J.Jpn. Surg. Soc.. 58(9): 1424-1449, 1957

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PATHOGENESIS OF THE SO-CALLED "STONELESS CHOLELITHIASIS"

It is well known that in the clinic, there are seen cases with complaints, and symptoms and pathological changes resembling cholelithiasis, despite there being no gall-stone according to clinical and operative findings.
The nature of the so-called "stoneless cholelithiasis" is still indistinct.
A hypothesis has been presented that "stoneless cholelithiasis" really exists, judging from the chemical character and bacteriology of the bile.
Some investigators oppose this. The author had the chance to examine histologically gall-bladders of cases of so-called "stoneless cholelithiasis". Investigations were made of the differences between cholelithiasis with and without stone, and a study was made of the nature of the so-called "stoneless cholelithiasis". The following are the results obtained.
(1) The author observed with the naked eye gall-bladders of 33 cases of so-called typical "stoneless cholelithiasis ", in whose gall-bladders, despite the symptoms of cholelithiasis, no gall-stones were macroscopically seen, or found and, moreover, no grain like sand. Histological preparations from the fundus, corpus and neck parts of these gall-bladders were made.
(2) The macroscopic findings of these gall-bladders showed in general, the state of a thickened cholecystitis with characters resembling '' stone cholelithiasis '', though there were some differences in degree between the two, but no qualitative differences were found between them at all. In stoneless cholelithiasis, however, the gall-bladder showed partial thickening histologically, less than in stone cholelithiasis.
Compared with gall-bladder of stone cholelithiasis, in which, ulcer, erosion and sometimes necrotic changes are observed on the mucous membrane, in stoneless cholelithiasis, homogeneous findings are mostly found on the mucous membrane.
(3) Regarding the changes in villi of the mucous membrane, some showed extension, some shortening and some hypertrophy papilliferously. In some cases, the top of villi was necrotic. Generally, at the top of the villi, infiltration by many cells was seen and in the bottom of the mucous membrane, infiltration was relatively less found, as well as infiltration of cells in case, the mucous membrane atrophied intensively and became fibrous. The types of infiltrative cells were mainly lymphocytes and plasmacells, and acidophil leucocytes were found here and there. Oftere, there were seen the findings of chronic inflammation changing into an acute one.
(4) The muscle layer of the mucous membrane showed partial hypertrophy and proliferation, and appeared undulatory. The neighboring tissues, on the contrary, showed atrophy. In most cases, the layer showed unequal arrangement. In stone cholelithiasis, these phenomena are relatively rare and all showed hypertrophy and proliferation.
(5) Changes in muscle layer were generally of two forms. In aone, the muscle hypertrophied and proliferated. In the other, the muscle fibers were atrophied, and between them, fibrous tissues were substituted for connective tissues. Most cases belonged to the former and only a few to the latter. The 2nd form is acase in which granulation tissue or scar are formed in the muscle layer. The serous membrane, whether they are cases with or without stone, showed hypertrophy and hyalinization.
(6) Luschka's crypts were observed in a high percentage and distinctly in stone cholelithiasis, but, in stoneless cholelithiasis, few of these crypts were seen, sometimes, in the neck part of the gall-bladder. Luschka's crypts are, as shown in the literature, result of the development of mucosal epithelium in different places following chronic cholecystitis.
(7) In tissues of the mucous membrane, basophil granules, different from Russell's bodies, are observed. Their nuclei are large and vary to some degree. These granules exist in the mucous membrane only. They are not always related to proliferation of connective tissue, but also are found in the infiltrative part. The author investigated for their free state in the gall-bladder, but could not observe them.
(8) Hemorrhage is rarely seen in the mucous membrane. Some plasmacells are visible among the infiltrative cells.
(9) The fact that, in so-called "stoneless cholelithiasis ", basophil granula, that is, fine lime-granules are seen in the mucous membrane, resembles that of "stone cholelithiasis''. But there were more of these and the rate of detection is higher in the former than the latter.
These facts are of significance, for discussing the nature of stoneless cholelithiasis.
(10) Although, in stoneless cholelithiasis, gall-stones and gall-sands are not demonstrated with the naked eye, many fine lime-granules are observed histologically. These granules always appear in bile and furthermore chonic cholecystitis is always found. Hence, we may assert that so-called "stoneless cholelithiasis" is a form of real cholelithiasis, even though no stone can be detected. The difference between cholelithiasis with and without stone, should be made, only by whether macroscopical stone exists or not. In the former, large stone to some degree is produced, but the latter showed only microscopical billiary stones. Between the two diseases, there is a type of cholecystitis due to fine granula, billiary sand. These three are considered to form a series of gall-bladder diseases of the same nature. Stoneless cholelithiasis is not a resuit of gall-ston formation mechanism caused by impairment of metabolism, but can be explained to be a type of inflammatory stone formation. By this explanation, the histological findings of the muscularis mucosae and muscle layer an asily be convinced. Luschka's crypts are phenomena caused by stimulation of relatively large stones, but in this disiease, these crypts are found rather rarely. This fact shows fully the true nature of the above-mentioned conception.
(author's abstract)

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