Læknablaðið : fylgirit - 01.08.1978, Blaðsíða 13

11
Prof. R. Hermon Dawling* M.D. F.R.C.P.
THE 3 S’s OF THE MEDICAL TREATMENT
OF GALLSTONES
Selection Secures Success
INTRODUCTION
Gallstones are common and Iceland is
certainly no exception to the rule that
there is an increasing prevelance of gall-
stones throughout the Western world. At
a conservative estimate, some 25,000
patients in Iceland have cholelithiasis and
many more have symptoms attributable to
disorders of the biliary tree.
With the advent of chenodeoxycholic
acid (CDCA) and the emergence of urso-
deoxycholic acid (UDCA) in the family of
substances which improve cholesterol solu-
bility in bile, we now have an effective and
safe alternative to surgery for the treat-
ment of many gallstones. But like many
potent drugs, the indications for prescrib-
ing CDCA must be right before it is used
since its efficacy largely depends on care-
ful patient selection. In many patients, the
gallstones are ,,silent“ and of those who
do have symptoms, not all are suitable
for ,,chenotherapy“. Despite this, experi-
ence in countries where CDCA is already
freely available suggests that it is often
prescribed for the wrong reasons. The pur-
pose of this article, therefore, is to
summarise the current ,,state-of-the-art“ in
the medical treatment of gallstones with
emphasis on the importance of selecting
only those patients who are likely to
benefit from treatment.
* Gastroenterology Unit, Department of Medi-
cine, Guy’s Hospital and Medical School,
London. SEl 9RT.
** For those who wish to read a selected biblio-
graphy on the subject the reader is referred
to Dowling, R.H., 1977, Clinics in Gastro-
enterology 6: 141-163: for those wanting
a full bibliography, see „Chenodeoxycholic
acid and Gallstone Dissolution” — a biblio-
graphy of relevant articles, abstracts and
editorials. Ed. A.F. Hofmann, MTP Press
Lancaster, 1978.
In writing this review no attempt has
been made to provide a chomprehensive
bibliography.** Instead, a simplified prag-
matic approach has been adopted (al-
though apparently didactic statements are,
in fact, based on sound clinical evidence).
The article does not attempt to cover the
whole field of gallstone dissolution. Little
information is given, for example, about
the pharmacology, bioavailability and
mechanism of action of CDCA. Further-
more, the topics of toxicity, carcinogenicity
and mutagenicity are mentioned only
briefly — mainly because they are largely
irrelevant to the practicing clinician and
family doctor for whom this practical
guide was designed.
This article is based on a lecture given
at St. Joseph’s Hospital, Landakot, Reykja-
vík on the occasion of the hospital’s 75th
anniversary when the author was the
fortunate recipient of splendid Icelandic
hospitality.
GALLSTONE FORMATION AND THE
PRINCIPALS OF MEDICAL TREAT-
MENT
As a brief introduction to the topic one
can say that:
1. In most Westernised countries, the
majority of gallstones consist predomin-
antly of cholesterol.
2. Gallstones tend to form when fasting
gallbladder bile becomes supersaturated
in cholesterol.
3. Bile becomes supersaturated in chol-
esterol when there is an excess of
biliary cholesterol relative to the
amounts of bile acid and phospholipids
present which normally ensure thai
biliary cholesterol is maintained in a
micellar solution.