Gallstone disease and mortality: a cohort study

[Establishment and Validation of a Predictive Model for Gallstone Disease in the General Population: A Multicenter Study]

Objective

Gallstone disease (GSD) is one of the common digestive tract diseases with a high worldwide prevalence. The effects of GSD on patients include but are not limited to the symptoms of nausea, vomiting, and biliary colic directly caused by GSD. In addition, there is mounting evidence from cohort studies connecting GSD to other conditions, such as cardiovascular diseases, biliary tract cancer, and colorectal cancer. Early identification of patients at a high risk of GSD may help improve the prevention and control of the disease. A series of studies have attempted to establish prediction models for GSD, but these models could not be fully applied in the general population due to incomplete prediction factors, small sample sizes, and limitations in external validation. It is crucial to design a universally applicable GSD risk prediction model for the general population and to take individualized intervention measures to prevent the occurrence of GSD. This study aims to conduct a multicenter investigation involving more than 90000 people to construct and validate a complete and simplified GSD risk prediction model.

Methods

A total of 123634 participants were included in the study between January 2015 and December 2020, of whom 43929 were from the First Affiliated Hospital of Chongqing Medical University (Chongqing, China), 11907 were from the First People's Hospital of Jining City (Shandong, China), 1538 were from the Tianjin Medical University Cancer Institute and Hospital (Tianjin, China), and 66260 were from the People's Hospital of Kaizhou District (Chongqing, China). After excluding patients with incomplete clinical medical data, 35976 patients from the First Affiliated Hospital of Chongqing Medical University were divided into a training data set (n=28781, 80%) and a validation data set (n=7195, 20%). Logistic regression analyses were performed to investigate the relevant risk factors of GSD, and a complete risk prediction model was constructed. Factors with high scores, mainly according to the nomograms of the complete model, were retained to simplify the model. In the validation data set, the diagnostic accuracy and clinical performance of these models were validated using the calibration curve, area under the curve (AUC) of the receiver operating characteristic curve, and decision curve analysis (DCA). Moreover, the diagnostic accuracy of these two models was validated in three other hospitals. Finally, we established an online website for using the prediction model (The complete model is accessible at https://wenqianyu.shinyapps.io/Completemodel/, while the simplified model is accessible at https://wenqianyu.shinyapps.io/Simplified/).

Results

After excluding patients with incomplete clinical medical data, a total of 96426 participants were finally included in this study (35876 from the First Affiliated Hospital of the Chongqing Medical University, 9289 from the First People's Hospital of Jining City, 1522 from the Tianjin Medical University Cancer Institute, and 49639 from the People's Hospital of Kaizhou District). Female sex, advanced age, higher body mass index, fasting plasma glucose, uric acid, total bilirubin, gamma-glutamyl transpeptidase, and fatty liver disease were positively associated with risks for GSD. Furthermore, gallbladder polyps, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and aspartate aminotransferase were negatively correlated to risks for GSD. According to the nomograms of the complete model, a simplified model including sex, age, body mass index, gallbladder polyps, and fatty liver disease was constructed. All the calibration curves exhibited good consistency between the predicted and observed probabilities. In addition, DCA indicated that both the complete model and the simplified model showed better net benefits than treat-all and treat-none. Based on the calibration plots, DCA, and AUCs of the complete model (AUC in the internal validation data set=74.1% [95% CI: 72.9%-75.3%], AUC in Shandong=71.7% [95% CI: 70.6%-72.8%], AUC in Tianjin=75.3% [95% CI: 72.7%-77.9%], and AUC in Kaizhou=72.9% [95% CI: 72.5%-73.3%]) and the simplified model (AUC in the internal validation data set=73.7% [95% CI: 72.5%-75.0%], AUC in Shandong=71.5% [95% CI: 70.4%-72.5%], AUC in Tianjin=75.4% [95% CI: 72.9%-78.0%], and AUC in Kaizhou=72.4% [95% CI: 72.0%-72.8%]), we concluded that the complete and simplified risk prediction models for GSD exhibited excellent performance. Moreover, we detected no significant differences between the performance of the two models (P>0.05). We also established two online websites based on the results of this study for GSD risk prediction.

Conclusions

This study innovatively used the data from 96426 patients from four hospitals to establish a GSD risk prediction model and to perform risk prediction analyses of internal and external validation data sets in four cohorts. A simplified model of GSD risk prediction, which included the variables of sex, age, body mass index, gallbladder polyps, and fatty liver disease, also exhibited good discrimination and clinical performance. Nonetheless, further studies are needed to explore the role of low-density lipoprotein cholesterol and aspartate aminotransferase in gallstone formation. Although the validation results of the complete model were better than those of the simplified model to a certain extent, the difference was not significant even in large samples. Compared with the complete model, the simplified model uses fewer variables and yields similar prediction and clinical impact. Hence, we recommend the application of the simplified model to improve the efficiency of screening high-risk groups in practice. The use of the simplified model is conducive to enhancing the self-awareness of prevention and control in the general population and early intervention for GSD.

Longitudinal Study of Comorbidities and Clinical Outcomes in Persons with Gallstone Disease Using Electronic Health Records

BACKGROUND

Gallstone disease (GSD) is common and leads to significant morbidity, mortality, and health care utilization in the USA. We examined comorbidities and clinical outcomes among persons with GSD using electronic health records (EHR).

METHODS

In this retrospective study of 1,381,004 adults, GSD was defined by ICD-9 code 574 or ICD-10 code K80 using Optum® longitudinal EHR from January 2007 to March 2021. We obtained diagnosis, procedure, prescription, and vital sign records and evaluated associations between demographics, comorbidities, and medications with cholecystectomy, digestive cancers, and mortality.

RESULTS

Among persons with GSD, 30% had a cholecystectomy and were more likely to be women, White, and younger, and less likely to have comorbidities, except for obesity, gastroesophageal reflux disease (GERD), abdominal pain, hyperlipidemia, and pancreatitis. Among persons with GSD, 2.2% had a non-colorectal digestive cancer diagnosis during follow-up and risk was 40% lower among persons with a cholecystectomy. Non-colorectal digestive cancer predictors included older age, male sex, non-White race-ethnicity, lower BMI, other cancers, diabetes, chronic liver disease, pancreatitis, GERD, and abdominal pain. Among persons with GSD, mortality was 15.1% compared with 9.7% for the whole EHR sample. Persons with a cholecystectomy had 40% lower mortality risk and mortality predictors included older age, male sex, Black race, lower BMI, and most comorbidities.

CONCLUSIONS

In this EHR analysis of persons with GSD, 30% had a cholecystectomy. Mortality was higher compared with the whole EHR sample. Persons with cholecystectomy were less likely to have non-colorectal digestive cancer or to die.

The increasing incidence and high body mass index-related burden of gallbladder and biliary diseases-A results from global burden of disease study 2019

BACKGROUND

Gallbladder and biliary diseases are common gastrointestinal conditions associated with huge socioeconomic costs and are considered risk factors for cardiovascular diseases and digestive system cancers. The prevalence and incidence of gallbladder and biliary diseases have not received enough attention from 1990 to 2019. Several non-communicable diseases were associated with the incidence of gallbladder and biliary diseases. It is necessary to clarify the change in the incidence and disability burden of gallbladder and biliary diseases worldwide.

METHODS

Data on high body mass index (BMI)-related disease burden and incidence, years of life lost prematurely, and years lived with disability (YLDs) due to gallbladder and biliary diseases were obtained from the Global Burden of Disease 2019. The estimated annual percentage change was calculated to qualify the gallbladder and biliary disease burden change.

RESULTS

The global age-standardized incidence rate has increased from 585.35 per 100,000 (95% UI: 506.05-679.86) in 1990 to 634.32 per 100,000 (95% UI: 540.21-742.93) in 2019. And the increase in incidence was positively correlated with rising high BMI-related summary exposure value. The high BMI-related YLDs of gallbladder and biliary diseases have increased worldwide over time. Globally, the 25-49 age group suffered a rapid rise in incidence and high BMI attributable to the YLDs rate of gallbladder and biliary diseases.

CONCLUSION

The global incidence and high BMI-related YLDs of gallbladder and biliary diseases remain prominent to increase over the past 30 years. Notably, the incidence and high BMI-related YLDs among people aged 25-49 years have rapidly increased over time. Therefore, high BMI should be emphasized in strategic priorities for controlling gallbladder and biliary diseases.

Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis

Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.

Important risk factors for gallstones after laparoscopic gastrectomy: a retrospective study

Background

The frequency of gallstones is higher in patients who have undergone gastrectomy than in the general population. While there have been some studies of gallstone formation after open gastrectomy, there are few reports of gallstones after laparoscopic gastrectomy (LG). Therefore, this study aimed to evaluate the incidence of gallstones after LG.

Methods

We retrospectively reviewed the records of 184 patients who underwent LG between January 2011 and May 2016 at Saiseikai Utsunomiya Hospital. After gastrectomy, abdominal ultrasonography was generally performed every 6 months for 5 years. Patients who underwent cholecystectomy before LG, underwent simultaneous cholecystectomy, and did not undergo abdominal ultrasonography, with an observation period of < 24 months, were excluded from the study. Finally, 90 patients were analyzed. Laparoscopic cholecystectomy was performed whenever biliary complications occurred. Patient characteristics were compared using the two-tailed Fisher’s exact test or Chi-square test. In addition, the risk factors for postoperative gallstones were analyzed using logistic regression analysis.

Results

Among the 90 patients included in this study, 60 were men (78%), and the mean age was 65.5 years. Laparoscopic total gastrectomy was performed for 15 patients and laparoscopic distal gastrectomy for 75 patients. D2 lymph node dissection was performed for 8 patients (9%), whereas 68 patients underwent LG with Roux-en-Y reconstruction (76%). Gallstones were detected after LG in 27 of the 90 (30%) patients. Multivariate analysis identified Roux-en-Y reconstruction and male sex as significant risk factors of gallstones after gastrectomy. The incidence of gallstones was significantly higher (53%) in male patients who underwent Roux-en-Y reconstruction. Symptomatic gallstones after laparoscopic cholecystectomy were found in 6 cases (6/27, 22%), and all patients underwent laparoscopic cholecystectomy.

Conclusion

Roux-en-Y reconstruction and male sex were identified as significant risk factors for gallstones after LG.

Synchronous biliary gallstones and colorectal cancer: A single center analysis

Gallstones and colorectal cancer (CRC) are two common disorders that may develop simultaneously. In such situations, there is a significant chance of missing one of the conditions due to the primary clinical presentation. Late detection, diagnosis and treatment can be especially problematic in the case of unrecognized CRC. In the present study, the medical charts were retrospectively reviewed for all consecutive patients who were treated in the Second Department of Surgery, University Emergency Hospital Bucharest (Romania) between February 2015 and December 2017 following a diagnosis of CRC and/or biliary stones. There were 203 patients with CRC, 433 with biliary gallstones and 19 patients with both conditions. There were 125 men (61.6%) in the CRC group and 138 men (31.9%) in the gallstone group. The average age was 54.1±15.9 years in the gallstone group and 66.1±11.6 years in the CRC group. Obesity was observed in 96 patients (22.2%) with gallstones and in 14 (6.9%) patients in the CRC group. In the CRC group, 80 patients had medical comorbidities (39.4%), while in the gallstone group 126 patients (29.1%) had medical comorbidities. Bivariate analysis comparing gallstone only vs. gallstone and CRC identified age (P=0.001), male sex (P=0.001) and thyroid disease (P=0.001) as significant factors associated with synchronous diagnosis. The multivariable logistic regression of factors predicting CRC in patients with gallstones identified age (OR, 1.06; 95% CI, 1.023-1.105; P=0.002) and thyroid diseases (OR, 11.15; 95% CI, 2.532-49.06; P=0.001) as independent factors. There were significant differences regarding the location of the tumor between the CRC-only group and the gallstone and CRC group (P=0.001): Rectum (39.7 vs. 5.3%), left colon (26.6 vs. 21.1%), transverse colon (13 vs. 26.3%) and right colon (20.7 vs. 47.4%). The study concluded that, in patients with gallstones, age and thyroid conditions were significantly associated with CRC. Patients with a synchronous diagnosis of gallstones and CRC had significantly more right-sided CRC compared with regular CRC.

Relationship between high-sensitivity C reactive protein and the risk of gallstone disease: results from the Kailuan cohort study

OBJECTIVES

Gallstone disease (GSD) can be caused by various health and clinical factors such as obesity, dyslipidaemia and an unhealthy diet, all of which are associated with higher high-sensitivity C reactive protein (hs-CRP) concentrations. Whether hs-CRP represents an independent risk factor for GSD is still unclear. We prospectively investigated hs-CRP in relation to the occurrence of GSD based on the Kailuan study.

STUDY DESIGN

Prospective cohort study.

SETTING

The Kailuan cohort study was conducted in Tangshan City in northern China.

PARTICIPANTS

95 319 participants who were free from GSD were recruited in this study. Epidemiological data, anthropometric parameters and biochemical data of participants were collected.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cox proportional hazards regression models were used to evaluate the association between hs-CRP concentrations and the risk of GSD after adjustments for potential confounders.

RESULTS

During the mean 7.58 years of follow-up among 95 319 participants, 4205 participants were identified as newly diagnosed with GSD or having undergone cholecystectomy for cholelithiasis. Compared with the hs-CRP<1 mg/L group, elevated hs-CRP concentrations were significantly associated with higher risk of GSD with the corresponding HR of 1.11 (95% CI 1.03 to 1.19), 1.12 (95% CI 1.04 to 1.22) in the 1≤hs-CRP≤3 mg/L and hs-CRP>3 mg/L group, respectively. The multivariate model which included hs-CRP not only had a better line of fitness but also had better predictive values to help identify new cases of GSD during follow-up.

CONCLUSION

Elevated hs-CRP concentration is an independent risk factor for new-onset GSD among the Chinese population.

TRIAL REGISTRATION NUMBER

ChiCTR-TNC-11001489.

Determinants for symptomatic gallstone disease readmissions - results from a cohort with screen-detected gallstone disease

AIM OF THE STUDY

Selection of patients for cholecystectomy is hampered by lack of objective criteria. The objectives of this cohort study were to identify if patient, symptoms, or gallstone disease characteristics determined readmission in an unselected cohort with screen-detected gallstone disease and who had experienced a first admission with symptomatic gallstone disease.

METHODS

Data from three random sampled population-based cohorts were used. At baseline, participants were screened with ultrasound and 664 had gallstones of which 84 had a first admission without cholecystectomy performed. A cohort study was performed with follow-up up for hospital readmissions beyond 30 days through central registers. Age adjusted Cox regression analyses were performed.

RESULTS

Readmissions occurred in 60.8% and cholecystectomy was eventually performed in 47.7% of patients. Early readmissions were determined by abdominal pain in the epigastrium (Hazard ratio (HR) 3.63, 95% confidence interval (CI) [1.62;8.12]) and of moderate intensity (HR 2.71, 95% CI [1.20;6.16]). Late readmissions were determined by larger gallstone size, especially when above 10mm (HR 4.11, 95% CI [1.18;14.3]) and inversely determined by age (HR 0.97, 95% CI [0.95;0.998]). In patients with initially uncomplicated gallstone disease, cholecystectomy was inversely determined by age (HR 0.96, 95% CI [0.93;0.98]).

CONCLUSION

Once gallstones have become symptomatic and caused hospital admission, a persisting high risk for future readmission exists and half of patients end up having cholecystectomy. Pain in the epigastrium, larger gallstones, and younger age determine readmission. These determinants should be tested in future clinical treatment algorithms for gallstone disease.

Gastrointestinal defects in gallstone and cholecystectomized patients

BACKGROUND AND AIM

Several gallstone patients complain of dyspeptic symptoms, irrespective of the presence of typical colicky pain. Symptoms often persist after a cholecystectomy. Systematic studies on dyspepsia and dynamic gastrointestinal motor function are missing in gallstone patients with preserved gallbladder or after a cholecystectomy.

MATERIALS AND METHODS

Forty-six gallstone patients (age 55 ± 2 years; 15M, 31F) and 24 cholecystectomized patients (age 57 ± 2 years; 6M, 18F) (no difference in type and volume of gallstones between the two groups) were compared against a group of 65 healthy controls (age 51 ± 2 years; 30M, 35F). Dyspepsia occurring in the prior months was assessed by a questionnaire, gastric and gallbladder emptying by functional ultrasonography and orocecal transit time by a hydrogen breath test using a lactulose-enriched standard liquid meal.

RESULTS

Gallstone patients had significantly greater dyspepsia, fasting and residual gallbladder volumes, and slower gallbladder emptying, gastric emptying and small intestinal transit time than controls. In cholecystectomized patients, gastric emptying further delayed, compared to gallstone patients and controls.

CONCLUSION

Gallstone patients with the gallbladder "in situ" or after a cholecystectomy display dyspeptic symptoms. Symptoms are associated with multiple gastrointestinal motility defects involving the gallbladder, stomach and small intestine. After cholecystectomy, gastric emptying worsens.

Cholesterol cholelithiasis: part of a systemic metabolic disease, prone to primary prevention

Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones.

Management of complicated gallstones in the elderly: comparing surgical and non-surgical treatment options

Objective

The aim of this study was to evaluate the differences in clinical outcomes of endoscopic retrograde cholangiopancreatography (ERCP), ERCP followed by cholecystectomy (EC) and percutaneous aspiration (PA) in the elderly population with choledocholithiasis.

Methods

We included a total of 43 338 elderly patients aged 60 years or older and 45 295 patients younger than 60 years for comparison in our study. Data were obtained from the Nationwide Inpatient Sample (Healthcare Utilization Project) for years 2001–14 by identifying patients who were admitted for gallstone complications based on the ICD 9 diagnostic code. Multiple logistic regression was used to calculate the odds of in-hospital mortality and to detect statistical differences among the treatment groups, age groups and between male and female patients. Univariate ordinary linear regression was used to compare the length of hospital stay and readmission frequency among the different age groups.

Results

The age of the patient affected mortality and the length of hospital stay after any type of procedure of gallstones removal. In a manner independent of the patient’s age, PA was associated with the highest risk of death and length of stay, while the EC was characterized by lowest mortality and ERCP by the shortest length of stay. Neither age of the patient nor the type of procedure affected the likelihood of readmission. The odds of death and the probability of readmission were not affected by patient sex. However, in patients aged between 60 and 79 years, the female gender predicted a shorter duration of stay in the hospital.

Conclusions

A patient’s age negatively affects the treatment outcomes of cholelithiasis with associated complications. The EC procedure appears to be the method of choice for the management of complicated gallstones in patients of all ages.

Diet-quality scores and the risk of symptomatic gallstone disease: a prospective cohort study of male US health professionals

OBJECTIVE

To investigate the association between three diet-quality scores corresponding to adherence to healthy dietary patterns [alternate Mediterranean (aMed), Alternate Healthy Eating Index (AHEI-2010), Dietary Approaches to Stop Hypertension (DASH)] and the risk of symptomatic gallstone disease.

METHODS

The study comprised 43 635 men of the Health Professionals Follow-up Study-an ongoing prospective cohort study of US health professionals. Participants were free of symptomatic gallstone disease and diabetes and provided dietary information every 4 years from 1986 (baseline) until 2012. The aMed, AHEI-2010 and DASH scores were generated and associated with the risk of symptomatic gallstone disease using Cox proportional hazards regression.

RESULTS

During 716 904 person-years of follow-up, 2382 incident cases of symptomatic gallstone disease were identified. All three scores were inversely associated with risk of symptomatic gallstone disease after adjustment for potential confounders including age, smoking, physical activity, energy and coffee intake [hazard ratios (HRs) and 95% confidence intervals (CIs)] comparing the highest with the lowest quintiles: aMed: 0.66 (0.57-0.77), AHEI-2010: 0.64 (0.56-0.74) and DASH: 0.66 (0.58-0.76)]. Findings were similar after additional adjustment for body mass index and after inclusion of asymptomatic cases. Associations were stronger when analysis was restricted to cases who had undergone cholecystectomy.

CONCLUSIONS

In this prospective cohort of male US health professionals, higher adherence to the aMed, AHEI-2010 and DASH diets was associated with lower risk of symptomatic gallstone disease. Dietary recommendations focusing on high-quality diets targeting symptomatic gallstone disease may lower the incidence of this prevalent disease.

Screen-detected gallstone disease and autoimmune diseases - A cohort study

BACKGROUND

Gallstone disease is highly prevalent and is associated with systemic inflammation.

AIMS

To determine whether screen-detected gallstones or cholecystectomy are associated with the occurrence of autoimmune and autoinflammatory diseases and the most common subgroups thereof.

METHODS

A cohort study of three randomly selected general population samples from Copenhagen was performed. Participants (n = 5928) were examined in the period 1982-1992, underwent abdominal ultrasound examination to detect gallstone disease, and followed through national registers until December 2014 (median 24.7 years) for occurrence of immunological diseases. Multivariable Cox regression analyses were performed.

RESULTS

Gallstone disease was identified in 10% (591/5928) of participants, of whom 6.8% had gallstones and 3.2% had cholecystectomy at baseline. Gallstone disease was associated with incidence of autoimmune diseases (12.9% versus 7.92%; hazard ratio 1.46; 95% confidence interval [CI], [1.11;1.91]), diabetes mellitus type 1 (5.95% versus 3.67%; 1.53; [1.02;2.30]), and autoimmune thyroid disease (3.70% versus 1.59%; 2.06; [1.26;3.38]). Rheumatoid arthritis, autoinflammatory diseases, or any subgroups thereof were not associated.

CONCLUSIONS

In a large general population sample, screen-detected gallstone disease was associated with the development of autoimmune diseases during long-term follow-up. Future research efforts are needed to further explore common disease mechanisms.

Incidence of gallstone disease and complications

PURPOSE OF REVIEW

The purpose of this review was to describe the epidemiology of gallstone disease in the era of ultrasound screening and laparoscopic cholecystectomy.

RECENT FINDINGS

Recent general population cohorts, including ultrasound screenings, have contributed to our understanding of formation and clinical course of gallstone disease. Cohorts of symptomatic gallstone disease have been informative about symptom recurrence and need of treatment. Preventive targets for gallstone formation may include obesity and the associated metabolic changes. The presence of gallstone disease is best described as a continuum from asymptomatic to symptomatic disease, with the latter including both pain attacks and complicated disease. Symptomatic disease causes a persistent high risk of symptom recurrence and need of cholecystectomy. The majority of gallstone carriers will remain asymptomatic and about one in five will develop symptoms. Determinants of disease progression from asymptomatic to symptomatic disease include sex, age, body mass index, and gallstone ultrasound characteristics.

SUMMARY

Because of the absence of effective gallstone formation prevention, targets against the metabolic changes in obesity should be further explored in randomized controlled trials. To optimize patient selection for cholecystectomy, treatment algorithms including identified determinants of symptomatic disease in gallstone carriers should be explored in prospective clinical trials.

Recent advances in understanding and managing cholesterol gallstones

The high prevalence of cholesterol gallstones, the availability of new information about pathogenesis, and the relevant health costs due to the management of cholelithiasis in both children and adults contribute to a growing interest in this disease. From an epidemiologic point of view, the risk of gallstones has been associated with higher risk of incident ischemic heart disease, total mortality, and disease-specific mortality (including cancer) independently from the presence of traditional risk factors such as body weight, lifestyle, diabetes, and dyslipidemia. This evidence points to the existence of complex pathogenic pathways linking the occurrence of gallstones to altered systemic homeostasis involving multiple organs and dynamics. In fact, the formation of gallstones is secondary to local factors strictly dependent on the gallbladder (that is, impaired smooth muscle function, wall inflammation, and intraluminal mucin accumulation) and bile (that is, supersaturation in cholesterol and precipitation of solid crystals) but also to "extra-gallbladder" features such as gene polymorphism, epigenetic factors, expression and activity of nuclear receptors, hormonal factors (in particular, insulin resistance), multi-level alterations in cholesterol metabolism, altered intestinal motility, and variations in gut microbiota. Of note, the majority of these factors are potentially manageable. Thus, cholelithiasis appears as the expression of systemic unbalances that, besides the classic therapeutic approaches to patients with clinical evidence of symptomatic disease or complications (surgery and, in a small subgroup of subjects, oral litholysis with bile acids), could be managed with tools oriented to primary prevention (changes in diet and lifestyle and pharmacologic prevention in subgroups at high risk), and there could be relevant implications in reducing both prevalence and health costs.

Which Abdominal Symptoms are Associated with Clinical Events in a Population Unaware of Their Gallstones? a Cohort Study

BACKGROUND

High rates of persistent symptoms are found following cholecystectomy in patients with gallstones. The aim of this population based cohort study was to determine which symptoms were associated with the development of clinical gallstone events in a population unaware of their gallstones.

MATERIAL AND METHODS

Three random population samples from Copenhagen (N = 6037) were examined with ultrasound during 1982-1994. Participants were not informed about gallstone status. Abdominal symptoms were assessed at baseline through a questionnaire. Follow-up for clinical events was performed through central registers until 2011. Multivariable Cox regression analyses were performed.

RESULTS

Participants unaware of their gallstones (N = 595) were followed for median 17.5 years. A total of 16.6% participants developed clinical events. Both uncomplicated and complicated events were associated with high pain intensity at baseline. Complicated events were also associated with pain at night. Uncomplicated events were associated with pain localized in the epigastrium, of longer duration, and in need of pain medication. No associations were identified for dyspepsia or irritable bowel syndrome.

CONCLUSIONS

In a population of unaware gallstone carriers, it was possible to identify abdominal symptoms associated with later clinical detection of the gallstones. These finding may contribute to a better selection of patients for surgery.