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Hepatolithiasis (stones within the liver) occurs commonly in Asia. Patients with hepatolithiasis may also have common duct stones that originated not in the gallbladder, but rather in the liver. These stones and biliary (gallbladder) narrowing can cause severe biliary infection. These patients usually are seen to have acute cholangitis (inflammation of the bile ducts). Immediate operation is necessary in about 25 percent of patients; surgery is associated with a 10 percent mortality. It is not known why some patients and not others can be successfully treated without emergency surgery. A review was undertaken of 88 patients with acute cholangitis due to hepatolithiasis to identify any factors predisposing patients to needing surgery. Emergency surgery was required in 26 patients (30 percent); this was necessary because of septicemic shock in 15 patients, persistent fever in eight patients, or spread of peritoneal inflammation in three patients. Although the incidence of obstruction by stones within the liver was similar in patients undergoing emergency surgery or conservatively treated, those requiring immediate surgery also had obstruction outside the liver due to either impacted stones or narrowing of the common duct. Analysis of clinical and laboratory data found that a maximum pulse rate of more than 100 beats per minute within 24 hours of being seen and low numbers of platelets (cells involved in blood clotting) were independent predictors of the need for an emergency operation. This information may be helpful in identifying high-risk patients who need close monitoring and early surgery. (Consumer Summary produced by Reliance Medical Information, Inc.)