Causes associated with recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography: A large sample sized retrospective study
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摘要
BACKGROUND Recurrence of primary choledocholithiasis commonly occurs after complete removal of stones by therapeutic endoscopic retrograde cholangiopancreatography(ERCP). The potential causes of the recurrence of choledocholithiasis after ERCP are unclear.AIM To analyze the potential causes of the recurrence of choledocholithiasis after ERCP.METHODS The ERCP database of our medical center for the period between January 2007 and January 2016 was retrospectively reviewed, and information regarding eligible patients who had choledocholithiasis recurrence was collected. A 1:1 case-control study was performed for this investigation. Data including general characteristics of the patients, past medical history, ERCP-related factors,common bile duct(CBD)-related factors, laboratory indicators, and treatment was analyzed by univariate and multivariate logistic regression analysis and KaplanMeier analysisly.RESULTS First recurrence of choledocholithiasis occurred in 477 patients; among these patients, the second and several instance(≥ 3 times) recurrence rates were 19.5%and 44.07%, respectively. The average time to first choledocholithiasis recurrence was 21.65 mo. A total of 477 patients who did not have recurrence were selected as a control group. Multivariate logistic regression analysis showed that age > 65 years(odds ratio [OR] = 1.556; P = 0.018), combined history of choledocholithotomy(OR = 2.458; P < 0.01), endoscopic papillary balloon dilation(OR = 5.679; P = 0.000), endoscopic sphincterotomy(OR = 3.463; P = 0.000), CBD stent implantation(OR = 5.780; P = 0.000), multiple ERCP procedures(≥2; OR =2.75; P = 0.000), stones in the intrahepatic bile duct(OR = 2.308; P = 0.000),periampullary diverticula(OR = 1.627; P < 0.01), choledocholithiasis diameter ≥10 mm(OR = 1.599; P < 0.01), bile duct-duodenal fistula(OR = 2.69; P < 0.05),combined biliary tract infections(OR = 1.057; P < 0.01), and no preoperative antibiotic use(OR = 0.528; P < 0.01) were independent risk factors for the recurrence of choledocholithiasis after ERCP.CONCLUSION Patient age greater than 65 years is an independent risk factor for the development of recurrent choledocholithiasis following ERCP, as is history of biliary surgeries, measures during ERCP, and prevention of postoperative complications.
BACKGROUND Recurrence of primary choledocholithiasis commonly occurs after complete removal of stones by therapeutic endoscopic retrograde cholangiopancreatography(ERCP). The potential causes of the recurrence of choledocholithiasis after ERCP are unclear.AIM To analyze the potential causes of the recurrence of choledocholithiasis after ERCP.METHODS The ERCP database of our medical center for the period between January 2007 and January 2016 was retrospectively reviewed, and information regarding eligible patients who had choledocholithiasis recurrence was collected. A 1:1 case-control study was performed for this investigation. Data including general characteristics of the patients, past medical history, ERCP-related factors,common bile duct(CBD)-related factors, laboratory indicators, and treatment was analyzed by univariate and multivariate logistic regression analysis and KaplanMeier analysisly.RESULTS First recurrence of choledocholithiasis occurred in 477 patients; among these patients, the second and several instance(≥ 3 times) recurrence rates were 19.5%and 44.07%, respectively. The average time to first choledocholithiasis recurrence was 21.65 mo. A total of 477 patients who did not have recurrence were selected as a control group. Multivariate logistic regression analysis showed that age > 65 years(odds ratio [OR] = 1.556; P = 0.018), combined history of choledocholithotomy(OR = 2.458; P < 0.01), endoscopic papillary balloon dilation(OR = 5.679; P = 0.000), endoscopic sphincterotomy(OR = 3.463; P = 0.000), CBD stent implantation(OR = 5.780; P = 0.000), multiple ERCP procedures(≥2; OR =2.75; P = 0.000), stones in the intrahepatic bile duct(OR = 2.308; P = 0.000),periampullary diverticula(OR = 1.627; P < 0.01), choledocholithiasis diameter ≥10 mm(OR = 1.599; P < 0.01), bile duct-duodenal fistula(OR = 2.69; P < 0.05),combined biliary tract infections(OR = 1.057; P < 0.01), and no preoperative antibiotic use(OR = 0.528; P < 0.01) were independent risk factors for the recurrence of choledocholithiasis after ERCP.CONCLUSION Patient age greater than 65 years is an independent risk factor for the development of recurrent choledocholithiasis following ERCP, as is history of biliary surgeries, measures during ERCP, and prevention of postoperative complications.
BACKGROUND Recurrence of primary choledocholithiasis commonly occurs after complete removal of stones by therapeutic endoscopic retrograde cholangiopancreatography(ERCP). The potential causes of the recurrence of choledocholithiasis after ERCP are unclear.AIM To analyze the potential causes of the recurrence of choledocholithiasis after ERCP.METHODS The ERCP database of our medical center for the period between January 2007 and January 2016 was retrospectively reviewed, and information regarding eligible patients who had choledocholithiasis recurrence was collected. A 1:1 case-control study was performed for this investigation. Data including general characteristics of the patients, past medical history, ERCP-related factors,common bile duct(CBD)-related factors, laboratory indicators, and treatment was analyzed by univariate and multivariate logistic regression analysis and KaplanMeier analysisly.RESULTS First recurrence of choledocholithiasis occurred in 477 patients; among these patients, the second and several instance(≥ 3 times) recurrence rates were 19.5%and 44.07%, respectively. The average time to first choledocholithiasis recurrence was 21.65 mo. A total of 477 patients who did not have recurrence were selected as a control group. Multivariate logistic regression analysis showed that age > 65 years(odds ratio [OR] = 1.556; P = 0.018), combined history of choledocholithotomy(OR = 2.458; P < 0.01), endoscopic papillary balloon dilation(OR = 5.679; P = 0.000), endoscopic sphincterotomy(OR = 3.463; P = 0.000), CBD stent implantation(OR = 5.780; P = 0.000), multiple ERCP procedures(≥2; OR =2.75; P = 0.000), stones in the intrahepatic bile duct(OR = 2.308; P = 0.000),periampullary diverticula(OR = 1.627; P < 0.01), choledocholithiasis diameter ≥10 mm(OR = 1.599; P < 0.01), bile duct-duodenal fistula(OR = 2.69; P < 0.05),combined biliary tract infections(OR = 1.057; P < 0.01), and no preoperative antibiotic use(OR = 0.528; P < 0.01) were independent risk factors for the recurrence of choledocholithiasis after ERCP.CONCLUSION Patient age greater than 65 years is an independent risk factor for the development of recurrent choledocholithiasis following ERCP, as is history of biliary surgeries, measures during ERCP, and prevention of postoperative complications.
引文
1 Ando T,Tsuyuguchi T,Okugawa T,Saito M,Ishihara T,Yamaguchi T,Saisho H.Risk factors for recurrent bile duct stones after endoscopic papillotomy.Gut 2003;52:116-121[PMID:12477771 DOI:10.1136/gut.52.1.116]
2 Kim DI,Kim MH,Lee SK,Seo DW,Choi WB,Lee SS,Park HJ,Joo YH,Yoo KS,Kim HJ,Min YI.Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy.Gastrointest Endosc 2001;54:42-48[PMID:11427840 DOI:10.1067/mge.2001.115335]
3 Sugiyama M,Atomi Y.Risk factors predictive of late complications after endoscopic sphincterotomy for bile duct stones:long-term(more than 10 years)follow-up study.Am J Gastroenterol 2002;97:2763-2767[PMID:12425545 DOI:10.1111/j.1572-0241.2002.07019.x]
4 Keizman D,Ish Shalom M,Konikoff FM.Recurrent symptomatic common bile duct stones after endoscopic stone extraction in elderly patients.Gastrointest Endosc 2006;64:60-65[PMID:16813804DOI:10.1016/j.gie.2006.01.022]
5 Kim KY,Han J,Kim HG,Kim BS,Jung JT,Kwon JG,Kim EY,Lee CH.Late Complications and Stone Recurrence Rates after Bile Duct Stone Removal by Endoscopic Sphincterotomy and Large Balloon Dilation are Similar to Those after Endoscopic Sphincterotomy Alone.Clin Endosc 2013;46:637-642[PMID:24340257 DOI:10.5946/ce.2013.46.6.637]
6 Kim KH,Rhu JH,Kim TN.Recurrence of bile duct stones after endoscopic papillary large balloon dilation combined with limited sphincterotomy:long-term follow-up study.Gut Liver 2012;6:107-112[PMID:22375179 DOI:10.5009/gnl.2012.6.1.107]
7 Kim JH,Kim YS,Kim DK,Ha MS,Lee YJ,Lee JJ,Lee SJ,Won IS,Ku YS,Kim YS,Kim JH.Shortterm Clinical Outcomes Based on Risk Factors of Recurrence after Removing Common Bile Duct Stones with Endoscopic Papillary Large Balloon Dilatation.Clin Endosc 2011;44:123-128[PMID:22741123DOI:10.5946/ce.2011.44.2.123]
8 Song ME,Chung MJ,Lee DJ,Oh TG,Park JY,Bang S,Park SW,Song SY,Chung JB.Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea.Yonsei Med J2016;57:132-137[PMID:26632393 DOI:10.3349/ymj.2016.57.1.132]
9 Strnad P,von Figura G,Gruss R,Jareis KM,Stiehl A,Kulaksiz H.Oblique bile duct predisposes to the recurrence of bile duct stones.PLoS One 2013;8:e54601[PMID:23365676 DOI:10.1371/journal.pone.0054601]
10 Park BK,Seo JH,Jeon HH,Choi JW,Won SY,Cho YS,Lee CK,Park H,Kim DW.A nationwide population-based study of common bile duct stone recurrence after endoscopic stone removal in Korea.JGastroenterol 2018;53:670-678[PMID:29192348 DOI:10.1007/s00535-017-1419-x]
11 Fritz E,Kirchgatterer A,Hubner D,Aschl G,Hinterreiter M,Stadler B,Knoflach P.ERCP is safe and effective in patients 80 years of age and older compared with younger patients.Gastrointest Endosc 2006;64:899-905[PMID:17140895 DOI:10.1016/j.gie.2006.05.010]
12 Almadi MA,Barkun JS,Barkun AN.Management of suspected stones in the common bile duct.CMAJ2012;184:884-892[PMID:22508980 DOI:10.1503/cmaj.110896]
13 Yin Z,Xu K,Sun J,Zhang J,Xiao Z,Wang J,Niu H,Zhao Q,Lin S,Li Y.Is the end of the T-tube drainage era in laparoscopic choledochotomy for common bile duct stones is coming?A systematic review and meta-analysis.Ann Surg 2013;257:54-66[PMID:23059495 DOI:10.1097/SLA.0b013e318268314b]
14 Lu Y,Wu JC,Liu L,Bie LK,Gong B.Short-term and long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones.Eur J Gastroenterol Hepatol 2014;26:1367-1373[PMID:25264985 DOI:10.1097/MEG.0000000000000218]
15 Yasuda I,Fujita N,Maguchi H,Hasebe O,Igarashi Y,Murakami A,Mukai H,Fujii T,Yamao K,Maeshiro K,Tada T,Tsujino T,Komatsu Y.Long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones.Gastrointest Endosc 2010;72:1185-1191[PMID:20869711 DOI:10.1016/j.gie.2010.07.006]
16 Baek YH,Kim HJ,Park JH,Park DI,Cho YK,Sohn CI,Jeon WK,Kim BI.[Risk factors for recurrent bile duct stones after endoscopic clearance of common bile duct stones].Korean J Gastroenterol 2009;54:36-41[PMID:19696548 DOI:10.4166/kjg.2009.54.1.36]
17 Bergman JJ,Rauws EA,Tijssen JG,Tytgat GN,Huibregtse K.Biliary endoprostheses in elderly patients with endoscopically irretrievable common bile duct stones:report on 117 patients.Gastrointest Endosc1995;42:195-201[PMID:7498682 DOI:10.1016/S0016-5107(95)70091-9]
18 Chopra KB,Peters RA,O'Toole PA,Williams SG,Gimson AE,Lombard MG,Westaby D.Randomised study of endoscopic biliary endoprosthesis versus duct clearance for bileduct stones in high-risk patients.Lancet 1996;348:791-793[PMID:8813987 DOI:10.1016/S0140-6736(96)06316-7]
19 Lee KM,Paik CN,Chung WC,Kim JD,Lee CR,Yang JM.Risk factors for cholecystectomy in patients with gallbladder stones after endoscopic clearance of common bile duct stones.Surg Endosc 2009;23:1713-1719[PMID:19118432 DOI:10.1007/s00464-008-0269-2]
20 Zoepf T,Zoepf DS,Arnold JC,Benz C,Riemann JF.The relationship between juxtapapillary duodenal diverticula and disorders of the biliopancreatic system:analysis of 350 patients.Gastrointest Endosc 2001;54:56-61[PMID:11427842 DOI:10.1067/mge.2001.115334]
21 Tzeng JJ,Lai KH,Peng NJ,Lo GH,Lin CK,Chan HH,Hsu PI,Cheng JS,Wang EM.Influence of juxtapapillary diverticulum on hepatic clearance in patients after endoscopic sphincterotomy.JGastroenterol Hepatol 2005;20:772-776[PMID:15853993 DOI:10.1111/j.1440-1746.2005.03782.x]
22 Tsai TJ,Lai KH,Lin CK,Chan HH,Wang EM,Tsai WL,Cheng JS,Yu HC,Chen WC,Hsu PI.Role of endoscopic papillary balloon dilation in patients with recurrent bile duct stones after endoscopic sphincterotomy.J Chin Med Assoc 2015;78:56-61[PMID:25241239 DOI:10.1016/j.jcma.2014.08.004]
23 Mu H,Gao J,Kong Q,Jiang K,Wang C,Wang A,Zeng X,Li Y.Prognostic Factors and Postoperative Recurrence of Calculus Following Small-Incision Sphincterotomy with Papillary Balloon Dilation for the Treatment of Intractable Choledocholithiasis:A 72-Month Follow-Up Study.Dig Dis Sci 2015;60:2144-2149[PMID:25875753 DOI:10.1007/s10620-015-3559-2]
24 Li X,Zhu K,Zhang L,Meng W,Zhou W,Zhu X,Li B.Periampullary diverticulum may be an important factor for the occurrence and recurrence of bile duct stones.World J Surg 2012;36:2666-2669[PMID:22911215 DOI:10.1007/s00268-012-1716-8]
25 Cetta F.The role of bacteria in pigment gallstone disease.Ann Surg 1991;213:315-326[PMID:2009013DOI:10.1097/00000658-199104000-00006]
26 Seo DB,Bang BW,Jeong S,Lee DH,Park SG,Jeon YS,Lee JI,Lee JW.Does the bile duct angulation affect recurrence of choledocholithiasis?World J Gastroenterol 2011;17:4118-4123[PMID:22039327DOI:10.3748/wjg.v17.i36.4118]
27 Stewart L,Ponce R,Oesterle AL,Griffiss JM,Way LW.Pigment gallstone pathogenesis:slime production by biliary bacteria is more important than beta-glucuronidase production.J Gastrointest Surg2000;4:547-553[PMID:11077333 DOI:10.1016/S1091-255X(00)80100-6]
28 Leung JW,Liu YL,Leung PS,Chan RC,Inciardi JF,Cheng AF.Expression of bacterial betaglucuronidase in human bile:an in vitro study.Gastrointest Endosc 2001;54:346-350[PMID:11522976DOI:10.1067/mge.2001.117546]
29 Begley M,Sleator RD,Gahan CG,Hill C.Contribution of three bile-associated loci,bsh,pva,and btlB,to gastrointestinal persistence and bile tolerance of Listeria monocytogenes.Infect Immun 2005;73:894-904[PMID:15664931 DOI:10.1128/IAI.73.2.894-904.2005]
2 Kim DI,Kim MH,Lee SK,Seo DW,Choi WB,Lee SS,Park HJ,Joo YH,Yoo KS,Kim HJ,Min YI.Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy.Gastrointest Endosc 2001;54:42-48[PMID:11427840 DOI:10.1067/mge.2001.115335]
3 Sugiyama M,Atomi Y.Risk factors predictive of late complications after endoscopic sphincterotomy for bile duct stones:long-term(more than 10 years)follow-up study.Am J Gastroenterol 2002;97:2763-2767[PMID:12425545 DOI:10.1111/j.1572-0241.2002.07019.x]
4 Keizman D,Ish Shalom M,Konikoff FM.Recurrent symptomatic common bile duct stones after endoscopic stone extraction in elderly patients.Gastrointest Endosc 2006;64:60-65[PMID:16813804DOI:10.1016/j.gie.2006.01.022]
5 Kim KY,Han J,Kim HG,Kim BS,Jung JT,Kwon JG,Kim EY,Lee CH.Late Complications and Stone Recurrence Rates after Bile Duct Stone Removal by Endoscopic Sphincterotomy and Large Balloon Dilation are Similar to Those after Endoscopic Sphincterotomy Alone.Clin Endosc 2013;46:637-642[PMID:24340257 DOI:10.5946/ce.2013.46.6.637]
6 Kim KH,Rhu JH,Kim TN.Recurrence of bile duct stones after endoscopic papillary large balloon dilation combined with limited sphincterotomy:long-term follow-up study.Gut Liver 2012;6:107-112[PMID:22375179 DOI:10.5009/gnl.2012.6.1.107]
7 Kim JH,Kim YS,Kim DK,Ha MS,Lee YJ,Lee JJ,Lee SJ,Won IS,Ku YS,Kim YS,Kim JH.Shortterm Clinical Outcomes Based on Risk Factors of Recurrence after Removing Common Bile Duct Stones with Endoscopic Papillary Large Balloon Dilatation.Clin Endosc 2011;44:123-128[PMID:22741123DOI:10.5946/ce.2011.44.2.123]
8 Song ME,Chung MJ,Lee DJ,Oh TG,Park JY,Bang S,Park SW,Song SY,Chung JB.Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea.Yonsei Med J2016;57:132-137[PMID:26632393 DOI:10.3349/ymj.2016.57.1.132]
9 Strnad P,von Figura G,Gruss R,Jareis KM,Stiehl A,Kulaksiz H.Oblique bile duct predisposes to the recurrence of bile duct stones.PLoS One 2013;8:e54601[PMID:23365676 DOI:10.1371/journal.pone.0054601]
10 Park BK,Seo JH,Jeon HH,Choi JW,Won SY,Cho YS,Lee CK,Park H,Kim DW.A nationwide population-based study of common bile duct stone recurrence after endoscopic stone removal in Korea.JGastroenterol 2018;53:670-678[PMID:29192348 DOI:10.1007/s00535-017-1419-x]
11 Fritz E,Kirchgatterer A,Hubner D,Aschl G,Hinterreiter M,Stadler B,Knoflach P.ERCP is safe and effective in patients 80 years of age and older compared with younger patients.Gastrointest Endosc 2006;64:899-905[PMID:17140895 DOI:10.1016/j.gie.2006.05.010]
12 Almadi MA,Barkun JS,Barkun AN.Management of suspected stones in the common bile duct.CMAJ2012;184:884-892[PMID:22508980 DOI:10.1503/cmaj.110896]
13 Yin Z,Xu K,Sun J,Zhang J,Xiao Z,Wang J,Niu H,Zhao Q,Lin S,Li Y.Is the end of the T-tube drainage era in laparoscopic choledochotomy for common bile duct stones is coming?A systematic review and meta-analysis.Ann Surg 2013;257:54-66[PMID:23059495 DOI:10.1097/SLA.0b013e318268314b]
14 Lu Y,Wu JC,Liu L,Bie LK,Gong B.Short-term and long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones.Eur J Gastroenterol Hepatol 2014;26:1367-1373[PMID:25264985 DOI:10.1097/MEG.0000000000000218]
15 Yasuda I,Fujita N,Maguchi H,Hasebe O,Igarashi Y,Murakami A,Mukai H,Fujii T,Yamao K,Maeshiro K,Tada T,Tsujino T,Komatsu Y.Long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones.Gastrointest Endosc 2010;72:1185-1191[PMID:20869711 DOI:10.1016/j.gie.2010.07.006]
16 Baek YH,Kim HJ,Park JH,Park DI,Cho YK,Sohn CI,Jeon WK,Kim BI.[Risk factors for recurrent bile duct stones after endoscopic clearance of common bile duct stones].Korean J Gastroenterol 2009;54:36-41[PMID:19696548 DOI:10.4166/kjg.2009.54.1.36]
17 Bergman JJ,Rauws EA,Tijssen JG,Tytgat GN,Huibregtse K.Biliary endoprostheses in elderly patients with endoscopically irretrievable common bile duct stones:report on 117 patients.Gastrointest Endosc1995;42:195-201[PMID:7498682 DOI:10.1016/S0016-5107(95)70091-9]
18 Chopra KB,Peters RA,O'Toole PA,Williams SG,Gimson AE,Lombard MG,Westaby D.Randomised study of endoscopic biliary endoprosthesis versus duct clearance for bileduct stones in high-risk patients.Lancet 1996;348:791-793[PMID:8813987 DOI:10.1016/S0140-6736(96)06316-7]
19 Lee KM,Paik CN,Chung WC,Kim JD,Lee CR,Yang JM.Risk factors for cholecystectomy in patients with gallbladder stones after endoscopic clearance of common bile duct stones.Surg Endosc 2009;23:1713-1719[PMID:19118432 DOI:10.1007/s00464-008-0269-2]
20 Zoepf T,Zoepf DS,Arnold JC,Benz C,Riemann JF.The relationship between juxtapapillary duodenal diverticula and disorders of the biliopancreatic system:analysis of 350 patients.Gastrointest Endosc 2001;54:56-61[PMID:11427842 DOI:10.1067/mge.2001.115334]
21 Tzeng JJ,Lai KH,Peng NJ,Lo GH,Lin CK,Chan HH,Hsu PI,Cheng JS,Wang EM.Influence of juxtapapillary diverticulum on hepatic clearance in patients after endoscopic sphincterotomy.JGastroenterol Hepatol 2005;20:772-776[PMID:15853993 DOI:10.1111/j.1440-1746.2005.03782.x]
22 Tsai TJ,Lai KH,Lin CK,Chan HH,Wang EM,Tsai WL,Cheng JS,Yu HC,Chen WC,Hsu PI.Role of endoscopic papillary balloon dilation in patients with recurrent bile duct stones after endoscopic sphincterotomy.J Chin Med Assoc 2015;78:56-61[PMID:25241239 DOI:10.1016/j.jcma.2014.08.004]
23 Mu H,Gao J,Kong Q,Jiang K,Wang C,Wang A,Zeng X,Li Y.Prognostic Factors and Postoperative Recurrence of Calculus Following Small-Incision Sphincterotomy with Papillary Balloon Dilation for the Treatment of Intractable Choledocholithiasis:A 72-Month Follow-Up Study.Dig Dis Sci 2015;60:2144-2149[PMID:25875753 DOI:10.1007/s10620-015-3559-2]
24 Li X,Zhu K,Zhang L,Meng W,Zhou W,Zhu X,Li B.Periampullary diverticulum may be an important factor for the occurrence and recurrence of bile duct stones.World J Surg 2012;36:2666-2669[PMID:22911215 DOI:10.1007/s00268-012-1716-8]
25 Cetta F.The role of bacteria in pigment gallstone disease.Ann Surg 1991;213:315-326[PMID:2009013DOI:10.1097/00000658-199104000-00006]
26 Seo DB,Bang BW,Jeong S,Lee DH,Park SG,Jeon YS,Lee JI,Lee JW.Does the bile duct angulation affect recurrence of choledocholithiasis?World J Gastroenterol 2011;17:4118-4123[PMID:22039327DOI:10.3748/wjg.v17.i36.4118]
27 Stewart L,Ponce R,Oesterle AL,Griffiss JM,Way LW.Pigment gallstone pathogenesis:slime production by biliary bacteria is more important than beta-glucuronidase production.J Gastrointest Surg2000;4:547-553[PMID:11077333 DOI:10.1016/S1091-255X(00)80100-6]
28 Leung JW,Liu YL,Leung PS,Chan RC,Inciardi JF,Cheng AF.Expression of bacterial betaglucuronidase in human bile:an in vitro study.Gastrointest Endosc 2001;54:346-350[PMID:11522976DOI:10.1067/mge.2001.117546]
29 Begley M,Sleator RD,Gahan CG,Hill C.Contribution of three bile-associated loci,bsh,pva,and btlB,to gastrointestinal persistence and bile tolerance of Listeria monocytogenes.Infect Immun 2005;73:894-904[PMID:15664931 DOI:10.1128/IAI.73.2.894-904.2005]