Biliary lipid secretion in cholesterol gallstone disease. The effect of cholecystectomy and obesity

Abstract

Cholesterol gallstone disease is initiated in a liver which produces abnormal bile with excess cholesterol relative to bile salts and phospholipid. To define the responsible secretory mechanism(s), the rate of biliary lipid secretion was measured by a duodenal marker perfusion technique, while the bile salt pool was simultaneously estimated by isotope dilution. Two groups of controls expected to have normal biliary composition compsition (14 subjects without hepatobiliary disease and 6 patients with pigment gallstones, were compared to 2 experimental groups expected to have abnormal bile), 10 nonobese patients with cholesterol gallstones and 7 obese subjects without gallstones. Both control groups had nearly identical biliary lipid secretion rates, and corresponding low relative molar concentration of cholesterol. Two different secretory mechanisms were responsible for the abnormal bile in the experimental groups. In the nonobese patients with cholesterol gallstones, bile salt and phospholipid secretion rates were both significantly reduced. Conversely, the grossly obese subjects had an increased cholesterol secretion. To determine how cholecystectomy improves biliary lipid composition, 3 groups of gallstone patients (6 with pigment stones, 4 grossly obese with cholesterol stones, and 13 nonobese with cholesterol stones) were all examined after full recovery from surgery. In the nonobese patients with cholesterol gallstones, both bile salt and phospholipid secretion significantly increased, causing a definite improvement in bile composition. Cholecystectomy produced a similar but less marked trend in the obese patients with cholesterol stones, and in the patients with pigment stones. Cholesterol secretion, however, was unaffected by surgery. The bile salt pool was definitely small in the nonobese patients with cholesterol gallstones and became slightly smaller after cholecystectomy. The pool was significantly reduced by cholecystectomy in the patients with pigment stones and also in the obese patients with cholesterol gallstones. Removal of the gallbladder in all 3 groups caused a greater fraction of the pool to cycle around the enterohepatic circulation each hour. This more rapid cycling produced the increase in bile salt and phospholipid secretion, and was responsible for the improved composition found after cholecystectomy.