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Impaired gallbladder motility in liver cirrhosis: yes, but …
THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 2000 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.
Vol. 95, No. 12, 2000 ISSN 0002-9270/00/$20.00 PII S0002-9270(00)02185-7
LETTERS TO THE EDITOR Impaired Gallbladder Motility in Liver Cirrhosis: Yes, But . . . TO THE EDITOR: Impaired gallbladder motility, including diminished ejection fraction, is a main pathogenic factor for gallstones (1). In liver cirrhosis, where the prevalence and incidence (2) of gallstone disease is increased, gallbladder motility is also impaired (3). Kao et al. showed in their recent paper that the ejection fraction of the gallbladder measured by cholescintigraphy is decreased in liver cirrhosis (4). This paper is technically excellent for the specialist in nuclear medicine, but a clinician may find some shortcomings in it. 1. Thus, there is no mention about the number of patients with liver cirrhosis classified in subgroups according to the severity (Child class A, B, and C). Only the total figure of patients with liver cirrhosis, n ⫽ 45, is given. It is necessary to know whether the number of patients from every subgroup is similar, in order to be sure that no sampling bias has interfered. 2. The patients have not been previously submitted to abdominal ultrasonography. Therefore, we do not know if they had silent gallstones. Patients with gallstones might have a lower ejection fraction (1) and this could also introduce a sampling bias. 3. The authors measured the ejection fraction of the gallbladder at 60 min after the test meal and this was found to be reduced in all three subgroups of patients with liver cirrhosis (Child class A, B, and C). Because the rate of gallbladder emptying is different in patients with liver cirrhosis (3), we feel that it would be more helpful to estimate the ejection fraction by ultrasound using the formula: EF ⫽ (minimal residual volume)
an interesting controversy in your journal last year (5, 6). In fact, the ultrasonographic and radioisotopic methods should be complementarily used in the assessment of biliary tract motility. Dan L. Dumitrascu, Senior Lecturer Monica Acalovschi, Professor Third Medical Department University of Medicine and Pharmacy Cluj, Romania
REFERENCES 1. Fisher RS, Stetzer F, Rock E, et al. Abnormal gallbladder emptying in patients with gallstone disease. Dig Dis Sci 1982; 27:1019 –24. 2. Sheen IS, Liaw YF. The prevalence and incidence of cholecystolithiasis in patients with chronic liver disease. A prospective study. Hepatology 1989;9:538 – 40. 3. Acalovschi M, Dumitrascu DL, Csakany I. Gastric and gallbladder emptying of a mixed meal are not coordinated in liver cirrhosis—a simultaneous sonographic study. Gut 1997;40: 412–7. 4. Kao CH, Hsieh JF, Tsai SC, et al. Evidence of impaired gallbladder function in patients with liver cirrhosis by quantitative radionuclide cholescintigraphy. Am J Gastroenterol 2000;95: 1301– 4. 5. Krishnamurty GT, Krishnamurty S. Hazards of formulating new theories about gallbladder (GB) function based on ultrasound volume data. Am J Gastroenterol 1999;94:1703– 4. 6. Pallotta N, Corazziari E, Scopinaro F, et al. . . . And dangers of clinging to old theories based on inconsistent data. Am J Gastroenterol 1999;94:1705–7.
Reprint requests and correspondence: Dan L. Dumitrascu, Medical Department, University of Medicine and Pharmacy, 3rd Str. Croitorilor 19-21, RO 3400 Cluj, Romania. Received July 6, 2000; accepted July 14, 2000.
⫻ 100/(basal volume). With this method, we found similar ejection fractions in Child class A patients and in controls (3). We would appreciate receiving supplementary information from the authors. 4. The authors are right by stating that ultrasonographic assessment of gallbladder motility requires experienced investigators and depends on the geometric shape of the gallbladder. However, when correctly used, ultrasonography provides more information on gallbladder motility than cholescintigraphy, by estimating both the emptying and refilling of the gallbladder. This topic was subject of
Response to Drs. Dumitrascu and Acalovschi TO THE EDITOR: We would like to thank Drs. Dan L. Dumitrascu and Monica Acalovschi for their comments regarding my recent paper that appeared in the journal (1). In accordance with the comments, we provide the detailed data about our patients with liver cirrhosis as follows: each group of Child class A (age: 60.7 to 70.3 yr), B (age: 60.8 to 80.0 yr), and C (age: 60.3 to 70.1 yr) included 15 patients (3 females and 12 males), respectively. Actually, each sub-
Vol. 95, No. 12, 2000 ISSN 0002-9270/00/$20.00 PII S0002-9270(00)02185-7
LETTERS TO THE EDITOR Impaired Gallbladder Motility in Liver Cirrhosis: Yes, But . . . TO THE EDITOR: Impaired gallbladder motility, including diminished ejection fraction, is a main pathogenic factor for gallstones (1). In liver cirrhosis, where the prevalence and incidence (2) of gallstone disease is increased, gallbladder motility is also impaired (3). Kao et al. showed in their recent paper that the ejection fraction of the gallbladder measured by cholescintigraphy is decreased in liver cirrhosis (4). This paper is technically excellent for the specialist in nuclear medicine, but a clinician may find some shortcomings in it. 1. Thus, there is no mention about the number of patients with liver cirrhosis classified in subgroups according to the severity (Child class A, B, and C). Only the total figure of patients with liver cirrhosis, n ⫽ 45, is given. It is necessary to know whether the number of patients from every subgroup is similar, in order to be sure that no sampling bias has interfered. 2. The patients have not been previously submitted to abdominal ultrasonography. Therefore, we do not know if they had silent gallstones. Patients with gallstones might have a lower ejection fraction (1) and this could also introduce a sampling bias. 3. The authors measured the ejection fraction of the gallbladder at 60 min after the test meal and this was found to be reduced in all three subgroups of patients with liver cirrhosis (Child class A, B, and C). Because the rate of gallbladder emptying is different in patients with liver cirrhosis (3), we feel that it would be more helpful to estimate the ejection fraction by ultrasound using the formula: EF ⫽ (minimal residual volume)
an interesting controversy in your journal last year (5, 6). In fact, the ultrasonographic and radioisotopic methods should be complementarily used in the assessment of biliary tract motility. Dan L. Dumitrascu, Senior Lecturer Monica Acalovschi, Professor Third Medical Department University of Medicine and Pharmacy Cluj, Romania
REFERENCES 1. Fisher RS, Stetzer F, Rock E, et al. Abnormal gallbladder emptying in patients with gallstone disease. Dig Dis Sci 1982; 27:1019 –24. 2. Sheen IS, Liaw YF. The prevalence and incidence of cholecystolithiasis in patients with chronic liver disease. A prospective study. Hepatology 1989;9:538 – 40. 3. Acalovschi M, Dumitrascu DL, Csakany I. Gastric and gallbladder emptying of a mixed meal are not coordinated in liver cirrhosis—a simultaneous sonographic study. Gut 1997;40: 412–7. 4. Kao CH, Hsieh JF, Tsai SC, et al. Evidence of impaired gallbladder function in patients with liver cirrhosis by quantitative radionuclide cholescintigraphy. Am J Gastroenterol 2000;95: 1301– 4. 5. Krishnamurty GT, Krishnamurty S. Hazards of formulating new theories about gallbladder (GB) function based on ultrasound volume data. Am J Gastroenterol 1999;94:1703– 4. 6. Pallotta N, Corazziari E, Scopinaro F, et al. . . . And dangers of clinging to old theories based on inconsistent data. Am J Gastroenterol 1999;94:1705–7.
Reprint requests and correspondence: Dan L. Dumitrascu, Medical Department, University of Medicine and Pharmacy, 3rd Str. Croitorilor 19-21, RO 3400 Cluj, Romania. Received July 6, 2000; accepted July 14, 2000.
⫻ 100/(basal volume). With this method, we found similar ejection fractions in Child class A patients and in controls (3). We would appreciate receiving supplementary information from the authors. 4. The authors are right by stating that ultrasonographic assessment of gallbladder motility requires experienced investigators and depends on the geometric shape of the gallbladder. However, when correctly used, ultrasonography provides more information on gallbladder motility than cholescintigraphy, by estimating both the emptying and refilling of the gallbladder. This topic was subject of
Response to Drs. Dumitrascu and Acalovschi TO THE EDITOR: We would like to thank Drs. Dan L. Dumitrascu and Monica Acalovschi for their comments regarding my recent paper that appeared in the journal (1). In accordance with the comments, we provide the detailed data about our patients with liver cirrhosis as follows: each group of Child class A (age: 60.7 to 70.3 yr), B (age: 60.8 to 80.0 yr), and C (age: 60.3 to 70.1 yr) included 15 patients (3 females and 12 males), respectively. Actually, each sub-