Faculty Bibliography

The safety and efficacy of gallbladder extracorporeal shock-wave lithotripsy combined with 600 mg/day ursodiol were examined in 85 patients with radiolucent gallstones, 15 with lightly calcified gallstones, and 12 with radiolucent stones pretreated for greater than or equal to 2 months with 600 mg/day ursodiol. Results were compared with those of a well-matched lithotripsy-eligible group of 32 subjects treated with ursodiol alone (no lithotripsy). Pretreatment with ursodiol significantly improved while gallstone calcification interfered with fragmentation. Small gallstone size and number also aided fragmentation. Biliary lithotripsy plus ursodiol increased efficacy twofold compared with ursodiol therapy alone (47% vs. 22% of subjects gallstone free; P less than 0.02). Gallstones did not disappear in any subject with calcified gallstones (P less than 0.001) vs. lithotripsy). Product-limit analysis showed that the efficacy for gallstone dissolution increases in the following order: ursodiol alone, lithotripsy-ursodiol, lithotripsy-ursodiol pretreated with ursodiol (P less than 0.02, pairwise). Similar mean gallstone-dissolution rate constants (stone size divided by time to disappear) of stone fragments and whole gallstones during ursodiol therapy suggest that most fragments disappear by dissolution not expulsion. This finding explains why fragmentation appears to be the key predictor of disappearance and even partial fragmentation accelerates gallstone clearance.

The purpose of our study was to determine whether the qualitative features of gallstones, as expressed by their sonographic image, are related to the degree of fragmentation by shock-wave lithotripsy and the rate of stone clearance. The sonographic stone images of 73 patients with 1-3 uncalcified gallstones, followed for at least 1 yr after extracorporeal shock-wave lithotripsy, were analyzed and categorized by three independent observers into two distinct groups: type I--crescent to disc shape with gradual attenuation of echoes, and type II--rim-shape with abrupt shadowing. The degree of fragmentation and rate of stone clearance were significantly greater for type I stones than for type II stones. For all subjects, 1 yr after lithotripsy, 56% (27/48) of type I stones and 12% (3/25) of type II stones had cleared completely (p less than 0.0005). The clearance rate for solitary type I stones was 63% (20/32) versus 14% (2/14) for type II stones (p less than 0.005). Our observations suggest that sonographic analysis of stone patterns might help in predicting success, and contribute to greater cost-effectiveness of biliary extracorporeal shock-wave lithotripsy.

HLA-phenotypes were determined in 31 (30 unrelated) patients with hemochromatosis and compared to the distribution of HLA-antigens in the general German population. A significant excess of HLA-A3 was observed (76.7% vs. 30.2%). The frequency of HLA-B7 was also increased (53.3% vs. 27.0%). However, the difference did not quite reach the level of statistical significance, when correction for multiple comparisons was made. Our findings are in accord with previous observations for different ethnic groups, indicating an association of IH with the A3/B7 haplotype.