Prevalence of gallbladder disease in diabetes mellitus

Non-Invasive Prediction of Choledocholithiasis Using 1D Convolutional Neural Networks and Clinical Data

This paper introduces a novel one-dimensional convolutional neural network that utilizes clinical data to accurately detect choledocholithiasis, where gallstones obstruct the common bile duct. Swift and precise detection of this condition is critical to preventing severe complications, such as biliary colic, jaundice, and pancreatitis. This cutting-edge model was rigorously compared with other machine learning methods commonly used in similar problems, such as logistic regression, linear discriminant analysis, and a state-of-the-art random forest, using a dataset derived from endoscopic retrograde cholangiopancreatography scans performed at Olive View-University of California, Los Angeles Medical Center. The one-dimensional convolutional neural network model demonstrated exceptional performance, achieving 90.77% accuracy and 92.86% specificity, with an area under the curve of 0.9270. While the paper acknowledges potential areas for improvement, it emphasizes the effectiveness of the one-dimensional convolutional neural network architecture. The results suggest that this one-dimensional convolutional neural network approach could serve as a plausible alternative to endoscopic retrograde cholangiopancreatography, considering its disadvantages, such as the need for specialized equipment and skilled personnel and the risk of postoperative complications. The potential of the one-dimensional convolutional neural network model to significantly advance the clinical diagnosis of this gallstone-related condition is notable, offering a less invasive, potentially safer, and more accessible alternative.

Waist-to-height ratio for the prediction of gallstone disease among different obesity indicators

Background

Factors of metabolic syndrome such as obesity are well-known risk factors for gallstone disease (GSD). There are different indicators of obesity, including weight, body mass index, waist circumference, and waist-to-height ratio. The predictive ability of different obesity indicators for GSD remains unclear.

Objective

To explore the most efficient predictor of GSD among the different anthropometric indicators of obesity.

Methods

This population-based cross-sectional study included 2263 participants who completed a questionnaire detailing their demographics, medical history, and lifestyle between 2014 and 2017 in Taiwan. Blood samples were collected and physical examinations, including anthropometric measurements, were performed. Gallstone disease was ascertained using ultrasonography. Multivariate analyses were performed to identify independent risk factors for GSD.

Results

The overall prevalence of GSD was 8.8%. According to the multivariate analysis, individuals with a waist-to-height ratio ≥0.5 (odds ratio|odds ratios (OR) = 1.65, 95% confidence interval (CI) = 1.10-2.48, p = 0.017) had an increased risk of GSD. Diabetes was the main risk factor for GSD in men (OR = 2.06, 95% CI = 1.17-3.65, p = 0.013). Among women, waist-to-height ratio >0.5 (OR = 1.76, 95% CI = 1.03-3.02, p = 0.040) and current hormone drug use (OR = 2.73, 95% CI = 1.09-6.84, p = 0.033) were significant risk factors for gallstones.

Conclusion

GSD was independently associated with central obesity and exogenous hormone intake in women. Among the anthropometric indicators used to assess central obesity, waist-to-height ratio was the most accurate predictor of GSD.

Novel insights into the pathogenic impact of diabetes on the gastrointestinal tract

Type 2 and type 1 diabetes are common endocrine disorders with a progressively increasing incidence worldwide. These chronic, systemic diseases have multiorgan implications, and the whole gastrointestinal (GI) tract represents a frequent target in terms of symptom appearance and interdependent pathophysiological mechanisms. Metabolic alterations linked with diabetic complications, neuropathy and disrupted hormone homeostasis can lead to upper and/or lower GI symptoms in up to 75% of diabetic patients, with multifactorial involvement of the oesophagus, stomach, upper and lower intestine, and of the gallbladder. On the other hand, altered gastrointestinal motility and/or secretions are able to affect glucose and lipid homeostasis in the short and long term. Finally, diabetes has been linked with increased cancer risk at different levels of the GI tract. The presence of GI symptoms and a comprehensive assessment of GI function should be carefully considered in the management of diabetic patients to avoid further complications and to ameliorate the quality of life. Additionally, the presence of gastrointestinal dysfunction should be adequately managed to improve metabolic homeostasis, the efficacy of antidiabetic treatments and secondary prevention strategies.

Diabetes mellitus is associated with a higher rate of acute cholangitis among patients with common bile duct stones: A retrospective study

Common bile duct (CBD) stone is a commonly encountered disease that is associated with various clinical presentations ranging from the mild form of biliary colic to the severe complication of acute cholangitis. Recently, diabetes mellitus (DM) has been linked to the development of biliary diseases; however, no data regarding the association of DM with acute cholangitis development in the setting of CBD stone exist. The aim of the current study was to investigate whether DM represents a risk factor for acute cholangitis in patients with CBD stone. We performed a retrospective cross-sectional study from January 1, 2010 till June 1, 2020 of all patients presenting to Galilee Medical Center with various clinical presentations of documented CBD stone, including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes. Overall, 687 patients were included in the final analysis. Among them, 101 patients (14.7%) had CBD stone associated with acute cholangitis (group A), as compared to 586 patients (85.3%) without acute cholangitis (group B). The average ages in groups A and B were 77.7 ± 13.6 and 62.5 ± 20.5 years, respectively (P < .0001). The prevalence of DM was significantly higher in group A as compared to group B (52.5% vs 36.3%, P = .001). On univariate analysis, age (odds ratio [OR] 1.05, P < .0001), male gender (OR 1.54, P = .04), and DM (OR 1.92, P = .002) were associated with acute cholangitis development, and on multivariate logistic regression analysis, the correlation was preserved for DM (OR 1.93, 95% confidence interval 1.26-2.96, P = .002). DM showed a significant association with acute cholangitis development among patients with CBD stone. Identification of bile duct stones in diabetic patients is of paramount importance since early diagnosis and treatment might prevent further life-threatening complications.

Machine learning models compared to existing criteria for noninvasive prediction of endoscopic retrograde cholangiopancreatography-confirmed choledocholithiasis

BACKGROUND AND AIMS

Noninvasive predictors of choledocholithiasis have generally exhibited marginal performance characteristics. We aimed to identify noninvasive independent predictors of endoscopic retrograde cholangiopancreatography (ERCP)-confirmed choledocholithiasis and accordingly developed predictive machine learning models (MLMs).

METHODS

Clinical data of consecutive patients undergoing first-ever ERCP for suspected choledocholithiasis from 2015-2019 were abstracted from a prospectively-maintained database. Multiple logistic regression was used to identify predictors of ERCP-confirmed choledocholithiasis. MLMs were then trained to predict ERCP-confirmed choledocholithiasis using pre-ERCP ultrasound (US) imaging only and separately using all available noninvasive imaging (US/CT/magnetic resonance cholangiopancreatography). The diagnostic performance of American Society for Gastrointestinal Endoscopy (ASGE) "high-likelihood" criteria was compared to MLMs.

RESULTS

We identified 270 patients (mean age 46 years, 62.2% female, 73.7% Hispanic/Latino, 59% with noninvasive imaging positive for choledocholithiasis) with native papilla who underwent ERCP for suspected choledocholithiasis, of whom 230 (85.2%) were found to have ERCP-confirmed choledocholithiasis. Logistic regression identified choledocholithiasis on noninvasive imaging (odds ratio (OR) = 3.045, P = 0.004) and common bile duct (CBD) diameter on noninvasive imaging (OR=1.157, P = 0.011) as predictors of ERCP-confirmed choledocholithiasis. Among the various MLMs trained, the random forest-based MLM performed best; sensitivity was 61.4% and 77.3% and specificity was 100% and 75.0%, using US-only and using all available imaging, respectively. ASGE high-likelihood criteria demonstrated sensitivity of 90.9% and specificity of 25.0%; using cut-points achieving this specificity, MLMs achieved sensitivity up to 97.7%.

CONCLUSIONS

MLMs using age, sex, race, presence of diabetes, fever, body mass index (BMI), total bilirubin, maximum CBD diameter, and choledocholithiasis on pre-ERCP noninvasive imaging predict ERCP-confirmed choledocholithiasis with good sensitivity and specificity and outperform the ASGE criteria for patients with suspected choledocholithiasis.

Clinical presentation and outcomes of cholecystectomy for acute cholecystitis in patients with diabetes - A matched pair analysis. A pilot study

PURPOSE

The primary aim of this study is to compare the clinical course and laboratory parameters of acute cholecystitis in patients with diabetes vs. patients without diabetes.

MATERIALS AND METHODS

The study involved patients who underwent emergency cholecystectomy in the Department of General, Endocrine and Transplant Surgery of University Clinical Center in Gdansk (Poland) between 2007 and 2017. There were 267 patients included in the study. The control group of 197 patients was age and sex matched at a 3:1 ratio. The following was compared between the groups: symptoms at admission, course of surgery, postoperative course, length of hospitalization, total costs of hospitalization and antibiotic therapy, other than routine perioperative prophylaxis.

RESULTS

There was no significant difference between the patients with and without diabetes regarding symptoms at admission. Operative and postoperative complication rates were significantly higher in the patients with diabetes. The operative time and length of hospitalization were significantly longer in the study group. The conversion rate was not higher in the study group, but classic surgery was performed significantly more often. The patients without diabetes had less pronounced symptoms with more locally advanced disease.

CONCLUSIONS

Our study demonstrates that patients with diabetes have a significantly more eventful course of acute cholecystitis than patients without diabetes. Patients with diabetes should therefore be qualified for cholecystectomy early in the course of acute cholecystitis.

The Role of Diabetes Mellitus in Diseases of the Gallbladder and Biliary Tract

BACKGROUND

The increasing prevalence of diabetes mellitus worldwide continues to pose a heavy burden. Though its gastrointestinal impact is appropriately recognized, the lesser known associations may be overlooked.

OBJECTIVE

We aim to review the negative implications of diabetes on the gallbladder and the biliary tract.

METHODS

A MEDLINE® database search of literature was conducted with emphasis on the previous five years, combining keywords such as "diabetes," "gallbladder," and "biliary".

RESULTS

The association of diabetes to the formation of gallstones, gallbladder cancer, and cancer of the biliary tract are discussed along with diagnosis and treatment.

CONCLUSION

Though we uncover the role of diabetic neuropathy in gallbladder and biliary complications, the specific individual diabetic risk factors behind these developments is unclear. Also, in addition to diabetes control and surgical gallbladder management, the treatment approach also requires further focus.

Prevalence of Non-insulin-dependent Diabetes Mellitus Among Patients with Cholelithiasis: A Single-centered, Cross-sectional Study

Introduction Gallstone disease (GD) is one of the major causes of morbidity and mortality in the west and most of the countries worldwide. Cholelithiasis and diseases of the biliary tract are becoming more prevalent with the socioeconomic burden in developing countries like Pakistan. GD is a chronic, recurrent hepatobiliary disease, the basis of which is the impaired metabolism of cholesterol, bilirubin, and bile acids, which is characterized by the formation of gallstones in the hepatic bile duct, common bile duct, or gallbladder. Epidemiologic studies have shown that individuals with diabetes have a higher risk of cholelithiasis but only a few studies have been done in Pakistan to establish the association so far. Hence, the aim of the present study is to establish the association between diabetes and gallstone disease. Methods A cross-sectional study was conducted at Liaquat University Civil Hospital, Hyderabad, Pakistan, between February 2017 and August 2017. Patients between the ages of 10 and 70 from either sex, who were diagnosed with cholelithiasis were included in this study whereas those patients who underwent cholecystectomy previously were excluded. Diabetic cases were identified based on fasting glucose levels (FGL) and the serum levels of HbA1c. An interview-based questionnaire was employed to collect the patient's demographic profile and risk factors by the students. Informed consent was taken from all the study subjects and the confidentiality of the data was ensured. Results From the sample size of patients evaluated (a total of 204), based on investigative studies performed, 74 cholelithiatic patients (36.6%) were found to concurrently have diabetes as well. Among the 74 patients with both cholelithiasis and diabetes type-2 (NIDDM), 56 were female and 18 were males. The rest of the patients with cholelithiasis were found to be non-diabetic (78 were males and 52 female). The majority of the GD patients (51 (25 males and 26 females)) in the study sample was in the 50-60 age group. The mean age of the patients was 43 ± 12.1. In this study, we measured the fasting glucose levels (FGL). According to World Health Organization (WHO) and American Diabetes Association (ADA) criteria, we categorized 85 of the GD patients to be non-diabetic with serum fasting glucose levels between 70 and 100 gm/dL, and 45 patients were categorized to be in the pre-diabetic group with FGL levels between 100 and 126. Out of the 204 samples with GD, we found that 74 patients have diabetes, with serum FGL >126mg/dL. We measured HbA1c from each individual in the study sample. It was found that 79 patients had HbA1c levels <5.5, they are categorised as non-diabetic according to WHO and ADA criteria, 51 patients had values between 5.5 and 6.5 (pre-diabetic), and 35 GD patients had HbA1c values between 6.5 and 7.5 (categorized as diabetics with good control) and 39 patients with HbA1c above 7.5 (diabetes with poor control). Conclusion In this study, we concluded that there is a higher prevalence of NIDDM in GD patients and there is an association between GD and NIDDM. This study also reiterated the association between obesity and GD. Female sex and advancing age also contribute to the formation of cholelethiasis. Cigarette smoking and alcohol consumption further worsen cholelithiasis but are not established primary risk factors.

Hepatitis C virus infection and risk of gallstones: A meta-analysis

BACKGROUND/OBJECTIVES

Gallstones and its complications are one of the most common hepatobiliary tract diseases. Several epidemiologic studies have suggested that patients with hepatitis C virus (HCV) infection might be at an increased risk of gallstones. However, the data on this relationship remain inconclusive. This meta-analysis was conducted with the aims to summarize all available evidence.

METHODS

A literature search was performed using MEDLINE and EMBASE databases from inception to May 2016. Studies that reported relative risks, odd ratios, or hazard ratios comparing the risk of gallstones among HCV-infected patients versus subjects without HCV infection were included. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Eleven studies met our eligibility criteria and were included in the analysis. The pooled OR of gallstones in HCV-infected patients versus subjects without HCV infection was 1.83 (95% CI, 1.35 to 2.48, I²  = 89%). Subgroup analysis showed that significant risk was increased for both male (pooled OR of 2.07, 95% CI, 1.14 to 3.76) and female (pooled OR of 3.00, 95% CI, 2.16 to 4.17).

CONCLUSIONS

Our study demonstrated a significantly increased risk of gallstones among HCV-infected patients. Further studies are required to clarify how this risk should be addressed in the clinical picture.

Outcome Analysis of Patients with Gallstone Disease Receiving Cholecystectomy: A Population-Based Cohort Study

BACKGROUND/AIMS

Cholecystectomy is generally performed to treat patients with gallstone disease (GSD) in clinical practice. The present study aimed to investigate whether type 2 diabetes mellitus (T2DM) may influence the overall survival of GSD patients.

METHODS

The National Health Insurance Research Database, a population-based registry data in Taiwan, was used to identify GSD patients from 2001 to 2008. The risk of cancers and effects of T2DM on the overall survival of GSD patients receiving cholecystectomy were estimated by hazards ratios (HRs) and 95% CIs using the Cox proportional hazard model.

RESULTS

Among 392,028 eligible GSD patients, 81,971 underwent cholecystectomy, whereas 310,057 did not. After cholecystectomy, the HR for developing cancer was 1.14. The HR for the overall survival was 0.74-fold lower for patients who underwent cholecystectomy than that for patients who did not. GSD patients without T2DM who underwent cholecystectomy (0.78-fold lower risk) had a longer survival, whereas those with T2DM had shorter survival (1.64-fold higher risk without cholecystectomy and 1.13-fold higher risk with cholecystectomy) compared with those without T2DM who did not undergo cholecystectomy.

CONCLUSIONS

Our major findings suggest that T2DM may worsen the prognosis of GSD patients after cholecystectomy, which provides useful insight into the treatment of T2DM among GSD patients in clinical settings.

Hepatitis B virus infection and risk of gallstones: a systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Gallstone disease and its complications are common, particularly in Western populations. Recent studies have reported a significantly increased risk of gallstones among hepatitis C virus-infected patients. However, the data on patients with hepatitis B virus (HBV) infection are still limited. This meta-analysis was carried out with the aim of summarizing all available evidence.

PATIENTS AND METHODS

A literature search was performed using MEDLINE and the EMBASE database from inception to May 2016. Studies that reported relative risks, odd ratios, or hazard ratios comparing the risk of gallstones among HBV-infected patients versus patients without HBV infection were included. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse-variance method.

RESULTS

Nine studies fulfilled our eligibility criteria and were included in the analysis. We found no significant association between HBV infection and the risk of gallstones, with a pooled OR of 1.10 (95% CI, 0.91-1.33). The statistical heterogeneity was moderate, with an I of 69%. Subgroup analysis was carried out. The pooled OR of cross-sectional studies was 1.01 (95% CI, 0.91-1.12; I 0%), whereas the pooled OR of case-control studies was 1.53 (95% CI, 0.85-2.74; I 80%).

CONCLUSION

A significant association between HBV infection and the risk of gallstones was not observed in this study.

Long-term risk of pancreatitis and diabetes after cholecystectomy in patients with cholelithiasis but no pancreatitis history: a 13-year follow-up study

BACKGROUND & AIM

Patients with biliary pancreatitis are suggested to undergo cholecystectomy to prevent the recurrence of pancreatitis. However, it remains controversial whether cholecystectomy is associated with reduced risks of pancreatitis and diabetes in patients with cholelithiasis and no history of pancreatitis.

METHODS

From Taiwan's National Health Insurance Research Database, we identified the following cohorts and analyzed the long-term risks of pancreatitis and diabetes in each cohort: 1) cholecystectomy cohort: cholelithiasis patients who had no history of pancreatitis and diabetes and underwent cholecystectomy; and 2) comparison cohort: cholelithiasis patients who had no history of pancreatitis and diabetes and did not undergo cholecystectomy.

RESULTS

The cholecystectomy group and the comparison group had similar distributions of age, sex, and comorbidities, except for hyperlipidemia. The proportion of patients in the cholecystectomy group who underwent endoscopic cholangiographic procedures was higher than that in the comparison group. Cholecystectomy was associated with a reduced risk of pancreatitis (adjusted hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.36-0.68). Age-specific analyses showed that pancreatitis risk was decreased in patients younger than 50 and older than 65years. Both men and women exhibited reduced risks of pancreatitis after cholecystectomy. However, cholecystectomy was not associated with changes in the risk for diabetes.

CONCLUSION

Cholecystectomy for cholelithiasis is associated with a reduced risk of pancreatitis, but not of diabetes, in patients without previous history of pancreatitis and diabetes.

Colonic perforation by a large gallstone: A rare case report

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An 86-year-old woman with a history of cholelithiasis presented with abdominal pain and nausea.

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Imaging demonstrated pneumobilia, bowel dilation, and a 3.5 cm gallstone in the sigmoid colon.

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Conservative management, enemas, and an attempt to ensnare the gallstone by colonoscopy, failed.

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The patient underwent a sigmoid resection and a Hartmann’s procedure for gallstone perforation.

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She was discharged after a complicated post-operative course and has returned to her baseline.

INTRODUCTION

Herein we present the case of an 86-year-old woman with gallstone perforation of the sigmoid colon.

PRESENTATION OF CASE

An 86-year-old woman with known cholelithiasis presented to our office with one week of abdominal pain and nausea. X-rays taken at presentation demonstrated pneumobilia, and CT scan showed a 3.5 cm gallstone in the sigmoid colon. Medical management was unsuccessful in passing the stone, and a colonoscopy on day 4 was unsuccessful in incorporating the stone. Subsequent clinical deterioration prompted a laparotomy, where a perforation was discovered. A Hartmann's procedure was performed and the patient recovered after a complicated post-operative course.

DISCUSSION

Gallstone ileus is an uncommon, but medically important, cause of bowel obstruction. This presentation is considered a surgical emergency and thus prompt identification and removal is essential. Obstructions tend to occur in either the stomach or along the various segments of the small intestine but have been reported in the colon as well.

CONCLUSION

In cases of gallstones that manage to pass into the large intestine, it is prudent to attempt conservative measures for passage. Failure to do so should raise suspicion of a possible stricture, either benign or malignant, preventing its evacuation. Earlier surgical intervention should be considered in these cases.

Type II diabetes mellitus is associated with a reduced risk of cholangiocarcinoma in patients with biliary tract diseases

It has not yet been reported whether Type II diabetes mellitus (DM) is associated with an increased cholangiocarcinoma (CC) risk in patients with biliary tract diseases. We identified 123,050 patients concomitantly diagnosed with biliary tract diseases and DM between 1998 and 2010. The control cohort consisted of 122,721 individuals with biliary tract diseases but not DM. Both cohorts were followed-up until the end of 2010 to estimate the risk of CC. We also compared the risk of CC between DM and non-DM cohorts without biliary tract diseases. Overall, the incidence of CC was 21% lower among the DM patients than among the control patients (1.11 vs. 1.41 per 1,000 person-years). DM cohorts exhibited significantly reduced risks for both intrahepatic and extrahepatic CC. A multivariable Cox proportional hazards regression model was used, and the adjusted hazard ratio (HR) of CC was 0.74 (95% confidence interval [CI], 0.66-0.82) for the DM cohort in comparison with the control cohort. The age-specific data indicated that compared with the control patients, the adjusted HRs for the DM patients were significantly lower among patients 50-64 (adjusted HR = 0.67; 95% CI = 0.55-0.82) and 65-74 years old (adjusted HR = 0.70; 95% CI, 0.59-0.84). Furthermore, DM was associated with a lower risk of CC among patients with biliary diseases, regardless of the presence of comorbidities and the status of cholecystectomy. In the patients without biliary tract diseases, DM is associated with significantly increased risk of CC (adjusted HR = 1.58; 95% CI, 1.37-1.82).

Associations of organochlorine pesticides and polychlorinated biphenyls in visceral vs. subcutaneous adipose tissue with type 2 diabetes and insulin resistance

Background exposure to organochlorine (OC) pesticides and polychlorinated biphenyls (PCBs) has been linked to type 2 diabetes. As OC pesticides and PCBs mainly accumulate in adipose tissue and there are physiological and clinical differences between visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT), we explored if there were associations of OC pesticides and PCBs in VAT or SAT with type 2 diabetes and insulin resistance. Participants were 50 patients with or without type 2 diabetes who underwent surgery for either cancer or benign liver or gallbladder lesions. We analyzed 14 OC pesticides and 22 PCB congeners in both VAT and SAT. Insulin resistance was estimated using homeostasis model assessment (HOMA). Although concentrations of OC pesticides and PCBs were strongly correlated between VAT and SAT, absolute concentrations differed substantially between them. In particular, concentrations of all PCBs were consistently about 5-10 times higher in VAT than SAT, but these patterns were independent of diabetes status. Some OC pesticides or PCBs, such as dichlorodiphenyltrichloroethanes (DDTs), chlordanes, and PCBs with 5 or less chlorides showed significant associations with diabetes or insulin resistance. For example, when tertiles of concentration-based summary measures were used, adjusted ORs were 1.0, 2.3, and 9.0 (P trend=0.02) for DDTs in VAT and 1.0, 2.1, and 5.7 (P trend=0.08) for PCBs with 5 or less chlorides. This study generally confirmed previous findings using serum concentrations. It would be useful to study pharmacodynamics of POPs in VAT and SAT further.

Effect of delaying same-admission cholecystectomy on outcomes in patients with diabetes

Background

Recent studies have suggested that same-admission delayed cholecystectomy is a safe option. Patients with diabetes have been shown to have less favourable outcomes after cholecystectomy, but the impact of timing of operation for acute cholecystitis during the same admission is unknown.

Methods

This was a retrospective analysis of patients undergoing laparoscopic cholecystectomy for acute cholecystitis between 2004 and 2010, from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with no significant co-morbidities (American Society of Anesthesiologists grade I or II) were included. Propensity score matching (PSM) was used to match patients with diabetes with those who did not have diabetes, in a ratio of 1 : 3, to ensure homogeneity of the two groups. Logistic regression models were applied to adjust for differences between early (within 24 h) and delayed (24 h or more) surgical treatment. The primary outcome was development of local and systemic infectious complications. Secondary outcomes were duration of operation and length of hospital stay.

Results

From a total of 2892 patients, 144 patients with diabetes were matched with 432 without diabetes by PSM. Delaying cholecystectomy for at least 24 h after admission in patients with diabetes was associated with significantly higher odds of developing surgical-site infections (adjusted odds ratio 4·11, 95 per cent confidence interval 1·11 to 15·22; P = 0·034) and a longer hospital stay. For patients with no diabetes, however, delaying cholecystectomy had no impact on complications or length of hospital stay.

Conclusion

Patients with diabetes who undergo laparoscopic cholecystectomy 24 h or more after admission may have an increased risk of postoperative surgical-site infection and a longer hospital stay than those undergoing surgery within 24 h of admission.

Is there an association between type 1 diabetes in children and gallbladder stones formation?

BACKGROUND AND AIMS

A number of studies in adults have evaluated the prevalence of gallstones in the diabetic population and showed a significant association with type 1 diabetes (T1D) and type 2 diabetes. The pediatric literature is limited to a single small case series. We conducted a cross-sectional study to evaluate for the presence of association between T1D in children and gallstones formation.

PATIENTS AND METHODS

Children diagnosed with T1D in a diabetic clinic have been examined for existence of gall bladder stone formation from November 2008 through November 2009. All have been subjected to the following: History, physical examination, blood tests (liver function tests, lipid profile, glycosylated hemoglobin [HbA1C]), and an ultrasound (US) of the gall bladder.

RESULTS

One hundred and five children with T1D have been enrolled consecutively over a 1-year period: age ranged between 8 months and 15.5 years, 62 patients were females. The mean age at diagnosis was 6.3 ± 2.9 years (range 0.85-11 years), mean duration of T1D was 2.2 ± 2.1 years (range 0.2-8 years), mean body mass index was 16.5 ± 3.4, mean HbA1c was 10.7 ± 2.4%, and 61.3% of patients had a HbA1c level >10%. The mean serum cholesterol was 4.16 ± 0.75 mmol/L (normal 3.65-5.15 mmol/L) and mean serum triglyceride 1.02 ± 1.3 mmol/L (normal 0-1.7 mmol/L). Two patients had hyperlipidemia. US of the gallbladder did not show any case of gallstones or sludge formation.

CONCLUSION

Data from our study do not show any association between T1D in children and gallstones formation, with diabetes duration of less than 8 years. The relatively short duration of diabetes and possibility that our study was underpowered might have been reasons for the absence of any association.

A population-based cohort study of symptomatic gallstone disease in diabetic patients

AIM: To investigate the prevalence of gallstone disease (GSD) and to evaluate the risk of symptomatic GSD among diabetic patients.

METHODS: The study was conducted by analyzing the National Health Research Institutes (NHRI) dataset of ambulatory care patients, inpatient claims, and the updated registry of beneficiaries from 2000 to 2008. A total of 615 532 diabetic patients without a prior history of hospital treatment or ambulatory care visits for symptomatic GSD were identified in the year 2000. Age- and gender-matched control individuals free from both GSD and diabetes from 1997 to 1999 were randomly selected from the NHIR database (n = 614 871). The incidence densities of symptomatic GSD were estimated according to the subjects’ diabetic status. The distributions of age, gender, occupation, income, and residential area urbanization were compared between diabetic patients and control subjects using Cox proportion hazards models. Differences between the rates of selected comorbidities were also assessed in the two groups.

RESULTS: Overall, 60 734 diabetic patients and 48 116 control patients developed symptomatic GSD and underwent operations, resulting in cumulative operation rates of 9.87% and 7.83%, respectively. The age and gender distributions of both groups were similar, with a mean age of 60 years and a predominance of females. The diabetic group had a significantly higher prevalence of all comorbidities of interest. A higher incidence of symptomatic GSD was observed in females than in males in both groups. In the control group, females under the age of 64 had a significantly higher incidence of GSD than the corresponding males, but this difference was reduced with increasing age. The cumulative incidences of operations for symptomatic GSD in the diabetic and control groups were 13.06 and 9.52 cases per 1000 person-years, respectively. Diabetic men exhibited a higher incidence of operations for symptomatic GSD than did their counterparts in the control group (12.35 vs 8.75 cases per 1000 person-years).

CONCLUSION: The association of diabetes with increased symptomatic GSD may provide insight to the treatment or management of diabetes in clinical settings.

Diabetes mellitus and the risk of cholecystectomy

BACKGROUND

Whether diabetes mellitus is associated with an increased risk of cholecystectomy remains controversial.

AIMS

To explore the association between diabetes mellitus and the risk of cholecystectomy.

METHODS

Population-based case-control analysis using UK-based General Practice Research Database. Cases of cholecystectomy and up to four controls per case, matched on age, sex, BMI, general practice, calendar time, and years of history in the database were identified between 1994 and 2008. Conditional logistic regression was used to estimate the risk of cholecystectomy in diabetics compared to non-diabetics. Odds ratios (ORs) were calculated, adjusted for smoking, alcohol consumption, statin use, and additional confounders.

RESULTS

Amongst 22,574 cases with cholecystectomy and 72,476 controls, 1068 (4.7%) and 3270 (4.5%) had diabetes, respectively, yielding an adjusted OR for developing gallstone disease followed by cholecystectomy of 0.88, 95% CI 78-1.00, p=0.05) in association with diabetes mellitus. Neither glycaemic control, nor increasing diabetes duration or oral antidiabetic therapies were associated with an altered risk of cholecystectomy. Use of statins was protective in patients with (adj. OR 0.66, 95% CI 0.54-0.80, p<0.0001) or without diabetes (adj. OR 0.70, 95% CI 0.62-0.78, p<0.0001).

CONCLUSIONS

Diabetes mellitus was not associated with an altered risk of cholecystectomy.

Polymorphism at the mucin-like protocadherin gene influences susceptibility to gallstone disease

BACKGROUND

Gallstone disease (GSD) is a common disease that can be caused by environmental influences, common genetic factors and their interactions. Mucin glycoproteins may be one important factor for GSD. We conducted a case-control study to investigate the relationship between the mucin-like protocadherin (MUPCDH) gene polymorphisms and GSD.

METHODS

The study included 452 GSD cases and 491 healthy controls who had no evidence of gallstones by ultrasound examination. Two common tagging single nucleotide polymorphism (SNP) rs3758650 and rs7932167, and four non-synonymous SNPs rs34362213, rs2740375, rs7108757 and rs2740379 were genotyped. The genetic effects were evaluated using the multivariate regression model.

RESULTS

The genotypes of these SNPs were all in Hardy-Weinberg equilibrium. Three non-synonymous SNPs (rs34362213, rs7108757 and rs2740379) were monomorphic. The single SNP analysis showed two SNPs (rs7932167 and rs2740375) were not associated with GSD and only SNP rs3758650 had the association of the presence of GSD with an odds ratio (OR) of 1.59 (adjusted P=0.013) for the AG genotype and 5.82 (adjusted P=0.007) for the AA genotype when compared with the reference GG genotype. The haplotype analysis of the three polymorphic SNPs showed GCA was significant for GSD (adjusted p=0.001) with an odds ratio (OR) of 1.41 when compared to other haplotypes.

CONCLUSIONS

The MUPCDH genetic polymorphism rs3758650 was considered a genetic marker to predict symptomatic GSD subjects. It may be of importance for GSD patients with the risk SNPs to be frequently checked because they may develop symptomatic GSD.

The outcome of laparoscopic cholecystectomy in diabetic patients: a prospective study

BACKGROUND

Diabetes mellitus is considered a risk factor associated with morbidity in patients who undergo laparoscopic cholecystectomy (LC), in comparison with nondiabetics. The aim of this study was to evaluate this risk factor in Saudi patients and evaluate the outcome LC in diabetic patients with nondiabetics.

PATIENTS AND METHODS

We analyzed data from 968 patients with symptomatic gallbladder stones who underwent an LC between January 2005 and June 2008. Age, sex, operative records, morbidity, and length of hospital stay for each patient were analyzed.

RESULTS

There were 175 (18%) diabetic and 793 nondiabetic patients. There was no significant difference between the two groups regarding complication, conversion to open, or operative time. Length of hospital stay was significantly different in the two groups.

CONCLUSIONS

LC in diabetic patients had the same outcome in nondiabetic patients. Careful preoperative preparations, meticulous intraoperative surgical technique, and cautious postoperative care are mandatory to achieve this outcome.

Laparoscopic versus open cholecystectomy in diabetic patients and postoperative outcome

BACKGROUND

Diabetes mellitus is associated with an increased risk of complications after abdominal surgery. We evaluated retrospectively the impact of preoperative risk factors and outcome of diabetic patients after laparoscopic cholecystectomy (LC) compared with open cholecystectomy (OC) for symptomatic gallstones.

METHODS

Altogether 2,548 consecutive patients (1,581 LC, 967 OC) with symptomatic gallstones underwent cholecystectomy at our secondary referral center, being the only operative unit in the catchment area. Between the years 1995 and 2008, we operated 227 (9%) patients with diabetes, of whom 45 (20%) had type 1 diabetes. Preoperative data and operative outcome of the diabetic patients undergoing LC (n = 102) and OC (n = 125) were compared. The effect of comorbidities of diabetes on the risk for postoperative complications was analyzed by multiple logistic regression analysis.

RESULTS

The percentage of morbidly obese diabetic patients did not change during the study period. Almost half of the cholecystectomies (n = 111) in diabetics were performed as acute surgery due to cholecystitis. Conversion to open surgery was required in 16% of the diabetic patients undergoing LC compared with 7% in the nondiabetic controls (p < 0.0001). Mortality rate was zero and nine patients (7.2%), respectively, in the LC and OC groups (p < 0.01). Other complications were also more frequently observed in the OC than LC groups. This outcome difference was unchanged during time. On multivariate analysis, comorbidities of diabetes were associated with an elevated risk for complications, but obesity or acute surgery was not independently associated with postoperative complications.

CONCLUSIONS

When feasible, LC was a safe procedure in diabetes. Open surgery with comorbidities increased the operative risks. Our study was not randomized, and therefore selection bias to type of procedure may affect the results.

Diabetes in relation to biliary tract cancer and stones: a population-based study in Shanghai, China

BACKGROUND

Biliary tract cancers are rare but fatal malignancies. Diabetes has been related to biliary stones, but its association with biliary tract cancers is less conclusive.

METHODS

In a population-based case-control study of 627 cancers, 1037 stones, and 959 controls in Shanghai, China, we examined the association between diabetes and the risks of biliary tract cancer and stones, as well as the effect of potential mediating factors, including serum lipids and biliary stones (for cancer), contributing to the causal pathway from diabetes to biliary diseases.

RESULTS

Independent of body mass index (BMI), diabetes was significantly associated with gallbladder cancer and biliary stones ((odds ratio (OR) (95% confidence interval)=2.6 (1.5-4.7) and 2.0 (1.2-3.3), respectively). Biliary stones and low serum levels of high-density lipoprotein (HDL) were significant mediators of the diabetes effect on gallbladder cancer risk, accounting for 60 and 17% of the diabetes effect, respectively. High-density lipoprotein was also a significant mediator of the diabetes effect on biliary stones, accounting for 18% of the diabetes effect.

CONCLUSIONS

Independent of BMI, diabetes is a risk factor for gallbladder cancer, but its effect is mediated in part by biliary stones and serum HDL levels, suggesting that gallbladder cancer risk may be reduced by controlling diabetes, stones, and HDL levels.

Ultrasonic Gallbladder Function in Chronic Kidney Disease: Does Predialysis, Hemodialysis, or CAPD Affect it?

BACKGROUND

There are contradictory reports about the prevalence of cholelithiasis in chronic kidney disease (CKD). The pathogenesis of gallstones is associated with the lithogenic changes of bile composition, increased tendency to nucleation, and decreased gallbladder motility. The studies related to these factors can predict the development of cholelithiasis. The aim of this study was to evaluate the ultrasonic gallbladder function in CKD and to compare it in predialysis (PreD), hemodialysis (HD), and continuous ambulatory peritoneal dialysis (CAPD) patients.

METHODS

Age, gender, and body mass index matched 49 CKD patients (14 PreD, 19 HD, 16 CAPD), and 17 control individuals were included in the study. Diabetic and cirrhotic patients were not included. Ultrasonic gallbladder volume was evaluated in pre- and postprandial period, and ejection fraction was calculated. We also measured several biochemical parameters (cholesterol, triglyceride, blood urea nitrogen (BUN), creatinine, calcium, Phosphorus, parathormone, albumin, total protein) in blood.

RESULTS

Preprandial gallbladder volume in PreD, HD, CAPD, and control groups were 26.7 +/-13.6, 20.8+/-10.4, 23.2+/-14.7, and 26.4+/-14.8 mL, respectively (p > 0.05). Ejection fractions were 54.1 +/- 22.9%, 54.9 +/- 23.9%, 48.6 +/- 15.9%, and 51.8 +/- 19.2% in PreD, HD, CAPD, and control groups, respectively (p > 0.05). Serum triglyceride was higher in PreD patients than control group (207 +/- 144 vs. 110 +/-48 mg/dL) (p<0.05). Serum BUN, Cre, P, and PTH levels were higher in CKD groups than the control group, whereas serum total protein and albumin levels were higher in the control group (p<0.05). Serum Ca was lower in PreD and HD patients than in the controls (p<0.05).

CONCLUSIONS

In conclusion, CKD and renal replacement therapy (HD and CAPD) do not affect gallbladder functions, but more studies are needed to evaluate prevalence of gallstones, gallbladder motility, and the composition of bile in CKD.

Prevalence of Gall Bladder Stones among Type 2 Diabetic Patients in Benghazi Libya: A Case-control Study

Background: Diabetes mellitus and gall bladder stones are both common and costly diseases. Increasing age, female gender, overweight, familial history of the disease and type 2 diabetes mellitus is all associated with an increased risk of gallstones. Several studies from around the world reported an increased prevalence of gall bladder stones in patients with diabetes mellitus. Aims and objectives: The aim of this study was to define the frequency of gall bladder stones among Libyan diabetics and to evaluate the possible associated risk factors in these patients. Patients and methods: A case-control study was performed during 2007 at Benghazi Diabetes and endocrinology Center. The study involved 161 randomly selected type-2 diabetic patients under regular follow up at the center, and 166 age and sex matched non-diabetic outpatients at the 7th of October teaching hospital. Real-time abdominal ultrasound was performed by two radiologists to examine the abdomen after an overnight fast. Results: About 40% of the diabetic cohort had gall bladder stones as compared to 17.5% of non-diabetic patients. Females were significantly more affected than males. Patients with gall bladder stones were significantly older and had a significantly higher body mass index than those without stones. Conclusion: The prevalence of gallstones in Libyan diabetic patients is higher than the rates reported in other parts of the world. Libyan diabetic patients with gallstones tend to be older and more obese than those without gallstones. Duration of diabetes mellitus and type of treatment does not seem to influence the frequency of gall bladder stones among Libyan diabetics.

Serum lipid levels and the risk of biliary tract cancers and biliary stones: A population-based study in China

Biliary tract cancers, encompassing the gallbladder, extrahepatic bile ducts and ampulla of Vater, are rare but highly fatal malignancies. Gallstones, the predominant risk factor for biliary cancers, are linked with hyperlipidemia. As part of a population-based case-control study conducted in Shanghai, China, we examined the associations of serum lipid levels with biliary stones and cancers. We included 460 biliary cancer cases (264 gallbladder, 141 extrahepatic bile duct, and 55 ampulla of Vater), 981 biliary stone cases and 858 healthy individuals randomly selected from the population. Participants completed an in-person interview and gave overnight fasting blood samples. Participants in the highest quintile of triglycerides (>/=160 mg/dl) had a 1.4-fold risk of biliary stones (95% CI = 1.1-1.9), a 1.9-fold risk of gallbladder cancer (95% CI = 1.3-2.8), and a 4.8-fold risk of bile duct cancer (95% CI = 2.8-8.1), compared to the reference group (third quintile: 90-124 mg/dl). Participants in the lowest quintile of high-density lipoprotein (HDL) (<30 mg/dl) had a 4.2-fold risk of biliary stones (95% CI = 3.0-6.0), an 11.6-fold risk of gallbladder cancer (95% CI = 7.3-18.5), and a 16.8-fold risk of bile duct cancer (95% CI = 9.1-30.9), relative to the reference group (third quintile: 40-49 mg/dl). In addition, total cholesterol, low-density lipoprotein (LDL) and apolipoprotein A (apo A) were inversely associated with biliary stones; whereas low levels as well as high levels of total cholesterol, LDL, apo A and apolipoprotein B (apo B) were associated with excess risks of biliary tract cancers. Our findings support a role for serum lipids in gallstone development and biliary carcinogenesis.

Gallstone formation after pancreas and/or kidney transplantation: an analysis of risk factors

Pancreas and kidney transplantation (SPK) is the treatment of choice for patients with type 1 diabetes mellitus and end-stage renal failure. Gallstones are common after SPK transplantation but little is known about the true incidence and etiology of gallstones in this group. We therefore evaluated the incidence of gallstones and the presence of transplant-related risk factors in patients after SPK and kidney transplantation alone (KTA). Data were evaluated of 56 consecutive patients who underwent SPK transplantation and compared the results with those of 91 consecutive nondiabetic patients who underwent KTA transplantation at the Leiden University Medical Center between 1987 and 1994. Of the 58 evaluable KTA patients, 20.7% developed gallstones during 7.7 yr of follow-up and in the SPK group 43.9% of the 41 evaluable patients developed gallstones during 7.1 yr of follow-up. Postoperative weight loss and cyclosporin A-related hepatotoxicity correlated with gallstone formation both in SPK and KTA patients. In addition, the duration of postoperative fasting and autonomic neuropathy correlated with gallstones in SPK patients. It is concluded that both in patients after SPK transplantation and in patients after KTA transplantation, the risk to develop gallstones is significantly increased. Physicians should be aware of the high incidence of gallstones in SPK recipients.

The multifaceted associations of hepatobiliary disease and diabetes

OBJECTIVE

To investigate the association of diabetes and hepatobiliary disease.

METHODS

We performed a MEDLINE search of the English-language literature published between January 1980 and January 2007 for studies in which diabetes was associated with liver diseases.

RESULTS

Through its association with the insulin resistance syndrome, type 2 diabetes is associated with nonalcoholic fatty liver disease, nonalcoholic steatohepatitis (NASH), NASH-cirrhosis, and NASH-cirrhosis-related hepatocellular carcinoma. Because of the association with insulin resistance, insulin sensitizers may slow or even arrest the progress of these diseases. Type 2 but not type 1 diabetes is associated with hepatitis C virus but not hepatitis B viral infection. This association is likely due to hepatitis C viral infection of the pancreatic beta-cells. Early detection and antiviral therapy can decelerate the development of diabetes. Type 1 diabetes is associated with hemochromatosis and autoimmune hepatitis. Because of the presence of autonomic neuropathy, cholelithiasis but not cholecystitis is more common in patients with diabetes than in the general population. Therefore, asymptomatic cholelithiasis in patients with diabetes no longer warrants a cholecystectomy. In patients with advanced liver disease of any cause, insulin resistance and diabetes have an increased frequency of occurrence and can be reversed with liver transplantation. Rarely, medications used to treat type 2 diabetes have been associated with drug-induced hepatitis.

CONCLUSION

The prevalence of hepatobiliary diseases is increased in patients with diabetes. Early recognition and treatment of these conditions can prevent, stabilize, or even reverse hepatic damage and prevent the development of hepatic carcinoma and liver failure.

Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy

Asymptomatic cholelithiasis is increasingly diagnosed today, mainly as a result of the widespread use of abdominal ultrasonography for the evaluation of patients for unrelated or vague abdominal complaints. About 10-20% of people in most western countries have gallstones, and among them 50-70% are asymptomatic at the time of diagnosis. Asymptomatic gallstone disease has a benign natural course; the progression of asymptomatic to symptomatic disease is relatively low, ranging from 10-25%. The majority of patients rarely develop gallstone-related complications without first having at least one episode of biliary pain ("colic"). In the prelaparoscopy era, (open) cholecystectomy was generally performed for symptomatic disease. The minimally invasive laparoscopic cholecystectomy refueled the discussion about the optimal management of asymptomatic cholelithiasis. Despite some controversy, most authors agree that the vast majority of subjects should be managed by observation alone (expectant management). Selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications. Concomitant cholecystectomy is a reasonable option for good-risk patients with asymptomatic cholelithiasis undergoing abdominal surgery for unrelated conditions. Routine cholecystectomy for all subjects with silent gallstones is a too aggressive management option, not indicated for most subjects with asymptomatic cholelithiasis. An in-depth knowledge of the natural history of gallstone disease is required to select the optimal management option for the individual subject with silent gallstones. Management options should be extensively discussed with the patient; he or she should be actively involved in the process of therapeutic decision making.

Prevalence and risk factors of gallstone disease in an adult population of Taiwan: an epidemiological survey

BACKGROUND AND AIMS

The aim of this study was to determine the prevalence and risk factors of gallstone disease (GSD) in an adult population of Taiwan through a population-based screening study.

METHODS

A cross-sectional community study in a rural village of Taiwan was conducted in 3333 Chinese adults (aged > or = 18 years) undergoing ultrasonography. A questionnaire on personal history was completed to ascertain whether the removed gallbladder contained stones in all cholecystectomized subjects, the dietary habits (vegetarian/non-vegetarian diet), the history of GSD in the participant's first-degree relatives, the history of gastrointestinal surgery (vagotomy, gastrectomy for peptic ulcer disease, or ileal resection), parity, and use of oral contraceptives. The demographic characteristics and biochemical parameters were recorded.

RESULTS

The overall prevalence of GSD was 5.0% (4.6% in men, 5.4% in women) with no significant sex differences (men/women: odds ratio [OR] 0.71, 95% confidence interval [CI] 0.50-1.01, P = 0.058). Logistic regression analysis showed that increasing age (men: 40-64 years, OR 7.38, 95% CI 2.59-21.01, P < 0.001 and > or = 65 years, OR 14.16, 95% CI 4.84-41.47, P < 0.001; women: 40-64 years, OR 4.08, 95% CI 1.90-8.75, P < 0.001 and > or = 65 years, OR 6.78, 95% CI 2.97-15.46, P < 0.001) and the presence of fatty liver evidenced by ultrasonography (men: OR 2.24, 95% CI 1.32-3.80, P = 0.003; women: OR 2.13, 95% CI 1.33-3.42, P = 0.002) were risk factors for GSD. Additionally, fasting plasma glucose > or = 126 mg/dL (OR 2.11, 95% CI 1.16-3.83, P = 0.014), history of GSD in the first-degree relatives (OR 7.47, 95% CI 2.22-25.12, P = 0.001), and use of oral contraceptives (OR 10.71, 95% CI 3.06-37.49, P < 0.001) were risk factors for GSD in women, but fasting plasma glucose > or = 126 mg/dL was only correlated to GSD without controlling for other confounding factors in men. Other demographic characteristics and biochemical parameters, such as high body mass index (> or = 25 kg/m2), increased parity, hypercholesterolemia, hypertriglyceridemia, hyperuricemia, hepatitis C infection and cirrhosis, did not exhibit any correlation to GSD in logistic regression analysis, although they appeared to be related to GSD in women in univariate analysis.

CONCLUSIONS

Age and fatty liver in both sexes were found to be risk factors for GSD in the study population. The finding of a correlation between fatty liver and GSD is an important addition to the literature concerning the risk factors of GSD. Diabetes mellitus, history of GSD in the first-degree relatives, and use of oral contraceptives were also risk factors for GSD in women.

Risk factors for gallstone-related hospitalization during pregnancy and the postpartum

OBJECTIVES

Gallbladder disease is a leading nonobstetrical cause for hospitalization in the first year postpartum. The aim of this study was to define the incidence and risk factors for postpartum hospitalization as a result of gallstone-related disease.

METHODS

We identified 6,670 women with discharge diagnoses related to biliary disease from linked birth certificate and hospital discharge databases for Washington State from 1987 through 2001. Cases were women with gallstone-related diagnoses at delivery or as primary diagnosis in the postpartum. Four controls who were within 1 yr postpartum were randomly selected for each case and matched for year of delivery. From the birth certificates, we obtained data about patient demographics, reproductive history, and pregnancy-related risk factors. In a retrospective case-control study, we developed multiple logistic regression models to identify independent risk factors for hospitalization.

RESULTS

We identified 6,211 women as cases (0.5% of all births) during the study period. The median time to hospitalization was 95 days (interquartile range 46-191 days), with a median length of stay of 3 days. Seventy-six percent were diagnosed with uncomplicated cholelithiasis, 16% with pancreatitis, 9% with acute cholecystitis, and 8% with cholangitis. Seventy-three percent of hospitalized women underwent cholecystectomy, and 5% underwent endoscopic retrograde cholangiopancreatography (ERCP). On multivariate analysis, independent risk factors for hospitalization included maternal race, age, being overweight or obese prepregnancy, pregnancy weight gain, and estimated gestational age.

CONCLUSIONS

Hospitalization for gallstone-related disease is common in the first year postpartum, most commonly for uncomplicated cholelithiasis. Risk factors for hospitalization include prepregnancy body mass index, race, Hispanic ethnicity, and maternal age.

Prognostic parameters for the prediction of acute gangrenous cholecystitis

BACKGROUND/PURPOSE

The aim of this study was to identify preoperative prognostic parameters for gangrenous cholecystitis to differentiate this subgroup of patients with acute cholecystitis in order to provide immediate surgical therapy.

METHODS

The medical records of patients who had an emergency cholecystectomy with the diagnosis of acute cholecystitis between January 2002 and June 2005 were reviewed retrospectively. Univariate and multivariate analysis were performed on the data.

RESULTS

Out of 203 individuals with the clinical diagnosis of acute cholecystitis, 21 (10.3%) patients had a histological diagnosis of gangrenous cholecystitis. Multivariate analysis demonstrated an independent association of male sex, diabetes mellitus and white blood cell (WBC) count with the development of acute gangrenous cholecystitis.

CONCLUSIONS

The risk for gangrenous cholecystitis is increased in male patients who have diabetes and a greater WBC count than 14 900/mm(3). Urgent surgical intervention should be considered for these patients because of the high morbidity and mortality rate of the condition.

CYP17 MspA1 polymorphism and risk of biliary tract cancers and gallstones: a population-based study in Shanghai, China

Biliary tract cancers, encompassing cancers of the gallbladder, extrahepatic bile duct and ampulla of Vater, are rare but highly fatal malignancies. Other than gallstones, little is known about the risk factors for biliary tract cancers. Endogenous estrogens are thought to play a role in the etiology of gallstones and gallbladder cancer, since both conditions predominate in females and are associated with parity and obesity. In view of reports linking the CYP17 MspA1 polymorphism to high circulating levels of estrogens and a predisposition to other hormonally related cancers, we examined the relationship between CYP17 MspA1 variants and risk of biliary disease in a population-based case-control study in Shanghai. The study included 446 cancer cases (254 gallbladder, 139 extrahepatic bile duct, 53 ampullary cancers), 929 biliary stone cases (691 gallbladder, 238 bile duct) and 818 population controls. Genomic DNA from peripheral blood lymphocytes was used for genotyping. Relative to those with the A2/A2 genotype, A1 carriers (A1/A1 and A1/A2 genotypes) had an increased risk of gallbladder cancer (odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.1-2.1). In addition, women with the A1 allele and high parity (> or =3) had a 3-fold risk of gallbladder cancer (OR = 3.3, 95% CI = 1.6-6.9), compared to those with the A2/A2 genotype and lower parity, with the highest risk seen for those also having biliary stones (OR = 4.6, 95% CI = 1.8-11.7, P(interaction) = 0.04). The A1 allele was not associated with a higher risk of gallstones except among those with body mass index (BMI) greater than 25 kg/m2 (OR = 3.1, 95% CI = 2.0-4.8, P(interaction) = 0.02) and among those with a history of diabetes (OR = 2.5, 95% CI = 1.4-4.3, P interaction = 0.09). No clear relation was seen between the CYP17 polymorphism and cancers of the bile duct or ampulla of Vater. The association of the CYP17 MspA1 polymorphism with an increased risk of gallbladder cancer, as well as biliary stones among overweight and diabetic individuals, suggests an interplay between genetic and hormonal risk factors in gallbladder disease.

Gallstone disease: Primary and secondary prevention

Several risk factors for cholesterol gallstone formation in the general population have been identified. There is a strongly increased risk of gallstone disease during prolonged fasting, rapid weight loss, total parenteral nutrition, and somatostatin(-analogue) treatment. The annual risk of biliary colic and gallstone complications in asymptomatic gallstone carriers has been investigated sparsely. In asymptomatic and symptomatic gallstone carriers, treatment with the hydrophilic bile salt ursodeoxycholic acid (UDCA) has been claimed to reduce the risk of biliary colic and gallstone complications such as acute cholecystitis and acute pancreatitis. Also, prophylactic cholecystectomy could be beneficial in certain subgroups of asymptomatic gallstone carriers. However, randomized, double-blind, placebo-controlled trials are lacking. In this review, strategies for the prevention of gallstone formation in the general population and in high-risk conditions are dealt with. Also, strategies for the prevention of biliary colic and gallstone complications in asymptomatic and symptomatic gallstone carriers are discussed.

Prevalência ultra-sonográfica de litíase biliar em pacientes ambulatoriais

OBJETIVO: Este estudo tem por objetivo determinar a prevalência ultra-sonográfica de litíase biliar em pacientes ambulatoriais. MÉTODO: No período de julho de 2001 a março de 2002, 500 pacientes que procuraram o Hospital Universitário Presidente Dutra e que foram submetidos a exame ultra-sonográfico para doença não biliar foram avaliados. Havia 250 pacientes do sexo masculino e 250 do sexo feminino com idade variando de 19 a 72 anos. RESULTADOS: A prevalência de colelitíase ou de pacientes que haviam sido previamente submetidos à colecistectomia por colelitíase foi de 18,4%. A colelitíase foi mais frequentemente observada naqueles pacientes com idade superior a 60 anos, sexo feminino, multípara e com um índice de massa corporal superior a 30. CONCLUSÕES: A prevalência de colelitíase está aumentada na presença de fatores de risco.

Leptin-resistant obese mice do not form biliary crystals on a high cholesterol diet1,2

INTRODUCTION

Human obesity is associated with leptin resistance and cholesterol gallstone formation. Previously, we demonstrated that leptin-resistant (Lep(db)) obese mice fed a low cholesterol diet have enlarged gallbladders, but a decreased cholesterol saturation index, despite elevated serum cholesterol. Obese humans, however, consume a high cholesterol diet. Therefore, we hypothesized that on a high cholesterol diet, leptin-resistant mice would have cholesterol saturated bile and would form biliary crystals.

METHODS

Eight-week old female lean control (n = 70) and leptin-resistant (n = 72) mice were fed a 1% cholesterol diet for 4 weeks. All animals then had cholecystectomies. Bile was collected, grouped into pools to determine cholesterol saturation index (CSI), and examined for cholesterol crystals. Serum cholesterol and leptin were also measured.

RESULTS

Gallbladder volumes for Lep(db) mice were enlarged compared with the lean mice (35.8 microl versus 19.1 microl, P < 0.001), but the CSI for the Lep(db) mice was lower than for the lean animals (0.91 versus 1.15, P < 0.03). The obese animals did not form cholesterol crystals, whereas the lean animals averaged 2.2 crystals per high-powered field (hpf) (P < 0.001). Serum cholesterol and leptin were also elevated (P < 0.001) in the obese animals.

CONCLUSIONS

These data suggest that Lep(db) obese mice fed a high cholesterol diet have increased gallbladder volume and decreased biliary cholesterol saturation and crystal formation despite elevated serum cholesterol compared with lean control mice. We conclude that the link among obesity, diet, and gallstone formation may not require hypersecretion of biliary cholesterol and may be related to the effects of diabetes, hyperlipidemia, or both on gallbladder motility.

Gallbladder myocytes are short and cholecystokinin-resistant in obese diabetic mice

BACKGROUND

Obesity is associated with diabetes and gallstone formation. Obese leptin-deficient (Lepob) and leptin-resistant (Lepdb) mice are hyperglycemic and have enlarged gallbladders with diminished response in vitro to cholecystokinin (CCK) and acetylcholine (ACh). Whether this phenomenon is secondary to hyperosmolar myocytes and/or decreased neuromuscular transmission remains unclear. We hypothesize that myocytes from Lepob and Lepdb obese mice would not respond normally to neurotransmitters.

METHODS

Cholecystectomy was performed on 39 lean, 19 Lepob, and 20 Lepdb 12-week-old female mice. The gallbladder was divided and enzymatically digested. Half of each gallbladder's myocytes had contraction induced by CCK (10(-8) mol/L, n = 38) or ACh (10(-5) mol/L, n = 40).

RESULTS

Body weights, gallbladder volumes, and serum glucoses were greater for Lep(ob) and Lepdb mice compared to controls (P < .001). Resting myocyte lengths from Lepob and Lepdb mice were 93% and 91% of the length of controls (P < .001). In response to CCK, lean myocytes shortened 6% (P < .01), while myocytes from obese mice demonstrated no shortening. None of the myocytes demonstrated significant shortening with ACh.

CONCLUSIONS

These data suggest that gallbladder myocytes from obese mice are (1) foreshortened and (2) have a diminished response to cholecystokinin. We conclude that altered leptin and/or increased glucose may foreshorten myocytes and decrease response to cholecystokinin.

Diabetes and hyperlipidemia correlate with gallbladder contractility in leptin-related murine obesity

Obesity is associated with many comorbid conditions including diabetes, hyperlipidemia, and gallstones. However, the interaction among these modalities remains unclear. We recently demonstrated that both leptin-deficient and leptin-resistant obese mice have impaired biliary motility. These obese mice also are diabetic and hyperlipidemic. Therefore, we tested the hypothesis that serum glucose, insulin, cholesterol, and triglyceride levels would correlate with gallbladder contractility. Thirty-four lean control, 10 lean heterozygous leptin-deficient, 18 obese homozygous leptin-deficient, and 12 obese homozygous leptin-resistant mice were fed a nonlithogenic chow diet while nine lean control and nine obese homozygous leptin-deficient mice were fed a high-cholesterol diet for 4 weeks. In vitro gallbladder responses to cholecystokinin (CCK; 10(-8) mol/L), acetylcholine (ACh; 10(-5) mol/L), and neuropeptide Y (NPY; 10(-6) mol/L) were measured. Serum glucose, insulin, cholesterol, and triglyceride levels were measured from pooled serum from an additional 704 animals. Gallbladder responses were greatest for CCK, intermediate for ACh, and least for NPY. Serum glucose, insulin, cholesterol, and triglyceride levels and body weight all correlated similarly, negatively, and significantly (P<0.001) with gallbladder contractility. Hyperglycemia, insulin-resistance, hyperlipidemia, and body weight in obese mice with leptin dysfunction are associated with poor gallbladder contractility, which in turn may contribute to the association between obesity and gallstone formation.

Evaluation of gallbladder volume and motility in non-insulin-dependent diabetes mellitus patients using real-time ultrasonography

AIMS

The prevalence of cholelithiasis is 2 to 3 times higher in patients with diabetes mellitus than in the normal population, especially in a group of patients with non-insulin-dependent diabetes mellitus (NIDDM). We investigated the pathogenesis of this increased prevalence by ultrasonography with a brief comparison of demographic features.

MATERIALS AND METHODS

The study group was consisted of NIDDM patients (41 males and 47 females, mean age 53.5 +/- 11 years), and the control group included healthy volunteers (33 males and 34 females, mean age 50.3 +/- 18 years). All patients were investigated after 12 hours of fasting and 30 minutes after a standard test meal. Pre-meal and post-meal gallbladder volumes were used for calculation of the ejection fraction of the gallbladder and fasting gallbladder volume.

RESULTS

In the study group, there was no correlation between the fasting gallbladder volume and age, parity, and body mass index. However, fasting gallbladder volume and duration of diabetes mellitus showed significant correlation (r = 0.212, P < 0.05). The mean ejection fraction of gallbladders in the study group was 48.48%, whereas that of the control group was 56.32%. There was a significant reduction of ejection fraction in the study group (P = 0.003).

CONCLUSION

Our study indicated that there were an increased fasting gallbladder volume and impaired ejection fraction in NIDDM patients. This may be the initiator of bile stasis in the gallbladder and subsequent cholesterol crystal and stone formation.

Alcohol consumption in relation to risk of cholecystectomy in women

BACKGROUND

Alcohol consumption has been linked to a lower risk of gallstone disease. However, the magnitude of the association is uncertain, and little is known about the relation of alcohol consumption patterns and individual types of alcoholic beverages to gallstone disease risk.

OBJECTIVE

We prospectively examined the association between alcohol intake and cholecystectomy, a surrogate for symptomatic gallstone disease, in a large cohort of women.

DESIGN

Women from the Nurses' Health Study who had no history of gallstone disease in 1980 (n = 80,898) were followed for 20 y. Alcohol consumption, which was measured every 2-4 y by food-frequency questionnaires, was used to predict subsequent cholecystectomy through multivariate analysis.

RESULTS

We ascertained 7831 cases of cholecystectomy. Relative to subjects who had no alcohol intake, subjects who had alcohol intakes of 0.1-4.9, 5.0-14.9, 15.0-29.9, 30.0-49.9, and >/=50.0 g/d had multivariate relative risks of cholecystectomy of 0.95, 0.86, 0.80, 0.67, and 0.62 (95% CI: 0.49, 0.79), respectively. Relative to subjects who never consumed alcohol, subjects who consumed alcohol 1-2, 3-4, 5-6, and 7 d/wk had multivariate relative risks of cholecystectomy of 0.94, 0.88, 0.87, and 0.73 (0.63, 0.84), respectively. All alcoholic beverage types were inversely associated with cholecystectomy risk, independent of consumption patterns (for quantity of alcohol consumed, P = 0.04, 0.001, and 0.003 for wine, beer, and liquor, respectively; for frequency of alcohol consumption, P = 0.01, 0.07, and <0.0001 for wine, beer, and liquor, respectively).

CONCLUSIONS

The intake of all alcoholic beverage types is inversely associated with the risk of cholecystectomy. Recommendations regarding the benefit of consuming moderate quantities of alcohol should be weighed against the potential health hazards.

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.

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.

Cisapride improves gallbladder emptying in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

Gallbladder motor function is impaired in many patients with diabetes, and may be related to cholinergic nerve damage. Cisapride is a prokinetic drug of the gastrointestinal tract and acts by releasing acetylcholine from cholinergic nerve endings. The aim of this study was to determine the effect of cisapride on gallbladder emptying in patients with type 2 diabetes mellitus (DM).

METHODS

Gallbladder emptying and tests for autonomic neuropathy (AN) were performed in 27 patients with type 2 DM and in 10 healthy subjects. Gallbladder emptying was studied by using real-time ultrasonography after an overnight fast, and after the subjects received a breakfast that contained 2500 J. Gallbladder emptying was repeated after the treatment with cisapride (10 mg t.i.d.) for 1 week in all subjects.

RESULTS

Abnormal gallbladder emptying was present in 14 (51.9%) patients. The residual gallbladder volume (mean +/- SEM) was higher (9.3 +/- 1.0 vs 4.6 +/- 0.6; P = 0.002), and ejection fraction was lower (57.4 +/- 4.0 vs 74.2 +/- 2.4; P = 0.015) in diabetic patients than it was in healthy subjects. Cisapride produced a reduction in fasting and residual volumes (24.6 +/- 2.4 vs 20.0 +/- 1.4; P = 0.034 and 9.3 +/- 1.0 vs 5.9 +/- 1.1; P = 0.00003, respectively), and an improvement in ejection fraction (57.4 +/- 4.0 vs 72.6 +/- 3.8; P = 0.000007). The improvement in gallbladder emptying after cisapride therapy was confined to the patients with AN (n = 13) (57.3 +/- 5.4 vs 80.4 +/- 2.9; P = 0.0017), suggesting denervation supersensitivity with an upregulation of cholinergic receptors. There was no significant change in the ejection fraction in patients without AN (57.5 +/- 6.1 vs 65.4 +/- 6.5; P = NS). Sex, duration of diabetes, peripheral neuropathy, diabetic retinopathy and serum cholesterol level did not influence gallbladder emptying.

CONCLUSION

Impaired gallbladder emptying is common in patients with type 2 DM. Cisapride significantly improves gallbladder emptying in patients with autonomic neuropathy.

Real-time sonography for screening of gallbladder dysfunction in children with type 1 diabetes mellitus

The aim of this study was to evaluate the occurrence of gallbladder dysfunction in children with type 1 diabetes mellitus using real-time ultrasonography. The study population consisted of 20 diabetic children (11 male, 9 female; age 11.7+/-2.8 years; diabetes duration 0.5-7 years) with clinically negative neuropathy findings and 15 healthy controls (11 male, 4 female; age 10.5+/-3.7 years). Three-dimensional measurements of the gallbladder were made before and 15, 30, 45, 60 min after intake of diet chocolate. Gallbladder volumes were calculated by the ellipsoid formula. Fasting gallbladder volume of diabetic children (16.9+/-9.5 ml) was significantly greater than that of the controls (10.6+/-5.3 ml; p=0.017). Ejection fraction and maximal contraction showed no significant difference between the two groups. Diabetic patients with multiple microvascular complications had diminished gallbladder motility. There was a negative correlation between BMI and maximal contraction (p<0.05). Nerve conduction velocity was diminished in 45% of the diabetic patients. In conclusion, gallbladder function is preserved in pediatric type 1 diabetic patients with a disease duration less then 10 years, but dilated gallbladder at rest may be an early sign of gastrointestinal autonomic neuropathy and a risk factor for gallstone formation.