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10 20 30 40 50 Bile salt secretion [mmol - kg-1- h-1]

(after G. Paumgartner et al.)

10 20 30 40 50 Bile salt secretion [mmol - kg-1- h-1]

(after G. Paumgartner et al.)

The gallbladder, in which the specific bile components (Ch, BS, Pch) are concentrated many times over by withdrawal of water, also plays an important part (^ D) in the formation of gallstones (cholelithiasis after cho-lecystectomy is rare). Disorders of gallbladder emptying can be among the causes, either due to insufficient CCK being liberated (lack of free fatty acid [FFA] release in the lumen in pancreatic insufficiency), so that the main stimulus for gallbladder contraction is weakened, or because after nonselective va-gotomy the second most important contraction signal, acetylcholine, is absent. Gallbladder contraction is also weakened in pregnancy. This means that not only occasional or absent emptying (see above) but also incomplete emptying increases the duration for which bile remains in the gallbladder. As a result, there is enough time for the precipitated crystals to form large concrements. A raised mucus secretion (stimulated by prostaglan-dins) can thus lead to an increased number of nuclei of crystallization.

Possible consequences of cholelithiasis are (^ E):

4 Colic. When the cystic duct or the common bile duct is transiently blocked by a stone, pressure rises in the bile ducts and increased peristaltic contraction in the region of the blockage causes severe visceral pain in the epigastric area, possibly with radiation into the back, as well as vomiting (^ p. 140).

4 In acute cholecystitis fever and leukocytosis are added to the symptoms listed above. Important causes are trauma to the gallbladder epithelium caused by stones. Prostaglan-dins are liberated from the gallbladder epithelium in addition to phospholipase A2. The latter splits phosphatidylcholine to lysoleci-thin (i.e., removal of the fatty acid at C2), which in turn brings about acute cholecystitis. In some circumstances it may lead to gallbladder perforation.

♦ Bacterial cholangitis usually occurs when bile flow is stopped because of cholelithiasis. A rise in pressure with dilation of the bile ducts is the result, and posthepatic cholestasis and biliary pancreatitis may also develop.

♦ In relatively rare cases gallbladder cancer develops on the basis of gallstone disease.

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