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• One hundred cases of pancreatic abscess were identified at five hospitals affiliated with UCLA between 1973 and 1985. Patients were included if a pancreatic mass or phlegmon followed an episode of pancreatitis, if the clinical impression was pancreatic abscess, and if drainage cultures were positive. Less than three Ranson's signs were present on admission in 72% of patients. The admission temperature was less than 38.3°C in 71% of patients, and 27% of patients never had a fever. Abdominal tenderness was absent in 40% of patients. The admission amylase concentrations and white blood cell counts were normal in 36% and 23% of patients, respectively. Extensive debridement, external drainage, and a low threshold for reoperation were the mainstays of surgical therapy. Twenty patients (20%) died, but Ranson's signs did not predict outcome. Pancreatic abscess may have an insidious presentation. A high index of suspicion, early computed tomographic scanning, and diagnostic needle aspiration may be necessary to establish this diagnosis. (Arch Surg1988;123:1067-1072)

The sphincter of Oddi and the duodenum exhibit cyclical activity in phase with the migrating myoelectric complex. Both motilin and cholecystokinin have been shown to modulate gastrointestinal and sphincter of Oddi motility. However, previous studies have not monitored the effects of these hormones on simultaneously recorded sphincter of Oddi and duodenum pressures. The present investigation was undertaken, therefore, to determine the influence of both motilin and cholecystokinin on simultaneously recorded sphincter of Oddi and duodenal motility. In seven anesthetized prairie dogs, a triple-lumen, side-hole, pressure-monitored perfusion catheter was positioned with the proximal port in the sphincter of Oddi and the distal port in the duodenal lumen. Sphincter of Oddi and duodenal motility was recorded before and during 20-min infusions of motilin and cholecystokinin octapeptide (CCK-8) at 1, 10, and 100 ng.kg-1.min-1. Both hormones produced dose-related increases in sphincter of Oddi and duodenal motility. No response was observed with either hormone at 1 ng.kg-1.min-1. At 10 ng.kg-1.min-1, the duodenum was slightly more sensitive to motilin than to CCK-8, while the sphincter of Oddi was equally affected by both hormones. At 100 ng.kg-1.min-1, both hormones stimulated the sphincter of Oddi and the duodenum equally. These data indicate that in the prairie dog, both motilin and cholecystokinin stimulate sphincter of Oddi and duodenal motility.

In two 5 year periods (1975 to 1979 and 1980 to 1984), 96 patients underwent pancreatoduodenal resection, which included 74 partial pancreatic resections and 22 total pancreatectomies. Thirty-seven of these patients had resections with preservation of the pylorus. Substantial reductions in perioperative mortality (2 percent versus 10 percent) and morbidity (26 percent versus 49 percent) (p less than 0.05) were achieved in the latter period. Pylorus preservation, with a mortality and morbidity of 3 percent and 27 percent, respectively, did not increase operative risk or compromise long-term survival in patients with malignant disease. In comparison, relatively high mortality and morbidity rates (14 percent and 59 percent) accompanied total pancreatectomy without improved long-term survival. Five year actuarial survival for nonpancreatic periampullary adenocarcinomas was 58 percent. Thus, we recommend pancreatoduodenectomy with preservation of the pylorus for resection of periampullary tumors. These patients, whose only possibility for cure is a major pancreatic resection, should not be denied this opportunity on the basis of reports from a previous era.

Cholesterol saturated bile and gallbladder stasis are important factors in the pathogenesis of cholesterol gallstones. The degree to which either or both of these factors affect gallbladder transport of fluid remains obscure. The authors tested the hypothesis that both cholesterol saturated bile and gallbladder stasis, and not stasis alone, promotes gallbladder fluid absorption. Prairie dogs were maintained for 2 weeks on either a control chow, total parenteral nutrition (TPN), or a 1.2% cholesterol enriched chow. The bile acid pool was labeled with 14C-cholic acid and indexes for cholesterol saturation (CSI) and gallbladder stasis (Rsa) were determined. Fluid transport was indirectly measured by calculating the ratio of gallbladder to hepatic bile concentrations of individual and total biliary lipids. Despite evidence of stasis in prairie dogs maintained on TPN, bile was unsaturated, and gallbladder absorption was not appreciably changed. In contrast, cholesterol-fed animals had cholesterol supersaturated bile, gallbladder stasis, and altered gallbladder absorption, as manifested by a significant change in the ratio of gallbladder to hepatic bile concentrations of individual and total biliary lipids. These data suggest that both cholesterol saturated bile and gallbladder stasis, and not stasis alone, are essential in promoting the enhanced gallbladder absorption, which has previously been observed during early cholesterol gallstone formation.

Gallbladder stasis occurs before gallstone formation and provides the link between the hepatic secretion of supersaturated bile and cholesterol cholelithiasis. We recently observed that cystic duct resistance increases while sphincter of Oddi resistance is unchanged in the presence of lithogenic bile without gallstones. Whether alterations in gallbladder function also lead to gallbladder stasis has been unclear. Therefore, we tested the hypothesis that before gallstone formation, stasis results from increased cystic duct resistance and altered gallbladder compliance. Adult, male prairie dogs were fed either a trace cholesterol (control) or a 0.4 percent cholesterol-enriched diet. Cystic duct resistance increased but gallbladder compliance was unchanged before gallstone formation. A significant correlation (p less than 0.001) was found between the lithogenic index and cystic duct resistance in pregallstone animals. We conclude that increased resistance to flow across the cystic duct, and not altered gallbladder compliance, is etiologically related to bile stasis, an important event in gallstone formation.

Debate continues as to the role that bacteria play in gallstone pathogenesis in Western countries. We therefore, examined gallbladder and common duct stones from 67 consecutive patients undergoing cholecystectomy and/or common bile duct exploration. Bile was cultured and stone cholesterol content was measured. Stones were examined by scanning electron microscopy (SEM) for bacteria. Individual calcium salts were classified by windowless energy-dispersive x-ray microanalysis. Gallbladder stones in 65 patients were identified as cholesterol in 46 (71%), black pigment in 17 (26%), and brown pigment in 2 patients (3%). Common bile duct stones from ten patients were cholesterol in 4, black pigment in 2, and brown pigment in 4 patients. The five patients with brown pigment stones were significantly (p less than 0.05) older, more likely to be men and to present with bile duct obstruction. Bile cultures were positive in 13% of patients with cholesterol stones, in 14% of those with black pigment stones, and in all of the patients with brown pigment stones (p less than 0.001). By SEM, bacteria were observed only within the calcium bilirubinate-protein matrix of brown pigment stones (p less than 0.001). In comparison to black pigment stones, brown stones were more likely to contain calcium palmitate (p less than 0.005) and cholesterol (p less than 0.001). We conclude that black and brown pigment stones have different pathogenic mechanisms and that bacterial infection is important only in the formation of brown pigment stones.

This document represents a consensus statement dealing with optimum patient care in a significant clinical area. The statement has been prepared by the Patient Care Committee of the American Gastroenterological Association with the advice of other experts and with peer review. As with all such guidelines, this should be interpreted in a nondogmatic manner, so as not to exclude other therapies or opinions in any particular situation. Based on present knowledge, limited at times, future modifications or other changes in this statement may be necessary.

Recent studies suggest that pancreatic polypeptide (PP) alters gallbladder pressure and reduces delivery of bile to the duodenum. Whether this peptide influences gallbladder emptying and/or filling is not clear. Using the prairie dog model, we tested the hypothesis that exogenous PP induces gallbladder filling. Animals maintained on control diets underwent laparotomy with placement of catheters into the gallbladder and common bile duct. The gallbladder was perfused with [14C]polyethtyleneglycol ([14C]PEG)-labeled lactated Ringer's solution (LR) at 0.1 ml/min. Effluent from the common bile duct was collected at 5-min intervals during 30-min intravenous infusions of LR, LR + 2% serum albumin, and LR + 2% serum albumin + bovine PP (10 and 50 ng/kg/min). Gallbladder pressure was continuously recorded. Total and incremental fillings were calculated based on volume and [14C]PEG concentration changes. Infusion of PP, 50 ng/kg/min, induced significant gallbladder filling. The filling response was progressive and peaked during the final 10 min of peptide infusion. These findings coupled with the observation that serum PP levels are increased for up to 6 hr postprandially suggest that PP may play an important role in the regulation of interdigestive gallbladder filling.

Numerous methods are presently available for gallstone dissolution, including oral bile salts; cholesterol solvents such as mono-octanoin and methyl tert-butyl ether; calcium or pigment solvents such as EDTA and polysorbate; mechanical extraction techniques through a T-tube tract or after endoscopic sphincterotomy; or fragmentation methods such as ultrasonography or electrohydraulic lithotripsy, lasers, and extracorporeal shock waves. Which, if any, of these methods will be appropriate for an individual patient depends on the type of stones, whether they are in the gallbladder or bile ducts, whether access to the biliary tree is available, the patient's age and general medical condition, and the availability of expert radiologists, endoscopists, and newer equipment. In the United States, the only available oral bile salt for cholesterol gallstone dissolution is chenodeoxycholate. Ursodeoxycholate, which is more rapid and less toxic, has not been approved by the Federal Drug Administration. These agents are most effective in thin women with small, floating, radiolucent cholesterol gallstones in a functioning gallbladder. Only about half of this small subset of patients, however, will experience partial or complete dissolution of stones in 6 to 12 months. Moreover, recurrence is very likely, and the potential toxicity of long-term therapy is unknown. Thus, for most patients, cholecystectomy remains the most cost-effective and, perhaps, safest option. Intragallbladder instillation of methyl tert-butyl ether and extracorporeal shock wave therapy are also likely to be applicable to only small subsets of patients and to be associated with high recurrence rates. In patients with retained ductal cholesterol stones and access to the biliary tree, mono-octanoin therapy is advantageous in that it can be begun as soon as cholangiography demonstrates no extravasation. In properly selected patients, a 90 percent success rate with mono-octanoin infusion can be expected within a week. Radiologic or endoscopic extraction techniques require maturation of a relatively straight T-tube tract but are not dependent on the type of stone. In the hands of experts, these techniques are highly successful. In postcholecystectomy patients without access to the biliary tree, endoscopic sphincterotomy has become the preferred method of management and can be expected to succeed in more than 90 percent of patients. At this point, the exact role for ultrasonic or electrohydraulic lithotripsy and lasers is unknown. However, these techniques may be applicable in the future in patients with retained bile duct stones in whom extraction and infusion techniques have failed.

• Patients undergoing urgent and complex biliary operations were studied to determine (1) whether bactibilia is associated with postoperative complications and (2) whether antibiotic therapy influences biliary bacteriology. Aerobic and anaerobic cultures were performed on hepatic bile obtained at surgery in 134 patients. Cultures were repeated four to seven days postoperatively in 111 patients who had indwelling biliary tubes. Positive operative bile cultures were associated with an increased incidence of wound infection and postoperative renal dysfunction. Postoperative bile cultures showed a significant increase in the number of patients having bactibilia, and a significant alteration in the types of organisms isolated. Anaerobes were cultured from 15% of operative and 23% of postoperative cultures. Antibiotic therapy did not sterilize bile, but merely altered biliary bacteriology. Furthermore, prolonged aminoglycoside therapy was associated with a high incidence of renal dysfunction, especially in elderly patients. ( Arch Surg 1982;117:445-449.

• We evaluated the risks and benefits of percutaneous transhepatic biliary drainage (PTD) in 44 patients. Patients were divided into two groups, palliative and preoperative, each of which had 22 patients. Major complications included bacteremia, hemobilia, and liver abscess and occurred in ten patients (23%). A liver abscess along the catheter tract may have contributed to the death of one patient with an advanced malignant neoplasm. Major complications were more likely to develop in palliative-group patients (36%v9%) and those patients were more likely to die within 30 days of the procedure (27%v0%). Four (57%) of seven palliative-group patients and none of six preoperative-group patients with pre-PTD bilirubin levels higher than 20 mg/dL died within 30 days after PTD. Liver function test results improved within seven days in approximately 85% of the patients. Twenty-one patients (95%) in the preoperative group survived surgery. We concluded that the risk of PTD may outweigh the benefit in the subset of patients with advanced malignant neoplasms and a bilirubin level higher than 20 mg/dL. Even then, however, PTD may be justified if pruritus is incapacitating. Pending results of further randomized trials, we have continued performing PTD preoperatively in patients whose bilirubin levels exceed 10 mg/dL. (Arch Surg1983;118:1388-1394)

Review of a 26-year experience with transduodenal sphincteroplasty and sphincterotomy was undertaken (1) to analyze critically the indications for and results of these procedures and (2) to determine which preoperative factors correlate with a good or poor outcome. Of 109 patients, 78 underwent sphincteroplasty, whereas 31 had a transduodenal sphincterotomy. Surgical indications included: group 1, 53 patients with common duct stones; group 2, 28 patients with dyskinesia or stenosis of the sphincter of Oddi (without choledocholithiasis or recurrent pancreatitis); and group 3, 28 patients with recurrent pancreatitis. Three elderly group 1 patients who presented with cholangitis died after surgery (a hospital mortality of 2.7%). Seventy-nine of the 103 patients (77%) in whom follow-up was obtained achieved an excellent or good result. Results were almost identical with sphincteroplasty and sphincterotomy. Abnormal preoperative liver function tests were the only predictors of a good postoperative outcome (p less than 0.05). Group 3 patients (good results in 63%) had significantly poorer (p less than 0.05) outcome than group 1 and 2 patients. Results were worst in group 3 patients who had undergone previous abdominal or pelvic surgery (p less than 0.025) and in group 2 patients who were narcotic users (p less than 0.025). The authors conclude that transduodenal sphincteroplasty or sphincterotomy can be performed relatively safely, but caution that careful selection of patients is important when the indication for surgery is either ampullary stenosis or recurrent pancreatitis.

Multiple factors including hormonal and neural influences as well as intravascular volume, body temperature, and pharmacologic agents have been shown to influence sphincter of Oddi function. Recent studies have also suggested that mechanical or electrical stimulation of the gallbladder and the degree of gallbladder filling may affect the frequency and amplitude of sphincter of Oddi phasic contractions. However, the effect of gallbladder filling on sphincter of Oddi phasic wave direction has not previously been studied. In acute terminal experiments, eight adult male prairie dogs underwent cannulation of the gallbladder with a pressure-monitored perfusion catheter. The common bile duct was cannulated proximally with a drainage catheter and distally with a triple-lumen, side-hole, closed-tipped catheter. The distal port of this catheter was positioned in the sphincter of Oddi (SO) while the proximal port was in the distal common bile duct (CBD). Distal CBD and SO phasic wave activity was recorded first with the gallbladder perfused with lactated Ringer's solution at 0.1 ml/min (mean intragallbladder pressure 8.1 ± 0.3 mm Hg) and then with the gallbladder (GB) empty. Sphincter of Oddi phasic wave frequency was 6.7 ± 0.9/min with the GB full and 5.4 ± 0.6/min with the GB empty (P < 0.02). Phasic wave amplitude was also greater with the GB full versus empty in both the distal CBD (6.4 ± 0.6 vs 4.3 ± 0.5 mm Hg, P < 0.05) and the SO (9.5 ± 1.5 vs 6.4 ± 0.8, P = 0.075). Baseline pressures and the direction of phasic waves were unaffected by the degree of gallbladder filling. It is concluded that the degree of gallbladder filling reflexly influences sphincter of Oddi phasic wave activity and should be considered in future studies of the choledochoduodenal junction.

Recent studies have explored the influence of various hormones, peptides, and neural innervation on the sphincter of Oddi (SO). However, only older and conflicting data are available on the effect of intraduodenal (ID) perfusion of acid on SO activity. Therefore, we tested the hypothesis that acidification of the proximal small bowel would alter SO motility. In acute terminal experiments, 19 adult male prairie dogs underwent cannulation of the gallbladder (GB) with a pressure-monitored perfusion catheter. The common bile duct was cannulated proximally with a drainage catheter and distally with a triple-lumen, side-hole, closed-tip catheter with one port positioned in the SO. The duodenum was cannulated distal to the SO to allow perfusion of the proximal 30 cm of intestine with saline. SO phasic wave frequency (F), amplitude (A), and baseline pressure as well as GB pressure were measured for 40 min prior to and during ID perfusion of saline at pH 8.8, pH 6.0, or pH 2.0. A SO motility index (MI = F × A) was calculated for each 10-min period of the experiment. Infusion of saline at pH 8.8 had no effect on SO function. ID perfusion of saline at pH 6.0 reduced SO MI to 39% (P < 0.05) and 34% (P < 0.05) of control values at 20–30 and 30–40 min, respectively. ID saline at pH 2.0 reduced the SO MI to 51% (P < 0.01) and 53% of control values during the same periods. SO phasic wave frequency was similarly reduced by ID perfusion with saline at pH 6.0 (P < 0.05) and pH 2.0 (P < 0.025). SO phasic wave amplitude, baseline pressure, and GB pressure were unaffected by ID perfusion. These findings indicate that in the prairie dog duodenal acidification inhibits SO activity without affecting GB pressure. This response differs from that observed with exogenous cholecystokinin or motilin infusion but is similar to that observed with intravenous peptide YY in this species.

Neural as well as hormonal influences regulate sphincter of Oddi function. Therefore, we tested the hypothesis that truncal vagotomy alters sphincter of Oddi phasic activity and response to hormonal stimulation. Adult, male prairie dogs underwent either sham laparotomy or truncal vagotomy and pyloroplasty. Postoperatively, all animals were fed a trace-cholesterol (nonlithogenic) diet for 3 months. In acute terminal experiments the distal common bile duct was perfused with lactated Ringer's solution at 0.1 ml/min. Sphincter of Oddi (SO) phasic contractions as well as baseline resistance were recorded before and during a 30-minute intravenous infusion of 10 ng/kg/min of cholecystokinin-octapeptide (CCK-OP). Before the CCK-OP infusion, both the frequency and amplitude of SO phasic contractions were significantly greater (P < 0.01) in vagotomized animals. During CCK-OP, the frequency of SO phasic contractions remained significantly greater (P < 0.01) in the vagotomy animals. The amplitude of SO phasic contractions, however, increased significantly (P < 0.03) in response to CCK-OP only in sham animals. Vagotomized animals failed to develop any further increase in the amplitude of SO phasic contractions during CCK-OP infusion. No differences in baseline resistance were noticed between sham and vagotomized animals before or during the infusion of CCK-OP. These findings suggest that (1) vagal tone inhibits sphincter of Oddi phasic contractions, (2) vagotomy increases sphincter of Oddi phasic activity, and (3) parasympathetic denervation alters the sphincter of Oddi's response to CCK-OP. Since the sphincter of Oddi plays an important role in normal gallbladder filling and emptying, altered sphincter of Oddi function may, in part, be responsible for the gallbladder stasis observed following vagotomy.

• A variety of remedies have been suggested for patients with chronic intestinal pseudo-obstruction. However, none of these treatments have been particularly effective, and many of these patients have died of malnutrition. Therefore, in an effort to maintain nutrition and avoid repetitive nasogastric intubation, 22 patients (12 adults and ten children) with chronic intestinal pseudo-obstruction were managed with long-term total parenteral nutrition (TPN), and 20 also received a "venting" enterostomy. Only two patients had to undergo revision of their gastrostomies. Prior to referral, these 22 patients required 56 admissions for obstruction (1.2 admissions per patient-year). Since the initiation of TPN and placement of a venting enterostomy, these 22 patients required only 17 hospitalizations for obstruction in a total of 80 patient years (0.2 admissions per patient-year). We conclude that patients with chronic Intestinal pseudo-obstruction who receive TPN at home and have a venting enterostomy can be safely managed for prolonged periods and require fewer hospitalizations for obstruction. Arch Surg1985;120:614-618)

• Extracorporeal shock wave lithotripsy has received increasing attention as a possible alternative to cholecystectomy. Good data, however, are not available on what percentage of the 500 000 Americans presently undergoing cholecystectomy annually might be eligible for extracorporeal shock wave lithotripsy. Therefore, we studied 100 consecutive adult patients undergoing cholecystectomy and applied present exclusion criteria to determine their suitability for extracorporeal shock wave lithotripsy. In each patient, preoperative history and operative findings were reviewed. Gallstone size and number were recorded, and cholesterol content and radiopacity were determined. Cholesterol stones were found in 74 patients, pigment stones in 21, and acalculous cholecystitis in 5. Of the 100 patients, only 19 (19%) had no exclusion criteria and, thus, would have been eligible for extracorporeal shock wave lithotripsy. These data suggest that approximately 95 000 Americans a year will be candidates for shock wave biliary lithotripsy. ( Arch Surg . 1989;124:1195-1200)

Chronic intestinal pseudo-obstruetion is an uncommon cause of repeated obstruction in children of undetermined etiology, often leading to repeated laparotomies and early death. TPN combined with venting gastrostomy provides sufficient calories for growth and minimizes the need for Operations and/or hospitalizations. Seventeen children managed with these techniques experienced a sixfold decrease in the number of hospitalizations, and more than a tenfold decrease in the number of laparotomies for obstruction compared to the period before routine use of TPN and gastrostomies. Oral feedings are encouraged whenever possible.

CLINICALLY evident generalized graft-versus-host disease is not thought to occur as a consequence of transplantation of most solid organs. The requisite large inoculum of donor lymphoid cells and inability of the recipient to destroy these passenger cells1 are apparently rarely produced by solid-organ transplantation. However, there is a high risk of graft-versus-host disease when normal spleens are included in vascularized pancreas-transplants.2 3 4 5 We report on a case of severe generalized acute graft-versus-host disease in a recipient of a liver transplant, involving documented transient chimerism of donor origin. This life-threatening complication was treated successfully with increases in the corticosteroid dosage and the . . .

One hundred patients undergoing postoperative cholangiography had blood cultures drawn prior to and 15 minutes and six hours after cholangiography. Bile cultures obtained prior to cholangiography grew organisms in 92 of 100 patients with E. coli, Klebsiella pneumoniae and enterococcus being the bacteria most frequently isolated. Anaerobes were isolated from the bile in 21% of the patients. Nine of 83 patients (11%) not receiving antibiotics developed a bacteremia after cholangiography with organisms identical to those in the bile. All nine patients recovered without further complications of cholangiography. Those who developed a bactermia could not be distinguished from the group as a whole on the basis of age, sex, laboratory data, type of surgery or cholangiographic findings. None of the eight patients with negative bile cultures and none of 17 patients on antibiotics at the time of cholangiography experienced a bacteremia. Ninety to 93% of 304 organisms isolated from the bile were sensitive to a combination of a penicillin and an aminoglycoside. Most patients undergoing postoperative tube cholangiography do not develop a bacteremia and do not require antibiotics. Only patients with positive bile cultures who might tolerate a bacteremia poorly, and those who are febrile from cholangitis immediately prior to cholangiography should be covered with a short course of systemic antibiotics.

Several recent clinical and laboratory observations suggest that impaired gallbladder emptying is important in the pathogenesis of cholesterol cholelithiasis. However, the exact mechanism by which gallbladder stasis occurs in the majority of patients who form gallstones has not been clear. We tested the hypothesis that impaired gallbladder emptying antedates cholelithiasis and results from increased resistance to bile flow. Using the prairie dog gallstone model, resistance to flow through the cystic duct (CD) and sphincter of Oddi (SO) was measured in control and cholesterol-fed animals. Prairie dogs were fed either a control (trace cholesterol) or a 0.4% cholesterol-enriched diet known to induce gallstones in 6 weeks. Resistance across the CD and SO was measured at 4 weeks (pregallstone) and 16 weeks (gallstone). Resistance was measured by infusing lactated Ringer's solution through the CD and SO at four separate flow rates while gallbladder and distal common bile duct pressures were recorded. Resistance to flow through the cystic duct increased prior to gallstone formation and continued to increase during the 16 weeks of cholesterol feeding. In comparison, sphincter of Oddi resistance remained normal despite chronic exposure to lithogenic bile and formation of stones within the gallbladder. The increased cystic duct resistance observed prior to gallstone formation provides a mechanism for diminished gallbladder emptying and suggests an etiological role for increased cystic duct resistance in the pathogenesis of cholesterol gallstones.

Traditional management of patients with primary sclerosing cholangitis (PSC) has included steroids and/or choledochotomy plus prolonged T-tube drainage. The authors have not been convinced, however, that either of these therapies significantly influence the course of the disease. Therefore, a more aggressive surgical approach was adopted that included performance of a choledochoenteric anastomosis in all patients with PSC who had either (1) a major area of extrahepatic blockage, or (2) primary involvement of the extrahepatic bile ducts. Using this approach, 17 of 22 patients (77%) managed surgically at the UCLA Medical Center from 1974 through 1980 have undergone a choledochoenteric anastomosis. Of these 17 patients, 13 (77%) have had an excellent or good result following surgery. Four patients whose disease was confined to the common bile duct have all had excellent results (mean follow-up 49.3 months since surgery). In addition, 18 of the entire group of 22 patients (82%) are still alive, a mean of 52.2 months after operation and 64.7 months following establishment of the diagnosis. These results in 22 patients encourage the authors to continue to pursue an aggressive surgical approach for patients with primary sclerosing cholangitis.

Patients who receive long-term parenteral nutrition have an increased incidence of both calculous and acalculous cholecystitis. In an attempt to establish guidelines for the clinical management of patients with TPN-induced gallbladder disease, we have reviewed the records of 35 patients who have undergone cholecystectomy for this problem since 1976 at the UCLA Medical Center. The mean age of the 23 adult and 12 children who had cholecystectomy was 29.1 years. Forty percent of these patients required emergency cholecystectomy. The overall operative morbidity was 54 percent, and the hospital mortality was 11 percent. Significant factors contributing to this high rate of complications included a delay in diagnosis, especially in the young children, and increased operative difficulty due to extensive adhesions and intraoperative hemorrhage. Our analysis suggests that patients receiving long-term TPN should have a program of ultrasound surveillance for gallstone formation, elective cholecystectomy when stones first appear, and consideration of cholecystectomy at the time of laparotomy performed for other reasons. Whether TPN-induced gallstones can be prevented through daily stimulated gallbladder emptying awaits the results of future studies.

Dietary calcium supplementation has been recommended for prevention of osteoporosis and has become a standard component of most "health food" diets. Biliary calcium has been recognized to play a central role in the formation of pigment gallstones. We have recently demonstrated that 5 days of oral calcium supplementation significantly increases biliary calcium in the prairie dog (K. D. Lillemoe, T. H. Magnuson, G. E. Peoples, et al., Gastroenterology 94: A563, 1988). We hypothesized, therefore, that long-term oral calcium supplementation would promote pigment gallstone formation. Sixteen adult male prairie dogs were maintained on a standard nonlithogenic diet. Eight animals received calcium supplementation (2.5 x control levels) in their water, while the remaining eight animals served as controls. After 8 weeks, cholecystectomy was performed, and the common bile duct was cannulated. Bile was examined microscopically and analyzed for ionized calcium, bilirubin, glycoprotein, and biliary lipids. The cholesterol saturation index (CSI) was calculated. Pigment stones and calcium bilirubinate sludge were present in all animals receiving calcium supplementation. Only one control animal had evidence of pigment stones (P less than 0.001). Biochemical analysis of gallbladder bile demonstrated a significant increase in total bilirubin and bilirubin monoglucuronide (P less than 0.01) as well as bile glycoprotein content (P less than 0.05) after oral calcium supplementation. Gallbladder bile ionized calcium was also increased although not significantly. These data suggest that oral calcium supplementation promotes gallbladder sludge and pigment gallstone formation in the prairie dog. This observation raises concern that oral calcium supplementation, especially in the older female population, may enhance gallstone formation.

bladder bile, despite the presence of gentamicin in common-duct bile in three of these patients. Minimal abnormalities were present in tests of liver function in 14 of the 16 patients studied but did not correlate with the levels of gentamicin achieved in the bile. Bacteria have been cultured from bile in a majority of patients with acute cholecystitis or partial obstruction of the common duct and in one-third of patients with chronic cholecystitis [1]. The bacteria most commonly associated with disease of the biliary tract reflect the anaerobic and aerobic intestinal flora. Gentamicin is highly effective in vitro and in vivo against many of the gramnegative organisms isolated [2-5]. The present study was undertaken to determine the concentration of gentamicin achieved in bile in the gallbladder and common duct of patients with biliary-tract disease.

A prospective, randomized, double-blind study was carried out to determine whether vitamin C prophylaxis, 2.0 g/day, vs placebo prophylaxis would reduce the incidence or morbidity of the common cold and other respiratory illnesses in 674 marine recruits during an eight-week period. Whole-blood ascorbic acid levels measured six weeks after initiation of the study were significantly higher in the vitamin C group. There was no difference between the two groups in the incidence or duration of colds. The vitamin C group rated their colds as being less severe, but this was not reflected in different symptom complexes or in fewer sick-call visits or training days lost. This study and the literature do not support the prophylactic use of vitamin C to prevent the common cold. ( JAMA 241:908-911, 1979)