P. Portincasa et al., AN UPDATE ON THE PATHOGENESIS AND TREATMENT OF CHOLESTEROL GALLSTONES, Scandinavian journal of gastroenterology, 32, 1997, pp. 60-69
The primum movens in cholesterol gallstone formation is hepatic choles
terol hypersecretion and chronic supersaturation of bile. A cascade of
events will then include: (i) multiple biochemical defects: increased
total biliary proteins (and qualitative shift to cholesterol crystall
ization-promoting factors), increased proportions of hydrophobic bile
salts, increased mucin secretion, and rapid nucleation/crystallization
of cholesterol from cholesterol-enriched biliary vesicles; iii) multi
ple motility defects: impaired gallbladder contractility in vitro and
gallbladder stasis in vivo, delayed intestinal transit. A genetic pred
isposition (together with environmental factors) might also be importa
nt. Therapy should be offered to patients with symptomatic gallstones.
Cholecystectomy remains the only radical therapy for cholelithiasis.
For a subgroup of patients with symptomatic, uncomplicated cholesterol
stones who are unwilling to undergo surgery, or who have a significan
t surgical risk, alternative non-invasive therapies include: (i) oral
litholysis of small stones by bile salts, (ii) fragmentation of 1-3 me
dium-sized stones by extracorporeal shock-wave lithotripsy, and (iii)
topical dissolution of multiple stones by methyl tertbutyl ether. A ma
jor disadvantage of all non-surgical therapies, however, is the 50% re
currence rate of stones at 5 years. A number of prokinetic agents can
improve gallbladder and/or intestine transit, two important contributi
ng factors in gallstone disease. In selected patients, administration
of these agents might enhance the clearance of cholesterol crystals/ga
llstones or might impede/delay gallstone formation and recurrence.