Silent Gallstones Research Articles

Management of gallstones. The new option of bile acid therapy.

Recent approval of chenodiol by the Food and Drug Administration has given physicians a new choice of therapy for silent gallstones, but it also presents a dilemma. The longest double-blind study of the drug in one patient population covered only two years and two dosages; no equally controlled data are available documenting drug safety beyond that period or at higher dosages. Recurrence of gallstones after discontinuation of dissolution therapy is common, and thus chronic treatment may be needed. Only the future can tell what place bile acid therapy will assume in the management of gallstone disease.

Prophylactic cholecystectomy or expectant management for silent gallstones. A decision analysis to assess survival.

Decision analysis was done to compare the consequences of prophylactic cholecystectomy with expectant management for silent gallstone disease. Probability values were derived from a study of the natural history of silent gallstone disease, published cholecystectomy mortality rates, and life tables. The two strategies were compared by calculating cumulative numbers of person-years lost for hypothetical cohorts of men and women. Prophylactic cholecystectomy slightly decreases survival. A 30-year-old man choosing prophylactic cholecystectomy instead of expectant management would lose, on average, 4 days of life; a 50-year-old man would lose 18 days. Consideration of monetary costs and discounting further disfavors prophylactic cholecystectomy. Sensitivity analysis shows that differences between the two strategies remain small over a broad range of probability values, both for men and women.

The natural history of silent gallstones: the innocent gallstone is not a myth.

ABOUT 15 million Americans have gallstones.1 A majority of these gallstones are silent (painless).2 , 3 Should silent gallstones be treated prophylactically or left alone? The answer depends in par...

Costs, Risks, and Benefits of Surgery.

Human life has traditionally been regarded as priceless. Therefore, no cost should be spared if a life can be saved. However, life-saving methods have now been developed that may well be beyond the capacity of society to pay for them. Perhaps coronary artery bypass surgery and renal transplantation cost more for society as a whole than society is willing to purchase. This book, using the methods of decision theory and cost-benefit analysis aims to clarify thinking rather than to be merely critical. The first part, background and general principles, introduces the methods of conditional probability, decision trees, and economic analysis. A second section, entitled Surgical Innovation, shows historically that surgical procedures were devised in the past on the basis of intuition and insight of singular individuals. Distinguished foreign visitors to this country had an enormous impact on surgical practice. For example, Arbuthnot Lane, in 1909, explained an elaborate pathology of abdominal bands and adhesions. Symptoms produced by these included headache, lassitude, mental distress, poor temper control, and diminution of libido. These, caused by autointoxication, could be relieved by lysis of adhesions and ileosigmoidostomy, with resection of all the colon proximal to this anasto¬ mosis. In surgery, before 1945, the concept of control in evaluation of methods seemed totally unknown to surgeons. In modern surgery, advances have been made in experimental design of clinical investigations, so that review of surgical innovations, al¬ though not perfect, is vastly improved. A third section of this book assesses risks and benefits of established proce¬ dures by decision analysis. For exam¬ ple, elective inguinal herniorrhaphy is critically assessed, as is life expectancy after cholecystectomy for silent gall stones and after hysterectomy for uterine dysfunction. Surprisingly, al¬ though the indications for inguinal herniorrhaphy are generally agreed on, the analysis in this volume casts doubt on the life-saving efficacy of the opera¬ tion as performed in the elderly. Wisely, the authors suggest that the unchallenged status of the operation is based on its effectiveness in improving quality of life, rather than the quantity of survival of the patient. The results of analysis of this operation show the difficulties of cost-benefit analysis in surgical decision-making. The fourth section focuses on costly procedures that have appeared recently on the medical scene. The data show, in general, that coronary artery bypass surgery is not particularly efficient in the use of scarce health resource funds. An exception to this generalization might be a young man with a strong heart with severe angina who under¬ goes this form of surgery. An estimate is made of the premium that might be paid each year by American men to

Cost-benefit analysis of surgery: Current accomplishments and limitations

The general principles of cost-benefit analysis are applicable to health care issues, which are in particular need of carefully detailed study at a time when health care expenditures are increasing and when there is competition for scarce resources. There are limitations to such analyses, particularly in the evaluation of the many intangible values so important in the costs and benefits of health care. As examples of the methodology, a simplified cost-benefit analysis is presented for cholecystectomy for silent gallstones in terms of an individual patient, and a more complex analysis is presented for a national program for renal transplantation or chronic hemodialysis for end-stage renal disease. Finally, costs of intensive care support are presented. These examples illustrate advantages and disadvantages of a revealing type of analysis that will be applied with increasing frequency to future health care issues.

Surgical indications in patients with silent gallstones

The characteristics of silent gallstones were investigated clinically and histopathologically to study the indications for operation in patients with this entity. The results are summarized as follows: 1. 1. In cases of silent gallstones, which are essentially cholecystolithiasis, the gallstones consisted entirely of cholesterol or pure pigment. 2. 2. Clinically, the incidence of silent gallstones was high among aged patients, but these patients showed no other inherent characteristics that could distinguish them from the patients with symptomatic cholecystolithiasis. 3. 3. Histopathologically, inflammatory changes in the wall of the gallbladder in patients with cholecystolithiasis were most prominent with cholesterol stones, followed by pure pigment stones, contrasting with comparatively slight changes in patients with calcium bilirubinate stones. This trend of changes in the wall of the gallbladder according to the types of gallstone was identical with the trend in patients with silent gallstones. 4. 4. The development of symptoms in patients with silent gallstones was more sudden in the older age groups and frequently accompanied acute cholecystitis. Prognosis in such cases was generally unfavorable. 5. 5. The incidence of cancer of the gallbladder associated with gallstones progressively increased with age, occurring in 3.8 per cent of men and 9.3 per cent of women older than sixty years of age. On the basis of these findings, the indications for cholecystectomy in patients with cholecystolithiasis with slight symptoms, including those of silent gallstones, are discussed.

The Treatment of Silent Gallstones

The author presents current information relative to gallstone formation and its sequelae, quantifies the incidence of truly asymptomatic stones, presents the arguments for surgical and nonsurgical approaches to the patient harboring asymptomatic biliary disease, and offers his rationale for therapy.

Hematuria and Cholethiasis With β-Thalassemia

To the Editor.— Since the report of Goodwin et al 1 in 1950 of painless hematuria associated with sickle cell hemoglobinopathy, numerous reports have confirmed the phenomenon in both sickle cell (SS) trait and SS disease. Gunnels and Grim 2 have reported painless hematuria in A/D hemoglobinopathy. We have previously reported a case of recurrent painless hematuria in a patient with hemoglobin C trait. 3 The present report concerns a child with painless hematuria who had β-thalassemia trait associated with silent gall stones. A 5-year-old black American child was found on routine preschool examination to have significant microscopic hematuria. Complete urological evaluation revealed no abnormality but x-ray films showed radiopaque gall stones. Results of hematological evaluation included a hemoglobin level of 10.8 gm/100 ml, normal bilirubin level, and normal reticulocyte count. Hemoglobin electrophoresis however revealed an A 2 hemoglobin value of 4.3%. Analysis of the parents revealed normal hematograms for both

Surgical indications in cholelithiasis: cholecystectomy on the bases of clinical studies of the silent gallstones and the primary gallbladder carcinomas

We are advocating the removal of all calculous gallbladders regardless of their symptoms, especially on patients of 50 years of age and older with nonvisualized gallbladder.

Surgical indication for the silent gallstone

According to the investigations of the autopsy incidence of gallstones, the follow up study of the silent gallstone and the correlation of the prognosis of the gallstones with the cholecystograms, prophylactic cholecystectomy for the silent gallstone should not be urged until the symptoms occurs.

The "silent" gallstone.

Management of the patient with silent gallstones has long been a controversial subject. Herewith two experienced, competent and recognized authorities in the field of biliary tract surgery present divergent opinions on the controversy.

The 'Silent' Gallstones: A Therapeutic Dilemma

Asymptomatic gall stones are defined as stones that have not caused biliary colic or other biliary symptoms. Nearly two-third of patients with gall stones are asymptomatic. Studies of the natural history of asymptomatic gall stones suggest that the cumulative probability of developing biliary colic after 10 years ranges from 15% to 25%. The incidence of other complications is much less. The operative mortality of elective cholecystectomy is <0.5% but increased mortality is seen in elderly persons (>60 year of age), particularly in those with complications such as acute cholecystitis. Most decision analysis studies do not favour prophylactic cholecystectomy for asymptomatic cholelithiasis. Nonetheless, many studies have listed certain criteria for carrying out elective cholecystectomy in asymptomatic patients. The authors, from their own experience and after reviewing the literature, propose the following criteria for cholecystectomy: life expectancy >20 years, calculi >3 cm in diameter, particularly in individuals in geographical regions with a high prevalence of gall bladder cancer or calculi <3 mm, chronically obliterated cystic duct, non-functioning gallbladder and calcified (porcelain) gallbladder. The widespread use of diagnostic abdominal ultrasonography has led to the increasing detection of clinically unsuspected gall stones. This, in turn, has given rise to a great deal of controversy regarding the optimal management of asymptomatic or 'silent' gall stones. While cholecystectomy is the undisputed gold standard treatment for symptomatic gall stones, the natural history of silent gall stones is not known well enough to recommend a definitive therapeutic strategy for such patients. The treatment options for asymptomatic or silent gall stones range from no treatment to selective cholecystectomy in at-risk group to elective cholecystectomy in all patients. There are a large number of proponents for each of these options so that each merits careful consideration. In this article, the authors examine the evidence for and against treating silent gall stones with the aim of providing more specific guidelines for the management of patients found to have asymptomatic gall stones.

PRIMARY CARCINOMA OF THE GALL-BLADDER IN A PATIENT WITH CONGENITAL HEMOLYTIC JAUNDICE

Case Reports1 November 1947PRIMARY CARCINOMA OF THE GALL-BLADDER IN A PATIENT WITH CONGENITAL HEMOLYTIC JAUNDICEHENRY G. HAGER JR., M.D., WESLEY VAN CAMP, M.D.HENRY G. HAGER JR., M.D.Search for more papers by this author, WESLEY VAN CAMP, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-27-5-823 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptINTRODUCTIONCongenital hemolytic jaundice and primary carcinoma of the gall-bladder are both relatively rare diseases. The occurrence of the two in our patient was probably not a mere coincidence—the former condition was undoubtedly indirectly responsible for the later fatal disease. It was because of this probable etiological sequence of events (congenital hemolytic jaundice → cholelithiasis at an early age → primary carcinoma of the gall-bladder and death at 36 years of age) that we are reporting this unusual case.CASE REPORTA white, 36 year old coast guardsman was admitted to the U. S. Marine Hospital, Kirkwood, Missouri, on October...Bibliography1. FOWLER WM: Hematology, 1945, Paul B. Hoeber & Co., New York. KRACKE, R. R.: Diseases of the blood, 2nd Edition, 1941, J. B. Lippincott Co., Philadelphia. DOWNEY, HAL, Editor: Handbook of hematology, 1938, Vol. iii, Paul B. Hoeber & Co., New York. WINTROBE, M. M.: Clinical hematology, 1942, Lea & Febiger, Philadelphia. Google Scholar2. BROOKSCLINTONASHLEY CDWRLB: Congenital hemolytic icterus with cholelithiasis, Am. Jr. Surg., 1935, xxix, 319. DIAMOND, L. K.: Congenital hemolytic anemia in infancy and childhood, Med. Clin. N. Am., 1937, xxi, 401. GAIRDNER, DOUGLAS: The association of gallstones with acholuric jaundice in children, Arch. Dis. Child., 1939, xiv, 109. CrossrefGoogle Scholar3. BOCKUS HL: Gastroenterology, 1946, Vol. iii, W. B. Saunders Co., Philadelphia. ROBERTSON, H. E.: Silent gallstones, Gastroenterology, 1945, v, 345. Google Scholar4. EWING J: Neoplastic diseases, 1946, W. B. Saunders Co., Philadelphia. Google Scholar5. BURROWS H: An experimental inquiry into the association between gall stones and primary carcinoma of the gall-bladder, Brit. Jr. Surg., 1933, xx, 607-629. BURROWS, HAROLD: Gall stones and cancer: a problem of aetiology, with special reference to the role of irritation, Brit. Jr. Surg., 1939, xxvii, 166. CrossrefGoogle Scholar6. MOORE RA: Textbook of pathology, 1944, W. B. Saunders Co., Philadelphia. BOYD, WILLIAM: Surgical pathology, 5th Edition, 1942, W. B. Saunders Co., Philadelphia. KAUFMANN, EDWARD (Translated by REIMANN, STANLEY): Pathology, 1929, P. Blakiston's Son & Co., Philadelphia. BELL E. T.: Textbook of pathology, 5th Edition, 1944, Lea & Febiger, Philadelphia. KARSNER H. T.: Human pathology, 6th Edition, 1942, J. B. Lippincott Co., Philadelphia. Google Scholar7. GRAHAM EA: The prevention of carcinoma of the gall-bladder, Ann. Surg., 1931, xciii, 317. CrossrefGoogle Scholar8. COLE WH: Textbook of surgery, in Christopher's 4th Edition, 1945, W. B. Saunders Co., Philadelphia. WARREN, RICHARD, and BALCH F. G., JR.: Carcinoma of the gall-bladder: the etiological role of gall stones, Surgery, 1940, vii, 657. Google Scholar9. FINNEYJOHNSON JMML: Primary carcinoma of the gall-bladder, Ann. Surg., 1945, cxxi, 425. GREENLEE, D. P., HAMILTON, R. C., and FERRARO, F. P.: Primary carcinoma of the gall-bladder, Arch. Surg., 1941, xlii, 598. KIRSHBAUM, J. D., and KOZALL, D. D.: Carcinoma of the gall-bladder and extrahepatic bile ducts, Surg., Gynec. and Obst., 1941, lxxiii, 740. LAM, C. R.: The present status of carcinoma of the gall-bladder: a study of 34 clinical cases, Ann. Surg., 1940, cxi, 403. MOHARDT, J. H.: Carcinoma of the gall-bladder: collective review, Surg., Gynec. and Obst., 1939, lxix, 440. CrossrefGoogle Scholar10. HORNE ED: Congenital hemolytic icterus, Am. Jr. Surg., 1944, lxv, 56. CrossrefGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Pueblo, Colorado*Received for publication May 27, 1946.From the Medical and Surgical Departments, U. S. Marine Hospital, Kirkwood, Missouri.†At the time this article was written both authors were on active duty in the Reserve Corps of the United States Public Health Service. This article was approved for publication by the Surgeon General of the USPHS.‡We wish to thank Dr. G. O. Broun, Medical Director of Firmin Desloge Hospital, for allowing us to review in detail the record of our patient's hospitalization in 1933 at that institution. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 November 1947Volume 27, Issue 5Page: 823-827KeywordsArmed forcesCholelithiasisClinical laboratoriesHemolytic jaundiceHospitalizationsMedical servicesResearch laboratoriesSurgeons ePublished: 1 December 2008 Issue Published: 1 November 1947 PDF downloadLoading ...

Cholecystitis, the Cholesterol Gall-Bladder, and Silent Gall Stones

Cholecystitis, the Cholesterol Gall-Bladder, and Silent Gall Stones