A population study on the prevalence of gallstone disease: the Sirmione Study

Gallstone disease: Epidemiology of gallbladder stone disease

Gallstone disease is common: >700,000 cholecystectomies and costs of approximately 6.5 billion dollars annually in the U.S. The burden of disease is epidemic in American Indians (60-70%); a corresponding decrease occurs in Hispanics of mixed Indian origin. Ten to fifteen per cent of white adults in developed countries harbour gallstones. Frequency is further reduced in Black Americans, East Asia and sub-Saharan Africa. In developed countries, cholesterol gallstones predominate; 15% are black pigment. East Asians develop brown pigment stones in bile ducts, associated with biliary infection or parasites, or in intrahepatic ducts (hepatolithiasis). Certain risk factors for gallstones are immutable: female gender, increasing age and ethnicity/family (genetic traits). Others are modifiable: obesity, the metabolic syndrome, rapid weight loss, certain diseases (cirrhosis, Crohn's disease) and gallbladder stasis (from spinal cord injury or drugs like somatostatin). The only established dietary risk is a high caloric intake. Protective factors include diets containing fibre, vegetable protein, nuts, calcium, vitamin C, coffee and alcohol, plus physical activity.

Pregnancy is not a risk factor for gallstone disease: Results of a randomly selected population sample

AIM: To investigate the prevalence, risk factors, and selection of the study population for cholecystolithiasis in an urban population in Germany, in relation to our own findings and to the results in the international literature.

METHODS: A total of 2 147 persons (1 111 females, age 42.8 ± 12.7 years; 1 036 males, age 42.3 ± 13.1 years) participating in an investigation on the prevalence of Echinococcus multilocularis were studied for risk factors and prevalence of gallbladder stone disease. Risk factors were assessed by means of a standardized interview and calculation of body mass index (BMI). A diagnostic ultrasound examination of the gallbladder was performed. Data were analyzed by multiple logistic regression, using the SAS statistical software package.

RESULTS: Gallbladder stones were detected in 171 study participants (8.0%, n = 2 147). Risk factors for the development of gallbladder stone disease included age, sex, BMI, and positive family history. In a separate analysis of female study participants, pregnancy (yes/no) and number of pregnancies did not exert any influence.

CONCLUSION: Findings of the present study confirm that age, female sex, BMI, and positive family history are risk factors for the development of gallbladder stone disease. Pregnancy and the number of pregnancies, however, could not be shown to be risk factors. There seem to be no differences in the respective prevalence for gallbladder stone disease in urban and rural populations.

Prevalence of gallstone disease in first-degree relatives of patients with cholelithiasis

AIM: To evaluate the influence of familiality on the prevalence of gallstone disease (GD) in Italy.

METHODS: Families of 79 subjects with gallstones (cases) and of 79 subjects without gallstones (controls) were investigated for the presence of gallstones by ultrasonography. Index cases and index controls were matched for age, sex, and operative unit. Sixty-three and sixty-two husbands and wives of index cases and index controls, respectively, were also studied.

RESULTS: Overall,the prevalence of GD was significantly higher ( χ²=14.52, P<0.001) in the 202 first-degree relatives of subjects with gallstones than that in the 201 first-degree relatives of subjects without gallstones (28.6% vs 12.4%, relative risk (RR) 1.80, 95% confidence interval (CI) 1.29-2.63). In particular, prevalence of GD was significantly higher in mothers, fathers, and sisters of index cases than that in the respective family members of index controls. The highest RR was observed in mothers (RR=2.35, 95%CI 1.38-4.3). Prevalence of GD was not obviously different in brothers and also in husbands and wives of index cases and index controls. Family members of index cases did not differ from family members of control cases with respect to the most important risk factors for gallstones (age, diabetes, BMI, and number of pregnancies) with an exception of a higher prevalence of diabetes in fathers of index controls than in fathers of index cases.

CONCLUSION: This study confirms that familiality plays a very important role in the pathogenesis of gallstones.

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES

Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy.

METHODS

Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations.

RESULTS

Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (<or=5 mm) gallstones (5,000 patients, 67% females, 45 yr old, 10-yr follow-up) indicates that life-years may be gained or lost by cholecystectomy, depending on incidence and mortality of pancreatitis.

CONCLUSIONS

Small gallstones are associated with pancreatitis. Prophylactic cholecystectomy may lead to gain or loss of life-years in patients with small stones, depending on incidence and mortality of pancreatitis.

Management of biliary ascariasis in pregnancy

Ascariasis is a helminthic infection of humans caused by the nematode Ascaris lumbricoides. Biliary ascariasis is one of the most common and well described entities caused by ascaris. In endemic areas pregnant women are prone to develop biliary ascariasis. Its management poses a great challenge to both the attending surgeon and the endoscopist. Between January 1993 and March 2003, 15 cases of biliary ascariasis were seen in pregnant patients in our institution. Ultrasonography was used as the main investigative tool. Treatment involved management by conservative, endoscopic, and surgical methods, taking due care of both the mother and the fetus. Ten patients (66.6%) were in the third trimester of pregnancy, and 10 (66.6%) patients were in their third pregnancy. Ultrasonography proved to be the best tool for diagnosing and monitoring worms inside the biliary ductal system. Nine (60%) patients responded to the conservative treatment; endoscopic extraction was successful in 4 (66.6%) patients. Surgical treatment was required in 2 (13.3%) patients. One (6.6%) patient had had spontaneous abortion at 12 weeks gestation, and one (6.6%) patient had a premature labor. The remaining patients had normal pregnancies. Management of biliary ascariasis in pregnancy is a challenge for both the attending surgeon and the endoscopist. Safe and effective management requires special attention to the gestational age and accurate recognition of the specific pathology in the patient. The majority of patients respond to conservative treatment, but endoscopic extraction may be needed in nonresponsive cases. Lead shielding of the fetus and limitation of the total fluoroscopic exposure during therapeutic endoscopy can minimize the teratogenic risk of ionizing radiation. Failures of endoscopic extraction may lead to surgical intervention, which carries risks of fetal wastage and premature labor. Routine worming of women in the child-bearing years is recommended in endemic areas of ascariasis. Though ascariasis is a problem in developing countries, because of increased travel and population migration, clinicians elsewhere should be aware of the problems associated with ascariasis.

Acute cholecystitis

Only 20-30% of patients with gallstones have symptoms and the probability of a patient with silent gallstones developing biliary-related pain is 1-2%, while the risk of developing a serious complication (e.g. empyema, perforation, peritonitis etc.) is less than 0.1% per year. Imaging techniques are important in establishing the diagnosis and evaluating the patient. Laparoscopic cholecystectomy (LC) is the golden standard for the management of symptomatic gallstones and there are two surgical treatment options: early cholecystectomy (same hospital admission) and interval (delayed) cholecystectomy (6-8 weeks after resolution of acute attack). Early LC has medical and socioeconomic advantages over interval LC. LC can be undertaken for the majority of patients with AC and in some high risk groups the postoperative mortality can even be reduced. LC in AC is associated with longer operating time, a higher rate of conversion and bile damage. Early diagnosis and early operation can prevent the development of complications associated with AC.

Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century?

Gallstone disease is common and costly, creating over 700,000 cholecystectomies annually. Its complications consume approximately $6.5 billion in the United States. Surveys using noninvasive ultrasonography have identified its true prevalence and the associated risk factors. In developed countries, at least 10% of white adults harbor cholesterol gallstones; women have twice the risk, and age further increases the prevalence in both sexes. Gallstones reach epidemic proportions in the North and South American Indian populations, accompanied by an increased risk for gallbladder cancer. In contrast, the rate in sub-Saharan Africa and Asia is quite low. Obesity, a major risk factor, likely relates to insulin resistance (the metabolic syndrome). Evolution and circumstance in American Indians may have ironically selected those with "thrifty" genes that conserve energy. Our abundant access to food places us at the increased risk of obesity and cholelithiasis. The general rise in obesity in many countries raises the specter of heightened disease, best identified by epidemiologic studies.

Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century?

Gallstone disease is common and costly, creating over 700,000 cholecystectomies annually. Its complications consume approximately $6.5 billion in the United States. Surveys using noninvasive ultrasonography have identified its true prevalence and the associated risk factors. In developed countries, at least 10% of white adults harbor cholesterol gallstones; women have twice the risk, and age further increases the prevalence in both sexes. Gallstones reach epidemic proportions in the North and South American Indian populations, accompanied by an increased risk for gallbladder cancer. In contrast, the rate in sub-Saharan Africa and Asia is quite low. Obesity, a major risk factor, likely relates to insulin resistance (the metabolic syndrome). Evolution and circumstance in American Indians may have ironically selected those with "thrifty" genes that conserve energy. Our abundant access to food places us at the increased risk of obesity and cholelithiasis. The general rise in obesity in many countries raises the specter of heightened disease, best identified by epidemiologic studies.

Physical activity and decreased risk of clinical gallstone disease among post-menopausal women

BACKGROUND

Physical activity may play a role in preventing gallstone disease.

METHODS

The activity/gallstone relationship was examined in post-menopausal women from the Study of Osteoporotic Fractures (SOF; 1986-1988), a prospective study of fracture risk factors in 8010 women (mean age = 71.1 years, SD = 4.9).

RESULTS

Multivariate logistic regression indicated women in the lowest two quartiles of physical activity, according to questionnaire, had a 59% {OR = 1.59 (1.11-2.29), P = 0.02} and a 57% higher risk {OR = 1.57 (1.11-2.23), P = 0.01} of developing gallstone disease compared to women in the highest quartile of activity (PTrend = <0.0001). Additionally, this relationship was examined in a cohort of 182 post-menopausal women (mean age 74.2 years, SD = 4.1) who participated in a randomized controlled trial of a walking intervention. Women in the randomized clinical trial in the lowest tertile of physical activity determined by a physical activity monitor had a higher risk of developing gallstone disease than women in the highest tertile of physical activity, 13% {OR-1.13 (1.01-1.28), P = 0.05, PTrend = <0.04}.

CONCLUSION

Physical activity appears to be inversely related to the development of gallstone disease in post-menopausal women independent of body mass index.

Controversies concerning pathophysiology and management of acalculous biliary-type abdominal pain

Acalculous biliary-type abdominal pain is a commonly encountered clinical problem whose pathophysiology is unclear and evaluation and management are controversial. Cholecystokinin cholescintigraphy to measure the gallbladder ejection fraction (GEF) has been advocated as a criterion for cholecystectomy. However, there is no consensus regarding the dose and rate of infusion of cholecystokinin, both of which can alter the GEF, and the definition of an abnormal ejection fraction varies among studies. Many but not all studies have concluded that a low GEF predicts good outcomes after cholecystectomy, but most studies suffer from poor methodology and there is only one prospective randomized controlled trial. Also, some patients with a normal GEF have responded to cholecystectomy. Another controversial area has been the role of sphincter of Oddi dysfunction (SOD) in patients with biliary-type pain and gallbladder in situ. Some reports suggest an overlap between SOD and low GEF, although a causal relationship has not been established. Yet another subject of interest is the role of visceral hyperalgesia in patients with acalculous biliary-type pain. We have reviewed the relevant literature relating to these issues and have highlighted the controversial aspects. In the absence of high-quality studies, an evidence-based treatment algorithm is difficult to design but will be proposed. More prospective controlled trials are warranted to better define the appropriate evaluation and management of patients with this syndrome.

Gallstone disease in non-alcoholic fatty liver: prevalence and associated factors

BACKGROUND

Insulin resistance is a risk factors for non-alcoholic fatty liver disease (NAFLD) and for gallstone disease (GD). Aims of the present study were to assess the prevalence of and factors associated with GD in unselected patients with NAFLD.

METHODS

A total of 161 consecutive patients with NAFLD diagnosed through compatible ultrasonography in the absence of known etiologies of liver disease (in all patients) and/or confirmed histologically (in 61 patients), was studied. Gallstone disease was diagnosed through ultrasound scanning or on the basis of previous cholecystectomy. Anthropometric and biochemical variables and concurrent diseases were compared in 32 NAFLD-GD patients and in 129 NAFLD patients without GD (controls) according to gender.

RESULTS

The overall prevalence of GD was 19.88%, higher in female patients (P < 0.05), who were older (P < 001). The overall percentage of GD increased with age (P < 0.05). The GD patients had higher uric acid (men), total cholesterol and apolipoprotein B (apo-B) serum concentrations (women; P < 0.05); women also had a higher prevalence of hypertriglyceridemia (P < 0.05). The age-corrected odds ratio of having GD by tertiles increased significantly with increasing uric acid (men) and with increasing total cholesterol, triglycerides and apo-B (women). At univariate continuous analysis GD was associated with insulin 120 min and uric acid in male patients; and with body mass index, insulin 120 min, apo-B, total cholesterol and triglycerides in female patients. On multivariate analysis it was found that among these factors only uric acid in men and apo-B in women were independently associated with GD in NAFLD.

CONCLUSIONS

The prevalence of GD in NAFLD is more elevated than reported in the general population. The factors independently associated with GD in NAFLD are different from those reported in the general population and vary according to the gender.

Association of clinical and laboratory variables with ultrasound findings in right upper quadrant abdominal pain

BACKGROUND

The purpose of this study was to determine how laboratory values and physical examination findings correlate with ultrasound findings in the setting of right upper quadrant pain.

METHODS

Patients undergoing emergent ultrasound for the evaluation of biliary disease between November 1999 and April 2000 were included. Physical examination findings, laboratory data, and ultrasound results were variables. Logistic regression was performed. Ultrasound diagnosis of acute cholecystitis, cholelithiasis, and normal biliary tract were end points. One hundred seventy-seven patients were enrolled.

RESULTS

Forty-two percent were diagnosed with acute cholecystitis, 30.5% with cholelithiasis, and 27.1% with normal biliary tract. Alkaline phosphatase, Murphy sign, white blood cell count, and total bilirubin were statistically significant predictors of acute cholecystitis. A Murphy sign was defined as arrest of inspiration with pressure over the right upper quadrant.

CONCLUSIONS

The findings from this study allow clinicians to apply objective significance to laboratory data and physical examination findings in patients with suspected gallstone disease. The data can be applied to create a predictive model.

Acute non-traumatic maternal illnesses in pregnancy: imaging approaches

The imaging methods used to obtain diagnostic information for pregnant patients presenting with acute non-traumatic maternal illnesses have been reviewed. Conditions affecting the gastrointestinal tract, urinary tract, uterus, adnexae, central nervous system and chest have been investigated via a variety of imaging methods, which include ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), intravenous pyelography (IVP), angiography and fluoroscopy. The method of choice, application, and safety to the mother and fetus are considered for investigation of each condition.

Prevalence of gallbladder disease among persons with hepatitis C virus infection in the United States

Although cirrhosis is a known risk factor for gallstones, little is known about gallbladder disease (GBD) in individuals with hepatitis C virus (HCV) infection. We determined the association between chronic HCV infection and GBD in a representative sample of adults in the United States. Data on HCV infection and GBD were available for 13,465 persons 20 to 74 years of age who participated in the Third National Health and Nutrition Examination Survey. The presence of GBD (gallstones or cholecystectomy) was determined using abdominal ultrasonography, and HCV infection was assessed via a positive HCV antibody test and a positive HCV RNA test. Overall, 1.6% of adults (95% CI, 1.1-2.1) had chronic HCV infection and 12.5% (95% CI, 11.3-13.7) had GBD. After adjusting for potential confounding variables, the odds of gallstones (OR = 3.20; 95% CI, 1.08-9.45) and cholecystectomy (OR = 4.57; 95% CI, 1.57-13.27) among HCV-positive men was significantly higher compared with HCV-negative men. In contrast, the adjusted odds of gallstones (OR = 2.55; 95% CI, 0.58-11.25) and cholecystectomy (OR = 0.70; 95% CI, 0.21-2.37) among HCV-positive women was not significantly higher. The odds of GBD increased significantly with the severity of liver disease as assessed via elevated serum bilirubin levels and low levels of serum albumin and platelets. In conclusion, chronic HCV infection was strongly associated with GBD among men but not women in the United States, and GBD was more common in adults with severe liver disease.

Prevalence and risk factors for gallstone disease

Gallstone disease is a main public health problem. The overall prevalence data range from 3.9% in the pre-echographic era to 13.7% when ultrasonography was used as a diagnostic tool. This study is aimed to determine the prevalence of gallstone disease in a medium income level population in Lima, as well as the relationship with some risk factors: age, sex, familiar history and obesity. A total of 534 adult men and women from a medium economic level underwent ultrasonographic examination of abdomen for detection of gallstone disease (July 2003). The echographic evaluation was performed by 10 general surgeons trained in ultrasonography. Likewise, 4 risk factors--age, gender, familial history, and obesity--were analyzed. Pearson chi2 test (2-sided) was used with a probability of <0.05 for statistical significance and logistic regression analyses for assessment of confounding factors. The prevalence founded was 15%. Eighty-one of 534 participants had lithiasis. Compared to the age group under 30, the odds ratio for the 31 to 50 years and >50 years of age group was 0.9 and 1.1, respectively. The female-male ratio was 1.07 and the odds ratio 0.8. The prevalence of gallstone disease in people reporting a first-degree relative with lithiasis was 21%, whereas in participants without such a condition, it was 13%. On the other hand, a familial history was present in 38% of the lithiasis group and in 25% of the nonlithiasis group. The odds ratio for familial history was 1.8 (P = 0.01, 95% confidence interval 1.1-2.9). The prevalence of the disease for body mass index <24, 25 to 29, and higher than 30 was 17%, 14% and 13%, respectively. Compared to the reference group (body mass index <24), the other 2 groups (body mass index 25-29 and >30) both had a similar odds ratio, 0.8. Logistic regression analyses showed an odds ratio of 1.9 for familiar history (95% confidence interval 1.1-3.2), whereas the odds ratio of the overweight (body mass index 25-29) and obese group (body mass index >30) when compared to the normal group, BMI <24, was 0.7 and 0.9, respectively. The prevalence data for gallstone disease remain slightly higher than those previously reported. Although the familiar history was the only characteristic with a statistically significant positive relationship with lithiasis, additional studies are needed because few biases could not be completely avoided and some confounding factors were not controlled.

Metabolic syndrome as a risk factor for gallstone disease

AIM: To establish an association between the presence of metabolic syndrome and the development of gallstone disease.

METHODS: We carried out a cross-sectional study in a check-up unit in a university hospital in Mexico City. We enrolled 245 subjects, comprising 65 subjects with gallstones (36 women, 29 men) and 180 controls (79 women and 101 men without gallstones). Body mass index, waist circumference, blood pressure, plasma insulin, and serum lipids and lipoproteins levels were measured. Insulin resistance was calculated by homeostasis model assessment. Unconditional logistic regression analysis (univariate and multivariate) was used to calculate the risk of gallstone disease associated with the presence of at least three of the criteria (Adult Treatment Panel III). Analyses were adjusted for age and sex.

RESULTS: Among 245 subjects, metabolic syndrome was present in 40% of gallstone disease subjects, compared with 17.2% of the controls, adjusted by age and gender (odds ratio (OR) = 2.79; 95%CI, 1.46-5.33; P = 0.002), a dose-dependent effect was observed with each component of metabolic syndrome (OR = 2.36, 95%CI, 0.72-7.71; P = 0.16 with one component and OR = 5.54, 95%CI, 1.35-22.74; P = 0.02 with four components of metabolic syndrome). Homeostasis model assessment was significantly associated with gallstone disease (adjusted OR = 2.25; 95%CI, 1.08-4.69; P = 0.03).

CONCLUSION: We conclude that as for cardiovascular disease and diabetes mellitus, gallstone disease appears to be strongly associated with metabolic syndrome.

Incidence, natural history, and risk factors for biliary sludge and stones during pregnancy

Gallstones are strongly associated with higher parity in women. This study prospectively assessed the incidence, natural history, and risk factors for biliary sludge and stones during pregnancy and the postpartum in 3,254 women at an army medical center. Women with a prior cholecystectomy or with stones at their first study ultrasound were excluded. Gallbladder ultrasound and subject questionnaires were obtained in each trimester and at 4 to 6 weeks postpartum. Serum glucose, lipids, insulin, leptin, estradiol, and progesterone were measured at 26 to 28 weeks' gestation. A nested case-control study was done to examine the effects of serum leptin and insulin on incident gallbladder disease. At least two study ultrasounds were available for 3,254 women. Sludge or stones had been found on at least one study ultrasound in 5.1% by the second trimester, 7.9% by the third trimester, and 10.2% by 4 to 6 weeks postpartum. Regression of sludge and stones was common, such that overall 4.2% had new sludge or stones on the postpartum ultrasound. Twenty-eight women (0.8%) underwent cholecystectomy within the first year postpartum. Prepregnancy body mass index was a strong predictor of incident gallbladder disease (P < .001). Serum leptin was independently associated with gallbladder disease (odds ratio per 1 ng/dL increase, 1.05; 95% CI, 1.01, 1.11), even after adjusting for body mass index. In conclusion, incident gallbladder sludge and stones are common in pregnancy and the postpartum, and cholecystectomy is frequently done within the first year postpartum. Prepregnancy obesity and serum leptin are strong risk factors for pregnancy-associated gallbladder disease.

The Amerindian's genes in the Mexican population are associated with development of gallstone disease

BACKGROUND

It has been suggested that genes related to Amerindian ancestry account for the high prevalence of gallstone disease (GD) observed in Mexican-Americans. The HLA-B39 is an allele found in higher frequency in Amerindians whereas HLA-B15 is rarely found. The aim of this study was to test the hypothesis that gallstone susceptibility genes are more prevalent in Mexicans with recent Amerindian ancestry.

METHODS

We carried out a prospective case-controlled study. Subjects were divided into those who had stones visible on gallbladder ultrasound (cases), and those whose ultrasounds were negative for gallstones (controls). Body mass index (BMI) was calculated, and serum lipids and lipoprotein, and glucose levels were measured. Class I HLA (HLA-B) typing was performed by PCR amplification of genomic DNA.

RESULTS

Of the 1,101 subjects, 146 were classified as subjects with GD (cases) and 955 as subjects without GD (controls). Mean age of the cases was 53.5 +/- 12.5 yr versus 44.78 +/- 12.0 yr for the controls, p= 0.001. A family history of GD was observed in 48% of the cases versus 28.4% of the controls, p= 0.001. HLA-B39 was more frequently increased in GD subjects (0.162), compared with controls (0.063), p= 0.008. The odds ratio of having HLA-B39 was 2.8 and 95% (CI 95%= 1.3-6.3) for GD; HLA-B15 was more frequently increased in controls than in cases.

CONCLUSIONS

The most prevalent HLA alleles detected in these GD cases are characteristic of Amerindian populations, supporting the role of genetics in the high prevalence of the development of GD in Mexican mestizos.

Ursodeoxycholic acid does not affect ethinylestradiol bioavailability in women taking oral contraceptives

OBJECTIVE

Contraception is recommended for female patients during ursodeoxycholic acid (UDCA) treatment for the potential teratogenic effect of this bile acid, and the aim of our study was to determine whether this treatment affects the bioavailability of ethinylestradiol (EE2).

METHODS

In this double-blind, randomised study, we measured EE2 pharmacokinetics in eight healthy volunteers randomly allocated to receive oral contraceptive (30 microg EE2 and 75 microg gestodene) plus either UDCA (8-10 mg/kg per day) or placebo for 21 days during the first of three consecutive menstrual cycles. After a washout period during the second cycle, the subjects received the alternative treatment during the third menstrual cycle. Serum EE2 and UDCA were measured using radioimmunoassay and gas chromatography-mass spectrometry, respectively.

RESULTS

The profile for serum EE2 concentration was similar during UDCA (mean maximum serum concentration 177 pg/ml, SEM 59) and during placebo treatment (153 pg/ml, SEM 62), and mean area under the curve (AUC) was 1374 pg/h per ml (SEM 580) and 1320 pg/h per ml (SEM 551) during the two regimens, respectively. The point estimates and 90% confidence intervals of UDCA/placebo ratios for EE2 AUC and for maximum serum concentration were 1.1 (0.8-1.5) and 1.2 (1.0-1.4), respectively. Mean serum triglycerides concentration increased from 58.3 mg/dl (SEM 6.8) at enrolment to 91.4 mg/dl (SEM 10.7) during placebo (P < 0.01) and to 88.6 mg/dl (SEM 13.7) during UDCA treatment (P < 0.05). During UDCA treatment, serum enrichment with this bile acid and with the metabolite iso-UDCA was 29% (16%) and 3% (2%), respectively.

CONCLUSION

Co-administration with UDCA does not affect the bioavailability of EE2 in healthy volunteers, indicating that contraceptive efficacy is not affected.

Prospective study of abdominal adiposity and gallstone disease in US men

BACKGROUND

Obesity is an established risk factor for gallstones, but whether abdominal adiposity contributes independently to the risk, particularly in men, remains unclear.

OBJECTIVE

The purpose of the study was to examine the associations of abdominal circumference and waist-to-hip ratio, as measures of abdominal adiposity, with the risk of symptomatic gallstone disease in men.

DESIGN

We prospectively studied measures of abdominal obesity in relation to the incidence of symptomatic gallstone disease in a cohort of 29 847 men who were free of prior gallstone disease and who provided complete data on waist and hip circumferences. Data on weight, height, and waist and hip circumferences were collected in 1986 and in 1987 through self-administered questionnaires. As part of the Health Professionals Follow-Up Study, men reported newly diagnosed symptomatic gallstone disease on questionnaires mailed to them every 2 y.

RESULTS

We documented 1117 new cases of symptomatic gallstone disease during 264 185 person-years of follow-up. After adjustment for body mass index and other known or suspected risk factors for gallstones, men with a height-adjusted waist circumference > or = 102.6 cm (40.4 in) had a relative risk of 2.29 (95% CI: 1.69, 3.11; P for trend < 0.001) compared with men with a height-adjusted waist circumference < 86.4 cm (34 in). Men with a waist-to-hip ratio > or = 0.99 had a multivariate relative risk of 1.78 (1.38, 2.28; P for trend < 0.001) compared with men with a waist-to-hip ratio < 0.89.

CONCLUSIONS

Our data suggest the presence of a significant association between abdominal adiposity and the incidence of symptomatic gallstone disease. As measures of abdominal adiposity, abdominal circumference and waist-to-hip ratio predict the risk of developing gallstones independently of body mass index.

Development of symptoms and complications in individuals with asymptomatic gallstones

BACKGROUND

Gallbladder stones are common in the developed world. Complications of gallstones contribute substantially to healthcare costs and may be life threatening. The identification of individuals likely to develop complications would be of benefit in clinical practice as elective cholecystectomy could then be performed.

METHODS

Seven hundred and thirty-nine subjects aged 35-85 years from the general population were screened for gallbladder problems by ultrasonography and questionnaire assessment of putative risk factors and digestive symptoms. Gallstones, cholesterolosis or sludge in the gallbladder were diagnosed in 123 (16.3 per cent) of 739 subjects, 120 of whom were followed for a median of 87 (range 3-146) months to May 2003 or until treatment was required.

RESULTS

Fourteen patients were admitted to hospital and treated for gallstone-related complications or symptoms. The cumulative risk of being treated during the first 5 years after detection of asymptomatic gallstones was 7.6 per cent and there was no indication of this risk levelling off. There were no significant differences between treated and untreated subjects with regard to digestive symptoms or any of the risk factors monitored at the initial screening, although treated subjects were significantly younger than those who were not treated.

CONCLUSION

Nearly one in ten individuals with asymptomatic gallbladder stones in the general population may be expected to develop symptoms or complications that require treatment within 5 years. Age may be inversely related to the incidence of complications.

Polymorphisms at cholesterol 7α-hydroxylase, apolipoproteins B and E and low density lipoprotein receptor genes in patients with gallbladder stone disease

AIM: To investigate the relationship between gallbladder stone disease (GSD) and single nucleotide polymorphisms of cholesterol 7α-hydroxylase (CYP7A) gene promoter, apolipoprotein (APO) B gene exon 26, APOE gene exon 4 or microsatellite polymorphism of low density lipoprotein receptor (LDLR) gene exon 18.

METHODS: Genotypes of CYP7A, APOB, APOE and LDLR genes were determined in 105 patients with GSD diagnosed by B-mode ultrasonography and 274 control subjects. Serum lipids were analyzed with HITACHI 7060 automaic biochemical analyzer.

RESULTS: Body mass index (BMI) was significantly higher in patients with GSD (24.47 ± 3.09) than in controls (23.50 ± 2.16). Plasma total cholesterol was lower in patients with GSD (4.66 ± 0.92 mmol/L) than in controls (4.91 ± 0.96 mmol/L), P < 0.01 after adjusted for age, sex and BMI. The significantly higher frequency of A allele of CYP7A gene polymorphism and X+ allele of APOB gene polymorphism was seen in GSD patients. Percentages of A allele in patients and controls were 62.86% and 54.38% (P < 0.05) and those of X+ allele 8.57% and 4.01% (P < 0.01). Subjects with A allele had significantly lower plasma total cholesterol and LDL cholesterol than subjects with CC homozygote. In a multiple variable logistic regression model, the BMI (OR = 1.13, 95%CI: 1.05-1.22), A allele (OR = 1.48, 95%CI: 1.05-2.09) and X+ allele (OR = 2.28, 95%CI: 1.14-4.59) were positively associated with GSD (P < 0.05). Plasma total cholesterol (OR = 0.69, 95%CI: 0.64-0.74) was negatively related to GSD (P < 0.05).

CONCLUSION: With an association analysis, it was determined that A allele of CYP7A gene and X+ allele of APOB gene might be considered as risk genes for GSD. These alleles are related with differences of serum lipids among subjects. Multiple-variable logistic regression model analysis showed that besides BMI, GSD was affected by polygenetic factors. But the mechanism for these two alleles responsible for GSD requires further investigations.

Prognostic significance of antrum-predominant gastritis in functional dyspepsia

BACKGROUND

The role of Helicobacter pylori infection in functional dyspepsia is still controversial, and subgroups of patients with functional dyspepsia who may benefit from H. pylori eradication should be identified. Patients with functional dyspepsia and antrum-predominant H. pylori-positive chronic gastritis, it has been argued, have fewer symptoms after eradication therapy. In the present study, we analysed the clinical significance of antrum-predominant gastritis on the long-term prognosis of functional dyspepsia.

METHODS

Consecutive unselected dyspeptic patients were investigated in primary care and the patients with functional dyspepsia were enrolled in this long-term follow-up study. Altogether 182 patients were recruited: 65 with normal histology of the stomach, 36 with antrum-predominant gastritis, 21 with corpus-predominant gastritis and 60 with pangastritis. Patients' medical histories were reviewed after 6 to 7 years, with total number and outcome of repeated investigations analysed. At the end of follow-up, all patients were invited for voluntary gastroscopy.

RESULTS

At the end of follow-up, the proportion of asymptomatic patients ranged from 21% (normal histology) to 26% (antrum-predominant gastritis). No statistically significant differences between groups appeared in regard to re-visits or to proportion of patients examined by sigmoideo- or colonoscopy during follow-up. Patients with antrum-predominant gastritis less often underwent upper endoscopy. Peptic ulcer was more frequent (P = 0.05) in patients with antrum gastritis than in other groups, but no other differences existed among any organic gastrointestinal findings. No significant differences between subgroups appeared among the 30% of patients using drugs for upper abdominal complaints during the previous year.

CONCLUSIONS

Functional dyspepsia has an excellent long-term prognosis. Antrum-predominant gastritis in functional dyspepsia seems to carry an increased risk for peptic ulcer, and for this group in particular, H. pylori eradication should be considered. This finding requires confirmation in future studies performed in primary care.

Ultrasound evaluation of centenarians' gallbladder

Background: Ultrasound (US) examination of gallbladder is considered to be reliable, both in morphological and functional evaluation. We used US to study the gallbladder of a series of centenarians in order to show the characteristics of this organ in these subjects. We then compared the data obtained with two control populations omposed of elderly and adult subjects, respectively. Methods: US examination was done after an overnight fast and after emptying the gallbladder at 15-min intervals for a period of 90 min. To induce emptying of the gallbladder, we chose a semisolid meal with a small caloric value (370 kcal). The following parameters were evaluated: fasting gallbladder volume (in milliliters) before administration of the meal (considered to be 100%); gallbladder emptying (according to the formula: fasting gallbladder volume minus post-meal gallbladder volume at 10-min intervals divided by fasting gallbladder volume: the result of this operation was multiplied by 100); gallbladder motor functions, such as ejection volume (ml), is considered as the difference between fasting gallbladder volume and residual volume; ejection fraction (%), considered as the difference between fasting gallbladder volume and residual volume, is expressed as percentage fasting volume; and ejection rate (%/min) is calculated by dividing ejection fraction by time requested to reach the residual volume. Results: We found a common bile duct diameter that was significantly higher in centenarians than in the elderly and adults. Gallbladder wall thickness was significantly higher in centenarians than in adults. We also found substantially significant differences between centenarians with and without gallstones and elderly and adult subjects in the following parameters: mean gallbladder volume (reduced), residual volume (reduced), ejection volume (reduced) and ejection rate (reduced). The differences were not significant for the ejection fraction, and they were slightly reduced in centenarians compared to the other groups. There was a negative correlation between age and axial length (transverse diameter), age and width and age and common bile duct (CBD) diameter in the elderly group only. Conclusions: The study of gallbladder function in elderly people and centenarians is important because this parameter is related to the quality of digestion and absorption of many alimentary substances as well as to the formation of cholesterol gallstones. We found that gallbladder functions in centenarians are almost normal with respect to the elderly and adults. Contractility was higher than in our elderly sample. This fact ensures a correct concentration of bile salts and a good intestinal transit rate. It may represent one of the factors allowing for good digestive function in these subjects, which contributes to their health status.

Risk factors for symptomatic gallstones in patients with liver cirrhosis: a case-control study

OBJECTIVES

Liver cirrhosis is a well-documented risk factor for the formation of gallstones. In cirrhotic patients, gallstones are almost always "silent," and surgery is rarely required. When indicated (symptoms or complications), cholecystectomy implies a high morbidity risk in these patients, especially in the advanced stages of cirrhosis. The aim of this study was to estimate the risk factors for symptom development in cirrhotic patients with gallstones to identify the subgroup of patients at risk of undergoing surgery.

METHODS

A total of 140 patients with liver cirrhosis and gallstones were studied: 97 with asymptomatic and 43 with symptomatic gallstone disease. The risk factors for gallstone formation (age, gender, family history, parity, obesity, diabetes mellitus, hyperlipoproteinemia) and the characteristics of liver cirrhosis (etiology, duration, Child class, hypersplenism), gallstones (duration, number, size), and gallbladder (size, wall thickness) were assessed in all patients. In 12 patients (four symptomatic, eight asymptomatic), gallbladder emptying was also evaluated by ultrasound. The association of asymptomatic and symptomatic gallstones with all these parameters was statistically evaluated by Student's t, Mann-Whitney, and chi(2) tests, as well as by means of multiple logistic regression. The causal relationship between these characteristics and gallstone symptoms was also examined by means of the KDD (knowledge discovery from databases) method, with an algorithm for learning Bayesian networks.

RESULTS

Advanced age, female gender, viral etiology of cirrhosis, family history of gallstones, and duration of gallstone disease were significantly associated with symptomatic gallstone disease. The number or size of gallstones and the size or emptying of the gallbladder did not differ in symptomatic versus asymptomatic patients. Male gender and alcoholic cirrhosis were inversely correlated with symptom presence. In the multivariate analysis, family history (p = 0.0098) and advanced age (p = 0.0422) were positively correlated and male gender (p = 0.0049) and alcoholic etiology of cirrhosis (p = 0.0116) negatively correlated with symptom presence. These relationships (except for age) were also evidenced by the KDD method.

CONCLUSIONS

The risk of gallstones becoming symptomatic is significantly lower in men and in alcoholic cirrhosis. In cirrhotic women, and especially in the presence of a positive family history and of advanced age, the risk of developing symptoms and undergoing surgery was significantly greater.

Gallbladder motility in obesity, diabetes mellitus and coeliac disease

We reviewed data on gallbladder motility in obesity, diabetes and coeliac disease. In obesity, a condition characterised by increased risk of gallstone(s), decreased gallbladder motility has heterogeneously been reported as a consequence of the different type of meals used to induce gallbladder contraction, characteristics of the population studied, technique used, and proportion of patients with hyperinsulinaemia. Moreover, recent studies have evaluated the effect of dietary restriction on gallbladder motility in obese patients. A two- to three-fold increase in the risk of cholesterol gallstone(s) has been reported in diabetic patients, mainly in relation to obesity and hypertriglyceridaemia. Furthermore, decreased gallbladder motility has been described and attributed to other factors, including underlying autonomic neuropathy, reduced gallbladder sensitivity to cholecystokinin and/or reduced number of cholecystokinin receptors on the gallbladder wall. Impaired gallbladder motility has been reported also in patients with coeliac disease in relation to reduced secretion of enteric hormones and/or decreased gallbladder sensitivity to them. In particular, untreated coeliacs, when compared to controls, showed low postprandial cholecystokinin and increased fasting somatostatin levels. Interestingly, the correlation between fasting somatostatin levels and gallbladder size has clearly been confirmed in patients affected by somatostatinoma or treated with somatostatin or its analogues. Gallbladder motility can be affected by various clinical conditions, such as obesity, diabetes mellitus and coeliac disease.

Acalculous biliary pain: new concepts for an old entity

Biliary pain is commonly reported in household surveys with the presumed cause being gallstones. When gallstones are absent or other abnormalities as a potential cause of similar pain do not exist, a different approach is necessary. Although trans-abdominal ultrasound can detect stones down to 3-5 mm, the advent of endoscopic ultrasound provides an even better definition for microlithiasis of < 3 mm. Duodenal aspiration of bile can further detect cholesterol microlithiasis or bilirubin granules, another potential source of biliary-type pain and perhaps even pancreatitis. Only in this way can acalculous gallbladder disease be clearly defined. The percentage of cholecystokinin-stimulated gallbladder emptying has been reputed to be the most sensitive diagnostic test for 'biliary dyskinesia', but abnormality of gallbladder emptying can be due to a smooth muscle defect of the gallbladder itself or heightened tone in the sphincter of Oddi. The value of surgical intervention has not been clearly established. The advent of laparoscopic cholecystectomy, however, has increased the number of patients with acalculous biliary disease who undergo surgery. Surgery is best done using impaired gallbladder emptying as the criterion for operation with improved outcome. Often, following cholecystectomy, biliary pain does not resolve the so-called 'post cholecystectomy syndrome'. Absence of the gallbladder as a pressure reservoir leaves the sphincter of Oddi as the prime determinant of bile duct pressure. Sphincter of Oddi dysfunction also exists in patients with an intact biliary tract and may become evident following cholecystectomy. Biliary manometry has clarified who might benefit from sphincterotomy. Choledochoscintigraphy is a non-invasive preliminary test. Advent of visceral hypersensitivity and better definition of this entity has shown, that in some of these patients with type III sphincter of Oddi, dysfunction appears to reside in duodenal hyperalgesia. It is clear that improved criteria are required to perform gallbladder emptying and better techniques to detect visceral hypersensitivity. Nonetheless, functional biliary pain in the absence of gallstone disease is a definite entity and a challenge for clinicians.

Gallstones, gallbladder disease, and pancreatitis: cross-sectional and 2-year data from the Swedish Obese Subjects (SOS) and SOS reference studies

OBJECTIVES

Obesity and weight loss have been associated with gallstone disease. There is also an association between gallstones and pancreatitis. We investigated cross-sectional relationships between body mass index (BMI), body fat distribution, and prevalence of gallstones, gallbladder disease, and pancreatitis in men and women. Furthermore, 2-yr incidences of these disorders were examined in relation to changes in weight and body fat distribution after surgical and conventional obesity treatment.

METHODS

Self-administered questionnaires were used to assess biliary and pancreatic disease. In the cross-sectional investigation, 6328 obese patients and 1135 randomly selected reference individuals were used. Longitudinally, 1422 operated and 1260 conventionally treated patients were examined.

RESULTS

Obese subjects had significantly higher prevalence of cholelithiasis, cholecystitis, cholecystectomies, and pancreatitis as compared with the reference population. In women, BMI and waist-hip ratio (WHR) were independently related to an increased biliary disease prevalence. In men, only BMI was independently associated with biliary disease. Compared with conventional treatment, obesity surgery significantly increased the incidence of cholelithiasis, cholecystitis, and cholecystectomies in men. There was no incidence difference among women. In both genders, weight loss, but not change in WHR, was related to an increased incidence of biliary disease.

CONCLUSIONS

This study showed an increased prevalence of gallstones, gallbladder disease, and pancreatitis in the obese. Biliary disease was related to BMI and WHR in women, but only to BMI in men. Weight loss, but not change in WHR, increased the risk of biliary disease in both genders.

Incidence of gallstones in chronic renal failure patients undergoing hemodialysis: experience of a center in Turkey

OBJECTIVE

In this case-control study, we sought to determine whether the incidence of gallbladder stones (GBS) was increased in chronic renal failure (CRF) patients on a hemodialysis (HD) program. We also evaluated factors, such as lipid profiles and gallbladder motility, that could affect the formation of GBS. In addition, we reviewed other available studies on this subject and compared the factors that might have some influence on the development of GBS.

METHODS

A total of 182 CRF patients (135 male, 47 female, mean age 32.1 yr) undergoing chronic HD and who were referred to our transplantation center in the last 10 yr and 194 healthy controls (137 male, 57 female, mean age 33.3 yr) were included in the study. Abdominal ultrasound was performed on all patients, and ALT, AST, and lipid profiles were determined. In addition, 19 patients with CRF (12 male, 7 female, mean age 33.5 yr) and 22 controls (14 male, 8 female, mean age 33.2 yr) who were age and sex matched were randomly chosen for gallbladder emptying, monitored by ultrasound at 30-min intervals for 2 h after a mixed meal. Fasting volume, minimal residual volume, and ejection fraction of the gallbladder were assessed. For statistical analysis, chi(2), t test, and logistic regression analysis were used.

RESULTS

GBS were detected in seven patients with CRF (3.85%, 5 male, 2 female) and three controls (1.55%, one male, two female) (p > 0.05). The mean follow-up time of CRF patients after diagnosis was 39.3 months (range: 2-168), the mean duration of HD was 21.8 months (range: 1-120). The analysis of seven stones in the CRF group revealed that five were cholesterol-rich stones, and two were mixed (cholesterol and bilirubin) stones. Cholesterol levels were higher in the control group, and triglycerides were higher in the CRF group, but these findings were nonsignificant (p > 0.05). Other biochemical values were not significantly different between the groups. CRF patients with and without GBS were similar in their duration of CRF and HD, age, and other biochemical parameters (p > 0.05). When gallbladder emptying was considered, there was no difference between the two groups in fasting volume, residual volume, and ejection fraction (CRF: 89.7%; controls: 92.3%) of the gallbladders (p > 0.05).

CONCLUSIONS

We detected similar incidences of GBS in CRF patients undergoing HD and healthy controls, and this was comparable to the results of most of the previous studies. Young male CRF patients had a nonsignificantly higher incidence of GBS than control males. Although cholesterol-rich GBS were predominant, we could not find any significant difference between the groups when factors that could affect GBS formation, such as lipid profiles and gallbladder motility, were taken into account.

Morphological and demographic associations of biliary symptoms in subjects with gallstones: findings from a population-based survey in Rosario, Argentina

BACKGROUND

Gallstone disease is a frequently encountered disorder in subjects living in Rosario. The reasons for the presence or absence of symptoms are unknown.

AIMS

To determine associations between biliary symptoms and ultrasonographic features of gallbladder and gallstones.

SUBJECTS

A random study was conducted on 1,173 subjects, inhabitants of 20 years and older, in the city of Rosario, Argentina.

METHODS

High-resolution abdominal ultrasound examinations were performed. Biliary pain was defined based on previously published definitions.

RESULTS

Gallstones were found in 149 subjects (101 female, 48 male) of whom 51% of females and 35% of males with cholelithiasis were symptomatic. Mean age was 53 years in symptomatic and 55 in asymptomatic subjects. Gallbladder size was normal in 97% of symptomatic and in 96% of the asymptomatic participants. There were no significant differences between the groups as far as concerns size and gallstone number. Impacted stones were observed in 10% of symptomatic and in none of the asymptomatic subjects (p<0.01).

CONCLUSIONS

Subjects' age and gender, gallstones size and number, as well as ultrasonographic features of gallbladder and biliary tract did not differ significantly between symptomatic and asymptomatic subjects. Only impacted stones were significantly more frequent in symptomatic subjects.

Gallstones: genetics versus environment

OBJECTIVE

The aim of this study was to determine if a significant genetic component contributes to the pathogenesis of symptomatic gallstones.

SUMMARY BACKGROUND DATA

Gallstones represent a polygenic disorder that affects more than 30,000,000 Americans and results in more than 750,000 cholecystectomies in the United States annually. Risk factors include age, gender, race, parity, obesity, and diabetes. A family history of gallstones also has been identified as a risk factor suggesting that genetics play a role in gallstone formation. However, the role of genetics in the pathogenesis of gallstone formation has not been determined.

METHODS

A gallbladder disease-specific questionnaire was administered to 904 healthy unrelated adult volunteers (association study). The questionnaire ascertained a history of cholecystectomy and gallstone disease in first-degree relatives, as well as medical history, demographic, and anthropometric data. A logistic regression model was used to identify risk factors for symptomatic gallstone disease in a multivariate analysis. A maximum likelihood based variance decomposition approach was then used in 1,038 individuals from 358 families (family study) to estimate the additive genetic heritability of symptomatic gallstone disease.

RESULTS

In the association study significant risk factors for symptomatic gallstone disease were female gender (relative risk 8.8, P <.003), obesity (BMI > 30, relative risk 3.7, P <.001), age > 50 (relative risk 2.5, P <.001), and a positive family history of previous cholecystectomy in a first-degree family member (relative risk 2.2, P <.01). In the family study the additive genetic heritability of symptomatic gallstones was 29% (P <.02), age and gender were significant covariates and explained 9.3% of the phenotypic variation in gallbladder disease.

CONCLUSIONS

These data suggest that genetic factors are responsible for at least 30% of symptomatic gallstone disease. However, the true role of heredity in gallstone pathogenesis is probably higher because data based on symptomatic gallbladder disease underestimates the true prevalence in the population.

Gallstone disease prevalence in Western Siberia: cross-sectional ultrasound study versus autopsy

BACKGROUND

The aims of this study were: (i) to evaluate the prevalence of gallstones in a Western Siberian urban population; and (ii) to compare the results of ultrasonographic screening of the living population with hospital autopsy data.

METHODS

A representative sample of 842 men and 870 women (aged 25-64 years) living in Novosibirsk, Western Siberia, was screened for the presence of gallstones by gallbladder ultrasonography. Participants were considered to have gallstone disease if they had already had cholecystectomy or if gallstones were revealed during the survey. Hospital autopsy data (n = 1124) were reviewed retrospectively for the 8-year period in the same region.

RESULTS

The prevalence of gallstone disease was significantly higher in women than in men and increased with age. Age-adjusted prevalence rates of gallstone disease for the 25-64-year age group were 1.9% in men and 9.5% in women in a cross-sectional ultrasonographic study. Corresponding values in the autopsy series were 2.2% in men and 11.2% in women.

CONCLUSIONS

The present report shows that the prevalence of gallstone disease in the female population is in the range of that reported from Western countries, whereas that in the male population is lower than that in other countries. The results of the ultrasonographic survey of the living population and of hospital autopsy data were comparable, with slightly higher gallstone detection rates in the autopsy study.

Prevalence of gallbladder disease in American Indian populations: findings from the Strong Heart Study

American Indians are believed to be at high risk of gallbladder disease (GBD), but there has been no systematic evaluation of its prevalence among diverse groups of American Indians. Therefore, we determined the prevalence of GBD and associated risk factors among specified American Indian populations using ultrasonography of the gallbladder and standardized diagnostic criteria. Enrolled members, aged 47 years and older, of 13 American Indian tribes or communities in Arizona, Oklahoma, and South and North Dakota who participated in the Strong Heart Study were analyzed. GBD was the sum of gallstones (determined by ultrasound examination) and cholecystectomy (determined by ultrasound and self-report). The proportion of American Indian heritage was based on the heritage of the grandparents of participants. GBD prevalence was determined among 3,296 participants at the 3 sites. Among women, 17.8% had gallstones, and 46.3% had evidence of a cholecystectomy, for a total of 64.1% with GBD. Among men, 17.4% had gallstones, and 12.1% had evidence of a cholecystectomy, for a total of 29.5% with GBD. When figures were adjusted for age and Indian heritage, there was no significant difference in GBD prevalence across the 3 geographical areas. In multivariate logistic regression analysis, age, American Indian heritage, and waist circumference were associated with GBD among men, and age, American Indian heritage, diabetes, and parity were associated with GBD among women. Body mass index was not independently associated with GBD in either sex. In conclusion, GBD was found in epidemic proportions in diverse American Indian populations.

Liver disease in the elderly

Ageing of the liver mainly affects the sinusoids and the Kupffer cells. Pseudocapillarization, manifested by reduced sinusoidal fenestration and subendothelial collagen deposition, causes a reduction in oxygen-dependent hepatocyte functions such as oxidative drug metabolism. The liver mass in old people is somewhat reduced and the liver blood flow is diminished. This causes a reduction in the clearance of rapidly cleared drugs, but the clearance of slowly cleared drugs is not affected. The overall capacity of the liver to regenerate is maintained in old people. Therefore, hepatic resections for hepatocellular carcinoma can be carried out in non-cirrhotic elderly people. For liver transplantations, biological age is more important than calendar age. Transplantations in frail old people and in elderly people with very poor liver function are associated with increased morbidity and limited survival. In relatively healthy old people, the results are as good as those in younger age groups. An increased prevalence of hepatitis C associated cirrhosis and hepatocellular carcinoma in the elderly population is to be expected, at least in the next 20 years. There is a high prevalence of gallstones among old people, in particular among females. For symptomatic choledocholithiasis in elderly patients, endoscopic bile duct clearance does not necessarily need to be followed by cholecystectomy.

Insulin injections enhance cholesterol gallstone incidence by changing the biliary cholesterol saturation index and apo A-I concentration in hamsters fed a lithogenic diet

BACKGROUND/AIMS

A link between insulin and cholesterol gallstone disease has often been suspected but never demonstrated. The aim was to evaluate the direct implication of insulin in the gallbladder cholesterol gallstone formation process.

METHODS

Hamsters fed with a soft-inducing lithogenic diet, enriched with sucrose, were injected daily, for 1 week, either with long-acting insulin or saline (controls).

RESULTS

Insulin injections doubled the cholesterol gallstone incidence. The cholesterol saturation index (CSI) of bile significantly increased (+19%) and biliary apolipoprotein A-I (apo A-I) decreased, both in concentration (-71%) and the proportion relative to the total biliary proteins (-25%). No modifications in the biliary bile acid composition were noticed. Hepatic HMGCoA reductase activity was higher (+341%), CYP7A1 activity was lower (-52%), whereas CYP27A1 and CYP7B1 were not affected. The hepatic low-density liprotein (LDL)-receptor and SR-BI masses did not vary. The hepatic total cholesterol content increased (+42%). Fasting plasma phospholipid and triglyceride concentrations significantly decreased (-15 and -60%, respectively), but the cholesterol concentration remained constant.

CONCLUSIONS

These results suggest that insulin injections enhance cholesterol gallstone incidence by increasing the CSI of bile and decreasing the concentration and proportion of a biliary anti-nucleating protein, apo A-I. Insulin modulates the major enzymes of cholesterol and bile acid metabolisms in vivo.

Gallstones

Gallstones are estimated to affect over 20 million people in the United States. Recent studies have clarified the role of various dietary components in gallstone disease. Also, insulin resistance has been demonstrated to be a risk factor for gallstones. Other research has focused on the pathophysiology of gallstones and on clarifying the underlying mechanisms of previously noted risk factors for gallstones. New techniques for the noninvasive diagnosis of bile duct stones continue to be developed and tested. These techniques include computed tomography and magnetic resonance cholangiography. The impact and appropriateness of laparoscopic cholecystectomy continue to debated, and studies point to both overuse and underuse of this operation in the management of the disease.

Incidência de colelitíase em necropsias realizadas em hospital universitário no município de Campinas-SP

OBJETIVO: avaliar a incidência de colelitíase em pacientes submetidos à necropsia no Hospital das Clínicas da UNICAMP e relacioná-la com a ocorrência de outras doenças associadas. MÉTODO: Os autores analisaram a incidência de colelitíase em 2.355 necropsias realizadas pelo Departamento de Anatomia Patológica da UNICAMP, no período de 1975 a 1998, considerando-se somente os casos com idade acima de 10 anos. O teste do qui-quadrado e a "odds ratio" (OR) foram utilizados para análise de correlação com outras afecções. RESULTADOS: A incidência foi de 243 (10,3%) casos de colelitíase; com 110 (7,9%) casos em homens e 133 (13,6%) em mulheres (p=0,00001), resultando numa proporção de 1:1,7. A incidência aumentou com a idade (p<0,000000001) e diferiu, significativamente, entre os grupos raciais estudados, sendo 195 (11,1%) casos em indivíduos da raça branca e 48 (7,8%) em não brancos (p=0,02). Quando relacionada com as demais doenças hepáticas associadas, observou-se que as de maior incidência foram a esteatose, com 33 (13,5%) casos; as neoplasias, com 31 (12,7%); a cirrose, com 30 (12,3%); a hepatite e a congestão crônica do fígado, cada uma com 16 (6,5%) casos, respectivamente. Na análise de correlação verificou-se que as neoplasias, o infarto hepático e a atrofia parda do fígado mostraram associações estatisticamente significantes com a incidência de colelitíase. CONCLUSÕES: Os resultados indicam um aumento progressivo na incidência de colelitíase com a idade, sendo mais incidente na população acima dos 80 anos e, com predomínio, em indivíduos da raça branca.

Orlistat maintains biliary lipid composition and hepatobiliary function in obese subjects undergoing moderate weight loss

OBJECTIVES

Orlistat, an intestinal lipase inhibitor, has recently been approved by the US Food and Drug Administration for treatment of obesity. The effects of orlistat on hepatobiliary function have not been previously defined. A 4 wk study was performed involving modest weight loss in obese subjects to observe any short-term hepatobiliary responses that occur after initiating treatment with orlistat and a hypocaloric diet.

METHODS

A total of 23 obese (BMI 30-41 kg/m2) subjects were randomized to a double blind t.i.d. treatment with 120 mg of orlistat or a placebo in conjunction with a hypocaloric diet (1200-1500 kcal/day). The study was designed to achieve similar modest weight loss in both groups in order to be able to directly assess the effects of orlistat. Cholesterol saturation, bile composition, and gallbladder motility were measured.

RESULTS

At the end of the treatment period, mean weight loss of 3.8 kg was achieved in the orlistat group (vs 2.3 kg with placebo, p = NS). Total bile acid concentration decreased significantly with placebo (-18.57 +/- 6.99 mmol/L; 95% CI = -32.26 to -4.87), but not with orlistat. Biliary phospholipid concentration decreased significantly with placebo (-4.38 +/- 1.91 mmol/L; 95% CI = -8.13 to -0.64) but not with orlistat. Mean changes from the baseline in cholesterol saturation index and gallbladder motility were similar in both groups. Microscopy of bile failed to reveal cholesterol microcrystals before or after treatment in either group.

CONCLUSIONS

Our findings indicate a primary initial effect of weight loss is a reduction in biliary bile acids and phospholipids. Orlistat blocks these adverse changes in biliary lipid composition and maintains hepatobiliary function. We speculate that the risk of formation of gallstones during weight loss may actually be lowered with orlistat.

Physical activity, biliary lipids, and gallstones in obese subjects

OBJECTIVE

Gallstone disease is a major source of morbidity in the US. Reduced physical activity has been shown to be a risk factor for gallstone formation in recent studies; however, the mechanisms to explain how physical activity may protect against gallstone formation have not been well elucidated. We investigated the relationships between physical activity, biliary lipids, and gallstone disease.

METHODS

Three types of habitual physical activity (work, sport, and leisure time), biliary lipids, and serum lipids were estimated or measured in 53 obese subjects undergoing gastric bypass surgery. These physical activities were defined as activity at work, sport activity during leisure time, and activity during leisure time excluding sports, respectively.

RESULTS

We found that sport activity but not work and leisure time activities was inversely associated with gallstone disease. Lower levels of biliary bile salts and percent biliary bile salts (expressed in percentage of total biliary lipids) and higher levels of percent cholesterol were also found to be associated with gallstone disease. A lower level of sport activity appeared to be associated with higher levels of biliary cholesterol, percent biliary cholesterol, and serum triglycerides.

CONCLUSION

Our findings demonstrate that low levels of physical activity are associated with gallstone formation. Our study also suggests that a possible mechanism for the protective effect of physical activity on gallstone formation is the lowering of biliary cholesterol levels, thus preventing cholesterol from precipitating in the bile. In addition, our data suggest that sport activity is a more effective form of physical activity than working and leisure activities in the prevention of gallstone disease.

Epidemiology of gallstone disease in Chandigarh: a community-based study

BACKGROUND

Cholelithiasis is frequent in our country (India), and is a common cause for abdominal surgery. We studied the prevalence of gallstone disease and its association with various risk factors in the city of Chandigarh.

METHODS

A house-to-house survey of residents aged 15 years or above in a subsector of Chandigarh was conducted as a part of a pilot survey. All individuals with a history of gallstone disease, and equal or more number of asymptomatic individuals were asked to attend the outpatient department of the Postgraduate Medical Institute. On the basis of the pilot survey, the sample size to be studied was 2648 and we screened 2649 persons.

RESULTS

Two hundred and fifty-four individuals attended the outpatient services of the Institute, and 248 underwent an ultrasound. There were 37 symptomatic and 211 asymptomatic individuals (male: female, 93:155). Gallstone disease was seen in 24 out of 37 (64.9%) in the symptomatic, and seven out of 211 (3.3%) in the asymptomatic group. Out of these, 27 females and four males had gallstone disease (mean age: 48.30 +/- 16.03 years). Approximately 67% of patients were between 20 and 60 years of age. Gallstone disease was more frequently seen in those from high socioeconomic status as compared to middle socioeconomic status (chi2 = 8.9, d.f. = 1, P < 0.01), and in multiparous as compared to nulliparous females (chi2 = 4.8, d.f. = 1, P < 0.05). Body mass index, smoking, alcohol consumption, and a vegetarian/non-vegetarian diet did not influence the prevalence of gallstone disease.

CONCLUSIONS

Gallstone disease is frequent in northern India. Gallstones were frequent in those belonging to high socioeconomic status and multiparous females. However, body mass index, smoking, alcohol or other dietary habits did not make a difference.

Medical complications in scoliosis surgery

Several medical complications can occur after scoliosis surgery in children and adolescents. They include the syndrome of inappropriate antidiuretic hormone; pancreatitis; cholelithiasis; superior mesenteric artery syndrome; ileus; pnemothorax; hemothorax; chylothorax; and fat embolism. This review focuses on the pathophysiology, diagnosis, and treatment of the various conditions that occur after correction of spinal deformity. Attention is given to recent literature specifically related to scoliosis surgery. Surgical complications like urinary tract infection, wound infection, and hardware failure will not be addressed.

Clinical presentations and predisposing factors of cholelithiasis and sludge in children

BACKGROUND

In contrast to adults, little is known about the epidemiology and the best therapeutic regimen for cholelithiasis and sludge in children.

METHODS

Eighty-two children with cholelithiasis detected by ultrasonography were studied from 0 to 18 years of age with regard to cause, symptomatology, and treatment outcome. Seventy-five children with sludge within the same age group were studied as well.

RESULTS

Idiopathic gallstones were found in 19 (23%) patients, and 32 (39%) had gallstones in association with a hemolytic disease. Predominant factors associated with the development of gallstones and clinical presentation differed with age. In patients with sludge, total parenteral nutrition and systemic infection or administration of antibiotics were most frequently found to be possible predisposing factors. Sludge can develop and disappear within a few days. Complications of cholelithiasis were observed in 13 patients. Cholecystectomy was performed in 41 patients and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction in 9 patients; 32 children were not treated. After a follow-up (mean, 4.6 years) in 50 patients, 46% of the children who had cholecystectomy or therapeutic ERCP experienced clinical recurrence of abdominal symptoms. In the patients who did not receive surgical or endoscopic therapy during the follow-up, no complications occurred, and only one patient experienced abdominal symptoms during follow-up.

CONCLUSIONS

The difference in associated conditions may indicate that the pathogenesis of cholelithiasis and sludge differ as well. Furthermore, sludge should be viewed as a dynamic condition not predisposing for the development of gallstones, per se. Cholecystectomy should not be performed routinely but only after careful selection in patients at risk for complications.

Biliary symptom scoring as a method of selecting patients for cholecystectomy

BACKGROUND

A group of patients referred to general surgeons for the treatment of gall bladder stones was studied to evaluate the role of a numerical symptom scoring system (biliary symptom score (BSS)) as a tool to improve the assessment of patients and reduce the incidence of post-cholecystectomy symptoms.

METHODS

Fifty-seven patients with gallstones and abdominal symptoms referred to general surgeons were studied. All patients were interviewed by a surgeon in training independently from the treating surgeon and given a subjective and objective assessment of their symptoms (using the BSS); they were then categorized into biliary, non-biliary and possible biliary groups. The results of the interviews remained unknown to the treating surgeon throughout the period of study. The symptom status of all patients was reevaluated 6-12 months later; the patients' outcome was compared with their initial objective score and the subjective assessment by the independent assessor and with the treating surgeon's initial assessment.

RESULTS

Fifty-one patients were able to be analysed. Subjective independent assessment and BSS were closely correlated (phi = 0.89). Use of the BSS improved the accuracy of the independent assessor from 53% (subjective assessment) to 69%, but this was at the cost of recommending cholecystectomy in 30% of the patients with non-biliary symptoms. The accuracy of experienced consultant general surgeons was 98% with a single case of post-cholecystectomy syndrome (2%).

CONCLUSION

Numerical BSS improves diagnostic accuracy for a surgeon in training by reducing the number of patients classified with possible biliary symptoms, but it remains significantly less accurate than the subjective clinical assessment of an experienced consultant general surgeon.

The pancreas and inflammatory bowel diseases

This article reviews the literature and gives an overview on prevalence and possible explanations for pancreatic involvement in inflammatory bowel diseases (IBD). IBD patients have a markedly elevated risk for developing acute pancreatitis as well as pancreatic insufficiency. Multiple potential causes for pancreatitis in IBD patients exist. In the majority of cases acute pancreatitis appears to be related to drug side effects or local structural complications rather than a true extraintestinal manifestation of IBD. Nevertheless, some cases of acute pancreatitis remain unexplained. Prevalence of chronic pancreatitis in IBD patients also seems to be relatively high. However, etiology of pancreatic duct changes and/or the occurrence of exocrine insufficiency remain unclear. In most cases chronic pancreatitis is clinically unapparent, although in some patients it may be accompanied by clinically relevant exocrine insufficiency.

Review article: epidemiology of gall-bladder disease--role of intestinal transit

Recent epidemiological studies have suggested that hyperinsulinaemia may be a central factor in the pathogenesis of cholesterol gallstones, explaining a probable link with physical inactivity as well as abdominal adiposity. There is also increasing evidence for the hypothesis that enrichment of bile with DCA. 'the colonic bile acid', leads to enrichment of bile with cholesterol. Biliary DCA can be raised and lowered by slowing down and speeding up colonic transit, respectively. Slow transit is characteristic of non-obese British women with gallstones and of non-obese peasants in a gallstone-prone mountain community. High biliary DCA predicts recurrence of gallstones and so does laxative usage, a pointer to constipation and therefore to slow transit. In some studies, at least, a high fibre intake is protective against gallstones. Much else besides fibre influences colonic function. Future studies of gallstone aetiology should include measurements of colonic function. Measures that speed up colonic transit should be tested for their ability to prevent gallstone formation in high-risk individuals.