Læknablaðið : fylgirit - 01.08.1978, Page 15

13
gallbladder has become non-functioning in
the interim.
IV Large gallstones
Based on results of 2 studies from
Germany and on a retrospective analysis
of our own results, we would suggest that
one should be reluctant to accept patients
for CDCA treatment with stones mea-
suring > 15xl5mm in diameter. These old
stones seem to have a tightly packed, lami-
nated crystalline array which makes them
resistant to dissolution even though the
bile has been made unsaturated in chol-
esterol by CDCA treatment. Although such
stones do dissolve occasionally, they do
so too infrequently and too slowly to
enable one to recommend CDCA for this
sub-group of patients unless the indications
for medical treatment are particularly
strong.
SELECTION BASED ON CLINICAL
PRESENTATION
I Frequency and severity of symptoms
Having decided (from a consideration
of the X-rays) that the patient is suitable
for chenotherapy, one should next con-
sider the advisability of medical treatment
based on the overall clinical picture.
At one end of the spectrum, the patient
who was discovered to have gallstones
five years previously because of trivial
epigastric discomfort and who has re-
mained symptom-free ever since, may
justifiably feel that she wants neither
medical nor surgical treatment. At the
other end of the scale, patients with re-
peated attacks of biliary colic may be
judged to have too severe and frequent
symptoms to jus'tify medical treatment
which could take up to 2 years before the
gallstone dissolve.
II Women in the child-bearing age group
In some countries. CDCA may be given
to women of child-bearing age only if ac-
companied by „the pill“. In other contries
(such as the U.K.), one is not permitted
to prescibe CDCA for women capable of
bearing children and the combination of
CDCA and the oestrogen-rich contraceptive
pill is forbidden. This is a serious limita-
tion to the use of CDCA since gallstones
are common in women of 15—45 age
group. Although erring on the side of
caution, drug registration authorities are
probably right to be conservative in their
approach but the author believes that the
progesterone-rich, low-oestrogen or „mini-
pill“ should be acceptable as a means of
contraception in patients taking CDCA.
III Obesity
Gallstone patients who are obese pre-
sent a special problem. The bile in obese
subjects who do not have gallstones tends
to be supersaturated in cholesterol as does
that in non-obese patients with gallstones.
When the 2 conditions co-exist, the effects
seem to be additive and before treatment.,
obese gallstone patients have a greater
degree of biliary cholesterol supersatur-
ation than patients with cholelithiasis
alone. Furthermore, the obese gallstone
patients respond poorly to CDCA. On
standard doses of 13—15 mg CDCA Kg-1
day-1 (see below) many are left with
supersaturated bile and their gallstones
do not dissolve. Fortunately, most of these
obese gallstone patients respond to larger
doses of CDCA (up to 20 mg Kg-1 day-1)
but even then, their response is unpredic-
table. As, yet, we do not know enough
about the effect of weight reduction on the
bile lipid response to CDCA to permit
generalisations about the management of
these patients. At present, therefore, we
would recommend that the lipid response
of fasting bile-rich duodenal fluid to CDCA
should be monitored in all obese gallstone
patients. Normally this should be done in
special hospital clinics where such faci-
lities are available.
SELECTION OF MEDICAL VERSUS
SURGICAL TREATMENT
I Contraindications to anaesthesia and
surgery
Chronic lung disease or ischaemic heart
disease may contraindicate rallbladder
surgery for anything short of a major
emergency. For obese gallstone patients,
surgeons often suggest that elective chole-
cystectomy should be postponed until they
have managed to lose weight. In some
countries, the waiting list for non-urgent