, Volume 42, Issue 8, pp 1775-1782

Gallstone Dissolution with Oral Bile Acid Therapy Importance of Pretreatment CT Scanning and Reasons for Nonresponse

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Abstract

In patients with cholesterol-rich gallbladderstones and a patent cystic duct, complete stoneclearance rates of 65-90% have been reported with oralbile acids (OBAs) alone or with adjuvant lithotripsy (extracorporeal shock-wave lithotripsy; ESWL).The aims of the present study were to analyzepretreatment gallstone characteristics that predict thespeed and completeness of dissolution with OBAs ±ESWL, and to assess, in patients with incompletedissolution, the reasons for the poor response. Wecompared pretreatment gallstone characteristics in 43patients who became stone-free after a median of 9months OBAs ± ESWL with those in 43 age- andsex-matched patients whose stones failed to dissolveafter two years of treatment. In those with incompletegallstone dissolution, we repeated the oralcholecystogram and computed tomogram (CT) and, in selectedpatients, obtained gallbladder bile by percutaneousfine-needle puncture. In patients who became stone-free,those with stones that were isodense with bile and/or had CT scores of 75 Hounsfield units had thefastest dissolution rates. In the 43 nonresponders, themain causes for treatment failure were impairedgallbladder contractility and acquired stonecalcification. CT-lucent, noncholesterol stones, or failure ofdesaturation of bile with the prescribed bile acids,occurred in a minority. We conclude that thepretreatment CT attenuation score predicts both thespeed and completeness of gallstone dissolution. Inpatients with incomplete stone dissolution, thecombination of oral cholecystography, CT, and analysisof gallbladder bile will determine the underlyingreasons for treatment failure in most, but not all,cases.