G.. Diagnostic Percutaneous Cholecystoscopy After Nonsurgical Treatment of Gallstones. Gastrointestinal Endoscopy Clinics of North America 1991; 1:127.
  46. Zakko SF, Srb S, Ramsby GR. Sensitivity of percutaneous endoscopy compared with ultrasonography in the detection of residue or mucosal lesions after topical gallbladder stone dissolution. Gastrointest Endosc 1995; 42:434.
  47. Zakko S. Diagnostic imaging before and after dissolution of gallbladder stones. Recenti Prog Med 1992; 83:407.
  48. T. Schöffmann; F.. Extracorporeal Shockwave Lithotripsy (Eswl) for the Treatment of Gallbladder Stones: Long-term Results after More than 20 Years. Hepato-Pancreato-Biliary 2016; 18:854e.
  49. Rabenstein T, Radespiel-Tröger M, Höpfner L, et al. Ten years experience with piezoelectric extracorporeal shockwave lithotripsy of gallbladder stones. Eur J Gastroenterol Hepatol 2005; 17:629.
  50. Paumgartner G, Sauter GH. Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment. Eur J Gastroenterol Hepatol 2005; 17:525.
  51. Sackmann M, Delius M, Sauerbruch T, et al. Shock-wave lithotripsy of gallbladder stones. The first 175 patients. N Engl J Med 1988; 318:393.
  52. Meiser G, Heinerman M, Lexer G, Boeckl O. Aggressive extracorporeal shock wave lithotripsy of gall bladder stones within wider treatment criteria: fragmentation rate and early results. Gut 1992; 33:277.
  53. Nicholl JP, Ross B, Milner PC, et al. Cost effectiveness of adjuvant bile salt treatment in extracorporeal shock wave lithotripsy for the treatment of gall bladder stones. Gut 1994; 35:1294.
  54. Kallien G, Lange K, Stange EF, Scheibner J. The pravastatin-induced decrease of biliary cholesterol secretion is not directly related to an inhibition of cholesterol synthesis in humans. Hepatology 1999; 30:14.
  55. Duane WC. Effects of lovastatin and dietary cholesterol on bile acid kinetics and bile lipid composition in healthy male subjects. J Lipid Res 1994; 35:501.
  56. Hoogerbrugge-vd Linden N, de Rooy FW, Jansen H, van Blankenstein M. Effect of pravastatin on biliary lipid composition and bile acid synthesis in familial hypercholesterolaemia. Gut 1990; 31:348.
  57. Tazuma S, Takizawa I, Kunita T, et al. Effects of long-term treatment with low-dose pravastatin on biliary lipid and bile acid composition in patients with nonfamilial hyperlipoproteinemia. Metabolism 1995; 44:1410.
  58. Duane WC, Hunninghake DB, Freeman ML, et al. Simvastatin, a competitive inhibitor of HMG-CoA reductase, lowers cholesterol saturation index of gallbladder bile. Hepatology 1988; 8:1147.
  59. Tsai CJ, Leitzmann MF, Willett WC, Giovannucci EL. Statin use and the risk of cholecystectomy in women. Gastroenterology 2009; 136:1593.
  60. Bodmer M, Brauchli YB, Krähenbühl S, et al. Statin use and risk of gallstone disease followed by cholecystectomy. JAMA 2009; 302:2001.
  61. Erichsen R, Frøslev T, Lash TL, et al. Long-term statin use and the risk of gallstone disease: A population-based case-control study. Am J Epidemiol 2011; 173:162.
  62. Smit JW, van Erpecum KJ, Renooij W, et al. The effects of the 3-hydroxy, 3-methylglutaryl coenzyme A reductase inhibitor pravastatin on bile composition and nucleation of cholesterol crystals in cholesterol gallstone disease. Hepatology 1995; 21:1523.
  63. Sackmann M, Koelbl R, Pauletzki J, et al. Simvastatin added to ursodeoxycholic acid does not enhance disappearance of gallstone fragments after shock wave therapy. Z Gastroenterol 1995; 33:585.
  64. Tazuma S, Kajiyama G, Mizuno T, et al. A combination therapy with simvastatin and ursodeoxycholic acid is more effective for cholesterol gallstone dissolution than is ursodeoxycholic acid monotherapy. J Clin Gastroenterol 1998; 26:287.
  65. Wang HH, Portincasa P, Mendez-Sanchez N, et al. Effect of ezetimibe on the prevention and dissolution of cholesterol gallstones. Gastroenterology 2008; 134:2101.
  66. de Bari O, Wang HH, Portincasa P, et al. Ezetimibe prevents the formation of oestrogen-induced cholesterol gallstones in mice. Eur J Clin Invest 2014; 44:1159.
  67. Doran J, Keighley MR, Bell GD. Rowachol--a possible treatment for cholesterol gallstones. Gut 1979; 20:312.
  68. Ellis WR, Somerville KW, Whitten BH, Bell GD. Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation. Br Med J (Clin Res Ed) 1984; 289:153.
  69. Petroni ML, Jazrawi RP, Pazzi P, et al. Risk factors for the development of gallstone recurrence following medical dissolution. The British-Italian Gallstone Study Group. Eur J Gastroenterol Hepatol 2000; 12:695.
  70. Portincasa P, van Erpecum KJ, van De Meeberg PC, et al. Apolipoprotein E4 genotype and gallbladder motility influence speed of gallstone clearance and risk of recurrence after extracorporeal shock-wave lithotripsy. Hepatology 1996; 24:580.
  71. Lanzini A, Jazrawi RP, Kupfer RM, et al. Gallstone recurrence after medical dissolution. An overestimated threat? J Hepatol 1986; 3:241.
  72. Sackmann M, Ippisch E, Sauerbruch T, et al. Early gallstone recurrence rate after successful shock-wave therapy. Gastroenterology 1990; 98:392.
  73. Villanova N, Bazzoli F, Taroni F, et al. Gallstone recurrence after successful oral bile acid treatment. A 12-year follow-up study and evaluation of long-term postdissolution treatment. Gastroenterology 1989; 97:726.
  74. Pereira SP, Hussaini SH, Kennedy C, Dowling RH. Gallbladder stone recurrence after medical treatment. Do gallstones recur true to type? Dig Dis Sci 1995; 40:2568.
  75. Tudyka J, Wechsler JG, Kratzer W, et al. Gallstone recurrence after successful dissolution therapy. Dig Dis Sci 1996; 41:235.
  76. Tsumita R, Sugiura N, Abe A, et al. Long-term evaluation of extracorporeal shock-wave lithotripsy for cholesterol gallstones. J Gastroenterol Hepatol 2001; 16:93.
Topic 670 Version 22.0

References

1 : The pros and cons of laparoscopic cholecystectomy and extracorporeal shock wave lithotripsy in the management of gallstone disease.

2 : An update on the pathogenesis and treatment of cholesterol gallstones.

3 : Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines.

4 : Microprocessor-assisted solvent-transfer system for gallstone dissolution. In vitro and in vivo validation.

5 : Dissolution of cholesterol gallbladder stones by methyl tert-butyl ether administered by percutaneous transhepatic catheter.

6 : Chemical contact dissolution of cholesterol gallbladder stones. One hundred years later.

7 : Chemical contact dissolution of cholesterol gallbladder stones. One hundred years later.

8 : Epidemiology and natural history of gallstone disease.

9 : Epidemiology of gallstone disease in Italy: prevalence data of the Multicenter Italian Study on Cholelithiasis (M.I.COL.)

10 : Factors associated with gallstone disease in the MICOL experience. Multicenter Italian Study on Epidemiology of Cholelithiasis.

11 : Factors associated with gallstone disease in the MICOL experience. Multicenter Italian Study on Epidemiology of Cholelithiasis.

12 : Pigment vs cholesterol cholelithiasis: clinical and epidemiological aspects.

13 : Computed tomography in predicting gall stone solubility: a prospective trial.

14 : Prospective, multicenter study on value of computerized tomography (CT) in gallstone disease in predicting response to bile acid therapy.

15 : Combination therapy with oral ursodeoxycholic and chenodeoxycholic acids: pretreatment computed tomography of the gall bladder improves gall stone dissolution efficacy.

16 : Gallstone dissolution with oral bile acid therapy. Importance of pretreatment CT scanning and reasons for nonresponse.

17 : Gallstone composition in relation to buoyancy at oral cholecystography.

18 : Identification of patients with cholesterol or pigment gallstones by discriminant analysis of radiographic features.

19 : Bile acid dissolution therapy of gallbladder stones.

20 : Ursodiol for hepatobiliary disorders.

21 : Long-term ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute cholecystitis in patients with gallbladder stones: a cohort analysis.

22 : Ursodeoxycholic acid treatment of cholesterol gallstone disease.

23 : Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. part I.

24 : Ursodeoxycholic acid in the treatment of cholesterol cholelithiasis. Part II.

25 : Ursodeoxycholic acid improves muscle contractility and inflammation in symptomatic gallbladders with cholesterol gallstones.

26 : Effect of ursodeoxycholate and its taurine conjugate on bile acid synthesis and cholesterol absorption.

27 : Differential effects of ursodeoxycholic acid and ursocholic acid on the formation of biliary cholesterol crystals in mice.

28 : Feeding natural hydrophilic bile acids inhibits intestinal cholesterol absorption: studies in the gallstone-susceptible mouse.

29 : Effects of ursodeoxycholic acid therapy on in vitro gallbladder contractility in patients with cholesterol gallstones.

30 : Ursodeoxycholic acid: a safe and effective agent for dissolving cholesterol gallstones.

31 : Ursodeoxycholic acid therapy in gallbladder disease, a story not yet completed.

32 : Targets for current pharmacologic therapy in cholesterol gallstone disease.

33 : Gallstone dissolution rate during chenic acid therapy. Effect of bedtime administration plus low cholesterol diet.

34 : Maintenance of hepatic bile acid secretion rate during overnight fasting by bedtime bile acid administration.

35 : In vivo kinetics of radiolucent gallstone dissolution by oral dihydroxy bile acids.

36 : Outcome of chenodeoxycholic acid (CDCA) treatment in 125 patients with radiolucent gallstones. Factors influencing efficacy, withdrawal, symptoms and side effects and post-dissolution recurrence.

37 : Efficacy of bile acid therapy for gallstone dissolution: a meta-analysis of randomized trials.

38 : Acquired gallstone opacification during cholelitholytic treatment with chenodeoxyholic, ursodeoxycholic, and tauroursodeoxycholic acids.

39 : Calcification of radiolucent gall stone during treatment with ursodeoxycholic acid.

40 : Ursodeoxycholic acid: a review of its pharmacological properties and therapeutic efficacy.

41 : Ursodeoxycholic acid alone or with chenodeoxycholic acid for dissolution of cholesterol gallstones: a randomized multicentre trial. The British-Italian Gallstone Study group.

42 : Ursodeoxycholic acid in the treatment of dyspepsia; Report of a multicenter controlled trial

43 : Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results.

44 : Minicholecystostomy and radiologic stone extraction in high-risk cholelithiasis patients. Preliminary experience.

45 : Diagnostic Percutaneous Cholecystoscopy After Nonsurgical Treatment of Gallstones

46 : Sensitivity of percutaneous endoscopy compared with ultrasonography in the detection of residue or mucosal lesions after topical gallbladder stone dissolution.

47 : Diagnostic imaging before and after dissolution of gallbladder stones.

48 : Extracorporeal Shockwave Lithotripsy (Eswl) for the Treatment of Gallbladder Stones: Long-term Results after More than 20 Years

49 : Ten years experience with piezoelectric extracorporeal shockwave lithotripsy of gallbladder stones.

50 : Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment.

51 : Shock-wave lithotripsy of gallbladder stones. The first 175 patients.

52 : Aggressive extracorporeal shock wave lithotripsy of gall bladder stones within wider treatment criteria: fragmentation rate and early results.

53 : Cost effectiveness of adjuvant bile salt treatment in extracorporeal shock wave lithotripsy for the treatment of gall bladder stones.

54 : The pravastatin-induced decrease of biliary cholesterol secretion is not directly related to an inhibition of cholesterol synthesis in humans.

55 : Effects of lovastatin and dietary cholesterol on bile acid kinetics and bile lipid composition in healthy male subjects.

56 : Effect of pravastatin on biliary lipid composition and bile acid synthesis in familial hypercholesterolaemia.

57 : Effects of long-term treatment with low-dose pravastatin on biliary lipid and bile acid composition in patients with nonfamilial hyperlipoproteinemia.

58 : Simvastatin, a competitive inhibitor of HMG-CoA reductase, lowers cholesterol saturation index of gallbladder bile.

59 : Statin use and the risk of cholecystectomy in women.

60 : Statin use and risk of gallstone disease followed by cholecystectomy.

61 : Long-term statin use and the risk of gallstone disease: A population-based case-control study.

62 : The effects of the 3-hydroxy, 3-methylglutaryl coenzyme A reductase inhibitor pravastatin on bile composition and nucleation of cholesterol crystals in cholesterol gallstone disease.

63 : Simvastatin added to ursodeoxycholic acid does not enhance disappearance of gallstone fragments after shock wave therapy.

64 : A combination therapy with simvastatin and ursodeoxycholic acid is more effective for cholesterol gallstone dissolution than is ursodeoxycholic acid monotherapy.

65 : Effect of ezetimibe on the prevention and dissolution of cholesterol gallstones.

66 : Ezetimibe prevents the formation of oestrogen-induced cholesterol gallstones in mice.

67 : Rowachol--a possible treatment for cholesterol gallstones.

68 : Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation.

69 : Risk factors for the development of gallstone recurrence following medical dissolution. The British-Italian Gallstone Study Group.

70 : Apolipoprotein E4 genotype and gallbladder motility influence speed of gallstone clearance and risk of recurrence after extracorporeal shock-wave lithotripsy.

71 : Gallstone recurrence after medical dissolution. An overestimated threat?

72 : Early gallstone recurrence rate after successful shock-wave therapy.

73 : Gallstone recurrence after successful oral bile acid treatment. A 12-year follow-up study and evaluation of long-term postdissolution treatment.

74 : Gallbladder stone recurrence after medical treatment. Do gallstones recur true to type?

75 : Gallstone recurrence after successful dissolution therapy.

76 : Long-term evaluation of extracorporeal shock-wave lithotripsy for cholesterol gallstones.

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟