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Background: Endoscopic sphincterotomy has been shown to inhibit stone formation in the gall bladder of experimental animals., Aims: To investigate the alterations in bile composition and gall bladder motility after endoscopic sphincterotomy., Patients: A study was performed of gall bladder bile composition and gall bladder motility in patients with gallstone disease ((n = 20; age 40-60 years, median age 55 years: seven men), with gall bladder calculi (n = 12) and with diseased gall bladder (chronic inflammation) without gall bladder calculi (n = 8)), who had received endoscopic sphincterotomy for common bile duct stones. Age and sex matched disease controls comprised 20 patients with gallstone disease but without stones and an intact sphincter of Oddi (with gall bladder calculi (n = 10) and diseased gall bladder without gall bladder calculi (n = 10))., Methods: Gall bladder motility was assessed by ultrasound. Duodenal bile collected by nasoduodenal tube after stimulation of gall bladder by intravenous ceruletid infusion was analysed for cholesterol, phospholipid, and bile acid concentrations, cholesterol saturation index, and nucleation time., Results: There was a significant reduction in mean (SEM) fasting volume (12.5 (1.7) ml v 26.4 (2.5) ml; p < 0.001) and mean (SEM) residual volume (4.34 (0.9) ml v 14.7 (0.98) ml; p < 0.001), and increase in mean (SEM) ejection fraction (65.7 (4.2)% v 43.6 (5.52)%; p < 0.001) and mean (SEM) rate constant of gall bladder emptying (-0.031/min v -0.020/min; p < 0.01) in patients who had been subjected to endoscopic sphincterotomy. Median nucleation time was significantly longer (17 days v 6 days; p < 0.006) in treated patients. There was a reduction in total mean (SEM) lipid concentrations (6.73 (0.32) g/dl v 7.72 (0.84) g/dl; p < 0.05), cholesterol (5.6 (1.5) mmol/l v 10.3 (2.23) mmol/l; p < 0.001) and CSI (0.72 (0.15) v 1.32 (0.31); p < 0.001). There was no significant change in mean (SEM) phospholipid (25.6 (3.5) mmol/l v 23.4 (6.28) mmol/l) and bile acid (93.7 (7.31) mmol/l v 105.07 (16.6) mmol/l) concentrations., Conclusions: After endoscopic sphincterotomy there was enhanced contractility of the gall bladder, accompanied by a prolongation of nucleation time and reduction in cholesterol saturation index.

The high failure rate of contact litholytic therapy for common bile duct stones with currently available cholesterol solvents has been attributed to the inclusion of patients with pigment stones, as no pretreatment investigation is undertaken to distinguish the two stone types. In 36 patients with common bile duct stones we prospectively evaluated the utility of microscopic examination of bile collected from the biliary tree in predicting stone composition. The bile, obtained by means of either an endoscopically placed nasobiliary catheter (n = 27) or a surgically placed T-tube (n = 9), was subjected to microscopic examination, and findings were compared with the composition of stones retrieved subsequently. On the basis of quantitative infrared spectroscopy, stones were classified as cholesterol (n = 28) or pigment (n = 8) stones. The presence of cholesterol crystals in bile correctly identified 24 of 28 patients with cholesterol stones (sensitivity, 86%; specificity, 100%; positive predictive value, 100%). Calcium bilirubinate granules, when present alone (without cholesterol crystals), correctly identified all eight patients with pigment stones (sensitivity, 100%; specificity, 89%; positive predictive value, 73%). Thus, microscopic examination of bile from the biliary tree, if used as a pretreatment screening test, may help distinguish between patients with cholesterol and pigment stones and thereby considerably improve the results of litholytic therapy of common bile duct stones with currently available solvents.