Chemolysis of gallbladder debris left over after contact litholysis with methyl tert-butyl ether.

Rapid and safe gallbladder clearance from residual, post-MTBE stone debris is believed to be absolutely necessary to reduce stone recurrence after contact litholysis. Because the clearing effect of prokinetic agents is considered an uncertain postdissolution trial, we investigated by in vitro experiments whether and to what extent debris from various cholesterol and "mixed stones" could be removed by direct (topical) chemolysis. Debris from radiolucent cholesterol stones could be dissolved very easily, using the aqueous solvent S-01, composed of EDTA-2Na (1-2%), lauryl sulfobetaine-12 (0.1 M), and 0.1 M sodium carbonate/boric acid buffer, pH 9,5. Its dissolution capacity (DC) was 8.06 +/- 2.3 mg debris/ml and its dissolution efficacy (DE) was 16.2 +/- 4.6 mg debris/ml/hr. Debris from mixed, slightly to moderately calcified stones needed another treatment with S-05, composed of sodium citrate (0.25 M), lauryl sulfobetaine-12 (0.01 M), and citric acid. The initial pH was 5.2. The DC of S-05 ranged from 1.61 +/- 1.1 (debris enriched with Ca-phosphate) to 3.94 +/- 1.3 mg/ml (debris enriched with Ca-carbonate). Stones which did not respond immediately to MTBE because of a thin rim of inorganic or/and organic Ca salts could be made ready for MTBE litholysis by pretreatment with S-01 or S-05 or with a combination of both solvents. Debris containing large portions of biliary mucus could be dissolved most effectively by successive application of S-01 and S-06 (2 M urea).

Mucin-like high molecular mass protein fractions from total pig gallbladder bile mucus, pig gallbladder wall mucus, and total human gallbladder bile mucus.

Native mucin-like complexes were obtained from both pig gallbladder bile and pig gallbladder wall mucus by precipitation, centrifugation, and gel permeation chromatography. Crude preparations by either dialysis (native mucus from bile, and native gallbladder wall mucus) or by precipitation (crude total bile mucus, and lipomucoid) were purified by gel permeation chromatography on Sephacryl S-300HR and Sephacryl S-500HR (Pharmacia). The elution profiles obtained with a reversibly denaturing and detergent-containing eluent showed the same pattern for all samples, although the amounts of the four main fractions differed somewhat. The excluded fraction with the highest carbohydrate portion had an apparent M(r) > 10(7). This fraction and the following included lipomucoid (in physiological solution tightly bound to fraction I), and an eluent-insoluble mucus portion from all samples were characterized by determination of the protein concentration, carbohydrates, sialic acids, and lipids, using standard methods. Sugar analysis was performed by gas-liquid chromatography. Human gallbladder bile was subjected to the same procedures of mucus precipitation and separation. Human gallbladder bile mucus showed identical behaviour to that of pig gallbladder bile mucus, and showed a very similar elution pattern in gel chromatography.

Experimental dissolution of pigment gallstone material using alkaline EDTA and adjuvant bile salts/non-bile salt detergents, thiols and urea, with respect to local chemolitholysis.

In order to enhance the dissolution capacity and the kinetics of topical solvents used in local pigment chemolitholysis, a series of dissolution experiments was performed with intact brown and black pigment stones and with standardized solutes such as pigment stone powder and compressed powder (static disc method). The basic dissolution medium was a 0.1 M boric acid/sodium carbonate buffer (pH 9.5), and the basic lytic agent was EDTA-4Na, working satisfactorily at 1-3 g/dl. It could be demonstrated that the dissolution efficiency of this basic solvent was enhanced significantly in the presence of a detergent (surfacant) and of urea. Among the detergents the zwitterionic (e.g., Sulfobetain-12) and the nonionic types (e.g., a polyoxyethylene ether like Lubrol PX) proved to be most effective. The adjuvant effect of the investigated thiols was disappointing. Only dithioerythritol/dithiothreitol and N-acetylcysteine showed any moderate, if consistent, lytic activity. The highest dissolution rates in dissolving compressed powder standards (disc method) were achieved with the ternary solvent (1% w/v EDTA/80 mM Lubrol PX/1 M urea, pH 9.5). Intact black pigment stones, well known as problematic candidates for chemolitholysis, could be largely dissolved up to approximately 70% of their initial weight. This was not merely a physical disintegration, but a chemical process.

[Computerized tomography differentiation of pigment and cholesterol bile duct calculi]. / Computertomographische Differenzierung von Pigment- und Cholesteringallensteinen.

Successful oral litholytic and other non-operative therapies of gallstones require exact determination of the stone components. Since computed tomography (CT) provides highly sensitive measurement of density, we performed a study to evaluate whether CT measurement of stone density allows to predict the composition of radiolucent gallstones. 28 patients presenting with 29 radiolucent gallbladder (n = 17) or common bile duct stones (n = 12) were included. Prior to operative or endoscopic therapy the attenuation values (Hounsfield Units/HU) were assessed in vivo by CT under standardised conditions (Somatom II; 125 KV; 130 mAs). After surgical or endoscopic stone removal the concrements were dehydrated, homogenised and then analysed by infrared spectroscopy. 18 cholesterol and 11 pigment stones could be identified. The attenuation values (Hounsfield Units) of cholesterol stones amounting to 28-98 HU (48.7 +/- 4.4 HU) differed significantly (p less than 0.001) from pigment stones (90-120 HU/105.5 +/- 2.8 HU). We conclude that computed tomography provides exact discrimination between cholesterol and pigment stones in vivo. Since only cholesterol stones can be dissolved by cheno/ursodeoxycholic acid we recommend to measure the radiodensity of gallstones by CT prior to any litholytic therapy.

Analysis of radiolucent gallstones by computed tomography for in vivo estimation of stone components.

Successful oral litholytic and other nonoperative therapies of gallstones require exact determination of the stone components. Since computed tomography (CT) provides highly sensitive measurement of density, we performed a study to evaluate whether CT measurement of stone density allows a prediction of the composition of radiolucent gallstones. Twenty-eight patients presenting with 29 radiolucent gallbladder (n = 17) or common bile duct stones (n = 12) were included. Prior to operative or endoscopic therapy the attenuation values (Hounsfield Units, HU) were assessed in vivo by CT under standardized conditions (Somatom II, 125 KV, 130 mAs). After surgical or endoscopic stone removal the concrements were dehydrated, homogenized and then analysed by infra-red spectroscopy. The previously measured Hounsfield units were not known to the investigator. Eighteen cholesterol and 11 pigment stones could be identified. The attenuation values (Hounsfield units) of cholesterol stones amounting to 28-98 HU (48.7 +/- 4.4 HU) differed significantly (P less than 0.001) from pigment stones (90-120 HU/105.5 +/- 2.8 HU). We conclude that computed tomography provides exact discrimination between cholesterol and non-cholesterol stones in vivo. Since only cholesterol stones can be dissolved by cheno- and ursodeoxycholic acid we recommend measurement of the radiodensity of gallstones by CT prior to any litholytic therapy. Furthermore the prediction of the stone composition facilitates the decision on extracorporeal shock wave lithotripsy and the selection of specific solvents for contact lysis via a nasobiliary probe.

Pigment gallstone dissolution in vitro. Solubilization of brown bilirubinate and black polybilirubinate stone material by buffered solvents containing ethylenediaminetetraacetic acid, bile salts, and reducing thiols.

The efficacy of a buffered 1% ethylenediaminetetraacetic acid (EDTA)-2Na solution (pH 9.2) in solubilizing carefully pulverized material from brown bilirubinate and black polybilirubinate pigment stones can be intensified stepwise by admixtures of detergents and mucolytic active thiols. Solubilization effects were quantified either photometrically by measuring the dissolved calcium bilirubinate or gravimetrically by measuring the total weight loss of solids after a defined incubation period. Maximum effects were achieved when using a buffered solvent with 1 g/dl disodium-EDTA, 1 g/dl sodium taurocholate (NaTCA), and 2 g/dl N-acetylcysteine (NAC). Whereas admixtures of NAC enhanced the solubilization of brown bilirubinate stone material additionally by an average of 21.3% (related to the effect of an EDTA/NaTCA-containing solvent), black polybilirubinate material responded rather poorly and inconsistently to NAC (mean, 8.4 +/- 11.7%).

Fragmentation of gallstones using extracorporeal shock waves: an in vitro study.

Eighty in vitro experiments were performed with single (n = 51) or multiple (n = 29) gallstones in order to find out which parameters are of prime importance for their disintegration by extracorporeal shock waves. A Dornier lithotripter and an upper limit of 1,500 discharges were employed. Although computed tomography density was significantly lower in cholesterol stones than in the noncholesterol stones (p less than 0.0001) and although the latter were significantly more often radiopaque (p less than 0.0001), we found no clear-cut correlation between the cholesterol content or computed tomography density and the degree of fragmentation of the stones. The most important variable which limited successful disintegration was the total stone volume. In stones with a mean total volume of 0.83 ml +/- 0.25 S.E. (diameter for single stones = 11.5 +/- 0.9 mm), none of the fragments exceeded 2 mm, whereas in stones with a mean volume of 3.6 ml +/- 0.64 (diameter = 17.2 +/- 1.5 mm) at least one fragment larger than 2 mm remained (p less than 0.002). Under the in vitro conditions, fragmentation was similar in multiple and solitary stones, provided the volume of the stones was comparable. These data show that, in general, the number and size of the stones, i.e. their total volume, and much less significantly their chemical composition are the major determinants of fragmentation by extracorporeal shock waves.

Dissolution of calcified cholesterol stones and of brown and black pigment stones of the gallbladder.

The influence of different solvents on cholesterol and pigment stones was investigated in vitro. Stone analysis was performed chemically, with infrared spectroscopy (IRS), scanning electron microscopy, energy-dispersive X-microanalysis (EDXA) and wave-length-dispersive X-microanalysis (WDXA). Each set of stones came from one source: eight human calcified cholesterol stones (CHS), eight fragments of bovine radiopaque Ca-bilirubinate stones (BBIL), and two complete BBIL. CHS and BBIL fragments were treated with (1) a buffered, alkaline 1% ethylenediamine tetraacetate solution (BA-EDTA; pH 9.5); (2) with BA-EDTA and monooctanoin preparation (GMOC) alternately; (3) with GMOC alone, and (4) with methyl-tert-butyl ether (MTBE). The complete BBIL were treated with BA-EDTA and MTBE. Furthermore, two human black pigment stones (BPS) were incubated in BA-EDTA. Calcified cholesterol stones are not dissolved by GMOC alone, nor by alternating treatment with BA-EDTA. They are dissolved by MTBE. MTBE is unsuitable for complete Ca-bilirubinate stones but MTBE, GMOC and GMOC/BA-EDTA alternately disaggregate stone fragments. This means that stone fragments behave differently from complete Ca-bilirubinate stones, which is important for further in vitro investigations. Ca-bilirubinate and black pigment stones are disaggregated in BA-EDTA. These results were confirmed with six CHS, 12 BBIL and 12 BPS from 5 further patients, incubated in the most eligible solvent for any individual stone type.

[Spontaneous intra-antral rhinolith. A case study]. / Spontaner intra-antraler Rhinolith. Eine Fallbeschreibung.

Rhinoliths of the paranasal sinuses have often been reported and are generally due to trauma and surgery of these cavities and to retained foreign bodies. In the present case, an unilateral chronic rhinosinusitis had been treated by antiinflammatory agents only, but never underwent surgery or trauma. Tomography revealed a high density concretion. A solid rhinolith was removed by a Caldwell-Luc procedure and was then submitted to spectrographic and electron microscopic investigations.

[Solitary black pigment stones]. / Solitäre schwarze Pigmentsteine.

Solitary pigment stones of the gallbladder are rare (1.7%). 82.5% are radiopaque, 17.5% radiolucent. 64.8% of radiopaque solitary pigment stones have the structure of a cockade. Such cockades take years to develop. Solitary cholesterol stones with a nucleus of a radiopaque pigment stone should not be treated for litholysis. 8% of solitary cholesterol stones with a cross diameter below 15 mm. possess a radiolucent pigment stone nucleus. X-ray diagnosis for selecting litholytic treatment remains the safest method, especially if the radiologist compares his films regularly with the specimens after surgery.

[Cholelitholysis--gallbladder sediments and pigment stones]. / Cholelitholyse--Gallenblasensedimente und Pigmentsteine.

Dissolution of cholesterol stones in the gallbladder can give rise to insoluble sediment and pigment stones. Thus can lead to a change of the type of gallstones. We have observed such a development during a period of 4 years in 23.5% of a group of 51 patients, whose cholesterol stones originally had been dissolved. Formation of pigment stones can be prevented, if calcium sediments with a grain size below 3 mm are removed early and forcefully enough out of the gallbladder. The voiding function of the gallbladder must be intact for such treatment, and this has to be tested before appropriate drug therapy is choosen.

The sugar spectrum of human cholesterol gallstones, mixed and pigment gallstones: combined quantitative analysis of neutral sugars, N-acetylhexosamines, hexuronic and N-acetylneuraminic acids by capillary gas-liquid chromatography.

Glycoproteins were investigated in different types of biliary calculi by a methanolysis procedure of the carbohydrate moiety, the formation of 2,6-dinitro-4-trifluoromethylbenzenesulphonate derivatives of N-acetylhexosamines and N-acetylneuraminic acid, followed by separation, identification and quantification of the liberated monosaccharides using capillary gas-liquid chromatography. This indirect method avoids several analytical problems caused by the presence of bile pigment derivatives; unless these are carefully removed they interfere strongly in the measurement of protein. The carbohydrate contents were much higher in pigment stones than in cholesterol and mixed stones. Rhamnose, a non-mammalian monosaccharide, was identified in most samples, but was significant increased in pigment stones, indicating a bacterial history of this stone type.

Colloid chemical aspects of pigment lithiasis in man: solubilization of calcium bilirubinate by bile salts (a preliminary report).

Calcium bilirubinate, an important constituent of pigment gallstones, can be solubilized in aqueous systems (including bile) to a considerable extent, depending on colloid mechanisms, strongly influenced by the actual ionic strength. Simple bile salt micelles protect colloid calcium bilirubinate against coagulation more effectively than do mixed bile salt-lecithin micelles, in particular when the latter are cholesterol saturated. The dissolved pigment does not enter the bile salt micelle. Pigment stone formation is believed to be due not merely to calcium bilirubinate overproduction, but also to pathological conditions leading to a coagulation of the colloid pigment in bile.

Scanning electron microscopy in gallstone research.

Nidation of gallstones by inorganic or organic Ca salts was studied in 336 consecutive cases by SEM/EDXA and additional methods (X-radiography, X-diffraction, IR spectroscopy). SEM/EDXA proved to be a useful method in studying very small radio-dense nuclei, since common means of phase analysis are limited because of the small amounts of material to be analyzed. In 20.3% stones had radio-dense nuclei composed of either Ca-phosphate- and/or Ca-carbonate microcalculi. Ca-palmitate and/or pigments were at the centre of stones showing a less dense X-shadow. Nidation of cholesterol stones by defined pigment microcalculi was observed in 10 cases. Microstructures, for instance Ca-carbonate- and pigment microcalculi of identical structure to the central nidi, were found in corresponding bile sediments, confirming the role of such structures in gallstone nidation. Two structural features were identified in pigment stones: small, irregular granules, and glassy, poorly structured masses. Ca-bilirubinate calculi were built up from granules while the so called 'black' stones were composed entirely of the glassy masses or contained both structural elements, indicating that bilirubinate may be involved in the formation of some black stones, too. As revealed by EDXA and EPMA Ca was predominant in both subtypes while the black stones additionally contained Cu, Fe and, above all, considerable amounts of S. the latter was found to be in a low, non-SO4-valence state.

Investigations on common bile duct stones.

Common bile duct stones from 59 consecutive patients who underwent cholecystectomy more than 1 year before radiological detection of choledocholithiasis (group I) and from 31 consecutive patients with choledocholithiasis and gallbladder in situ (group II) were subjected to chemical analysis and compared with the composition of gallbladder stones from the same population (two consecutive biopsy and autopsy series, n = 343). In contrast to cholecystolithiasis, inorganic calcium salts were infrequent in choledocholithiasis while calcium bilirubinate and fatty acid calcium salts played an important role in the composition of common bile duct stones. This is of particular importance in terms of litholysis. With respect to stone pathogenesis, clinical and radiological data were analyzed, as was hepatic bile lipid composition. There was no significant difference in the lithogenic index (percent cholesterol saturation) in cholecystectomized and in non-cholecystectomized patients with choledocholithiasis. The most important cause of stone recurrence in the common duct after surgery was incrustation of unabsorbed suture material, which was the case in 30.5% of group-I patients.

[Cholelithiasis in a previously not described case of congenital erythropoietic porphyria (author's transl)]. / Cholelithiasis bei einem bisher nicht beschriebenen Fall von Porphyria erythropoetica congenita.

The signs of congenital erythropoietic porphyria (Günther) had their onset at the age of two in a male patient born in 1934: there were blisters and scars after exposure to sunlight, red urine, marked cutaneous pigmentation, acral mutilation, lanugo and erythrodontia. Porphyrin levels in red blood cells and urine confirmed the diagnosis. Splenectomy was performed in 1966 for hypersplenism and haemolysis. No transfusion has been necessary since and the haemolysis has completely disappeared, but signs of ineffective erythropoiesis have continued. Cholecystectomy with choledochal revision was performed because of right upper abdominal colics, fever and biliary stasis in 1977: five partly pigmented, partly mixed gall-stones were removed. The latter had a black, friable centre with high porphyrin content and a cholesterol coating. Thus, as in other chronic haemolyses, pigmented gall-stones may also occur in congenital erythropoetic porphyria.

Solubilization of unconjugated bilirubin by bile salts.

Freshly precipitated unconjugated bilirubin (UCB) is solubilized rapidly and to a large extent by the sodium salts of di- and trihydroxy bile acids. The solubilization effect depending on bile salt concentration, pH and ionic strength is based on micellar mechanisms.