Effect of Colectomy on Bile Composition, Cholesterol Crystal Formation, and Gallstones in Patients With Ulcerative Colitis
P. R. C. HARVEY, PH.D., M.D., R. S. McLEOD, M.D., F.R.C.S.(C), Z. COHEN, M.D., F.R.C.S.(C), and S. M. STRASBERG, M.D., F.R.C.S.(C) From the Samuel Lunenfield Research Institute and the Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
Bile composition and the presence of cholesterol crystals in bile were studied in bile samples obtained at the time of surgery in patients with ulcerative colitis. Some patients were sampled before colectomy and others at a second operation months to years after a colectomy. Patients in the precolectomy group were found to have bile composition similar to control patients without gallstones, and few had crystals in their bile. In the postcolectomy group, cholesterol concentrations were very high, all biles were supersaturated, and almost all patients had cholesterol crystals in their bile. These findings are similar to those found in persons with cholesterol gallstones. Twenty patients have been followed for at least 3 years after colectomy and to date three have formed cholesterol gallstones.
to gallstones. To do this gallbladder bile composition and crystal observation time of patients with ulcerative colitis were examined in samples obtained at the time of surgery. Patients then were followed to determine if any formed gallstones. Methods
T n HE CRYSTAL OBSERVATION time (or nucleation time) is a test used to determine the rapidity of cholesterol crystal formation in bile. Bile from patients with cholesterol gallstones usually exhibits rapid crystallization in 1 to 2 days." 2 Most biles from patients without cholesterol gallstones have longer crystal observation times, but occasionally rapid nucleation is seen in the absence of gallstones. Recently we reported a group of such patients without gallstones, but with rapidly nucleating bile.3 We noted that a number of these patients previously had had a colectomy for ulcerative colitis. Furthermore two patients under our care formed gallstones after colon surgery for ulcerative colitis. Formation of gallstones after colectomy in ulcerative colitis has been
described.4 The purpose of this study was to determine whether ulcerative colitis or colectomy in patients with this disease produced changes in bile composition that predisposed these patients to crystal formation and perhaps ultimately Presented at the 11 1th Annual Meeting of the American Surgical Association, April 1 1-13, 1991, Boca Raton, Florida. Supported by a grant from the Medical Research Council of Canada, MA 4491. Dr. Harvey is an Ontario Ministry of Health Scholar. Address reprint requests to Dr. S. M. Strasberg, Suite 1225, 600 University Ave., Toronto, Canada M5G 1 X5. Accepted for publication April 23, 1991.
Bile Collection Gallbladder bile was collected from 28 patients during elective surgery for ulcerative colitis. Seventeen patients were admitted for elective surgery and had no previous surgery on the digestive tract. At surgery 11 had colectomy, 4 had colectomy and pelvic pouch construction, and 2 had colectomy and Kock pouch construction. This group is referred to as the precolectomy group. A postcolectomy group consisted of 11 patients who had had subtotal colectomy 5 months to 14 years previously; six of these had colectomy between 5 months and 1 year before sampling, and five had the procedure more than 3 years before sampling. At the time of admission, 2 of the 11 had a Kock pouch, one had a pelvic pouch, and the remainder had conventional ileostomy. Eight of the eleven were admitted for conversion from conventional ileostomy to pelvic pouch (7 patients) or Kock pouch (1 patient), two for revision of Kock pouch, and one for excision of a pelvic pouch. Only very small lengths of ileum, (1-4 cm) were resected in any patient. Preoperative ultrasound examinations were done in all 28 patients, and none had cholelithiasis. Bile samples were obtained at the start of surgery. The technique of bile sampling for normal gallbladders recently has been described in detail.' Briefly a 22-gauge needle was advanced under the gallbladder serosa for 1
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EFFECT OF COLECTOMY ON BILE COMPOSITION IN PATIENTS WITH ULCERATIVE COLITIS
cm before puncturing the mucosa to enter the gallbladder. This is done to create a self-sealing tunnel in the gallbladder wall. The bile was aspirated as completely as possible using gentle gallbladder compression to facilitate this. Procedures were approved by the Human Ethics Committee of the University of Toronto. Written informed consent was obtained before bile collection.
Follow-up Studies
Twenty of twenty-eight patients (9 men and 11 women) were examined by abdominal ultrasound from September 1990 to January 1991 at least 36 months after bile sampling. The others either could not be contacted or they refused.
90
E
397
300
75
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0 L-
-
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-.
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0 0
45
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0 v 0. ._
0. co 0
0 FIG. 1. Bile salt, phospholipid and cholesterol concentrations, and CSI in patients with ulcerative colitis. The precolectomy group in each comparison is shown on the left. Results for postcolectomy patients are shown on the right. Open symbols indicate that the particular sample contained cholesterol
0C
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0
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100
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0
0
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Post
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P. R. C. HARVEY, PH.D., M.D., R. S. McLEOD, M.D., F.R.C.S.(C), Z. COHEN, M.D., F.R.C.S.(C), and S. M. STRASBERG, M.D., F.R.C.S.(C) From the Samuel Lunenfield Research Institute and the Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
Bile composition and the presence of cholesterol crystals in bile were studied in bile samples obtained at the time of surgery in patients with ulcerative colitis. Some patients were sampled before colectomy and others at a second operation months to years after a colectomy. Patients in the precolectomy group were found to have bile composition similar to control patients without gallstones, and few had crystals in their bile. In the postcolectomy group, cholesterol concentrations were very high, all biles were supersaturated, and almost all patients had cholesterol crystals in their bile. These findings are similar to those found in persons with cholesterol gallstones. Twenty patients have been followed for at least 3 years after colectomy and to date three have formed cholesterol gallstones.
to gallstones. To do this gallbladder bile composition and crystal observation time of patients with ulcerative colitis were examined in samples obtained at the time of surgery. Patients then were followed to determine if any formed gallstones. Methods
T n HE CRYSTAL OBSERVATION time (or nucleation time) is a test used to determine the rapidity of cholesterol crystal formation in bile. Bile from patients with cholesterol gallstones usually exhibits rapid crystallization in 1 to 2 days." 2 Most biles from patients without cholesterol gallstones have longer crystal observation times, but occasionally rapid nucleation is seen in the absence of gallstones. Recently we reported a group of such patients without gallstones, but with rapidly nucleating bile.3 We noted that a number of these patients previously had had a colectomy for ulcerative colitis. Furthermore two patients under our care formed gallstones after colon surgery for ulcerative colitis. Formation of gallstones after colectomy in ulcerative colitis has been
described.4 The purpose of this study was to determine whether ulcerative colitis or colectomy in patients with this disease produced changes in bile composition that predisposed these patients to crystal formation and perhaps ultimately Presented at the 11 1th Annual Meeting of the American Surgical Association, April 1 1-13, 1991, Boca Raton, Florida. Supported by a grant from the Medical Research Council of Canada, MA 4491. Dr. Harvey is an Ontario Ministry of Health Scholar. Address reprint requests to Dr. S. M. Strasberg, Suite 1225, 600 University Ave., Toronto, Canada M5G 1 X5. Accepted for publication April 23, 1991.
Bile Collection Gallbladder bile was collected from 28 patients during elective surgery for ulcerative colitis. Seventeen patients were admitted for elective surgery and had no previous surgery on the digestive tract. At surgery 11 had colectomy, 4 had colectomy and pelvic pouch construction, and 2 had colectomy and Kock pouch construction. This group is referred to as the precolectomy group. A postcolectomy group consisted of 11 patients who had had subtotal colectomy 5 months to 14 years previously; six of these had colectomy between 5 months and 1 year before sampling, and five had the procedure more than 3 years before sampling. At the time of admission, 2 of the 11 had a Kock pouch, one had a pelvic pouch, and the remainder had conventional ileostomy. Eight of the eleven were admitted for conversion from conventional ileostomy to pelvic pouch (7 patients) or Kock pouch (1 patient), two for revision of Kock pouch, and one for excision of a pelvic pouch. Only very small lengths of ileum, (1-4 cm) were resected in any patient. Preoperative ultrasound examinations were done in all 28 patients, and none had cholelithiasis. Bile samples were obtained at the start of surgery. The technique of bile sampling for normal gallbladders recently has been described in detail.' Briefly a 22-gauge needle was advanced under the gallbladder serosa for 1
396
Vol. 214 - No.4
EFFECT OF COLECTOMY ON BILE COMPOSITION IN PATIENTS WITH ULCERATIVE COLITIS
cm before puncturing the mucosa to enter the gallbladder. This is done to create a self-sealing tunnel in the gallbladder wall. The bile was aspirated as completely as possible using gentle gallbladder compression to facilitate this. Procedures were approved by the Human Ethics Committee of the University of Toronto. Written informed consent was obtained before bile collection.
Follow-up Studies
Twenty of twenty-eight patients (9 men and 11 women) were examined by abdominal ultrasound from September 1990 to January 1991 at least 36 months after bile sampling. The others either could not be contacted or they refused.
90
E
397
300
75
iE
60
5 I-
0 L-
-
co
-.
200
4.
0 0
45
cn U
0 v 0. ._
0. co 0
0 FIG. 1. Bile salt, phospholipid and cholesterol concentrations, and CSI in patients with ulcerative colitis. The precolectomy group in each comparison is shown on the left. Results for postcolectomy patients are shown on the right. Open symbols indicate that the particular sample contained cholesterol
0C
0
0
30
100
CD U)
._
m
15
a.
0
0
Pre
Post
Pre
40
2.0
crystals.
Post
-Y0
x E 0 ._
a)
30
C
1.5
p
