Choleretic Agents

CHOLERETIC AGENTS, choleretica, cholagoga. The composition of preparations recommended as choleretics includes both substances that are choleretics in the direct sense and substances that have a primarily auxiliary choleretic value, such as laxatives, antiseptics, antispasmodics, and others. Brugsch and Horsters distinguish choleretica and cholagoga. Choleretica are substances that increase the production of bile by liver cells, while cholagogues are substances that act on the muscular apparatus of the biliary passages, exciting their peristalsis. It is difficult to strictly separate choleretic agents into these two groups, as many substances act simultaneously as choleretica and cholagogues. Ramond, Borcesco, and Zizine, based on clinical studies using a duodenal probe, divide choleretic agents into three groups according to the predominance of one effect or the other. 1. Cholecystokinetic, i.e., those that primarily enhance the peristalsis of the gallbladder and bile ducts. 2. True choleretics (cholagoga vera, or, according to the terminology of Brugsch and Horsters, choleretica), which excite bile secretion. 3. Hepatic water-givers, or bile diluents, which increase the amount of bile secreted primarily by increasing the water content in it. - Choleretica. Most authors recognize that bile itself, the bile acid compounds cholic, deoxycholic, and dehydrocholic acids, as well as atophan and its compounds, increase the production of bile by liver cells. Cholagogues include pituitary preparations, magnesium sulfate, sodium sulfate, fatty milk, egg yolk, olive oil, oleic acid, pepsin, and HCl. Pituitary preparations probably act directly on the musculature of the biliary passages. As for the mechanism of action of the other cholagogues mentioned above, the opinion of most authors is that these substances, upon contact with the mucosa of the duodenum, cause a reflex contraction of the musculature of the gallbladder and bile ducts and relaxation of the Oddi sphincter, thereby increasing the discharge of bile into the duodenum. However, according to the data of Ramond, Borcesco, Zizine, and others, these substances also partly enhance bile secretion. Magnesium sulfate causes the discharge of gallbladder bile only when introduced into the duodenum in a concentrated solution (10–33%); a good reflex choleretic was a 60% solution of grape sugar. According to Ramond, Borcesco, and Zizine, glycerin, sodium salicylate, aspirin, and Vichy water are choleretics and bile diluents; bull bile (Fel Tauri inspissatum) and evonimin are only choleretics; sodium sulfate, sodium bicarbonate, and sodium phosphate are only mild bile diluents. Steinmetzer, based on his experimental studies on dogs, concluded that the most powerful choleretics are: salicylic acid, then peppermint oil, chloral hydrate, atophan, camphor, menthol, Natr. oleinicum, Natr. benzoicum, and quinine. Weaker acting are: Karlbad salt, sodium sulfate, rhubarb, calomel, HCl, turpentine, aloe, and morphine. Laxatives as choleretics. The question of the choleretic action of laxatives, such as aloe, podophyllin, jalap, and others, is not fully elucidated; nevertheless, many preparations recommended as cholagogues include laxative substances. The benefit of laxatives in diseases of the liver and biliary passages can be thought to be based primarily on the fact that laxatives, by enhancing intestinal peristalsis, eliminate constipation, reduce the reverse absorption of bile into the blood by the intestine, and increase the amount of bile constituents discharged from the intestine. Some choleretics contain antiseptics: urea compounds, tripaflavin, silver compounds, and others. Although these agents are not choleretics in the direct sense, by acting antiseptically and anti-catarrhally on the bile passages, they can substantially assist the action of choleretic agents when disinfection of the bile passages is necessary. This same group (auxiliary antiseptics) should also include essential oils, which possess to some extent a direct choleretic action. The role of agents that exert an antispasmodic and analgesic action (atropine group, papaverine, Perichol, morphine group, etc.) is also played by those that facilitate the action of cholagogues. Application of choleretic agents. In view of the fact that many questions concerning choleretic agents are not sufficiently developed and that choleretic agents are controversial in terms of the mechanism of their action and the possibility of exciting bile secretion in a diseased liver cell, one must always pay the main attention to a gentle regimen for the liver cell in diseases of the liver. Generally, choleretics (bile acid compounds, atophan) are prescribed primarily in cases of weakened bile formation. The use of bile acids is contraindicated in the cholemic complex. Cholagogues are prescribed primarily in cases of bile retention in the gallbladder and ducts. In cases of persistent mechanical obstruction of the biliary passages, it is necessary to resort to operative intervention. Choleretic agents are administered both per os into the stomach and directly into the duodenum (e.g., magnesium sulfate, oil, bile). The following preparations belong either to one of the above groups or represent combinations and mixtures of substances of different groups. The prescription of one or another preparation depends on the nature and symptoms of the disease. The following preparations are used in cholelithiasis, cholecystitis, cholangitis, and jaundice. Agobilin - tablets of strontium bile acid and salicylic acid and phenolphthalein diacetate; orally, two times a day, 2 tablets. Atophan - 0.5 g, three to six times a day, preferably in the form of water-soluble Atophan-natrium. Bilagit - tablets of the sodium salt of bile acids, peppermint oil, phenolphthalein, urea, novotropin, and papaverine; 1 tablet orally 2-3 times a day. Btlival - pills with 0.15 g of the sodium salt of lecithincholic acid; 3 times a day orally, 1-4 pills. Cholel'lavin - a mixture of tripaflavin, papaverine, podophyllin, and peppermint oil; orally, 2 pills 3 times a day before meals. Cholelysin - consists mainly of oleinic sodium with the addition of 1% oil of Menthae. Cholelysinum liquid. (20% solution of eina-trol) orally 1/4-1 teaspoon 3 times a day; Cholelysinum siccum (tablets) orally 1-2 tablets 3 times a day. Choleval - brown-black powder containing 10% colloidal silver with bile acid sodium; intravenously, 10 cc of a 1-2% solution; tablets of 0.25 and 0.5 orally. Chologen - a mixture of calomel with podophyllin, camphor, caraway, and melissa; orally, 1 tablet two to three times a day. Decholin - sodium dehydrocholic acid, a powder easily soluble in water; intravenously daily 5-15 cc of a 5% solution; ampoules of 10 cc (5-20% solution), tablets of 0.25; orally 2-4 times a day, 2 tablets. Dega-lol - deoxycholanic acid, a colorless crystalline powder; 3 times a day, 1-2 tablets of 0.1. Durand's mixture - 1 part of turpentine oil and 4 parts of ether; 10-20 drops orally several times a day. Euna-trol - oleinic sodium, a yellowish-white powder; 0.25-1.0 g two times a day in pills (1-4 pills per dose). Evonymin - evonimin, a glycoside from the bark of Evonymus atropurpurea, a strong laxative and choleretic; orally, 0.03-0.1-0.2 g in pills with Belladonna extract. Felamin - bile acid hexamethylenetetramine; orally, 0.3 g three times a day in tablets. Fel Tauri depura-tum siccum - 0.3-0.5 g orally in pills. Gallophysin - a solution of 0.5 g Atophan-natrium with the addition of an anesthetic substance and pituitary extract; ampoules of 5 cc. Ictero-san - ampoules of 5 cc of a 10% aqueous solution of Atophan-natrium with 0.16% p-Eucain; intravenously or intramuscularly 1-2 ampoules daily. Natr. glycocholicum - 0.2-0.3 g orally in pessaries or capsules. Oleum olivarum - 1-2 tablespoonsful orally several times a day or in the form of an emulsion. t Ovogal, ovogal - a protein compound of tauro- and glycocholic acids, a greenish-yellow powder, almost odorless; orally, 3-4 times a day, 0.5 g in gelatin capsules or pessaries. Sapo medicatus - up to 1.0 g several times a day, orally in pills (or solution).