Gastrointest Radiol 4, 265-267 (1979) Gastrointestinal Radiology

Spontaneous Disappearance of Gallstones

Thomas R. Liebermann Division of Gastroenterology, Scott and White Clinic, Temple, Texas, USA

Abstract. A case of spontaneous disappearance of gallstones in a 55-year-old woman is presented. Exam- ination of biliary lipids after the stones had disap- peared revealed supersaturated bile with cholesterol. This suggests that the stones migrated from the gall- bladder to the small intestine via the biliary ductal system.

Key words: Gallstones Oral cholecystography Biliary tract Bile chemistry.

Spontaneous disappearance of gallstones is an inter- esting event of unknown frequency important in view of the current interest in dissolving gallstones by ad- ministering bile acids [1 3].

Case Report

A 55-year-old woman was originally seen in March 1973 because of weight loss, weakness, and fatigue. One year previously, she had undergone a vagotomy with pyloroplasty and a diaphragmatic hernia repair a t an outside institution. Diffuse cramping, abdomi- nal pain, diarrhea, and a 32-pound weight loss ensued postopera- tively. Two mon ths prior to coming here she was told that her gallbladder showed multiple radiolucent stones. Physical examina- tion revealed a thin woman who had an apical systolic click. Exami- nation was otherwise unremarkable.

Laboratory evaluation at that time found the hemoglobin and hematocri t values to be 13.5 g/dl and 40ml/dl , respectively. T4 was 12.1 gg/dl; T3 was 38.7% with an index of 0.97. T4 uptake was 7% at 6 hours and 9.8% at 24 hours. Five-hour urinary D-xylose was 8.8 g with a volume of 906 ml. Proctosigmoidoscopic examination was normal. Upper GI series revealed evidence of a pyloroplasty deformity; small bowel series was normal. Barium enema study was normal. Oral cholecystogram showed innumer- able nonopaque stones (Fig. 1).

Address reprint requests to." T.R. Liebermann, M.D., Scott and White Clinic, 2401 South Thirty-First Street, Temple, TX 76501, USA

Table 1. Lipid analysis of bile sample

Chemical compound Molecular % mg/50 ml

Cholesterol 6.1 17.8 Phospholipid 15.7 92.55 Bile acids 78.2 295.01 % saturation" 65.6 Hegard t -Dam index 1.15

Admirand and Small [11]

Table 2. Individual bile acids

Acid Molecular %

Cholic 35.6 Deoxycholic 24.0 Chenodeoxycholic 38.8 Lithocholic 1.0 Ursodeoxycholic 0.7

She was dismissed with the diagnosis of postpyloroplasty and postvagotomy diarrhea, and asymptomatic cholelithiasis and ad- vised to go on a high-residue diet, which the patient failed to follow. She was seen in follow-up 10 months later. The diarrhea had decreased and her weight had increased by about 11 pounds. Her next follow-up visit occurred 3 years later. Two weeks prior to her visit, she experienced an episode of slight upper abdominal pain with radiation to the back. She had also experienced some episodic pain around the left abdomen. A follow-up oral cholecys- togram (Fig. 2) demonstrated disappearance of the gallstones. Ta- bles 1 and 2 show values of biliary lipids obtained after duodenal intubation and st imulation of the gallbladder with cholecystokinin.

Discussion

The spontaneous disappearance of gallstones has been described previously [4-10]. Its mechanism is uncer- tain and three possibilities exist: (a)passage of the gallstones to the duodenal lumen from a fistulous

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266 T.R. Liebermann: Spontaneous Disappearance of Gallstones

Fig. 1. Oral cholecystogram. (A) Supine view showing many radio- lucent gallstones. (B) Decubitus view with layering of radiolucent stones

Fig. 2. Supine (A) and decubitus (B) views of oral cholecystogram demonstrating disappearance of the stones

communication between the gallbladder and the small intestine, (b) spontaneous dissolution of the stones, and (c) spontaneous passage of the stones into the duodenum through the biliary ductal system.

Gallstones may disappear from the gallbladder by eroding the gallbladder wall passing into the duode- num through a fistula. The clinical and radiographic findings of this condition are characteristic and we do not believe they apply to our patient [4].

Gallstones usually occur in individuals whose bile is supersaturated with cholesterol. Bile acids and phospholipids are major determinants of cholesterol

solubility in bile because of their capacity to form mixed micelles. In 1968 Admirand and Small [11] presented data for the limits of cholesterol solubility in systems which contained these three components and plotted these in a triangular phase diagram and demonstrated the limited zone of cholesterol solubil- ity. Mixtures whose composition lay outside this zone would contain crystalline material present as a sepa- rate phase or should eventually precipitate. Since this report, it has become apparent that the physicochem- istry of cholesterol solubility is more complex than Admirand and Small envisioned. In determining the

T.R. Liebermann: Spontaneous Disappearance of Gallstones 267

line of maximum cholesterol solubility, these investi- gators used relatively short equilibration times and sought the presence of relatively large crystals. He- gardt and Dam [12], employing longer periods of equilibration and microfiltration to isolate cholesterol crystals, found that maximum cholesterol solubility is less than originally proposed.

Currently, the Hegardt-Dam index is the accepted indicator of biliary lithogenicity; values greater than 1.0 are meant to imply biliary supersaturation (i.e., lithogenicity). Our patient had an index of 1.15 after the stones had disappeared from the gallbladder sug- gesting that dissolution probably had not occurred as desaturation of bile is necessary before stones dissolve [3]. In order to achieve dissolution, investigators have administered chenodeoxycholic acid or ursodeoxy- cholic acid as a therapeutic agent [2, 3]. In addition, our patient's individual bile acid analysis was normal, an unusual proportion of chenodeoxycholic acid or ursodeoxycholic acid was not present, as one might speculate that a proportional increase of one of these bile acids might cause stone dissolution.

The most likely explanation for the disappearance of the calculi is their passage from gallbladder into the biliary ductal system and into the proximal small bowel. Finding calculi in feces, vomitus, or stomach in the absence of fistula formation has been advanced as evidence that stones enter the bowel spontaneously [13]. Stones have been found in the stool of patients after acute pancreatitis induced by stones [14]. Schem- bra [13] reported that calculi were seen to pass pain- lessly into the bowel under radiographic observation. In our case, the stones were small enough that they could have passed through the biliary ductal system with slight or no discomfort.

Autofragmentation of gallstones along their fis- sures with subsequent passage into the duodenum has been observed and may explain the spontaneous disappearance of larger stones [15].

References

1. Hoffman AF, Thistle JL, Klein PD, Szczepanik TA, Yu PYS: Chenotherapy for gallstone dissolution. II. Induced changes in bile composition and gallstone response. JA MA 239: 1138 1144, 1978

2. McKino I, Shinosaki K: Dissolution of cholesterol gallstones by ursodeoxycholic acid. Jpn J Gastroenterol 72:690-705, 1975

3. Connell JL: Spontaneous disappearance of gall-stones. MF Aust 2.956-957, 1963

4. Zatzkin HR, Tugendhaft RT, Curran HP: Roentgen diagnosis of spontaneous internal biliary fistulas and gallstone ileus. Surg Gynecol Obstet 102.'234~38, 1956

5. Ortmayer M, Austin M : Passage of gallstones through sphinc- ter of Oddi. Am J Dig Dis 5:411-413, 1938

6. Redlich FH: Uber einen Fall mit inter vitam nachgewiesenem intragastralen Gallenstein ohne Perforationsgeschehen. Fortschr Geb R6ntgenstr Nuclearmed 89:116 118, 1958

7. Arcomano JP, Schwinger HN, DeAngelis J: The spontaneous disappearance of gall stones. Am J Roentgenol 99.'637-641, 1967

8. Ochsner SF, Giesen AF: Problem of disappearing gallstones: another case of spontaneous disappearance on cholecystog- raphy. Am J Roentgenol Radium Ther Nuclear Med 83 : 831-834, 1960

9. Ochsner SF: Disappearing gallstones: lesson in management of patients with gallstones. Am J Surg 99:336 338, 1960

10. Gardner AMN, Holden WS, Monks PJW: Disappearing gallstones. Br J Surg 53.'114 120, 1966

11. Admirand WH, Small DM : The physicochemical basis of cho- lesterol gallstone formation in man. J Clin Invest 47." 1043-1052, 1968

I2. Hegardt FG, Dam H: The solubility of cholesterol in aqueous solutions of bile salts and lecithin. Z Ernaehrungswiss 10: 223-233, 1971

13. Schembra FW: Spontaner Gallensteinabgang im R6ntgenbild. Arztl Wochenschr 13:895-899, 1958

14. Richards P: Spontaneous migration of gallstones. N Engl J Med 266:299-300, 1962

15. Meyers MA, O'Donohue N: The Mercedes-Benz sign: Insight into the dynamics of formation and disappearance of gallstones. Am J Roentgenol 119.'63, 1973

Acknowledgement. I wish to thank Dr. Scott Grundy for kindly Received." November 27, 1978," accepted after revision: performing the biliary lipid determinations. January 15, 1979