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Increased Gall Bladder Volume in Primary Sclerosing Cholangitis Gut: First Published As 10.1136/Gut.39.4.594 on 1 October 1996

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Increased Gall Bladder Volume in Primary Sclerosing Cholangitis Gut: First Published As 10.1136/Gut.39.4.594 on 1 October 1996 594 Gut 1996; 39: 594-599 Increased gall bladder volume in primary sclerosing cholangitis Gut: first published as 10.1136/gut.39.4.594 on 1 October 1996. Downloaded from P C van de Meeberg, P Portincasa, F H J Wolfhagen, K J van Erpecum, G P VanBerge-Henegouwen Abstract the typical beading appearance of the biliary Background-The diagnosis of primary tree on endoscopic retrograde cholangiography sclerosing cholangitis (PSC) requires in- (ERC). Most early stage patients are asympto- vasive procedures such as liver biopsy and matic and present only with raised liver endoscopic retrograde cholangiography enzymes during routine blood tests.1 The (ERC). Sonographic measurement of prevailing reluctance to perform a liver biopsy fasting gall bladder volume, which has and ERC in asymptomatic patients is under- been reported to be enlarged in PSC, standable in view of the morbidity and could serve as a non-invasive screening mortality from these procedures.2 3 Therefore, test. the diagnosis ofPSC is often suspected without Methods-Fasting gall bladder volume being confirmed. Recently, it has been shown was studied in patients with PSC (n=24), that the hydrophilic bile salt ursodeoxycholic primary biliary cirrhosis (PBC, n=13), acid (UDCA) has beneficial effects on clinical, liver cirrhosis due to other causes (n=18), biochemical, and histological parameters of ulcerative colitis (n=15), and healthy con- PSC.`6 In primary biliary cirrhosis (PBC), trols (n=23). Meal induced gall bladder another cholestatic liver disease, progression is emptying was studied in patients with slowed and the need for liver transplantation is PSC, patients with PBC, and healthy reduced in patients treated with UDCA.7 controls. These promising results suggest that early Results-In patients with PSC gall treatment, requiring an early diagnosis, is bladder volume was greatly enlarged (72.9 important. In this regard, a non-invasive (SEM 3.7) ml) compared with healthy method to detect patients at risk for PSC, controls (25.4 (1.7) ml, and patients with especially among patients with ulcerative colitis PBC (30.9 (2.7) ml), liver cirrhosis (31.3 of whom about 5% develop PSC, would be of (4.0) ml) or ulcerative colitis (25.8 (2.0) considerable value. http://gut.bmj.com/ ml) (p<00005 v all). In four patients with In a preliminary study, we reported that the PSC the gall bladder wall was irregularly fasting gall bladder volume is enlarged in thickened (>4 mm) as previously de- patients with PSC.8 Although a few studies scribed in PSC. Postprandial residual have reported on gall bladder and cystic duct fractions (% offasting volume) were com- involvement in PSC, gall bladder enlargement parable between patients with PSC (17.5 has never been described.9'-3 Wondering (3.7)%) and those with PBC (23.6 (7.1%) whether sonographic measurement of gall on September 27, 2021 by guest. Protected copyright. and healthy controls (12.7 (2.3)%) bladder volume could serve as a non-invasive Although gall bladder emptying seems screening test for PSC, we examined gall in bladder in Department of normal, increased biliary pressure volume patients with PSC. Healthy Gastroenterology, patients with PSC cannot be excluded. persons, patients with PBC, patients with liver University Hospital Conclusion-Apart from wall thickening, cirrhosis due to other causes, and patients with Utrecht, Utrecht, patients with PSC often present with en- ulcerative colitis with normal liver bio- The Netherlands P C van de Meeberg largement of the gall bladder. Sono- chemistry were studied as controls. In P Portincasa graphic determination of fasting gail addition, gall bladder emptying in response to K J van Erpecum bladder volume may be a useful, non- a meal was studied in patients with PSC or G P VanBerge- Henegouwen invasive, and easy to perform tool in the PBC and healthy controls. evaluation of patients suspected of having Institute of Clinica PSC. Medica I, University Medical School, Bari, (Gut 1996; 39: 594-599) Methods Italy Fasting gall bladder volume was measured in P Portincasa Keywords: gall bladder, primary sclerosing cholangitis, 24 patients with PSC (median age 37, range cholestasis, ulcerative colitis, ultrasonography. Department of 18-49 years; men:women 17:7, body mass Internal Medicine II, index (BMI) 23-9 (SD 0.6)). Sixteen patients Dijkzigt University (67%) had concomitant inflammatory bowel Hospital, Rotterdam, The Netherlands Primary sclerosing cholangitis (PSC) is a rare disease (14 ulcerative colitis, two Crohn's F H J Wolfhagen chronic liver disease of unknown aetiology, disease). Bile duct lesions were found both Correspondence to: characterised by fibrosing strictures of the proximal and distal to the cystic duct in 14 Dr P C van de Meeberg, intrahepatic and extrahepatic bile ducts and (58%) patients whereas only proximal lesions Department of Gastroenterology, progressive liver dysfunction. In 70% of cases were found in seven (29%) patients on ERC. University Hospital Utrecht, the disease is associated with ulcerative colitis In three patients attempts to perform ERC PO Box 85500, 3508 GA Utrecht, The Netherlands. and, less often, with Crohn's disease. The were unsuccessful. Liver biopsies were per- Accepted for publication diagnosis is based on typical histological formed in all patients and were compatible 16 April 1996 findings (onion skin lesions) in liver tissue and with PSC in all. All patients had biochemical Increased gall bladder volume in primary sclerosing cholangitis 595 signs of cholestasis as reflected by a serum ute intervals the maximum longitudinal and alkaline phosphatase or y-glutamyl transpepti- transversal (height and width) dimensions were dase concentration >150%, the upper level of measured three times and the longitudinal normal, but none of the patients had overt perimeter of the gall bladder encircled with a jaundice during the study (Table). According caliper. The volume of the gall bladder was Gut: first published as 10.1136/gut.39.4.594 on 1 October 1996. Downloaded from to Ludwig et al 19 patients (79%) had early calculated with built in software according to stage disease (stage I or II), five patients (21%) the sum of cylinders method.'6 Fasting gall had late stage disease (stage III, n=3; stage IV, bladder volume was the mean of these three n=2).' Only one patient had portal hyper- measurements. The sum of cylinders method tension (varices and splenomegaly). Twenty estimates gall bladder volume more accurately three healthy subjects (median age 31, range than the ellipsoid'7 and area-length methods'8 24-57 years; men:women 17:6, BMI 22.4 (SD and has recently been validated in vivo.'9 0.5) were studied as controls. Also studied Postprandial gall bladder emptying was were 15 patients with ulcerative colitis with determined in patients with PSC (except those normal liver biochemistry (ulcerative colitis with thickening (>0 4 mm) of the gall bladder controls, median age 35, range 22-57 years; wall), patients with PBC, and healthy controls men:women 10:5, BMI 24 (SD 0.6), 13 after ingestion of a mixed meal (2815 kJ, 35 g patients with PBC (median age 50, range fat) containing an egg, one slice of bread with 37-71 years; men:women 4:9, BMI 25.9 (SD cheese, sweetened yogurt, and a cup of tea. 1.1); all with positive antimitochondrial anti- Subsequently, gall bladder volume was bodies) including two patients with cirrhosis measured every 10 minutes during two hours. and portal hypertension and 18 patients The smallest postprandial volume was con- (median age 52, range 26-70 years; sidered to be the residual volume. men:women 9:9, BMI 24.1 (SD 0.7) with liver The protocol was approved by the ethics cirrhosis of other aetiology (alcohol misuse, committee of the University Hospital Utrecht n=4; autoimmune hepatitis, n=3; hepatitis B, where all examinations were performed. n=2; hepatitis C, n=6; cryptogenic, n=3). Nine Informed consent was obtained from each (50%) patients with liver cirrhosis had signs of patient. portal hypertension (ascites or varices). Liver biochemistry was comparable between patients with PSC and those with PBC; however, in the DATA ANALYSIS group of patients with liver cirrhosis of differ- Data are presented as means (SEM). For data ent aetiology some had normal liver enzymes not normally distributed, median and range are (Table). None of the patients with PSC and given and log transformation was used. ulcerative colitis control patients had active Statistical analysis of fasting and residual gall colitis at the time of the study. Patients with bladder volumes was performed by analysis of http://gut.bmj.com/ PSC were matched with ulcerative colitis variance (ANOVA) and confirmed with control patients regarding the extent of the Fisher's least significance difference test; colitis. Colectomised patients were excluded. p<005 was considered significant. Multiple One ulcerative colitis control and two patients regression analysis was used to compare fasting with PBC proved to have gall stones. No other gall bladder volumes with biochemical disease controls and none of the healthy variables. subjects or patients with PSC had gall stones. on September 27, 2021 by guest. Protected copyright. Since gall bladder volume can be increased during UDCA'4 and decreased during choles- Results tyramine'5 treatment, these drugs were inter- rupted at least one month before the study. In FASTING GALL BLADDER VOLUME a separate study we found only trace amounts Fasting gall bladder volume in patients with of UDCA (<2% of total bile salts) in duodenal PSC was enlarged more than twofold (72.9 bile samples one month after interrupting (13.7) ml, median 55.6 ml, range 15-4-324-7 UDCA treatment in five patients with PSC ml) compared with healthy controls (25.4 (1 7) participating in a dose finding study (un- ml), patients with PBC (30.9 (2.7) ml), liver published data).
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