NON-SURGICAL MANAGEMENT OF GALL STONE WITH UDCA: A CASE REPORT

The patient a 66 years old adult male, hailing from Dhaka city, belonging to upper socio-economic class presented to us in May 2005 with complaints of epigastric discomfort, especially after fatty meals. He is diabetic and hypertensive. He is non-alcoholic, but smoker. He had received treatment for peptic ulcer disease for several months, without significant improvement of symptoms.


On clinical examination his abdomen was normal. Investigations show Hb 14.5 gm/dl, TC of WBC 6800, neutrophil 62%, lymphocyte 33%, monocyte 3%, eosinophil 2%, ESR 15 mm in 1st hour, serum bilirubin 0.6 mg/dl, serum ALT 21 U/L, serum alkaline phosphatase 131 U/L, fasting blood sugar 4.5 mmol/L, serum amylase 80 U/L and normal endoscopy of upper GIT. Ultrasonography of whole abdomen revealed moderately contracted gall bladder with some echodense areas 5.5-6.8 mm in diameter and smaller (Figure 1). The patient was reluctant to undergo either open or laparoscopic cholecystectomy. His repeat ultrasonography 2 months later yielded similar finding (Figure 2). As the patient declined to undergo surgery, he was advised tablet UDCA (300 mg) 1 tablet twice daily.


His follow up ultrasonography of upper abdomen in July 2006 revealed no evidence of calculus and sludge in the gall bladder. The size is normal and wall is also normal with regular thickness (Figure 3). A repeat ultrasonography of upper
 


obese individuals. It is superior to chenodeoxycholic acid for this indication.12 During treatment gallstones may undergo surface calcification, but this is probably of little significance.13 Floating stones of 5 mm or less in diameter dissolve completely in 80-90% cases in 12 months.14 Patency of cystic duct increases the chance of response.5 Larger non-floating stones take longer and may never disappear. Careful evaluation by CT scan to see the degree of calcification of stone allows avoiding inappropriate UDCA therapy.14 Minimal or no change in gall stone diameter within 6-12 months of UDCA therapy is a poor prognostic sign. After stone dissolution, UDCA should be continued for 3 more months to ensure dissolution of microscopic stones that may escape recognition at ultrasonography.5


It has been proposed that UDCA causes unsaturation of bile. This result in solubilization of cholesterol from the surface of gall stone leading ultimately to stone dissolution.5
The effect of bile acid therapy on symptoms is variable. Biliary pain is less frequent in patients who are on long term ursodeoxycholic acid therapy.15 Recurrence of gallstone occurs in 25-50% patients at a rate of 10% per year. It is most likely in the first 2 years and unlikely after the first 3 years. Recurrence is higher in those with multiple stones.14 Low dose ursodeoxycholic acid (300 mg/day) is effective in reducing the recurrence.16

FATTY LIVER

Introduction

The term non-alcoholic fatty liver disease (NAFLD) or fatty liver, as it is popularly referred to, involves a spectrum of liver diseases ranging from simple steatosis (non-alcoholic fatty liver; NAFL) at one end to non-alcoholic steatohepatitis (NASH) at the other. Histologically NASH resembles alcohol-induced liver disease in the absence of alcohol abuse.
Figure 1 : Abdominal ultrasound in May 2005 showing stones in gall bladder.
 
abdomen 2 months later confirmed the result (Figure 4). The patient was advised to continue tablet UDCA (150 mg) 1 tablet twice daily for 4 more months.

It has been shown that at a dose of 8-10 mg/kg/day, UDCA dissolves 20-30% radioluscent gallstones completely, rising to 60% with careful patient selection.11 The dose is higher for