Biliary stones may be classified according to their chemical composition (cholesterol stones and non-cholesterol stones) or according to their anatomical location (stones in the gallbladder and stones in the biliary tree).
About 80% of the gallbladder stones are cholesterol stones. These stones are in principle amenable to dissolution using oral bile acids or direct applications of solvents (methyl-tert-butyl ether, MTBE). Contrary to this only about one third of stones in the biliary tree are cholesterol stones, one third mixed stones and one third pure pigment stones (mostly brown pigment stones). Ideal solvents for pigment stones have not yet been developed.
Only about one third of gallbladder stones eventual leads to biliary related symptoms (mostly biliary colics). Two thirds remain silent". Death related to gallbladder stones is a rare event and in 90% of patients complicated gallbladder stone disease is preceded by biliary colics. Therefore, treatment of gallbladder stones is only required in symptomatic patients. With bile duct stones, however, the natural history is much less favourable. Most individuals are elderly high risk patients and there is general agreement that patients with stones in the biliary tree should receive an active treatment irrespective of symptoms.

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We studied the origin (or nature) of a non-dilated (or stenotic) portion of common bile duct in a patient with congenital biliary dilatation (C. B. D. ). In a control case with a branch fusion type of ventral and dorsal pancreatic ducts, the upper branch of ventral pancreatic duct was situated in the ventral pancreas based on the distribution of PP cells, whereas the lower branch was located in the dorsal pancreas. In a patient with C. B. D. the non-dilated portion of common bile duct (or the upper branch of ventral pancreatic duct) was only situated in the ventral pancreas similar to that of control case. In addition, a duct from the pancreatic lobule was found in the non-dilated portion.
Therefore, the non-dilated (or stenotic) portion in a patient with C. B. D. was identified to be the ventral pancretic duct.

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To investigate the role of the gallbladder in cholesterol gallstone formation, the gallbladder in lithogenic diet-fed male golden hamsters was morphologically studied with histological, histochemical and cell kinetic methods.
As compared with control group, the gallbladder in experimental group showed its dilatation in size without changes of the epithelial cells. In the middle phase the epithelial cells showed an increased secretion of glycoprotein with occasional appearance of crypts and goblet cells. In the late phase the crypts and foldings of the epithelium more increased in number. No changes of histochemical quality of glycoprotein of the epithelium in the course of the gallstone formation was observed. Cell kinetic study using anti-BrdU monoclonal antibody revealed that labeling index of the epithelium in experimental group increased significantly before gallstone formation.
This study suggests that the gallbladder may play a contributory role such as mucus secretion in cholesterol gallstone formation.

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Clinical and pathological characteristics of primary carcinoma of the cystic duct were studied comparing to those of primary carcinoma of the gallbladder and extrahepatic bile duct. Incidence of co-existing gallstone (13.3%) and male to female ratio (1: 0.2) of the cystic duct carcinoma closely resembled to those of bile duct carcinoma. Acute acalculous cholecystitis was the typical clinical manifestation of cystic duct carcinoma in its early stage, while advanced carcinoma always showed obstructive jaundice due to invasion to the extrahepatic bile duct. Mode of direct extension of cystic duct carcinoma, ie, diffuse invasion into the hepato-duodenal ligament was similar to bile duct carcinoma. On the other hand, pattern of lymph node metastasis resembled to that of carcinoma of the gallbladder. Cumulative 3-year survival rate of cystic duct carcinoma after resection was only 9.1%. For differential diagnosis, it seemed essential to detect morphological change of the cystic duct by means of both direct cholangiography (ERC or PTC) and cholecystography (PTCCG).

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Promoting effect of pre- or co-existing cholangitic lesion on occurence of cholangiocarcinoma induced by DIPN was evaluated in hamsters. DIPN,250 mg/kg (B. W. ), was administrated subcutaneously once a week for 20 consecutive weeks to the hamsters. Lithocholic acid (LCA),25 mg/day was administrated orally five days a week until autopsy. LCA produced cholestatic and inflammatory changes of the intrahepatic bile ducts. Cholangiocarcinoma was produced by DIPN injection and its earlier and more multiple occurence was significantly facilinated by additional administration of LCA.

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The effects in 15 surgical cases of glyceryl Trinitrate (GTN), a new relaxant of the sphincter of Oddi, on biliary function were examined. The sphincter of Oddi was to be completely relaxed and biliary pressure decreased after direct infusion of GTN into the common bile duct. We attempted to eliminate gallstones in patients with residual stones and choledocholithiasis by perfusion of saline solution containing GTN (10 mg) into the common bile duct while using a biliary drainage tube. In 3 of 4 cases, gallstones were eliminated from the biliary tract. No side effects, such as abdominal pain and decreased blood pressure, were observed. Since this treatment can be performed safely and repeatedly, we believe that it is a useful method in the management of common bile duct stones in patients with biliary drainage.

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We studied how gallstones were disintegrated by water?bath?free micro?explosive extracorporeal shock wave lithotripter to assess the appropriate number of shock wave focusings for clinical use. A human gallastone installed in the model gallbladder filled with 50 ml of saline was set at the second focus and revelaed to shock waves repeatedly. Pure cholesterol stones and radiolucent mixed stones,10∼23 mm in diameter, needed 120∼150 more shocks to be broken in fine pieces after initial destruction. In the case of radiolucnet mixed stones, number of focusings before initial destruction depended on length of their diameter. Black stones and radiopaque mixed stones were able to be finely disintegrated, but fragments with calcified surface remained larger, which may cause such gallstones to be difficult to achieve perfect disappearance after extracorporeal shock wave lithotripsy sessions. Calcium bilirubinate stones had poor efficiency for disintegration by shock waves.

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Beween 1987 and 1990, ERCCE was performed in 14 patients with cholecystitis Male to female was 9 to 5. Averaged age was 67 years old. Diagnosis was made by clinical symptom and ultrasonographic and endoscopic ultrasonograhic findings. In 7 patients cause of acute cholecystitis was cholecytolitiasis and in remaining 7, stone was not found in the gallbladder. First, preshaped catehter (5-6. 5 Fr) was inserted into the gallbladder via the papilla of Vater, common bile duct and cystic duct. And then the gide wire was inserted into the gallbladder through preshaped catheter. Last of all, 7.2 Fr endoprosthesis was introduced by mean of a catheter exchanging method. In 9 patients symptom of acute cholecystitis were suicided.8 in those patients had improvement of thickening of the gallbladder wall on ultrasonogram. In 6 patients sludge in the gallbladder was disappeared. This procedure is non-invasive and effective for the treatment of cholecystitis.

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A 72 year-old woman was admitted to our hospital because of back pain due to compression fracture of the 8th thoracic spine. On the 34th hospital day she complained epigastric pain. Ultrasonogram revealed hypoechoic elevated lesions of gallbladder. ERCP and endoscopic ultrasonogram also demontrated protruded lesion of the Gallbladder. These findings suggested advanced gallbladder cancer, and extended cholecystectomy was performed.
Macroscopic finding of the resected gallbladder showed green elevated lesions with normal surrounding mucosa. Gallbladder stone was not present. Microscopic study disclosed the elevated lesions consisting of garnulation tissue and necrosis. Few cases of acute acalculous cholecystitis with mucosal elevation have been reported and attention should be payed for differential diagnosis from advanced gallbladder cancer.

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We reported a 50-year-old female with jaundice and positive shadows in the upper abdominal cavity on a plain X-ray film. The patient had been free of symptoms excluding this episode of jaundice. The stones were impacted in the common hepatic duct and in the intrahepatic bile ducts of the lateral, the medial and the posterior segment. Although any narrow segment of the bile duct was not demonstrated, the common bile duct showed normal calibre and the bile duct proximal to the common hepatic ducts did cystic dilatation. Left hepatic lobectomy and resection of the extrahepatic bile duct was performed, Ultrared analysis of the stones showed that main component parts were calcium carbonate with slight amount of bile pigment. From her clinical course and the characteristics of the stones, it was implies that she had congenital dilatation of the intrahepatic bile duct with intrahepatic cholestasis.

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This report describes 3 cases of primary sclerosing cholangitis (PSC). Case 1, a 52 yearold woman, developed an elevation of serum alkaline phophatase, and was diagnosed as PSC by endoscopic retrograde cholangiography (ERC). In this patient, ulcertive colitis was accompanied and died of colon cancer, with peritonitis carcinomatosa,5 years after the diagnosis of PSC. Case 2, a 22 year-old woman, visited our hospital because of jaundice and disorder of liver function. The diagnosis of PSC and eosinophilic colitis was made during her admission in our hospital. In spite of occasional development of eosinophilia which is unrelated to her symptoms or other laboratory data, she is still following-up and treated at our outpatient clinics. The onset of symptom, case 3, a 29 year-old woman, was progressive jaundice. The diagnosis of PSC was made by percutaneous transhepatic cholangiography (FTC), and the drainage failed to improved her repeating cholangitis. She died of liver failure 15 months after the diagnosis.

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A case of congenital biliary dilatation connected with Santorini's duct is presented. A 56year-old female was admitted to our hospital for the further examination of biliary tract recommended by a home doctor. Congenital biliary dilatation with stones was diagnosed by ERCP and US. Wirsungography revealed Santorini's duct connected with dilatated biliary tract by a connecting duct.
In the pancrcaticography from the accessory papilla, the bile duct was demonstrated through the connecting duct from Santorini's duct, followed by Wirsung's duct. Annomalous union of pancreaticobiliary duct has been thought embryologically to arise from malformation of ventral pancreas and biliary tract before fusion of ventral and dorsal pancreas.
In this theory, Santorini's duct cannot be connected with choledocal cyst with annomalous union of pancreaticobiliary duct. From the point of view, the connecting duct in our case may be inferred to be not a part of Santorini's duct but a terminal portion of elongated Wirsung's duct.

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A 48-year-old man was admitted to our hospital complaining of fever and right hypochondralgia. US showed dilated CBD and swelling of gallbladder with strong echo. ERCP revealed anomalous insertion of common bile duct into the pancreatic duct with fusiform dilatation of the bile duct and clover-like deformity of the dilated bile duct. Endoscopic retrograde biliary double contrast study was performed. It showed the presence of a shallow depression with mucosal convergence of the dilated bile duct. Group of adenocarcinoma cells was obtained from bile via nasobiliary catheter. Resected specimen with pancreatoduodenectomy showed a 2.0×3.5 cm sized papillary adenocarcinoma like a IIa + IIc lesion. Biliary double contrast radiography is recommended for a detection of a small bile duct cancer via nasobiliary catheter.

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A 28-year-old female was admitted to our hospital complaining of right hypochondralgia, nausea and vomiting. Abdominal ultrasonography, computed tomography and endoscopic retrograde cholangiopancreatography led us to a suspected diagnosis of intrahepatic bile duct stones in the left lateral segment of the liver, and the lateral segment hepatectomy was proposed. However, no stone was found in the resected liver. Further intraoperative examination by echogram and palpation revealed the stones in the caudate lobe. Then, the caudate lobe hepatectomy was additionally carried out. In the resected caudate lobe, two dilated intrahepatic bile ducts and fifteen cholesterol stones were seen. Some cases of intrahepatic bile duct stones in the caudate lobe were reported but all the cases were accompanied with stones in other region of the liver. This is a very rare case report of intrahepatic bile duct stones localized only in the caudate lobe.

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A 79-year-old man was admitted to our hospital suffering from abdominal pain. Abdominal US and CT revealed features of acute cholecystitis and a large elevated lesion in the fundus of the gallbladder. Cholangioscopy after PTCCD showed this tumor occupying the gallbladder to have a whitish surface with partial hemorrhage. Biopsied specimens were histologically diagnosed as adenocarcinoma. Celiac angiography demonstrated a marked increase in the number and caliber of cystic arteries in the area of the tumor. Extended cholecystectomy was performed. Macroscopically the resected tumor presented as a peducnculated polyp, measuring 65×30×30mm, with a smooth, multinodular surface, and a solid and whitish cut section.
Histopathology revealed the tumor to be composed of a mixture of spindle cell sarcoma and well differentiated adenocarcinoma elements. The sarcomatous component demonstrated stromal character on immunohistochemical analysis, but epithelial character on electron microscopic study. Therefore, the possibility of gallbladder carcinoma transformation to sarcoma was noted. This case may prove of assistance in elucidating the occurrence of carcinosarcoma.

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This paper describes a case of huge gallstones discharged into stomach through cholecystduodenal fistula, and successful removal of these stones by endoscopic electrohydraulic lithotripsy (EEHL) and endoscopic mechanical lithotripsy (EML) for prevetation of gallstone ileus.
A 60-year old woman was admitted with epigastric pain and nausea. An uppergastrointestinal tract examination demonstorated backward flow of contorast medium from duodenal bulb into gallbladder. Endoscopic examination revealed a large fistula (about 1 cm in diameter) on the anterior wall of duodenal bulb, and two brown stones (about 3 cm in diameter) in a mucus pool of stomach. In order to prevent from gallstone ileus, revoval of these gallstones was attempted endoscopically, using a basket cathether on the first hospital day, but they were too large to pass through the cardia. Then, they were brocken into some pieces by EEHL, crushed into smaller pieces by EML, and extirpated orally. Chemical analysis showed that 98% and more of this gallstone was consisted of cholesterol. The patient was discharged home one month after removal of gallstone and has since been asymptomatic.

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A 78-year-old woman admitted to our hospital complaining of nausea and vomitting and was diagnosed as intestinal obstruction. Emergency laparatomy was performed and revealed obstruction of the ileum due to a conglomerate of gallstones through cholecystduodenal fistula. The conglomerate was 4.5×3×3cm in size and composed of 10 mixed gallstones. Evcry stone was connected with the substance of same components as the mixed stones and a conglomerate was formed.

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A 61 year-old male was admitted to our hospital for further evaluation of jaundice. Percutaneous transhepatic cholangiography (PTC) revealed a severe stenosis of hilar bile ducts. In spite of percutaneous transhepatic biliary drainage (PTBD) into the left hepatic duct and the right anterior bile duct, total bilirubin level gradually increased. PTBD into the left medial bile duct and the right posteior bile duct was additionally performed two weeks after the 1st PTBD. Thereafter total bilirubin level decreased slowly but surely, and extended left hepatic lobectomy with total caudate lobectomy was done 57 days after the 2nd PTBD. The resected tumor was invasive type carcinoma originated from the left hepatic duct, and histopathological study showed moderately differentiated adenocarcinoma with paraaortic lymphnode metastasis.
The introduction of a PTBD catheter into each isolated bile duct is necessary as far as possible in malignant hepatic hilar obstruction, for the purpose of prevention of cholangitis, efficacy of decompression, and accurate diagnosis of extension of carcinoma.

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