Medical Therapy Oral Bile Acid Dissolution Therapy

Dissolution of cholesterol gallstones with oral bile acid supplementation is appropriate in selected candidates. The two bile acids which have been studied are chenodeoxycholic acid and UDCA.However, UDCA (ACTIGAL) has very few side effects, and has become the preferred bile acid for this indication. UDCA works by decreasing biliary cholesterol secretion and thus inducing the secretion of undersatu-rated bile. This favors the dissolution of cholesterol stones. To be considered for this therapy, patients should have small cholesterol gallstones (preferably < 10 mm) with a patent cystic duct. Stones with a diameter greater than 15 mm cannot usually be treated successfully. The number of stones is not an absolute contraindication to bile acid dissolution therapy. Cystic duct patency can be documented by hepatobiliary scintigraphy or, occasionally, by oral cholecystography. Some experts recommend evaluating stones by computed tomography to be sure they are buoyant and isodense or hypodense to bile, which are indicators that stones are composed primarily of cholesterol. Patients with calcified stones, which are generally not composed of cholesterol, are not candidates for dissolution therapy. The usual dose of UDCA for dissolution is 10 to 15 mg/kg of body weight daily. It can be administered either as single bedtime dose, or divided in 2 daily doses. Patients should be treated until stones are sonographically documented to resolve. Rarely, dissolution therapy can be accompanied by attacks of biliary colic as stones fragment and pass through to the duodenum. In addition, the risk of recurrent stones after UDCA is discontinued is not insubstantial (up to 50% at 5 years) (Villanova et al, 1989). Thus, bile acid dissolution is not curative for gallstones. This therapy should only be applied in patients who are unwilling or unable to undergo a definitive cholecystectomy.

Successful treatment is defined by complete stone disappearance, as confirmed by two consecutive ultrasound exams. Complete dissolution can be achieved in 20 to 70% of patients treated with UDCA (May et al, 1993). The success of dissolution therapy depends on adhering to strict selection criteria. Generally, the best results are obtained in patients with stones < 5 mm in diameter (up to 70% dissolution rate). Complete dissolution is seen in < 30% of patients with stones larger than 10 mm. There is also wide variation in the time needed for stone dissolution. However, on average, stone diameter will decrease by 0.7 to 1 mm per month of treatment.

In some patients, symptoms of biliary colic often improve before gallstones are documented to disappear. However, in some patients, biliary colic continues as stones dissolve and the fragments pass from the gallbladder. Long term therapy with bile acids may result in a lower risk of biliary colic and acute cholecystitis, whether or not stones completely resolve. Therefore, in patients with severe comorbidities who are not surgical candidates, long-term bile acid therapy could be considered to prevent recurrence of gallstone complications. If patients do now show evidence of gallstone dissolution after 6 months of therapy, or if stones shrink but do not eventually resolve, oral bile acid therapy should be discontinued.

Baby Sleeping

Baby Sleeping

Everything You Need To Know About Baby Sleeping. Your baby is going to be sleeping a lot. During the first few months, your baby will sleep for most of theday. You may not get any real interaction, or reactions other than sleep and crying.

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