An Evaluation of Acalculous Biliary Disease

Sunderland, Graham Thomas (1988) An Evaluation of Acalculous Biliary Disease. MD thesis, University of Glasgow.

Abstract

This thesis is based on the clinical and laboratory findings in 64 patients referred to the University Department of Surgery, Glasgow Royal Infirmary over a 2 year period. The patients were referred from surgeons and physicians in the West of Scotland on the basis of a diagnosis of acalculous biliary pain and were considered suitable for cholecystectomy. Chapter 1 introduces the concept of acalculous biliary disease. This clinical condition is not clearly understood and treatment has been empirical. Specific questions about this condition are the aims of the present studies. Chapter 2 reviews the literature available on gallbladder disease in the absence of stones. The possible aetiology of acalculous biliary pain is considered. The origin of pain from the biliary tree is examined and the literature reviewed suggests that qualitatively similar pain can be generated from all parts of the biliary tree. The diagnostic methods used to detect gallstones are discussed along with their role in acalculous biliary disease. There is a body of work available on the use of cholecystokinin in acalculous biliary disease and this is critically examined together with the reports on cholecystectomy as a method of treatment for this condition. Lastly post cholecystectomy symptoms which have been reported to occur more frequently after surgery for acalculous biliary disease are examined in the light of published work. Chapter 3 outlines the functional anatomy and physiology of the gallbladder, common bile duct and sphincter of Oddi. Recent work has suggested that the gallbladder may not be the only source of biliary pathology and this is discussed. The patients examined and the methods used in the clinical part of this work are outlined in detail in Chapter 4. The methodology used in the experiments described in Chapters 5, 6 and 7 is contained within this section. Chapter 5 deals with the history presented by the patients with a diagnosis of acalculous biliary pain. Each patient, had a further clinical history and a computer elicited history taken. Comparison is made between the two. The history profile of the patients with acalculous biliary disease is compared with that of patients with proven gallstones. One third of 64 patients gave a history typical of biliary origin on extensive clinical history. Previous studies have elucidated the features necessary to diagnose gallstones in our population. The computer analyses showed agreement between patients with acalculous biliary pain and patients with gallstones in the features used to diagnose gallstones. There were two exceptions. The duration of the symptoms was longer (>2 years against 6 months) in the acalculous patients and a greater percentage (80% against 20%) of the gallstone patients described 'attacks' of pain. Chapter 6 examines the cholecystokinin provocation test as a means of predicting outcome following cholecystectomy. Where pain develops with cholecystokinin it has been suggested that such patients will improve after cholecystectomy. Follow up of the 64 patients in the present study after cholecystectomy reveals no difference in outcome between the 9 patients who had positive CCK tests and the 43 who had negative CCK tests although follow up is relatively short (median 1 year). Chapter 7 describes the findings when gallbladder emptying is examined quantitatively by dynamic radionuclide imaging in patients with acalculous biliary pain and a cohort of normal volunteers. Gallbladder emptying was observed to be very variable (range 10-99%) in both patient and volunteer groups. Total emptying was assessed by the ejection fraction (EF) and the rate of emptying by the half life of gallbladder activity. Median ejection fraction and half life were 67% and 16 minutes for the patients and 64.5% and 12.6 minutes for the volunteers and did not differ significantly. In Chapter 8 the findings in gallbladders removed from patients with acalculous biliary pain are presented. The gross and histological appearances have been examined and compared with gallbladders removed for gallstone disease and a group of otherwise normal gallbladders removed during the course of hepatic artery cannulation. The in vitro contractility and sensitivity to acetylcholine, histamine and cholecystokinin octapeptide in each of these groups of specimens has also been examined. The acalculous patients had the highest proportion of cholesterolosis but not significantly so. Histological changes and contractility were the same in the control and acalculous patients but histological changes were significantly greater and contractility significantly reduced in the gallstone patients. Patients with acalculous pain appeared relatively resistant to acetylcholine and histamine but showed no alteration in sensitivity to CCK-8. The results of the patient studies and examination of the gallbladders suggest that a local gallbladder abnormality is an unlikely cause for this condition. (Abstract shortened by ProQuest.).

• Item Type: Thesis (MD)
• Qualification Level: Doctoral
• Keywords: Medicine
• Date of Award: 1988
• Depositing User: Enlighten Team
• Unique ID: glathesis:1988-77647
• Copyright: Copyright of this thesis is held by the author.
• Date Deposited: 14 Jan 2020 11:53
• Last Modified: 14 Jan 2020 11:53
• URI: https://theses.gla.ac.uk/id/eprint/77647