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

Apolipoprotein B-100 gene Xba I polymorphism and cholesterol gallstone disease

The apolipoprotein (apo) B gene Xba I polymorphism is associated with alterations in serum lipids. Disturbances in serum lipids may be a risk factor for cholesterol gallstone disease. However, the relation between the Xba I polymorphism and cholesterol gallstones is unknown. This study was aimed at characterizing the polymorphism of the apo B gene Xba I in patients with gallbladder stones and the association of Xba I polymorphism with serum lipids. Xba I genotypes were measured by PCR-RFLP, and serum lipids assayed in 190 patients with gallbladder stones and 441 control subjects. The frequency of the X+/- genotype (20.63 vs. 7.94%) and X+ allele (10.79 vs. 3.97%) was significantly higher in the patient group than in the control group. Patients with the X+/- genotype had a significantly higher concentration of total cholesterol, low-density lipoprotein (LDL)-cholesterol, and apo B in serum than patients with the X-/- genotype. The X+ allele of the apo B gene is characterized by a higher cholesterol concentration and a higher LDL-cholesterol concentration in serum, and it may be a marker for increased risk of cholesterol gallstone disease.

Acute pancreatitis in the postpartum period: a population-based case-control study

OBJECTIVE

To determine relationships among pregnancy (during and postpartum), acute pancreatitis, and gallstones.

PATIENTS AND METHODS

In this retrospective population-based case-control study, we identified all 12- to 50-year-old Rochester, Minn, females diagnosed between 1976 and 1991 as having acute pancreatitis (cases). For each case, we matched 4 women of the same age (+/- 6 years) with no history of acute pancreatitis (controls). Acute pancreatitis was defined as associated with pregnancy if it occurred from 10 months prior to delivery to delivery and with the postpartum period if it occurred within 10 months of the date of delivery. Logistic regression was used to assess associations between pregnancy-related acute pancreatitis, age, gallstone occurrence, and alcohol use.

RESULTS

In a cohort of 61 women who developed acute pancreatitis and 244 controls, the relative risk for acute pancreatitis associated with pregnancy was 1.43 (95% confidence interval, 0.61-3.40). All 10 cases of acute pancreatitis associated with pregnancy occurred in the postpartum period. Gallstones were present in 6 of them compared with 13 of 51 women with non-pregnancy-related acute pancreatitis (P < .05). Women with postpartum-related pancreatitis were younger than those with non-pregnancy-related pancreatitis (mean, 28 vs 36 years; P < .05). Alcohol was not associated with pregnancy-related pancreatitis.

CONCLUSIONS

Acute pancreatitis during the postpartum period is not directly related to pregnancy but is associated with gallstones and occurs in younger women.

Alterações histológicas da vesícula biliar litiásica: influência no diagnóstico e tratamento por videolaparoscopia

O objetivo deste trabalho é avaliar a influência das alterações histológicas presentes na vesícula biliar litiásica no diagnóstico e tratamento videolaparoscópico da afecção. De janeiro de 1994 a maio de 1997 foram estudados 290 pacientes submetidos à colecistectomia videolaparoscópica para tratamento de colelitíase. Realizou-se avaliação dos parâmetros morfológicos da vesícula biliar calculosa através de estudo histológico e correlacionaram-se essas alterações à propedêutica pré-operatória e tratamento cirúrgico. O estudo histológico permitiu classificar as vesículas biliares no grupo das colecistites crônicas em 71,7% dos casos e colecistites agudas em 13,1 %. Em 15,2% das vesículas estudadas não foram evidenciadas alterações histológicas, sendo estas classificadas como normais. A participação do sexo masculino foi mais expressiva no grupo de pacientes cuja vesícu1a apresentava sinais inflamatórios agudos (31,6%). A ultra-sonografia apresentou baixa sensibilidade (36,8%) no diagnóstico da colecistite aguda. Todos os pacientes portadores de vesículas normais foram operados por videolaparoscopia, sendo que, em pacientes portadores de colecistite aguda, houve a necessidade de conversão para a via aberta em 21,1% dos casos. Vesículas biliares apresentando alterações crônicas associaram-se de maneira estatisticamente significante a cálculos mistos. Concluiu-se pela baixa sensibilidade da ultra-sonografia no diagnóstico da colecistite aguda e pela elevada eficácia da videolaparoscopia no tratamento de pacientes portadores de colelitíase associada a vesícula sem alterações histológicas.

Association of diabetes, serum insulin, and C-peptide with gallbladder disease

An inconsistent association has been found between gallbladder disease and diabetes mellitus. We hypothesized that insulin resistance rather than diabetes status may be a primary factor involved in gallstone formation. A total of 5,653 adult participants in the third United States National Health and Nutrition Examination Survey without known diabetes underwent gallbladder ultrasonography and phlebotomy after an overnight fast for measurement of serum insulin, C-peptide, and glucose. Gallbladder disease was defined as ultrasound-documented gallstones or evidence of cholecystectomy. Subjects were characterized as having normal fasting glucose (<110 mg/dL), impaired fasting glucose (110 to <126 mg/dL), or undiagnosed diabetes (>/=126 mg/dL). After controlling for other known gallbladder disease risk factors, among women, undiagnosed diabetes was associated with increased risk of gallbladder disease (prevalence ratio [PR] = 1.91, 95% confidence interval [CI] = 1.29-2. 83); whereas impaired fasting glucose was unassociated. Gallbladder disease risk in women increased with levels of fasting insulin (PR = 1.63, 95% CI = 1.11-2.40) and C-peptide (PR = 2.07, 95% CI = 1.32-3. 25) comparing highest to lowest quintiles. However, the association of gallbladder disease with undiagnosed diabetes was not diminished when the model included fasting insulin (PR = 1.85, 95% CI = 1.24-2. 77). In men, there was a statistically nonsignificant association with undiagnosed diabetes (PR = 2.11, 95% CI = 0.76-5.85), but no association of gallbladder disease with insulin or C-peptide. Among women higher fasting serum insulin levels increased the risk of gallbladder disease, but did not account for the increased risk in persons with diabetes.

Abdominal symptoms: do they predict gallstones? A systematic review

BACKGROUND

Our objective was to evaluate the diagnostic accuracy of abdominal symptoms in gallstones in studies using ultrasonography or oral cholecystography as the reference standard and to assess the extent to which variability in diagnostic accuracy is explained by patient selection and other characteristics of study design.

METHODS

A Medline search (1966-1998) was conducted in combination with reference checking for further relevant publications. Two independent assessors selected controlled studies that included patients > or =18 years of age. Articles were excluded if sensitivity and specificity could not be extracted or the included patients were at extraordinary risk for gallstones. Seven abdominal symptoms were evaluated. Modification of the diagnostic accuracy by clinical setting, extent of the disease, blinding, age, and sex was analysed by using logistic regression.

RESULTS

A total of 24 publications were included. The symptoms 'biliary colic', 'radiating pain', and 'analgesics used' were consistently related to gallstones. The setting of the study had a significant effect on the diagnostic accuracy of these symptoms. The unadjusted, pooled diagnostic odds ratios, however, were low (2.6 (95% confidence interval, 2.4-2.9), 2.8 (2.2-3.7), and 2 (1.6-2.5), respectively). The diagnostic odds ratio of biliary colic increased with the extent of gallstone disease (13.3 (4.2-42).

CONCLUSIONS

Although biliary colic was specific for gallstones, 80% of the referred patients with gallstones presented with other abdominal symptoms. There is no current evidence that justifies the use of single abdominal symptoms, other than biliary colic, in the diagnosis of symptomatic gallstones. Further research should focus on the prognosis of patients with non-specific abdominal symptoms and gallstones.

Apolipoprotein E genotype and the risk of gallbladder disease in pregnancy

The E4 allele of apolipoprotein E (apoE4) has previously been associated with symptomatic gallstone disease. The aim of this study was to determine if apoE4 is associated with the development of gallbladder sludge and/or stones during pregnancy. We conducted a nested case-control study based on an ongoing cohort study of gallbladder disease in pregnancy. Women in this study receive gallbladder ultrasounds in each trimester of pregnancy. Cases (n = 52) were defined as women with incident gallbladder sludge or stones diagnosed at the third trimester ultrasound. Controls (n = 104) were defined as women without gallbladder sludge or stones on any of 3 study ultrasounds. ApoE genotyping was performed from stored white blood cell pellets. Data were analyzed by stratified analysis and multivariate logistic regression. Cases and controls were similar in baseline characteristics. Forty-two women had sludge, 6 had gallstones, and 4 had both sludge and stones. After adjusting for risk factors such as age, parity, and body mass index, the odds ratio (OR) for the association between heterozygosity or homozygosity for the apoE4 allele and incident gallbladder sludge or stones was 0.91 (95% confidence interval [CI], 0.41-2.02). Further adjustment for family medical history and serum lipid levels did not substantially change these results (OR, 0.73; 95% CI, 0.29-1.82). In conclusion, apoE4 appears to have little or no overall association with the development of new gallbladder sludge or stones in pregnancy. However, an effect could not be ruled out in certain subgroups, such as blacks or women who are homozygous for apoE4.

Impaired glucose tolerance, diabetes mellitus, and gallstone disease: an extended study of male self-defense officials in Japan

Few studies have investigated the relation between glucose tolerance status and ultrasonographically determined gallstone disease. Using a 75-g oral glucose tolerance test, we examined the association of impaired glucose tolerance (IGT) and non-insulin-dependent diabetes mellitus (NIDDM) with gallstone disease in Japanese men. Subjects were men aged 48 to 59 of the Japan Self-Defense Forces who received a preretirement health examination between October 1986 to December 1994. After exclusion of 12 men under insulin treatment in the consecutive series of 7637 men, 174 were found to have gallstones; 103 were at the state of postcholecystectomy, and 6899 had normal gallbladder. IGT and NIDDM were associated with a modestly increased risk of gallstone disease; adjusted odds ratios were 1.3 (95% confidence interval [CI]: 0.9-1.8) for IGT and 1.3 (95% CI: 0.8-2.0) for NIDDM after adjustment for hospital, rank, smoking, alcohol use, and body mass index. Adjusted odds ratio for IGT and NIDDM combined was 1.3 (95% CI: 1.0-1.7, p=0.08). When prevalent gallstones and postcholecystectomy were considered separately, NIDDM showed a significant, positive association with postcholecystectomy, but not with prevalent gallstones. The findings add to evidence that glucose intolerance is associated with a modest increase in the risk of gallstone disease.

Clinical manifestations of gallstone disease: evidence from the multicenter Italian study on cholelithiasis (MICOL)

Despite the many efforts to delineate the clinical manifestations of gallbladder disease, the precise symptom complex associated with gallstones is still a matter of debate, and even the existence of gallstone-specific symptoms has been questioned. We carried out a large population-based cross-sectional study (MICOL) to identify symptoms significantly related to gallstones. Fourteen centers throughout Italy enrolled 29,504 subjects aged 30 to 69 years. All subjects were administered an ultrasonographic examination of the upper abdomen and a precoded questionnaire. All subjects were divided into 4 groups: 25,374 (86.0%) gallstone-free subjects (GF), 1,832 (6.2%) patients with gallstones not previously diagnosed (GNPD), 638 (2.2%) patients with gallstones previously diagnosed (GPD), 1,660 (5.6%) patients with a history of cholecystectomy for gallstones (CC). In logistic regression analysis, pain at epigastrium and, even more, pain at right hypocondrium were significantly associated with gallstones. For pain at right hypocondrium, this association progressively increased from GNPD (OR = 1.60, 95% CI = 0.97-2.65) to GPD (OR = 8.77, 95% CI = 5.27-14.61) to CC (OR = 59.40, 95% CI = 43.87-80.42). Absence of heartburn combined with right hypocondrium or epigastrium pain and intolerance to fried or fatty food were also significantly related to gallstones. We also found some pain characteristics significantly associated with gallstones, i.e., pain radiated to the right shoulder, forcing the patient to rest, occurring soon after meals or unrelated to meals, not relieved by bowel movements, and frequently accompanied by gallstone-related morbidities. We developed a probability tree reporting the cumulative probability of having gallstones for each combination of those symptoms and characteristics of pain significantly associated with gallstones. In conclusion, we have identified symptoms and signs significantly associated with gallstones. We have shown that there is an increase in frequency and severity of these symptoms and signs across the different stages of gallstone disease. We have proposed a complex of symptoms and signs significantly associated with gallstones that might help physicians in clinical decision making.

The prevalence and natural history of gallstones in spinal cord injured patients

BACKGROUND

Individuals with a spinal cord injury are at increased risk for the development of gallstones. Because these patients cannot reliably manifest classic symptoms of biliary colic, they may be more likely to present with advanced biliary complications than patients with intact abdominal innervation. The natural history of gallstones in spinal cord injured patients has not been described.

STUDY DESIGN

All spinal cord injured patients seen at the Seattle Veterans Affairs Medical Center from January 1, 1993, to December 31, 1997 were included in the study. For each patient, the presence or absence of gallstones had been determined previously through screening abdominal ultrasonographic evaluations. Pertinent demographic information was obtained from medical records and patient interviews. Patients with gallstones were followed until death, cholecystectomy, or the conclusion of the study, and the annual incidence of biliary complications and patients requiring a cholecystectomy were determined. The prevalence of gallstones was established by studying the subset of patients seen at the Seattle Spinal Cord Injury Unit from January 1, 1995 to December 31, 1997.

RESULTS

Among the spinal cord injured patients, 31% either had gallstones or had undergone a cholecystectomy at some point after their injury. Increasing age, female gender, and greater severity of injury were risk factors for the formation of gallstones. Over the first 5 years after the diagnosis of gallstones, the annual incidence of cholecystectomy or biliary complications was 6.3% and 2.2%, respectively.

CONCLUSIONS

Spinal cord injured patients are at increased risk for the development of gallstones. Patients with gallstones are at an increased risk for the development of biliary complications compared with neurologically intact patients, but the magnitude of this risk does not warrant prophylactic cholecystectomy.

Long-term ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute cholecystitis in patients with gallbladder stones: a cohort analysis

Whether ursodeoxycholic acid (UDCA) therapy alters the long-term clinical course of gallstones (GS) without stone dissolution remains unknown. We aimed to clarify the relationship between long-term UDCA therapy and risks of biliary pain or acute cholecystitis in GS patients. We also aimed to identify factors affecting the natural course, and to explore a simple patient selection criteria for UDCA therapy. A cohort of 527 uncomplicated GS patients with or without UDCA (600 mg/d) followed for up to 18 years was analyzed. Patients who had frequent attacks or were complicated with cholecystitis were converted to cholecystectomy. History and UDCA therapy were identified on Cox analysis as 2 factors affecting the long-term clinical course. In patients without therapy, history was the only predictor of biliary pain among various patient or stone characteristics; biliary pain was rare in asymptomatic patients, while frequent in symptomatic patients (P <.001). UDCA therapy was associated with reduced risk for biliary pain in both symptomatic (62% vs. 92% in untreated patients at 10 years; P <.001; relative risk, 0.19; 95% CI, 0.10-0.34) and asymptomatic patients (6% vs. 12% in untreated patients at 10 years; P =.037; relative risk, 0.19; 95% CI, 0.04-0.91). Risk for the conversion was also reduced in UDCA-treated symptomatic patients (26% vs. 88% in untreated patients at 10 years, P <.001; relative risk, 0.08; 95% CI, 0.03-0.22). These effects were independent of stone dissolution. Three factors were identified on Cox analysis as affecting GS dissolution: radiolucency, small size (<10 mm) of stones, and visualized gallbladder (GB) on cholecystogram. A selection criteria based on these appears to exhibit high sensitivity (74%) and specificity (95%) for dissolution. UDCA therapy might be considered in symptomatic patients fulfilling these criteria, and also in patients who have significant surgical risk, because the longterm therapy is clearly associated with reduced risk of biliary pain and acute cholecystitis.

[Gastrointestinal complications of diabetes mellitus]

BACKGROUND

Diabetes mellitus leads to a broad spectrum of symptoms and manifestations in the field of gastroenterology.

BASIS

This article reviews the pathophysiology, differential diagnoses and secondary diseases of the gastrointestinal tract in diabetic patients.

CLINICAL APPEARANCE

Motility disorders, infectious complications, secondary diseases of the stomach, liver, pancreas, gall bladder, small and large bowel are considered and discussed. Diagnostic and therapeutic approaches for the management of diabetic enteropathy are presented.

CONCLUSION

The new strategies in diagnosis and therapy for a successful prevention or treatment of gastrointestinal complications due to diabetes mellitus need good cooperation of clinical specialties.

Dietary intake and gallbladder disease: a review

OBJECTIVE

Dietary intake has long been looked upon as a potentially modifiable risk factor for gallbladder disease (GBD), here defined as either having gallstones or having had surgery for gallstones. This paper reviews the epidemiological evidence for an association between dietary intake and GBD, focusing on six dietary factors that have received the most attention in studies in this area: energy intake, fatty acids, cholesterol, carbohydrates and fibre, calcium and alcohol. The objectives of this review are to evaluate the potential usefulness of altering the diet to prevent GBD and to consider future research in this area.

DESIGN

We reviewed all English-language epidemiological studies on diet and cholelithiasis that were cross-sectional, cohort or case-control in design and that were indexed in the Medline database from 1966 to October 1997.

RESULTS

A positive association was suggested with simple sugars and inverse associations with dietary fibre and alcohol. No convincing evidence was found for a role for energy intake or intake of fat or cholesterol. Variable means of ascertaining cases and inaccurate measurement of dietary intake may contribute to variation in results across studies.

CONCLUSIONS

Some specific components of the diet that may affect GBD include simple sugars, fibre and alcohol, but whether risk for GBD can be reduced by altering intake of a specific dietary factor has not been established. Although no specific dietary recommendations can be made to reduce risk of GBD per se, a 'healthy' diet aimed at reducing risk of other diseases might be expected to reduce risk for GBD as well.

Impaired glucose tolerance, diabetes mellitus, and gallstone disease: an extended study of male self-defense officials in Japan

Few studies have investigated the relation between glucose tolerance status and ultrasonographically determined gallstone disease. Using a 75-g oral glucose tolerance test, we examined the association of impaired glucose tolerance (IGT) and non-insulin-dependent diabetes mellitus (NIDDM) with gallstone disease in Japanese men. Subjects were men aged 48 to 59 of the Japan Self-Defense Forces who received a preretirement health examination between October 1986 to December 1994. After exclusion of 12 men under insulin treatment in the consecutive series of 7637 men, 174 were found to have gallstones; 103 were at the state of postcholecystectomy, and 6899 had normal gallbladder. IGT and NIDDM were associated with a modestly increased risk of gallstone disease; adjusted odds ratios were 1.3 (95% confidence interval [CI]: 0.9-1.8) for IGT and 1.3 (95% CI: 0.8-2.0) for NIDDM after adjustment for hospital, rank, smoking, alcohol use, and body mass index. Adjusted odds ratio for IGT and NIDDM combined was 1.3 (95% CI: 1.0-1.7, p=0.08). When prevalent gallstones and postcholecystectomy were considered separately, NIDDM showed a significant, positive association with postcholecystectomy, but not with prevalent gallstones. The findings add to evidence that glucose intolerance is associated with a modest increase in the risk of gallstone disease.

Prediction of common bile duct stones by noninvasive tests

OBJECTIVE

To define accurate and useful predictors of common bile duct stones (CBDS).

SUMMARY BACKGROUND DATA

The ability to predict CBDS with noninvasive tests can avoid unnecessary, costly, or risky procedures.

METHODS

All patients referred for examination for CBDS by endoscopic ultrasonography (EUS) from 1993-1996 were prospectively entered in a database. In a first sample selected randomly from the whole population, predictors of CBDS were determined by univariate analysis and logistic regression. Predictors were subsequently tested in that sample and in the rest of the population. A separate analysis was done for patients planned for cholecystectomy.

RESULTS

Eight hundred and eighty patients (328 men, 552 women), aged 57.8 +/- 17 years (range 16-94), were included. The prevalence of CBDS was 18.8%. Age, serum levels of bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase (GGT), and alkaline phosphatase, and the existence of jaundice and fever, a dilated bile duct, and a pathologic gallbladder were found to be associated with CBDS. Logistic regression was undertaken separately for patients younger than 70 years (predictors: GGT >7 x normal; pathologic gallbladder; dilated bile duct) and older than 70 years (predictors: GGT >7 x normal; fever > 38 degrees C; dilated bile duct). Odds ratios were 3 to 6.7. The model was satisfactorily applicable to the second sample; age <70 years: chi2 = 3.3 (NS); age >70 years: chi2 = 3.8 (NS). In patients younger than age 70 and planned for cholecystectomy, the combination of the level of GGT and dilated bile duct predicted CBDS accurately.

CONCLUSIONS

A simple screening of patients at risk for CBDS can be achieved with three predictive criteria adapted for the patient's age.

Progesterone alters biliary flow dynamics

OBJECTIVE

To test the hypothesis that progesterone alters sphincter of Oddi and gallbladder function and, therefore, bile flow dynamics.

SUMMARY BACKGROUND DATA

Although the effects of progesterone on the biliary tract have been implicated in the increased incidence of gallstones among women, the specific effects of prolonged elevation of progesterone levels, such as occurs with contraceptive progesterone implants and during pregnancy, on the sphincter of Oddi and biliary flow dynamics are still incompletely understood.

METHODS

Adult female prairie dogs were randomly assigned to receive subcutaneous implants containing either progesterone or inactive pellet matrix only. Hepatic bile partitioning and gallbladder emptying were determined 14 days later using 99mTc-Mebrofenin cholescintigraphy.

RESULTS

Significantly less hepatic bile partitioned into the gallbladder in progesterone-treated than in control animals. The gallbladder ejection fraction was significantly reduced from 73+/-6% in controls to 59+/-3% in the progesterone-treated animals. The rate of gallbladder emptying was significantly reduced from 3.6+/-0.3%/minute to 2.9+/-0.1%/minute.

CONCLUSIONS

Progesterone administered as subcutaneous implants alters partitioning of hepatic bile between gallbladder and small intestine and, therefore, gallbladder filling. Progesterone also significantly impairs gallbladder emptying in response to cholecystokinin. The effects of progesterone on the sphincter of Oddi and the gallbladder may contribute to the greater prevalence of gallstones and biliary motility disorders among women.

Diet, physical activity, and gallstones--a population-based, case-control study in southern Italy

BACKGROUND

Gallstones are a highly prevalent condition; however, the nutritional and lifestyle risk factors of this disease are not well understood.

OBJECTIVE

We evaluated the association between diet, physical activity, and incident cases of gallstones diagnosed by ultrasound in a population-based, case-control study.

DESIGN

One hundred patients with newly diagnosed gallstones and 290 randomly selected control subjects without gallstones were enrolled in the study. The presence of gallstones was determined by ultrasonography. Both patients and control subjects completed a questionnaire about their usual diet and physical activity for the 12 mo before the ultrasonography. The association between diet and physical activity and risk of gallstone formation was analyzed by using multiple logistic regression.

RESULTS

Body mass index and intake of refined sugars were directly associated with risk of gallstone formation, whereas physical activity, dietary monounsaturated fats, dietary cholesterol, and dietary fibers from cellulose were inversely associated with risk of gallstone formation. Saturated fats were a risk factor for gallstone formation and the association appeared to be stronger for men than for women.

CONCLUSION

These findings suggest that a sedentary lifestyle and a diet rich in animal fats and refined sugars and poor in vegetable fats and fibers are significant risk factors for gallstone formation.

Prevalence of gallstones in sonographic surveys worldwide

The use of diagnostic sonography allows determination of the prevalence of gallstones in a representative sample of the general population. The objective of this article is to review the reports of sonographically based studies of gallstone prevalence in the world literature. All available published epidemiologic studies on the prevalence of cholecystolithiasis as determined by diagnostic sonography are summarized. The sonographically based studies published to date confirm that there are significant regional differences in the prevalence of gallstones. Certain risk factors, notably age and heredity, are present worldwide.

Gallstone disease in high-altitude Peruvian rural populations

OBJECTIVE

Cholelithiasis is a common problem in hospitals of the Peruvian Andes; however, its prevalence in Andean communities is unknown. To estimate the prevalence of gallstone disease in this locale, we conducted a cross-sectional community study in three high-altitude Peruvian rural villages (i.e., > 3000 m above sea level).

METHODS

We examined 911 volunteers > 15 yr of age from three villages for gallstone disease by history and ultrasonography. Risk factors for gallstone disease were examined in 382 volunteers from one village.

RESULTS

The age-adjusted prevalence of gallstone disease ranged from 4-10% in men and from 18-20% in women. Women had significantly higher age-adjusted prevalence rates than did men. The prevalence of gallstone disease increased significantly with age and decreased significantly with alcohol consumption. Although not statistically significant, we found a positive association between gallstone disease and body mass index.

CONCLUSION

The results of this study indicate that gallstone disease, commonly perceived as a disease of the developed world, is also a common problem in high-altitude Peruvian communities.

Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics, Amerindians, and Maoris

BACKGROUND & AIMS

The etiology of cholesterol gallstones is multifactorial, with interactions of genes and the environment. The hypothesis that aborigine cholesterol lithogenic genes are widely spread among Chileans, a population with a high prevalence of gallstones, was tested.

METHODS

Medical history and anthropometric measurements were obtained and abdominal ultrasonography was performed in 182 Mapuche Indians, 225 Maoris of Easter Island, and 1584 Hispanics. Blood groups, DNA, lipids, and glucose were analyzed. The Amerindian Admixture Index and mitochondrial DNA (mtDNA) assessed the ethnicity and degree of racial admixture.

RESULTS

Amerindian Admixture Index was 0.8 in Mapuches and 0.4 in Hispanics. All Mapuches, 88% of Hispanics, but none of Maoris had Amerindian mtDNA haplotypes. Age- and sex-adjusted global prevalence of gallstone disease was higher in Mapuches (35%) than in Hispanics (27%) and Maoris (21%). Compared with Hispanics, the youngest group of Mapuches had the greatest corrected risk of gallstones: odds ratios of 6.0 in women and 2.3 in men. In contrast, the gallstone risk in Maoris was lower compared with Hispanics: odds ratios of 0.6 for women and 0.5 for men.

CONCLUSIONS

Cholesterol lithogenic genes appear widely spread among Chilean Indians and Hispanics. They could determine the early formation of gallstones and explain the high prevalence of gallbladder diseases among some South American populations.

Gallbladder contents and fasting gallbladder volumes during and after pregnancy

BACKGROUND

A high risk of developing sludge or gallstones has been associated with pregnancy. The aim of this study was to relate the prevalence of sludge and gallstones during and shortly after pregnancy to fasting gallbladder volume as an indicator of gallbladder motility.

METHODS

The population included 114 apparently healthy pregnant women from the Outpatient Clinic of Obstetrics of a large regional hospital and from the practices of regional midwives. Ultrasonography of the gallbladder was performed at weeks 15, 25, and 35 of gestation and at week 3 and month 6 postpartum.

RESULTS

At gestational week 15, 3 women had gallstones and 10 had sludge (mean volume, 33.8 ml), and 99 women had a normal gallbladder (mean volume, 30.5 ml). At week 25, 1 woman with a normal gallbladder formed gallstones and underwent cholecystectomy shortly after, and 22 women had sludge, of whom 13 had a normal gallbladder at first examination (mean volume, 33.2 ml). In 88 women with normal gallbladders (of whom 2 had sludge at week 15) mean volume was 31.9 ml. At week 35, 2 women had gallstones, and 21 had sludge (mean volume, 30.5 ml). In the remaining 79 women the gallbladders were clear (mean volume, 29.5 ml). Eight women developed sludge and two women gallstones in normal gallbladders at week 25. Seven women with sludge at week 25 had a normal gallbladder at week 35. Three weeks postpartum only 10 of 100 women had sludge (mean volume, 29.1 ml). Of these 10, 9 women had a normal gallbladder at week 35. Twenty of 21 women with sludge at week 35 had normal gallbladders week 3 postpartum. Gallstones found at week 35 had disappeared. In the women with a normal gallbladder the mean volume was decreased to 19.7 ml (P < 0.0001). Six months postpartum, sludge was found in 6 (mean volume, 18.4 ml) of 93 women (mean volume, 20.3 ml), of whom 5 had a normal gallbladder at week 3 postpartum. Only 61 women showed a normal gallbladder at each examination of the study. No differences in patient characteristics were found between women with normal gallbladders and those with sludge or gallstones.

CONCLUSIONS

Fasting gallbladder volume was increased in all pregnant women. This could not explain the formation of sludge or gallstones during gestation. Decrement of gallbladder volumes after delivery was faster in normal, clear gallbladders. More than a prerequisite, increased fasting gallbladder volume seemed to be a permissive factor of pregnancy-associated gallstone formation.

Organic causes of dyspepsia, and discriminating functional from organic dyspepsia

A wide variety of disorders affecting the upper gastrointestinal tract, as well as systemic disorders, are associated with symptoms of dyspepsia. The more important of these conditions are considered in this chapter, with particular reference to their symptom patterns on presentation. The differentiation, on clinical grounds, between these organic causes of dyspepsia and functional dyspepsia remains an important area of research. Those aspects of the history and physical examination most relevant to this distinction are also considered.

Pain patterns after distension of the gallbladder in patients with acute cholecystitis

BACKGROUND

Visceral pain is characterized by poor pain localization and a referred or radiating pain pattern. Its clinical importance in the abdomen is stressed by the finding that about one-third of patients still complain of abdominal pain after cholecystectomy. A better understanding of symptoms arising from the gallbladder and the underlying pathophysiology is therefore desirable. The aim of the present study was consequently primarily to characterize the symptom patterns after distension of the gallbladder. Secondary aims were to describe the pressure-volume relation in the gallbladder and the cystic duct opening pressure.

METHODS

Twelve patients (nine women, three men) treated with cholecystostomy for acute cholecystitis were investigated. Simultaneous cholescintigraphy and measurement of changes in intraluminal gallbladder pressure after injections of saline through a gallbladder catheter were performed. After each injection of saline the localization of pain and the presence of nausea and vomiting were registered. The injections continued until the patient felt abdominal pain necessitating cessation of the investigation or until the cystic duct opened (visualized on cholescintigraphy).

RESULTS

Distension of the gallbladder caused pain in 10 of the 12 patients. In 70% the pain was localized under the right costal margin or in the epigastrium. No mathematical formula could describe the pressure-volume relation in the gallbladder. The cystic duct opening pressure varied between 3 and 44 mmHg.

CONCLUSIONS

Pain caused by increased gallbladder pressure is localized mostly, but not always, under the right curvature and in the epigastrium. A substantial variation in cystic duct opening pressure was found.

Diet and gallstones in Italy: the cross-sectional MICOL results

Fifteen thousand nine hundred ten men and 13,674 women (age, 30-69 years) were enrolled in an epidemiological survey of the general population, between December 1984 and April 1987. Each participant was submitted to ultrasonography (US) of the gallbladder and completed a food-frequency questionnaire, covering 38 food items. A common portion size was identified and subjects were asked how often each item was consumed. Nutrient intake was computed by multiplying the intake frequency and nutrient content per portion for each item, and then by summing the product over all foods. Each nutrient intake was adjusted for energy intake. Alcohol intake was calculated by summing the consumption of wine, beer, and liquor. Having excluded subjects aware of having gallstones (GS) or previously submitted to cholecystectomy (to avoid prothopatic bias), 787 males and 1,014 females with GS and 14,272 males and 10,836 females without GS were available for analysis. Relative risks (RR) of GS were computed by quintiles of nutrient intake. The overnight fasting period was calculated as the difference between the specified time of dinner and the time of the next meal (breakfast or lunch). A significant negative association was found between RR of GS and total energy intake for males (chi2 for trend = 8.37; P = .004), fiber intake for females (chi2 = 5.45; P = .02), and daily alcohol consumption for males (chi2 = 10.86; P = .001). A positive association was observed between RR of GS and carbohydrate (chi2 = 5.95; P = .01 for males; chi2 = 9.39; P = .002 for females) and protein intake only for males (chi2 = 10.92; P = .01). Prevalence of GS was higher among subjects who had an overnight fasting period of over 12 hours than subjects with that of less than 12 hours. (RR: 1.35; 95% CI: 1.01-1.80 for males; RR: 1.28; 95% CI: 1.03-1.60 for females). These data do not confirm that high energy intake is associated with an increased risk of GS. Factors protecting against GS comprise: low carbohydrate (males and females) and protein (males) intakes, high fiber (females) and moderate alcohol intake (males) consumption, and a shorter overnight fasting period for both sexes.

Impaired G protein function in gallbladder muscle from progesterone-treated guinea pigs

This study was designed to elucidate the mechanism of action of progesterone on gallbladder smooth muscle in guinea pigs. Adult male guinea pigs were treated with either progesterone (2 mg.kg-1.day-1) or saline for 7 days. Gallbladder muscle cells were isolated by enzymatic digestion with collagenase. Contractile responses to agonists were expressed as percent shortening from control cell length. [35S]guanosine 5'-O-(3-thiotriphosphate) ([35S]GTP gamma S)-binding properties of G proteins were assessed in crude membranes of gallbladder muscle with or without cholecystokinin octapeptide (CCK-8) stimulation. Gallbladder muscle cells from progesterone-treated guinea pigs exhibited an impaired contractile response to CCK-8, GTP gamma S, or aluminum fluoride but a normal response to potassium chloride or D-myo-inositol 1,4,5-trisphosphate compared with controls. Western blot analysis of gallbladder muscle revealed the presence of Gi1-2, Gi3, Gq/11, and Gs proteins. The maximal contraction induced by CCK-8 was blocked by pertussis toxin and Gi alpha 3-specific antibodies, but not by Gi alpha 1-2 or Gq/11 alpha antibodies. CCK-8 caused a significant increase in [35S]GTP gamma S binding to Gi alpha 3, but not to Gq/11 alpha or Gi alpha 1-2. The stimulation of Gi alpha 3 binding, however, was significantly reduced in gallbladder muscle membranes from progesterone-treated guinea pigs compared with that in control animals. In conclusion, progesterone might cause gallbladder hypomotility by downregulating Gi3 proteins.

Hepatobiliary alterations in patients with inflammatory bowel disease: a multicenter study. Caprilli & Gruppo Italiano Studio Colon-Retto

BACKGROUND AND METHODS

Four hundred and eighty-four patients with inflammatory bowel disease underwent clinical examination, ultrasonography, and biochemical liver function tests, to estimate the prevalence of hepatobiliary alterations. The patient group included patients without a history of liver disease. Controls were recruited from patients with functional symptoms.

RESULTS

More patients with ulcerative colitis than controls had liver steatosis and increased alkaline phosphatase levels. Factors increasing the probability of liver damage were long-standing disease, the presence of moderate/severe disease activity, and treatment with steroids and mesalazine. A significant association was found between biliary disease and long-standing colitis and also therapy with steroids and mesalazine. Alkaline phosphatase and aminotransferase levels were significantly higher in Crohn's disease patients than in controls. Hepatic and biliary damage was found more commonly in the 1st year after diagnosis.

CONCLUSIONS

The monitoring of hepatobiliary function is suggested for patients with inflammatory bowel disease, even in the absence of symptoms and history.

Prevalence and associated factors for gallstone disease: results of a population survey in Spain

We conducted a cross-sectional survey to determine the prevalence of gallstone disease (gallstone or cholecystectomy) in a random sample of the adult population of Guadalajara, Spain. The sample stratified by age and sex was drawn from the municipal census. Stratum sample sizes were proportional to population sizes and to the expected prevalence rates calculated through a meta-analysis of the European literature. The screening protocol included a gallbladder ultrasonography, a questionnaire on personal and family history, a physical examination, and a blood sample for biochemical determinations. The response rate was 61.2%. The overall prevalence of gallstone disease was 9.7% (95% CI, 7.3-12.0). Prevalence was higher (but not statistically significant) in women (11.5%; 95% CI, 8.2-14.7) than in men (7.8%; 95% CI, 4.6-11.1). After controlling for confounding by multiple logistic regression, increasing age, body mass index, dyspeptic symptoms, smoking habit, and use of hypolipidemic drugs were positively associated with gallstone disease. Total serum cholesterol and alcohol consumption were negatively associated.

Diagnostic methods in dyspepsia: the usefulness of upper abdominal ultrasound and gastroscopy

OBJECTIVES

To examine the diagnostic value of gastroscopy and upper abdominal ultrasound, which are frequently used as primary tests in dyspeptic patients in general practice. To test the influence of age for accuracy of both diagnostic methods.

DESIGN

Clinical study.

SETTING

Four health centres in Kuopio Province, Finland.

SUBJECTS

Four hundred unselected consecutive dyspeptic patients (91 less than 45 years of age) who consulted their general practitioners.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values (PV), efficiency and usefulness index (UI) were calculated for upper abdominal ultrasound and for gastroscopy in detecting the causes of dyspepsia in primary care. Final diagnosis was determined after one year follow-up.

RESULTS

The sensitivity of upper abdominal ultrasound in detecting the cause of dyspepsia was 0.07, the specificity 0.91, PV+ 0.36, PV- 0.56, and UI -0.001. Ultrasound was not more efficient in older patients. Gastroscopy was the most efficient method with a sensitivity of 0.75, specificity 1.00, PV+ 0.99, PV- 0.83 and UI 0.56. The usefulness of gastroscopy was even better among patients over 45 years of age.

CONCLUSIONS

The usefulness of upper abdominal ultrasound is low regardless of patient's age. Gastroscopy is superior to upper abdominal ultrasound as a first line diagnostic method in diagnosing dyspepsia, especially among patients over 45 years of age.

Differences in diet and food habits between patients with gallstones and controls

OBJECTIVE

To compare the food, energy, macronutrient and micronutrient intake of patients with gallstones to those of a control group of similar demographic characteristics.

DESIGN

Patient-control study.

SUBJECTS

54 gallstone patients and 46 control subjects.

METHODS

Two 24-hour dietary recalls and a "food frequency intake" questionnaire were obtained from patients and controls. In both groups, the presence/absence of gallstones was confirmed by ultrasonography. Participants answered a questionnaire on their physical activity patterns.

RESULTS

Gallstone patients consumed less food per day (g/day) and less fish and fruits than did control subjects. They also showed greater intakes of cereals, oils, sugars and meats than did control subjects and ate fewer meals per day, tending to omit evening snacks and more substantial evening meals. Further, patients spent less time walking and slept more than did control subjects. They also experienced fluctuations in body weight with greater frequency. Patients consumed more total calories (energy) and fats (especially monounsaturated fatty acids and saturated fatty acids), and less fiber, folate and magnesium than did control subjects. Women with gallstones were shown to have significantly higher intakes of total fats, monounsaturated fatty acids, saturated fatty acids and cholesterol, and significantly lower intakes of fiber, folate, magnesium, calcium and vitamin C than control women. For all vitamins and minerals studied, patients showed a greater percentage of intakes below those recommended.

CONCLUSIONS

Dietary intervention might provide a method of avoiding the recurrence of gallstones as well as a method of prevention control subjects.

Gallbladder motility change in late pregnancy and after delivery

OBJECTIVES

The incidence of gallstone disease has increased recently in Korea and there seems to be an increased prevalence of gallstones when in association with pregnancy. Although the pathogenesis is incompletely defined, and altered motility of the gallbladder may contribute to the increased risk of gallstones during pregnancy.

METHODS

We measured gallbladder volume using real-time ultrasonography to find out the mechanism for the changes of gallbladder motility during late pregnancy. Eighteen pregnant women took the gallbladder ultrasonography during their last trimester of pregnancy and after delivery; gallbladder volume and ejection fraction were calculated in each patient.

RESULTS

Fasting gallbladder volumes increased significantly in the last trimester of pregnancy (25.28 +/- 14.26ml) compared with postpartum (17.44 +/- 5.82 ml) (p < 0.05). Gallbladder volumes measured after fatty meals showed more increment in pregnant women (10.13 +/- 7.19 ml) than in those after delivery (4.34 +/- 3.36 ml) (p < 0.005). A significantly reduced gallbladder ejection fraction was found in the pregnant group (60.56 +/- 18.80%) compared with those after delivery (77.48 +/- 13.37%) (p < 0.005).

CONCLUSION

Gallbladder motility in late pregnancy shows significant impairment compared with that in postpartum. Thus, we suggest that gallbladder hypomotility may occur during late pregnancy, and this impairment of gallbladder motility may play an important role in gallstone formation.

Prevalence of gallbladder disease in diabetes mellitus

A study was undertaken to compare the prevalence of gallstone disease (gallstones observed on ultrasound or history of cholecystectomy) in 308 diabetics and 318 controls. There was a higher prevalence of gallstone disease (GSD) in diabetics (32.7%) compared to controls (20.8%; P < 0.001 chi-squared test). However, when gender was taken into account, the difference was only significant in females (diabetics 41.8% versus controls 23.1%; P < 0.001). Analysis by type of diabetes revealed that subjects with non-insulin-dependent diabetes mellitus (NIDDM) had a higher prevalence of GSD than controls for both genders: males-controls 18.1%, NIDDM 33.3% (P < 0.05), IDDM 15.6% ns; females-controls 23.1%, NIDDM 48.6% (P < 0.001), IDDM 36.3% (P < 0.05). On univariate analysis the following risk factors were associated with gallstones (P < 0.1): increased age, body mass index (BMI), triglycerides, LDL cholesterol, decreased HDL cholesterol, alcohol intake, family history of GSD, and female parity > 3. Using stepwise multiple, logistic regression, the following variables were identified as independently predictive of gallstones for each gender/diabetic combination: Males-NIDDM (N = 54), increased age, and decreased HDL; IDDM (N = 90), age and family history; Females-NIDDM (N = 74), increased age, diabetes, increased BMI, and decreased alcohol; IDDM (N = 91), increased BMI, age, decreased alcohol and family history. The proportion of subjects who underwent cholecystectomy was higher in females (46.7%) compared to males (21.7%; P < 0.01) but there were no differences between diabetics and controls in either sex. In conclusion, there was a higher prevalence of GSD in diabetics compared to controls. However, GSD is multifactorial and only in NIDDM females was diabetes an independent risk factor. The proportion of diabetics and controls with GSD who underwent cholecystectomy was equivalent.

Antilithiasic and hypocholesterolemic effects of diets containing autoclaved amylomaize starch in hamster

The prevention of cholelithiasis by dietary manipulation was investigated in hamsters receiving a fat-free lithogenic (L) diet or this diet in which sucrose was replaced by 12 (group AS12), 36 (group AS36), 48 (group AS48), or 72.5% (group AS72.5) of autoclaved amylomaize starch for seven weeks. All hamsters (6/6) had cholesterol gallstones in groups L and AS12, while only 3/6 hamsters in group AS36 had gallstones. None were present in groups AS48 and AS72.5. Except in group AS12, biliary cholesterol level and lithogenic index (LI) decreased significantly in hamsters receiving amylomaize starch. Plasma cholesterol concentration was reduced by 31 and 54%, respectively, in groups AS48 and AS72.5 as compared to group L. The concentration of esterified cholesterol in the liver was also reduced significantly in all groups receiving amylomaize starch. Hepatic cholesterogenesis was decreased by 74 and 65%, respectively, in groups AS48 and AS72.5 as compared to group L. The transformation of cholesterol to bile acids was increased in group AS72.5 (+152%) as compared to L, while fecal cholesterol excretion was strongly lowered (-31%). Amylomaize starch reduced the microbial transformation of cholesterol to coprosterol and epicoprosterol, and in group AS72.5 it decreased the degradation of cholic acid. Thus, this autoclaved amylomaize starch, which could be used in human nutrition, prevents cholelithiasis and lowers cholesterolemia.

Gallbladder motility, gallstones, and the surgeon

Cholecystectomy is one of the commonest surgical procedures in the Western world, with more than half a million procedures performed annually in the United States alone. In recent years, studies of gallstone pathogenesis and gallbladder disease have increasingly focused on abnormal gallbladder motility in the pathogenesis of some, if not all, gallbladder conditions. The control of gallbladder motility is complex and depends on an intricate interplay of neural and hormonal factors. An understanding of the control of gallbladder motility is crucial to the understanding of the mechanisms of gallstone formation and may help to explain the failure to cure symptoms after cholecystectomy in up to one third of patients. The purpose of this article is to outline mechanisms controlling gallbladder motility, examine recent developments in our understanding of this complex process, and relate changes in motility to common disease conditions of the gallbladder. The role of altered motility in the pathogenesis of gallstones is discussed and the effects of commonly performed surgical procedures such as truncal vagotomy and cholecystectomy on upper gut physiology are reviewed.

Prevalence of gallstone disease in a Swedish population

BACKGROUND

It has been claimed that the prevalence of gallstone disease (GD) is unusually high in Sweden. The prevalence is not known in either men or women.

METHODS

An ultrasound technique was used in a population-based screening study to identify all subjects with GD and subjects with a history of cholecystectomy. Eight hundred 40- and 60-year-old men and women were asked to participate.

RESULTS

Five hundred and fifty-six subjects were included, giving a response rate of 70%. The overall prevalence of GD was 15%. Women had a higher prevalence both at 40 and 60 years of age--11% and 25%, respectively--as compared with men, at 4% and 15%. Fifty per cent of subjects with GD had been cholecystectomized.

CONCLUSIONS

Gallstone disease is common in Stockholm, and the prevalence is equal to that of other European cities where similar studies have been performed. Subjects with GD were more often cholecystectomized than in other parts of Europe.

Prevalence of previously undiagnosed gallstones in a population with multiple risk factors

This study was aimed at investigating whether it is possible, on the basis of the presence of multiple factors, to select a population with a higher prevalence of gallstones than that predicted simply on the basis of age and sex. Thus, we selected and screened for the presence of previously undiagnosed gallstones subjects with at least four of the following variables: female sex, age over 40, obesity, diabetes, biliary colic, family history of gallstones or cholecystectomy, hypertriglyceridemia, parity, and oral contraceptive use. The a priori probability (or expected prevalence) of having previously undiagnosed gallstones was calculated for each subject on the basis of sex and age according to data derived from epidemiological studies performed in Italy in the general population. Among the 821 males and 3930 females participating in this study, previously undiagnosed gallstones (GS) were found in 135 (16.4%) males and 691 (17.6%) females. The ratio between observed and expected prevalence of GS was higher in males (3.09) than in females (2.32). The highest ratios between observed and expected prevalence of GS were found in the lowest classes of expected prevalence in both sexes. The best predictors of the presence of GS were age, biliary colic, and diabetes in males and age, biliary colic, obesity, and number of pregnancies in females. It is concluded that selection of subjects with multiple factors associated with GS increases the a priori probability of GS diagnosis by a factor 2 in females or 3 in males. Stricter selection criteria should be used for females.

Dyspepsia--how noisy are gallstones? A meta-analysis of epidemiologic studies of biliary pain, dyspeptic symptoms, and food intolerance

BACKGROUND

In contrast to earlier beliefs, it is nowadays assumed that no relation exists between dyspeptic symptoms and the presence of gallstones. Although many studies indeed failed to show a relation, each has been too small to exclude it. The aim of this meta-analysis is to systematically review epidemiologic studies and to synthesize the data.

METHODS

Twenty-one controlled studies on the association between gallstones and dyspeptic symptoms were analyzed after critical appraisal with regard to selection bias, blinding, confounding, and data presentation. Most of them had reasonable validity. Inconsistencies between results of the studies could not be explained by differences in study design or validity. There was a slight indication of publication bias.

RESULTS

Upper abdominal pain was consistently associated with gallstones (pooled odds ratios, about 2.0), with no preference for the right side. The findings on biliary pain were inconsistent. The results exclude with reasonable certainty an association between gallstones and 'classical' dyspeptic symptoms such as flatulence, heartburn, and acid regurgitation, bloating, and belching. An exception was nausea and vomiting (odds ratio, 1.4). Unspecified food intolerance was related to gallstones, but fat intolerance was not.

CONCLUSIONS

We conclude that it is not sensible to call dyspeptic symptoms 'gallstone dyspepsia', since component symptoms do not show a consistent relation with gallstones, and their diagnostic meaning over and above abdominal pain has not been evaluated.

Magnetic resonance imaging for the visualization of cholesterol gallstones in hamster fed a new high sucrose lithogenic diet

Cholesterol gallstone induction in hamster gallbladder is usually achieved by specific diets. An X-ray in vivo follow-up of cholelithiasis development in this species is impossible, since cholesterol gallstones are transparent as long as they are not calcified. Moreover, their size (0.2 to 1 mm) also prevents their detection by ultrasonography. The current study presents an in vivo cholesterol gallstone detection by magnetic resonance imaging in hamsters fed a new high sucrose diet containing a low proportion of cholesterol (0.015%) and a normal ratio of lipids (10%). The diet produced gallstones and an increase in the cholesterol saturation index in about 50% of animals after a 5-week feeding period. The visualization of gallstones by magnetic resonance imaging in anaesthetized animals required synchronization between breathing movements and image acquisition. A high magnetic field was also necessary to allow a fine image resolution, adapted to gallstone size. Two major advantages of this technique are a direct selection of lithiasic animals with a functional gallbladder (in spite of the presence of gallstones) and a possible adjustment of the treatment period of potential litholytic drugs.

Effect of D2-dopamine receptor antagonist levosulpiride on diabetic cholecystoparesis: a double-blind crossover study

BACKGROUND

Abnormal gall-bladder motility has been reported in diabetics. The objective was to evaluate the effect of chronic D2-dopamine receptor inhibition on gall-bladder emptying in diabetic patients.

METHODS

Under double-blind placebo-controlled conditions and according to a crossover design, patients were randomly assigned to receive either 4 weeks treatment with levosulpiride 25 mg t.d.s. or 4 weeks treatment with placebo, with an interval of 15 days. Twenty-three consecutive long-standing, insulin-treated diabetics with autonomic neuropathy were studied.

MEASUREMENTS

At the beginning of the study and after levosulpiride or placebo treatment, gall-bladder emptying was measured ultrasonically by evaluating the gall-bladder volume in basal conditions and every 15 min for 90 min after the ingestion of a standard meal. Statistical analysis of the results was performed by means of analysis of variance.

RESULTS

Levosulpiride treatment reduced the basal mean gall-bladder volume from 21.6 +/- 2.3 to 18.6 +/- 2.3 mL (P < 0.05). Furthermore, the residual gall-bladder volume (9.3 +/- 1.4 mL) was significantly reduced compared to the corresponding pre-treatment volume (14.6 +/- 1.5 mL (P < 0.05). In placebo-treated patients, no significant differences were observed in gall-bladder volumes before and after treatment.

CONCLUSION

These results show that chronic oral administration of the D2-dopamine antagonist levosulpiride has a significant effect on gall-bladder motility in diabetic patients.

Gallstone disease among Japanese men in relation to obesity, glucose intolerance, exercise, alcohol use, and smoking

BACKGROUND

Risk factors for gallstones are not fully understood, especially in men. Obesity and other risk factors for gallstone disease were investigated in Japanese men based on gallbladder ultrasonography.

METHODS

Forty-one men with gallstones, 31 with postcholecystectomy state, and 2044 with a normal gallbladder were identified among 2228 men aged 49-55 years who received a retirement health examination at three hospitals of the Japan Self-Defense Forces between 1991 and 1992. Glucose tolerance was determined with a 75-g oral glucose tolerance test.

RESULTS

Body mass index was not associated with gallstones, although it was significantly, positively related to postcholecystectomy. Waist to hip circumference ratio tended to be weakly associated with gallstones. Diabetes mellitus was associated only with postcholecystectomy. Smoking, alcohol intake, and physical activity were not measurably related to either gallstones or postcholecystectomy.

CONCLUSIONS

The present study failed to substantiate an association of gallstone risk with either obesity or any other risk factor. Further observation is needed in view of the limited study power.

Prevalence of cholelithiasis according to alcoholic liver disease: a possible role of apolipoproteins AI and AII

Moderate alcohol intakes decreases the risk of gallstones; in contrast, the prevalence of gallstones is increased in patients with alcoholic cirrhosis. The aims of this prospective study were to assess the prevalence of cholelithiasis among drinkers according to the histological severity of liver disease, and to estimate the importance of serum apolipoproteins AI and apolipoprotein AII as risk factors for gallstones. Among the 320 drinkers included, 53 patients had cholelithiasis. The prevalence increased (p < 0.0001) from 5% in patients with normal liver (1 of 22) and 6% in patients with steatosis only (3 of 47) to 13% in patients with fibrosis (7 of 54), reaching 27% among patients with biopsy-proven cirrhosis (28 of 103). Among patients with clinically obvious cirrhosis on whom biopsy was not performed mainly because of the severity of liver disease, the prevalence of cholelithiasis reached a maximum of 46% (6 of 13). Among drinkers with nonsevere liver disease, patients with cholelithiasis were older (59 +/- 9 years, mean +/- SD vs. 45 +/- 11, p = 0.003) with lower apolipoprotein AI (118 +/- 37 vs. 163 +/- 45 mg/dl; p = 0.002) and apolipoprotein AII (30 +/- 12 vs. 53 +/- 20 mg/dl; p = 0.0002) in comparison with patients without cholelithiasis. These differences persisted after considering by multiple logistic regression analysis, sex, and ideal body weight. Alcohol consumption during the last 5 years was lower in patients with cholelithiasis (83 g/day) in comparison with patients without cholelithiasis (142 g/day; p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results after laparoscopic cholecystectomy

As part of a continuing audit of patients undergoing laparoscopic cholecystectomy (which now numbers over 1500) 468 of the 508 patients (92.1 per cent) operated on between October 1989 and March 1991 were studied between 350 and 988 days after the operation (mean 19 months). A questionnaire was filled in by each patient before operation and at the late follow-up visit. Eight specific symptoms were sought-non-colicky pain, colic, abdominal distension, nausea, vomiting, loss of appetite, flatulence, and dietary restriction. The result of each operation was assessed by two surgeons and by the patient. In 453 patients (96.8 per cent) the symptoms had improved as a result of the operation, but 260 patients (55.6 per cent) had some abdominal symptoms. The result was assessed as excellent in 310 patients (66.2 per cent); 143 (30.5 per cent) still had abdominal complaints but they were willing to cope with those symptoms. In 15 patients (3.2 per cent) the result was unsatisfactory. Statistical analysis of 26 preoperative variables showed few significant differences between patients with excellent results and patients with persisting or new symptoms. The percentage of patients with biliary colic was reduced from 82.9 per cent before to 6.4 per cent after laparoscopic cholecystectomy (P < 0.05), and of those with flatulence from 62.6 per cent to 45.3 per cent (P < 0.05). Flatulence persisted in 147 (50.2 per cent) of the 293 patients who had complained of flatulence before the operation, and of the 175 patients who had not complained of flatulence before surgery, 65 (37.1 per cent) reported the symptom for the first time after the operation. It appears that 'flatulent dyspepsia' after cholecystectomy has many causes, one of which may be removal of the gallbladder. It is concluded that the long-term results of laparoscopic cholecystectomy in patients with symptomatic gallstone disease were excellent but the prognosis in individual patients was unpredictable.

Outcomes of open cholecystectomy in the elderly: a longitudinal analysis of 21,000 cases in the prelaparoscopic era

OBJECTIVE

We sought to obtain unbiased estimates of open cholecystectomy outcomes in a population-based cohort of elderly patients during the immediate prelaparoscopic era.

METHODS

Medicare claims data were used to identify 21,131 patients aged 65 years or more who underwent open cholecystectomy in Pennsylvania between 1986 and 1989 and to develop longitudinal histories of hospitalizations and physician services utilization for these patients. Study patients were divided into three groups: simple cholecystectomy, cholecystectomy with intraoperative cholangiography (IOC) alone, and cholecystectomy with common bile duct exploration (CBDE). Outcomes examined included 30- and 90-day postoperative mortality rates and postoperative complications.

RESULTS

Postoperative mortality rates in all patients was 2.1% at 30 days and 3.6% at 90 days. Patients in the CBDE group had a significantly higher mortality rate than those in the simple cholecystectomy or IOC groups; adjusted for differences in case mix, the mortality rate in the CBDE group was 47% higher at 30 days and 29% higher at 90 days. Rates of retained or recurrent common duct stones, bile duct stricture, and recurrent biliary tract surgery by 42 to 60 months after cholecystectomy were 2.8%, 0.4%, and 1.0%, respectively. CBDE was a strong risk factor for these complications. In contrast, the IOC group had a significantly lower risk of having clinically manifest retained or recurrent common duct stones develop by 42 months after operation.

CONCLUSIONS

This study provides an unbiased assessment of open cholecystectomy outcomes necessary for future comparisons of open and laparoscopic cholecystectomy in elderly patients. Estimates of the excess mortality rates associated with CBDE provide a benchmark for assessing the outcomes of alternative strategies for managing common duct stones during laparoscopic cholecystectomy. Findings regarding the rates of retained or recurrent common bile duct stones in patients undergoing simple cholecystectomy and IOC challenge widespread beliefs about the limited clinical importance of unsuspected common duct stones, at least in the elderly population, and are relevant to the debate about routine IOC.

Composition of gall bladder stones associated with octreotide: response to oral ursodeoxycholic acid

Octreotide, an effective treatment for acromegaly, induces gall bladder stones in 13-60% of patients. Because knowledge of stone composition is essential for studies of their pathogenesis, treatment, and prevention, this was investigated by direct and indirect methods in 14 octreotide treated acromegalic patients with gall stones. Chemical analysis of gall stones retrieved at cholecystectomy from two patients, showed that they contained 71% and 87% cholesterol by weight. In the remaining 12 patients, localised computed tomography of the gall bladder showed that eight had stones with maximum attenuation scores of < 100 Hounsfield units (values of < 100 HU predict cholesterol rich, dissolvable stones). Gall bladder bile was obtained by ultrasound guided, fine needle puncture from six patients. All six patients had supersaturated bile (mean (SEM) cholesterol saturation index of 1.19 (0.08) (range 1.01-1.53)) and all had abnormally rapid cholesterol microcrystal nucleation times (< 4 days (range 1-4)), whilst in four, the bile contained cholesterol microcrystals immediately after sampling. Of the 12 patients considered for oral ursodeoxycholic acid (UDCA) treatment, two had a blocked cystic duct and were not started on UDCA while one was lost to follow up. After one year of treatment, five of the remaining nine patients showed either partial (n = 3) or complete (n = 2) gall stone dissolution, suggesting that their stones were cholesterol rich. This corresponds, by actuarial (life table) analysis, to a combined gall stone dissolution rate of 58.3 (15.9%). In conclusion, octreotide induced gall stones are generally small, multiple, and cholesterol rich although, in common with spontaneous gall stone disease, at presentation some patients will have a blocked cystic duct and some gall stones containing calcium.

Cholesterol gallstone formation in man and potential treatments of the gallbladder motility defect

Cholelithiasis affects 10-15% of the adult population in Western society, and about 75% of gallstones are of cholesterol type. Hepatic hypersecretion of cholesterol with the formation of instable cholesterol-rich vesicles in bile, an imbalance between nucleation-inhibiting and nucleation-promoting proteins with further aggregation of cholesterol crystals in a gallbladder with a motility defect (stasis), all play a role in the pathogenesis of cholesterol gallstones. Experimental animal models suggest that gallstone formation can be prevented by improving gallbladder emptying. Thus, a better understanding of the causes underlying the impaired gallbladder motor function in patients with gallstones might lead to the selection of therapeutic approaches for those individuals who are at increased risk for the formation or recurrence of gallstones. The present article focuses on current concepts and theories on the pathogenesis of cholesterol gallstones with emphasis on the gallbladder motility defect. Several treatment strategies for the correction of gallbladder hypomotility are also discussed.

Symptomatic versus silent gallstones. Radiographic features and eligibility for nonsurgical treatment

It is unknown whether demography, gallbladder function, or the radiographic appearance of gallstones predispose them to cause symptoms. We investigated these features in a consecutive series of 260 patients with newly diagnosed, uncomplicated gallstone disease, of whom 146 had experienced biliary pain and 114 were asymptomatic. All patients underwent double-dose oral cholecystography and cholecystosonography, and the combined data of these examinations were used to assess gallbladder function and stone number, size, and radiopacity. The gallstones were multiple in 68%, radiolucent in 73%, and in visualized gallbladders in 79% of the 260 patients. The comparison of different variables in patients with and without biliary pain showed that the female gender (P = 0.030; odds ratio 1.86), a family history of gallbladder disease (P = 0.022; odds ratio 1.89), a nonvisualized gallbladder (P < 0.001; odds ratio 3.14), multiple stones (P = 0.036; odds ratio 1.89), and those which were small (P = 0.009; odds ratio 2.08) or of dissimilar size (P = 0.041; odds ratio 1.91) were associated with biliary pain. Women with silent stones had been pregnant more often (P < 0.001, difference between means 1) than those with biliary pain. Gallbladder function and the radiologic characteristics of stones were unrelated to age and gender. Estimates of eligibility for nonsurgical therapies among the 146 symptomatic patients were 44% for bile acid therapy, 16% for lithotripsy, and 56% for methyl tert-butyl ether. In conclusion, some inherent features of gallstones are associated with biliary pain. Whether they have predictive value of future symptom development in subjects with silent stones can be determined by prospective follow up.

Incidence of gallstones in a population of patients with cirrhosis

One hundred and sixty-five patients with cirrhosis were prospectively investigated, by regular ultrasonographic follow up, to assess the incidence of gallstones. The mean length of follow up was 33 months (range 12 to 108). Cholelithiasis was diagnosed in 31 patients (18.8%), with a cumulative incidence over 84 months of 38.3% (4.7% yearly incidence). The risk of gallstones was similar in males (38%) and females (38.3%), although the final cumulative incidence was reached at 72 months in males. The percentage of patients with new stones was higher in alcoholic cirrhosis (28.9%) (with a cumulative incidence of 48.8% at 84 months) and lower in hepatitis-related cirrhosis (1.9%) (only one new case at 96 months of follow up) (p < 0.001). The cumulative incidence of gallstones in the Child's C group reached 49.3% at 48 months versus 24% in Child's B and 6.4% in Child's A (p < 0.0001). At multivariate analysis, Child's C and alcoholic cirrhosis were shown to be the independent variables significantly associated with a high risk of development of cholelithiasis. This study confirms that cirrhosis represents a high risk factor for gallstones. The risk is greater for alcoholic cirrhosis and increases with the severity of the disease.

Prevalence rates of gallstone disease in Italy. The Chianciano population study

The prevalence of gallstone disease and associated factors in the entire population of subjects aged 15-65 years born and resident in Chianciano Terme (Siena - Tuscany) was examined in the years 1985 and 1986. The investigation included gallbladder ultrasonography, administration of a questionnaire on personal and family history, physical examination and blood chemistry. A total of 1809 subjects (attendance rate 87.7%) participated in the study. Personal history and physical examination showed that Chianciano inhabitants have a low prevalence of obesity (4.3%) and only 4.4% of the female population had more than two pregnancies. Overall prevalence of gallstone disease (cholecystectomy+cholelithiasis) was 5.9% (3.7% for males and 8.4% for females). Age standardized relative risk of gallstone disease for females was 2.25 (95% confidence limits = 1.68-2.68). Prevalence of cholelithiasis was 3.5% (2.7% for males and 4.2% for females). Prevalence of gallstone disease increased with increasing age in both sexes, being extremely low in the age interval of 15-29 years (0.25%). The overall gallstones/cholecystectomy ratio was found to be lower (1:1) in females than in males (2.7:1). Although subjects with gallstones reported more frequently biliary colics and non-specific dyspeptic symptoms, the diagnostic power of all symptoms in identifying cholelithiasis was very poor due to low sensitivity. Only one third of subjects with gallstones was aware of having the disease. Age, obesity and number of pregnancies were positively associated with gallstone disease in univariate analyses. The association with obesity and parity disappeared in multivariate analysis. Blood lipids and glucose were not associated with the disease both in univariate and multivariate analyses.(ABSTRACT TRUNCATED AT 250 WORDS)