Ultrasonography improves diagnostic accuracy of acute appendicitis and provides cost savings to hospitals in Japan.

A cost analysis based on changes in patient care was used to evaluate the utility of abdominal ultrasonography in both the clinical management of patients clinically suspected of having acute appendicitis and in reducing expenditure of hospital resources. Among the 200 patients suspected of having acute appendicitis, 57 actually had acute appendicitis. Interpretation of appendiceal ultrasonographic results was 98.5% accurate. The ultrasonographic result led to changes in the treatment of 103 patients. Moreover, ultrasonography led to the prevention of unnecessary appendectomy in 25 patients, providing a savings to the hospital of about Yen 8,013,450 ($65,150), and prevented unnecessary hospital admission for 78 patient-days, thus saving the hospital approximately Yen 1,199,250 ($9750). The cost of performing the 200 ultrasonographic examinations was about Yen 1,096,176 ($8912), and thus the overall savings to the hospital was approximately Yen 40,590 ($330) per patient. Ultrasonography performed in patients with suspected acute appendicitis improves patient diagnostic accuracy, thus leading to more appropriate selection of patient treatment and reduced hospital expenditure.

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

We tested the possibility that pravastatin, a competitive inhibitor of hepatic hydroxymethyl glutaryl coenzyme A (HMG CoA) reductase, would alter cholesterol saturation of gallbladder bile by decreasing its cholesterol saturation index and/or degree of fatty acyl chain unsaturation in lecithin. Eighteen patients with type IIa hyperlipoproteinemia were treated with pravastatin 10 mg/d for 12 months. Gallbladder bile samples were aspirated with a duodenal tube by stimulating gallbladder contraction with intramuscular administration of cerulein before and after treatment. Serum cholesterol level was significantly reduced by 20% after 3 months, and this level was maintained after 12 months. In contrast, the cholesterol saturation index of gallbladder bile was not altered after 3 months (1.52 +/- 0.20 v 1.70 +/- 0.24), but it decreased significantly after 12 months (0.95 +/- 0.11, P < .01). The degree of fatty acyl chain unsaturation tended to decrease, although this was not statistically significant except for the decrease in molar percent of linoleate after 3 months. These findings suggest that long-term treatment with an inhibitor of HMG CoA reductase improves bile lithogenicity even at a comparatively low dose, and can decrease the incidence and complications of cholesterol gallstones.

Comparative effects on biliary concanavalin A-bound glycoproteins and calcium ion on cholesterol crystal nucleation and growth in model bile.

The concanavalin A-bound glycoproteins in human gallbladder bile have recently been demonstrated to be strong promoters of cholesterol crystal nucleation. In the present study, we investigated the mechanism(s) whereby such promoters affect cholesterol crystal nucleation and/or growth, and compared these mechanisms with those of another promoter, calcium ion. Concanavalin A-bound glycoproteins were isolated from the Helix pomatia-unbound fraction of gallbladder bile from stone-free patients, and determined by electrohoresis to consist of six subclasses (MW 143, 98, 80, 58, 50, and 40 kDa). A cholesterol crystal growth assay showed that concanavalin A-bound glycoproteins both accelerated nucleation time and increased growth rate, whereas calcium ion affected nucleation time only. In the presence of both concanavalin A-bound glycoproteins and calcium ion, both cholesterol nucleation and growth were markedly enhanced. A gel permeation chromatographic study revealed that concanavalin A-bound glycoproteins shifted a considerable amount of cholesterol from micelles to vesicles, whereas calcium ion did not. These results suggest that concanavalin A-bound glycoproteins promote cholesterol crystal nucleation and growth, partly by shifting cholesterol from stable micelles to metastable nonmicellar fractions in bile. In contrast, calcium ion promotes these processes by other mechanisms and, therefore, enhances the effect of concanavalin A-bound glycoproteins.

Degree of fatty acyl chain unsaturation in biliary lecithin dictates cholesterol nucleation and crystal growth.

To clarify factors involved in the formation of cholesterol gallstones, we studied the relationship between the degree of fatty acyl chain unsaturation of biliary lecithin and bile metastability. We used supersaturated model bile solutions (molar taurocholate/lecithin/cholesterol ratio (73:19.5:7.5), total lipid concentration 9 g/dl) that contained equimolar egg yolk or soybean lecithins or a sn-1 palmitoyl, sn-2 linoleoyl phosphatidylcholine. Gel permeation chromatographic studies showed that the vesicular cholesterol distribution and dimension were inversely related to the degree of unsaturation of the lecithin species, estimated by reverse phase, high-performance liquid chromatography. Differential interference contrast microscopy and assay of cholesterol crystal growth showed that a higher degree of fatty acyl chain unsaturation of the lecithin species was associated with a faster nucleation time and rate of crystal growth. Our results suggest that vesicular lecithins containing more unsaturated fatty acyl chains bind less tightly to cholesterol than lecithins containing predominantly saturated fatty acids, and that the biliary lecithin species dictates, in part, the nucleation and growth of cholesterol crystals in bile.

An estimation of human bile metastability: clinical application of a sensitive cholesterol crystal growth assay.

The formation of cholesterol monohydrate crystal initiates cholesterol gallstone formation. The nucleation time (NT), a light microscopy method, is used currently to estimate human bile metastability. Recently, a cholesterol crystal growth (CCG) assay utilizing photometric turbidity to quantitate cholesterol crystallization was developed using model bile systems. The object of this study was to determine whether this novel CCG assay was applicable to the quantitative assessment of native human bile metastability. Human gall-bladder bile samples were collected from patients undergoing cholecystectomy. There were five patients with cholesterol gallstone and five stone-free patients. A significant correlation between the onset time measured by the CCG assay and the NT observed by light microscopy was found in our modified assay condition where interference by bilirubin was negligible (P < 0.01). Also, the growth rate measured by the CCG assay significantly correlated with the NT (P < 0.05). These results indicate that the CCG assay is applicable to quantitative assessment of human bile metastability reflected by cholesterol crystal nucleation and that the cholesterol crystal growth is also conveniently estimated by this method.

Simultaneous microanalysis of biliary cholesterol, bile acids and fatty acids in lecithin using capillary column gas chromatography: an advantage to assess bile lithogenecity.

Simultaneous determination of biliary lipids was performed by alkaline hydrolysis, the formation of the methyl ester derivatives of fatty acids that are constituents of phospholipids and of the acetylated methyl ester derivatives of bile acids, and subsequent analysis by capillary column gas chromatography. Complete separation and satisfactory recovery of cholesterol, bile acids, and fatty acids were achieved. Also, the accuracy of the calculation of the bile cholesterol saturation index was enhanced by computation. Since the degree of acyl chain unsaturation affects the cholesterol-holding capacity in vesicles, this method provides a unique insight into bile metastability by the quantitative assessment of fatty acids in lecithin.

Reversibility of organic anion-induced cholestasis: association with compensatory hypersecretion of biliary phospholipid and protein in the dog.

The effect of a concomitant infusion of organic anions, structurally related phthaleins, on bile flow was studied in anaesthetized dogs. A combination of rose bengal and sulfobromophthalein was found to uniquely and synergistically produce an acute, reversible form of intrahepatic cholestasis (< 10% of control level). This phenomenon was not observed with the administration of those individual organic anions at concentrations previously associated with the induction of intrahepatic cholestasis. The infusion of either a micelle forming bile salt, sodium taurocholate, or a non-micelle forming bile salt, sodium dehydrocholate, rapidly reversed the intrahepatic cholestasis (within 20 min after bile salt infusion). During the choleretic phase immediately following the bile salt infusion, a transient but marked hypersecretion, a disproportionately increased output in relation to that of bile acids, of biliary phospholipid (176% of control level by taurocholate and 138% of control level by dehydrocholate), and an even more striking amount of biliary protein hypersecretion were observed (392% of control level by taurocholate and 357% of control level by dehydrocholate). Although the significance of these new post-cholestatic observations requires clarification, it is suggested that the intrahepatic cholestasis induced by organic anions reflects a reversible defect in the mechanism(s) involved in transcellular transport.

Partial characterization of mechanism(s) by which sulphobromophthalein reduces biliary lipid secretion.

This study was performed to explore the mechanisms by which sulphobromophthalein (BSP) reduces the secretion of biliary lipid using Sprague-Dawley rats (SDR) and mutant rats with congenital conjugated hyperbilirubinaemia bred from SDR (EHBR). We infused the bile-salt-pool-depleted rats with sodium taurocholate at a constant rate of 160 nmol/min per 100 g body wt. with BSP (12.5, 25 and 50 nmol/min per 100 g body wt.) or BSP-GSH (12.5, 25 and 50 nmol/min per 100 g body wt.). The biliary secretion of BSP and BSP-GSH was markedly impaired in EHBR as compared with that in SDR. BSP reduced the biliary secretion of cholesterol and phospholipids in a dose-dependent manner without affecting the secretion of bile salts and composition of fatty acids in phospholipids in SDR, but had no effect on lipid secretion in EHBR. In contrast, BSP-GSH had no such effect on biliary lipids, either in the SDR or EHBR. In addition, the amount of BSP in the liver of EHBR was in the same range as that of SDR. Therefore it is unlikely that an intracellular mechanism is involved in the phenomenon of uncoupling by BSP. We conclude that the uncoupling of biliary lipids from bile-salt secretion by BSP occurs at the level of the bile canaliculus following the secretion of unconjugated BSP.