Gallstone disease: Primary and secondary prevention

Risk Factors for Gallstones in Crohn's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Crohn's disease (CD) have an increased risk of gallstone disease. We aimed to systematically evaluate the prevalence rate and relevant risk factors of gallstones in CD patients.

METHODS

A comprehensive search of PubMed, Embase, and Web of Science databases from inception to September 10, 2023, identified studies investigating risk factors for gallstone development among CD patients. Gender, age, body mass index, disease duration, disease site, stenosis, prior surgery, hospitalization times, corticosteroids, immunomodulators, and total parenteral nutrition (TPN) were assessed as potential risk factors. Odds ratios (OR) and confidence intervals (CI) were calculated.

RESULT

Among 1184 articles, 11 observational studies (3588 patients) were included. The prevalence of CD patients with gallstones was approximately 14.7%. Factors significantly associated with increased gallstone risk included Age ≥ 40 years old (OR 3.06, 95% CI 2.09- 4.48), disease duration > 15 years (OR 3.01, 95% CI 2.06-4.42), lifetime surgery(OR 2.50, 95% CI 1.99-3.12), disease located in ileocolon (OR 1.38, 95% CI 1.04-1.83) and ileocecal(OR 1.93, 95% CI 1.16-3.21), multiple hospitalizations(OR 4.26, 95% CI 2.43-7.46), corticosteroid treatments(OR 2.65, 95% CI 1.52-4.63), immunomodulator therapy(OR 1.94, 95% CI 1.12-3.38), and TPN use(OR 2.66, 95% CI 1.29-5.51). Sex, stenosis, overweight, or low weight did not significantly increase the risk of gallstone developing.

CONCLUSION

Age, long disease duration, specific disease locations (ileocolon, ileocecal), surgery, number of hospitalizations, corticosteroids, immunomodulator therapy, and TPN were identified as factors that increased the risk of gallstones in CD patients. About 14.7% of CD patients experience gallstones, so raising awareness and implementing prevention are needed.

REGISTRATION

PROSPERO (CRD42023449299).

Genetic evidence causally linking gastroesophageal reflux disease to cholecystitis: a two-sample mendelian randomization study

BACKGROUND

Gastroesophageal reflux disease (GERD) and cholecystitis share overlapping symptoms, including belching, acid reflux, and heartburn. Despite this, the causal relationship between these two conditions remains unclear. This study aimed to investigate the causal link between GERD and cholecystitis using a Mendelian randomization (MR) approach.

METHODS

A two-sample MR analysis was conducted using the inverse variance weighted (IVW), weighted median, weighted mode, and MR-Egger method to assess the causal effects of GERD on the cholecystitis risk. Genome-wide association studies (GWASs) on GERD (N cases = 129080; N controls = 473524) and cholecystitis (N cases = 1930; N controls =359264) were obtained from the IEU Open GWAS project. Various techniques were employed to assess pleiotropy and heterogeneity.

RESULTS

Seventy-seven single nucleotide polymorphisms from GERD GWASs were selected as instrumental variables (IVs). The primary IVW method revealed a significant association between GERD and an increased risk of cholecystitis (odds ratio = 1.004; 95% confidence interval = 1.003-1.005, p = 2.68 × 10- 9). The absence of heterogeneity and pleiotropy in the data supports the reliability of the results.

CONCLUSIONS

GERD was positively associated with the risk of cholecystitis. This study provides insights into potential avenues for the development of prevention strategies and treatment options for cholecystitis in patients with GERD. These findings contribute to our understanding of the complex interplay between GERD and cholecystitis.

Regional variations in the treatment of gallstone disease may affect patient outcome: a large, population-based register study in sweden

BACKGROUND

The lack of studies showing benefit from surgery in patients with symptoms of gallstone disease has led to a divergence in local practices and standards of care. This study aimed to explore regional differences in management and complications in Sweden. Furthermore, to study whether population density had an impact on management.

METHODS

Data were collected from the Swedish National Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). Cholecystectomies undertaken for gallstone disease between January 2006 and December 2017 were included. Age, sex, American Society of Anesthesiologists (ASA) classification, intra- and post-operative complications, and the proportion of patients with acute cholecystitis who underwent surgery within 2 days of hospital admission were analyzed. The 21 different geographical regions in Sweden were compared, and each variable was analyzed according to population density.

RESULTS

A total of 139,444 cholecystectomies cases were included in this study. There were large differences between regions regarding indications for surgery and intra- and post-operative complications. In the analyses, there were greater divergences than would be expected by chance for most of the variables analyzed. Age of the cholecystectomized patients correlated with population density of the regions (R2 = 0.310; p = 0.0088).

CONCLUSIONS

There are major differences between the different regions in Sweden in terms of the treatment of gallstone disease and outcome, but these did not correlate to population density, suggesting that local routines are more likely to have an impact on treatment strategies rather than demographic factors. These differences need further investigation to reveal the underlying causes.

Incident Gallstones During Somatostatin Analog Treatment are Associated with Acute Biliary Complications Especially After Discontinuation

INTRODUCTION

Gallstones are a known adverse effect of somatostatin analogs, but the exact incidence and clinical implications are unknown.

OBJECTIVES

The aim of this study was to investigate the incidence of gallstones on imaging and related complications in unbiased trial data.

METHODS

Data from the DIPAK 1 trial, in which 305 polycystic kidney disease patients were randomized to standard of care (SoC) or lanreotide for 120 weeks, were used. Magnetic resonance imaging (MRI) was performed at baseline and end of treatment and was assessed for the presence, number, and size of gallstones. For all patients who had gallstones at the end of the trial, we obtained follow-up after the trial.

RESULTS

Of 249 patients with data available, 11 patients randomized to lanreotide and four randomized to SoC had gallstones at baseline. During the study, new gallstones were formed in 19/124 patients using lanreotide (15%) and 1/125 patients receiving SoC (1%). The odds ratio for gallstone formation with lanreotide use was 25.9 (95% confidence interval 3.37-198.8; p < 0.001). Gallstones during lanreotide treatment were multiple (> 20 stones in 69% of patients) and small (≤ 3 mm in 63% of patients). Of the 19 patients with incident gallstones during lanreotide treatment, 9 experienced gallstone-associated complications, 8 of whom experienced gallstone-associated complications after discontinuation of treatment (median time after discontinuation 2.5 years). In patients with gallstones at baseline and in patients receiving SoC, no complications occurred.

CONCLUSIONS

Treatment with a somatostatin analog leads to the formation of multiple, small gallstones that are associated with severe complications, especially after discontinuation of therapy.

CLINICAL TRIAL REGISTRY WEBSITE AND TRIAL NUMBER

ClinicalTrials.gov ( https://clinicaltrials.gov ); NCT01616927.

Pathophysiology and risk factors for cholelithiasis in patients with Crohn's disease

Cholelithiasis is more common in patients with Crohn's disease (CD) than in the healthy population. The aim here was to examine risk factors for cholelithiasis in a cohort of CD patients and to compare the prevalence of cholelithiasis in a cohort of CD patients with that in a control group. This was a single-center retrospective case-control study. The cohort comprised all consecutive CD patients who underwent abdominal ultrasound from January 2007 to January 2018. The control group comprised age- and gender-matched non-CD patients referred for upper gastrointestinal tract dyspepsia. The study included 238 CD patients and 238 controls. The prevalence of cholelithiasis in the CD and control groups was 12.6 % and 9.2 %, respectively (risk ratio (RR), 1.36; p=0.24). Univariate analysis revealed that cholelithiasis was associated with multiple risk factors. Multivariate analysis identified age (OR, 1.077; 95 % CI, 1.043-1.112; p<0.001) and receipt of parenteral nutrition (OR, 1.812; 95 % CI, 1.131-2.903; p=0.013) as independent risk factors for cholelithiasis in CD patients. The prevalence of cholelithiasis in CD patients was higher than that in the control group; however, the difference was not statistically significant. Age and receipt of parenteral nutrition were independent risk factors for cholelithiasis in CD patients.

Gallstones

Gallstones grow inside the gallbladder or biliary tract. These stones can be asymptomatic or symptomatic; only gallstones with symptoms or complications are defined as gallstone disease. Based on their composition, gallstones are classified into cholesterol gallstones, which represent the predominant entity, and bilirubin ('pigment') stones. Black pigment stones can be caused by chronic haemolysis; brown pigment stones typically develop in obstructed and infected bile ducts. For treatment, localization of the gallstones in the biliary tract is more relevant than composition. Overall, up to 20% of adults develop gallstones and >20% of those develop symptoms or complications. Risk factors for gallstones are female sex, age, pregnancy, physical inactivity, obesity and overnutrition. Factors involved in metabolic syndrome increase the risk of developing gallstones and form the basis of primary prevention by lifestyle changes. Common mutations in the hepatic cholesterol transporter ABCG8 confer most of the genetic risk of developing gallstones, which accounts for ∼25% of the total risk. Diagnosis is mainly based on clinical symptoms, abdominal ultrasonography and liver biochemistry tests. Symptoms often precede the onset of the three common and potentially life-threatening complications of gallstones (acute cholecystitis, acute cholangitis and biliary pancreatitis). Although our knowledge on the genetics and pathophysiology of gallstones has expanded recently, current treatment algorithms remain predominantly invasive and are based on surgery. Hence, our future efforts should focus on novel preventive strategies to overcome the onset of gallstones in at-risk patients in particular, but also in the population in general.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Curcuma longa L. as a therapeutic agent in intestinal motility disorders. 2: Safety profile in mouse

BACKGROUND

Curcuma extract exerts a myorelaxant effect on the mouse intestine. In view of a possible use of curcuma extract in motor functional disorders of the gastrointestinal tract, a safety profile study has been carried out in the mouse.

METHODS

Thirty mice were used to study the in vitro effect of curcuma on gallbladder, bladder, aorta and trachea smooth muscular layers and hearth inotropic and chronotropic activity. The myorelaxant effect on the intestine was also thoroughly investigated. Moreover, curcuma extract (200 mg/Kg/day) was orally administered to twenty mice over 28 days and serum liver and lipids parameters were evaluated. Serum, bile and liver bile acids qualitative and quantitative composition was were also studied.

RESULTS

In the intestine, curcuma extract appeared as a not competitive inhibitor through cholinergic, histaminergic and serotoninergic receptors and showed spasmolytic effect on K(+) induced contraction at the level of L type calcium channels. No side effect was observed on bladder, aorta, trachea and heart when we used a dose that is effective on the intestine. An increase in gallbladder tone and contraction was observed. Serum liver and lipids parameters were normal, while a slight increase in serum and liver bile acids concentration and a decrease in bile were observed.

CONCLUSIONS

Although these data are consistent with the safety of curcuma extract as far as its effect on the smooth muscular layers of different organs and on the heart, the mild cholestatic effect observed in absence of alteration of liver function tests must be further evaluated and the effective dose with minimal side effects considered.

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.

Benefit of intravenous antibiotic therapy in patients referred for treatment of neurologic Lyme disease

Background

We have shown previously that extended intravenous antibiotic therapy is associated with low morbidity and no mortality in patients referred for treatment of neurologic Lyme disease. In this study, we evaluated the benefit of extended intravenous antibiotic therapy in patients with symptoms of neurologic Lyme disease.

Methods

Patients with significant neurologic symptoms and positive testing for Borrelia burgdorferi were treated with intravenous antibiotics, and biweekly evaluation of symptom severity was performed using a six-level ordinal scale. Four symptoms were selected a priori as primary outcome measures in the study, ie, fatigue, cognition, myalgias, and arthralgias. Patients were placed into five groups according to time on treatment (1–4, 5–8, 9–12, 13–24, and 25–52 weeks), and changes in the primary symptoms as a function of time on treatment were analyzed using a mixed-effects proportional odds model.

Results

Among 158 patients with more than one follow-up visit who were monitored for up to 1 year, there were on average 6.7 visits per person (median 5, range 2–24). The last follow-up day was on average 96 days after enrollment (median 69, range 7–354 days), corresponding to the length of antibiotic therapy. Each primary symptom was significantly improved at one or more time points during the study. For cognition, fatigue, and myalgias, the greatest improvement occurred in patients on the longest courses of treatment (25–52 weeks) with odds ratios (OR) for improvement of 1.97 (P = 0.02), 2.22 (P < 0.01), and 2.08 (P = 0.01), respectively. In contrast, arthralgias were only significantly improved during the initial 1–4 weeks of therapy (OR: 1.57, P = 0.04), and the beneficial effect of longer treatment did not reach statistical significance for this symptom.

Conclusion

Prolonged intravenous antibiotic therapy is associated with improved cognition, fatigue, and myalgias in patients referred for treatment of neurologic Lyme disease. Treatment for 25–52 weeks may be necessary to obtain symptomatic improvement in these patients.

Surgical treatment of gallstones

Currently there is no evidence for prophylactic cholecystectomy to prevent gallstone formation (grade B). Cholecystectomy cannot be recommended for any group of patients having asymptomatic gallstones except in those undergoing major upper abdominal surgery for other pathologies (grade B). Laparoscopic cholecystectomy is the preferred treatment for all patient groups with symptomatic gallstones (grade B). Patients with gallstones along with common bile duct stones treated by endoscopic sphincterotomy should undergo cholecystectomy (grade A). Laparoscopic cholecystectomy with laparoscopic common bile duct exploration or with intraoperative endoscopic sphincterotomy is the preferred treatment for obstructive jaundice caused by common bile duct stones, when the expertise and infrastructure are available (grade B).

Cholelithiasis in patients on the kidney transplant waiting list

OBJECTIVES

To evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants.

INTRODUCTION

The prevalence and management of cholelithiasis in renal transplant patients is not well established.

METHODS

A total of 342 chronic renal failure patients on the waiting list for a kidney transplant were studied. Patients were evaluated for the presence of cholelithiasis and related symptoms, previous cholecystectomies and other abdominal surgeries, time on dialysis, and general data (gender, age, number of pregnancies, and body mass index).

RESULTS

Cholelithiasis was found in 41 out of 342 patients (12%). Twelve of these patients, all symptomatic, had previously undergone cholecystectomies. Five out of 29 patients who had not undergone surgery were symptomatic. Overall, 17 patients (41.5%) were symptomatic. Their mean age was 54 (range 32-74) years old; 61% were female, and their mean body mass index was 25.4. Nineteen (76%) out of 25 women had previously been pregnant, with an average of 3.6 pregnancies per woman.

CONCLUSIONS

The frequency of cholelithiasis was similar to that reported in the literature for the general population. However, the high frequency of symptomatic patients points toward an indication of routine pre-transplant cholecystectomy to avoid serious post-transplant complications.

Updates in the treatment of gallstones

For the treatment of symptomatic gallbladder stones, laparoscopic cholecystectomy is the procedure of choice. However, open cholecystectomy is advisable in some situations, and a new technique - natural-orifice transluminal endoscopic surgery - has been described recently. In addition, nonsurgical approaches have also been used in patients with gallbladder stones. For the treatment of common bile duct stones, endoscopic approaches comprise the most important and commonly used modality but, under certain conditions, surgical removal should be considered if the stones cannot be managed nonsurgically. Patients with concomitant gallbladder and common bile duct stones may have various options, depending on the patient's condition and the availability of local expertise. Intrahepatic stones usually have a lower rate of successful treatment compared with gallbladder or extrahepatic bile duct stones. Localized intrahepatic bile duct stones may be cured by surgical resection, or they may be safely and effectively managed using peroral or percutaneous cholangioscopy. Overall, a multidisciplinary approach is important for the optimal management of difficult gallstone diseases.

Gender modifies the effect of ursodeoxycholic acid in a randomized controlled trial in colorectal adenoma patients

PURPOSE

Ursodeoxycholic acid (UDCA) was one of the earliest agents investigated as a drug for colorectal cancer prevention. However, UDCA failed to show efficacy to prevent the development of colorectal adenomas in a large, phase III, randomized, placebo-controlled trial. We re-evaluated the effect of UDCA in men and women separately, based on sex-specific differences in bile acid metabolism and suspected variation in etiologic factors contributing to colorectal cancer risk.

EXPERIMENTAL DESIGN

We conducted a secondary analysis of the efficacy of UDCA to prevent colorectal adenoma in men (n = 804) and women (n = 388).

RESULTS

We found no reduction in risk of any metachronous adenoma with UDCA treatment in men or women. However, UDCA treatment significantly lowered the odds of advanced lesions [odds ratio (OR), 0.62; 95% confidence interval (CI), 0.43-0.89] in men, but not women. We also observed significantly higher odds of advanced lesions with UDCA treatment in women who were younger (age, <65 years; OR, 3.24; 95% CI, 1.10-9.56), obese (body mass index, > or = 30 kg/m(2); OR, 5.45; 95% CI, 1.42-20.9), or in the highest tertile of total dietary fat (> or = 56.2 g/day; OR, 3.48; 95% CI, 1.35-8.95). In a multivariate model, the interactive effect of fat intake accounted for the modulating effects of age and body mass index in women.

CONCLUSION

Our findings support the use of UDCA for preventing advanced colorectal adenomas in men. The increased odds of adenoma among women with high fat intake suggest a previously unrecognized harm that warrants further study, especially given the chronic exposure to UDCA in patients with primary biliary cirrhosis and the increasing investigational use of UDCA for several other conditions.

Research progress in liver targeted fatty acid bile acid conjugates

Fatty acid bile acid conjugates (FABACs) are synthetic lipid molecules designed to solubilize biliary cholesterol. FABACs were shown to delay, reduce, or prevent cholesterol crystallization in vitro and ex vivo in model bile solutions and in human bile. FABACs have also been shown to prevent the formation of cholesterol gallstones and to dissolve preexisting gallstones in experimental animal models. In addition to the beneficial effect on gallstone disease, FABACs have been demonstrated to be able to prevent diet-induced fatty liver, reduce atherosclerosis in C57Bl6 mice and increase faecal bile salt and neutral sterol secretion.

Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis

Gallstone disease is encountered commonly in clinical practice. The diagnosis of biliary stones has become less problematic with current, less-invasive imaging methods. The relatively invasive endoscopic techniques should be reserved for therapy and not used for diagnosis. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence. Appropriate noninvasive diagnostic studies, adequate monitoring/supportive care, and proper patient selection for invasive therapeutic procedures are elements of good clinical practice.

Progress in evidence-based medicine for treatment of severe acute pancreatitis

Severe acute pancreatitis (SAP) is an abdominal catastrophe with a high morbidity and mortality. Up to now, no special drugs or therapeutic methods are available for SAP. Since evidence-based medicine came into being, much more clinical evidence has provided better choice of treatment for SAP. However, such evidence does not fit for all ASP patients based on its critical inclusion and exclusion criteria. It is, therefore, important to treat ASP patients by combining such evidence with clinical experiences.