Secondary Stones Research Articles

Periampullary Diverticula Predispose to Primary rather than Secondary Stones in the Common Bile Duct

Periampullary duodenal diverticula are known to be associated with an increased incidence of common bile duct stones. The nature of the association with gallstones remains uncertain. We have examined the incidence of periampullary diverticula and stones after cholecystectomy to determine whether the stones originate primarily in the common duct or migrate from the gallbladder under the influence of abnormal biliary motility. Six hundred and forty-one patients undergoing ERCP were studied. Ninety-five patients had diverticula (14.8%). Diverticula occurred more commonly in jaundiced patients, 47/95, (48.4%) than in patients with normal bilirubin 185/546 (33.8%) (p less than 0.01). Common duct stones were associated with the presence of a diverticulum in 41/95 patients (43%), compared with only 98/546 without a diverticulum (18%) (p less than 0.001). There was no difference in the incidence of common duct stones in association with a diverticulum between those who had had a cholecystectomy 20/41, and those with intact gallbladders, 21/54 (N.S.). Thus the absence of a gallbladder did not alter the high incidence of common duct stones. We conclude that the stones in the common duct are most likely to be primary stones which have formed as a result of periampullary dysfunction.

Selective ERCP and preoperative stone removal in bile duct surgery.

This project was undertaken to evaluate in a prospective fashion the effects of selective preoperative endoscopic-retrograde cholangiography and stone extraction (ERCP-ST EXTR) on the results of biliary tract surgery. Over a 6-year period, 728 patients with primary or secondary biliary tract disease were admitted to the First Surgical Department, landeskrankenanstalten, Salzburg, Austria. If, based on preoperative screening, the possibility of common bile duct stones (CBDS) existed, the patients were subjected to ERCP-ST EXTR. Two to 4 days later, these patients underwent a simple cholecystectomy with intraoperative cholangiogram and functional manometry. Evaluation criteria for this study were morbidity, mortality, and retained stone (RST) rates. The overall complication rate for the entire series was 6%. In patients who underwent operative common duct stone removal (n = 78), the complication rate amounted to 21.8%. The rate was reduced to 2.1% by ERCP-ST EXTR. The RST rate was likewise reduced from 2.2% to 0.5% by ERCP-ST EXTR. Mortality in patients with CBDS fell from 3.8% to 1% through the use of this method. In those patients with secondary stones who were treated by ERCP-ST EXTR only, morbidity was 2%, the RST rate was 0%, and mortality was 0%. It is concluded that selective ERCP-ST EXTR, followed by simple cholecystectomy, is a suitable treatment protocol and that this approach may reduce complication and mortality rates.

Composition and morphologic and clinical features of common duct stones

No systematic study of the composition of common duct stones has been carried out to date. In this study, we assessed the chemical composition and morphologic characteristics of common duct stones from 115 patients, and compared them with gallbladder stones in 67 patients who had both. Visually and chemically, common duct stones could be divided into two groups: cholesterol stones and pigment stones. Cholesterol common duct stones contained 83 ± 1 percent cholesterol, 2.3 ± 0.4 percent bilirubin, and 5.5 ± 1 percent insoluble pigment residue. Pigment common duct stones contained 7 ± 1 percent cholesterol, 24 ± 2 percent bilirubin, and 38 ± 3 percent pigment residue. There were two subgroups of pigment stones: one with large amounts of bilirubin and one with large amounts of pigment residue. A high proportion (46 percent) of common duct stones were composed of pigment. Patients with pigment common duct stones were more likely to have cholangitis and pancreatitis than were patients with cholesterol stones. It was not possible to distinguish primary from secondary stones on morphologic grounds. In 65 of 67 patients (97 percent), gallbladder stones and common duct stones were of the same chemical type. Morphologically, cholesterol common duct stones were very similar (3.6+ on a scale of 0 to 4+) to their counterparts. Pigment common duct stones and gallbladder stones were less similar (2.4+). Chemically, cholesterol common duct stones were identical to their gallbladder counterparts. Pigment common duct stones regularly contained a greater fraction of bilirubin and less pigment residue than associated gallbladder stones (p < 0.05). Earthy common duct stones were associated with earthy gallbladder stones, and were chemically indistinguishable from other pigment stones. These data suggest that all cholesterol common duct stones, and when the gallbladder is present, most pigment common duct stones, are secondary. The latter stones, however, probably grow after entering the duct, adding pigment with a high proportion of bilirubin relative to pigment residue.

Calcification and calculus formation in the upper urinary tract.

SUMMARY Stones in the kidney are divided into primary and secondary. A series of 152 consecutive partial nephrectomies performed in infected and non‐infected cases for the treatment of calyceal stones (primary) is described with a recurrence rate of 7.9 per cent. over a period of sixteen years. The lymphatic theory of stone formation (Carr) has been helpful in explaining the cause of recurrent primary stone. A “stone‐forming” segment must be removed if recurrence of primary stone is to be prevented. In the treatment of secondary stones, elimination of residual urine in the kidney is necessary if recurrence is to be avoided. The surgeon, when dealing with these cases, is dependent upon radiographs of the highest quality. The surgeon and radiologist must work as a unit.

Vesical and Renal Calculi in Children

The purpose of this article is to report an unusually large, primary bladder stone and two stones apparently in the left kidney, in a three-year-old child. Primary stones develop in an acid urine without any antecedent inflammation, but probably with infection as the cause. They may consist of uric acid, urate of soda, lime, potash, oxalate of lime, cystin, xanthin, carbonate of lime, crystalline phosphates of lime, or indigo. Secondary stones which develop in an alkaline urine as a result of inflammation and probably infection may consist of calcium carbonate, and the phosphates of calcium, ammonium and magnesium. Uric acid stones are found in 80 per cent of cases, according to Keyes. The causes of stone formation are obscure. Primary calculi are rarely met among women. The influence of soil, climate, drinking water, occupation, diet, and the amount of salt consumed, seem to have a bearing on their formation. The increased density of the urine, the presence of colloid substances in solution with an exces...

OBSERVATIONS ON SOME CAUSES OF GALL STONE FORMATION

As previous papers from our laboratory have shown, there exists a well defined tendency for calcium carbonate to come out of solution in the normal liver bile of the dog, and for it to be deposited on certain nuclei not infrequent in the secretion under pathological circumstances. Gall stones that had arisen in this fashion were a frequent occurrence in the intubated animals we studied. The present paper is concerned with the reasons for the absence of such stones from dogs with an intact biliary tract. The solubility of calcium carbonate is known to be markedly affected by the reaction of the fluid in which it is contained. The normal liver bile, out of which it tends to precipitate, is alkaline, with an average pH of 8.20 but in the gall bladder where conditions might otherwise seem especially favorable to precipitation, the secretion undergoes a change toward the acid side, becoming on long sojourn there, strongly acid to litmus (pH 5.18 to 6.00). From bile as thus altered, no carbonate precipitation takes place, even when it becomes greatly concentrated as in fasting animals or after obstruction of the common duct. Furthermore, carbonate which has precipitated out of liver bile on standing dissolves again in it when the fluid is rendered slightly acid in vitro, or, in some cases merely neutral to litmus. There are several obvious reasons for the absence of carbonate stones from the normal ducts under ordinary conditions,-notably the motility of these latter, the flushing that they undergo from an intermittently quickened bile stream, and the cleansing and possibly antagonistic action of the secretion elaborated by the duct mucosa. In the fasting animal, one at least of these influences is almost done away with, the rate of bile flow is so greatly cut down; while furthermore the calcium concentration of the secretion undergoes a considerable increase. But pari passu with these changes there occurs one in the bile reaction, a diminution in alkalinity so great that the pH often approximates that of the neutral point for litmus. That this change is not a direct consequence of the increase in calcium, may be inferred from the findings with stasis bile, the calcium content and reaction of which were observed to vary independently, if in general in the same direction. These adjustments within the organism, some of which may be thought to exhibit an element of the purposeful, when considered with the test-tube experiments, strongly suggest that the reaction of the bile plays a critical part in determining the occurrence of carbonate stones, as furthermore that their absence from the normal gall bladder is a consequence of the changes in the bile reaction there occurring. The changes come about through a functional activity of the bladder. This being the case, one might suppose that the failure to act would be followed by a formation of carbonate stones. There is sufficient evidence available in the literature to indicate that this happens, in rabbits at least. It is important to know whether changes in the bile reaction play any part in determining the cholelithiasis of man. To determine the matter will require a large material. But this much we have shown, that carbonate spheroliths not infrequently serve in human beings as centers in a formation of secondary stones of carbonate and cholesterol, as further that cholesterol precipitation out of human bladder bile can be induced or prevented by slightly altering the reaction of the fluid toward the alkaline and acid sides, respectively. The possibility that cholelithiasis may be a consequence of sins of omission on the part of the biliary channels and reservoir deserves to be considered.