Insulin resistance and incident gallbladder disease in pregnancy

Association of milk consumption with the incidence of cholelithiasis disease in the US adult population

BACKGROUND

Cholelithiasis is a common digestive system disease that imposes major burden on patients and society. Investigating the relationship between dietary factors and cholelithiasis risk can provide a basis for disease prevention. Previous studies on milk intake and cholelithiasis incidence have been limited.Therefore, the aim of our study was to assess the association between milk consumption and the incidence of cholelithiasis in males and females.

METHODS

We selected 14,722 adults (≥ 18 years old) from National Center for Health Statistics (NHANSE) 2017-2020, and collected general characteristics of patients in the database, such as age, gender, race and body mass index (BMI), as well as dietary information (milk consumption). The occurrence of cholelithiasis was used as the outcome event, and the group was divided into cholelithiasis and non-cholelithiasis groups according to the outcome event. We used logistic regression models in generalized linear model (GLM) functions, controlling for demographic, lifestyle, and dietary factors, to estimate the association between milk intake and the incidence of cholelithiasis in males and females.

RESULTS

A total of 14,722 adults were included. In the present study, the overall weighted prevalence of cholelithiasis was 10.96%, with 15.18% and 6.48% prevalence in females and males, respectively. Compared to infrequent milk intake, frequent milk intake (once a week or more) in females was associated with reduced cholelithiasis risk (OR 0.74, 95% CI 0.61-0.90). Daily milk intake in males was also related to lower cholelithiasis risk (OR 0.69-0.82). As adjusted variables increased in the models, predictive performance was improved (AUC 0.711 in females, 0.730 in males).

CONCLUSIONS

Appropriate milk intake may correlate with decreased cholelithiasis risk. Our study provides a basis for dietary interventions against gallstones, but prospective studies are needed to verify the results.

Maternal smoking during pregnancy is risk factor for gallbladder disease in offspring during adulthood: a prospective study from UK Biobank

INTRODUCTION AND OBJECTIVES

Gallbladder disease is a common disease with high prevalence. Majority of gallbladder disease is due to gallstone. Though genetics are believed to play a role in its pathogenesis, the contribution of environmental pressures in early life to the development of this disease in adulthood has not been ever investigated. This study aimed to clarify the risk of maternal smoking exposure in association with gallbladder disease in adulthood. The interaction of maternal smoking and own smoking during adulthood on this association was studied as well.

PATIENTS AND METHODS

A total of 286,731 eligible participants from the UK Biobank population-based cohort were included. Multivariable Cox regression analysis were used to examine the HR and 95% CI with adjustment for covariates.

RESULT

During a median of 8.8 years follow-up, 7110 incident cases of gallbladder disease including 6800 (95.6%) gallstone were identified. Maternal smoking was associated with increased risk of incident total gallbladder disease (HR = 1.13; 95%CI: 1.06 - 1.21; P = 0.0002) as well as gallstones (HR = 1.13; 95%CI: 1.06 -1.21; P = 0.0003) in adulthood. Compared with those who were neither exposed to maternal smoking nor own smoking, subjects adherence to no smoking during adulthood but having maternal smoking exposure still had increased risk of total gallbladder disease (HR = 1.21; 95%CI: 1.1-1.34, P=0.0001) and gallstones (HR = 1.21; 95%CI: 1.1-1.35, P=0.0001).

CONCLUSION

The present study using large prospective cohort data from UK Biobank, for the first time, demonstrated maternal smoking exposure bringing elevated risk of incident total gallbladder disease/gallstone in adulthood.

The Association Between Cholecystectomy, Metabolic Syndrome, and Nonalcoholic Fatty Liver Disease: A Population-Based Study

Obesity is a risk factor for several phenotypes such as gallstones, metabolic syndrome (MS), and nonalcoholic fatty liver disease (NAFLD). It has been suggested that cholecystectomy is a risk factor for metabolic abnormalities and NAFLD. We aimed to determine whether cholecystectomy is associated with MS or NAFLD in a Dutch population-based study.

Risk of gallstones in patients with obstructive sleep apnea: a nationwide observational cohort study

PURPOSE

To assess the association between obstructive sleep apnea (OSA) and gallstones.

METHODS

We identified 3827 patients aged ≥ 20 years with OSA between 2000 and 2010 from the Longitudinal Health Insurance Research Database 2000 (LHID2000) as the study cohort. The beneficiaries without OSA were randomly selected and propensity-matched with the study cohort in a 1:1 ratio according to age; sex; occupation; urbanization; comorbidities of hypothyroidism, hyperlipidemia, diabetes, liver cirrhosis, alcohol-related illness, hypertension, chronic obstructive pulmonary disease (COPD), obesity, inflammatory bowel disease, stroke, coronary artery disease (CAD), hepatitis B virus, and hepatitis C virus; and the index year. All patients were followed until the end of 2011 or withdrawal from the National Health Insurance program to determine the incidence of gallstones.

RESULTS

The prevalence of OSA was higher in men (67.3%) and in patients younger than 49 years (57.0%; mean age 47.8 ± 15.1 years). The cumulative incidence of gallstones was higher in the OSA cohort than in the non-OSA cohort (log-rank test, P < 0.001). Compared with patients without OSA, those with OSA had an increased risk of gallstones (adjusted hazard ratio = 1.53, 95% confidence interval = 1.16-2.03) after adjustment for age, sex, hyperlipidemia, diabetes, hypertension, COPD, stroke, and CAD.

CONCLUSION

The study shows a strong association between OSA and gallstones. Moreover, our findings suggest the requirement for survey and health education for gallstones in OSA and further studies to verify whether the treatment of OSA can reduce the risk of gallstones.

Sex and ethnic/racial-specific risk factors for gallbladder disease

BACKGROUND

Gallbladder disease (GBD) is a highly prevalent condition; however, little is known about potential differences in risk factors by sex and ethnicity/race. Our aim was to evaluate dietary, reproductive and obesity-related factors and GBD in multiethnic populations.

METHODS

We performed a prospective analysis from the Multiethnic Cohort study who self-identified as non-Hispanic White (n = 32,103), African American (n = 30,209), Japanese (n = 35,987), Native Hawaiian (n = 6942) and Latino (n = 39,168). GBD cases were identified using Medicare and California hospital discharge files (1993-2012) and self-completed questionnaires. We used exposure information on the baseline questionnaire to identify exposures of interest. Associations were estimated by hazard ratios and 95% confidence intervals using Cox models adjusted for confounders.

RESULT

After a median 10.7 years of follow-up, there were 13,437 GBD cases. BMI over 25 kg/m2, diabetes, past and current smoking, red meat consumption, saturated fat and cholesterol were significant risk factors across ethnic/racial populations (p-trends < 0.01). Protective factors included vigorous physical activity, alcohol use, fruits, vegetables and foods rich in dietary fiber (p-trends < 0.01). Carbohydrates were inversely associated with GBD risk only among women and Latinos born in South America/Mexico (p-trend < 0.003). Parity was a significant risk factor among women; post-menopausal hormones use was only associated with an increased risk among White women (estrogen-only: HR = 1.24; 95% CI = 1.07-1.43 and estrogen + progesterone: HR = 1.23; 95% CI = 1.06-1.42).

CONCLUSION

Overall, dietary, reproductive and obesity-related factors are strong risk factors for GBD affecting men and women of different ethnicities/races; however some risk factors appear stronger in women and certain ethnic groups.

Physical Activity and the Biliary Tract in Health and Disease

BACKGROUND

Cholecystitis and gallstones affect a large segment of the population in developed nations, and a small proportion of affected individuals subsequently develop cancer of the gallbladder. However, little is known about the possible beneficial effects of physical activity.

OBJECTIVE

Accordingly, a systematic review examined the influence of both acute and chronic exercise on gallbladder motility, and relationships were examined between habitual physical activity, gallbladder disease, and gallbladder cancer.

METHODS

A search of Ovid/MEDLINE from 1996 to November 2014 yielded 67 articles relating to physical activity and gallbladder function or disease; 18 of these relevant to the objectives of the review were supplemented by 22 papers from personal files and other sources. Because of the limited volume of material, all were considered, although note was taken of the quality of activity measurement, care in excluding covariates, and experimental design (cross-sectional, case-control or randomized controlled trial).

RESULTS

The impact of physical activity upon gallbladder function remains unclear; acute activity could augment emptying by stimulating cholecystokinin release, and one of two training experiments found a small increase in gallbladder motility. The largest and most recent cross-sectional and case-control trials show a reduced risk of gallbladder disease in active individuals. A small number of randomized controlled trials in humans and one animal study generally support these trends, although the number of cases of gallstones are too few for statistical significance. Three studies of gallbladder cancer also show a non-significant trend to benefit from physical activity.

CONCLUSIONS

Although there remains a need for further research, regular physical activity seems likely to reduce the risk of both gallstones and gallbladder cancer. A substantial number of individuals must be persuaded to exercise in order to avoid one case of gallbladder disease, but the attempt appears warranted because of the other health benefits of regular physical activity.

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.

Cholesterol cholelithiasis in pregnant women: pathogenesis, prevention and treatment

Epidemiological and clinical studies have found that gallstone prevalence is twice as high in women as in men at all ages in every population studied. Hormonal changes occurring during pregnancy put women at higher risk. The incidence rates of biliary sludge (a precursor to gallstones) and gallstones are up to 30 and 12%, respectively, during pregnancy and postpartum, and 1-3% of pregnant women undergo cholecystectomy due to clinical symptoms or complications within the first year postpartum. Increased estrogen levels during pregnancy induce significant metabolic changes in the hepatobiliary system, including the formation of cholesterol-supersaturated bile and sluggish gallbladder motility, two factors enhancing cholelithogenesis. The therapeutic approaches are conservative during pregnancy because of the controversial frequency of biliary disorders. In the majority of pregnant women, biliary sludge and gallstones tend to dissolve spontaneously after parturition. In some situations, however, the conditions persist and require costly therapeutic interventions. When necessary, invasive procedures such as laparoscopic cholecystectomy are relatively well tolerated, preferably during the second trimester of pregnancy or postpartum. Although laparoscopic operation is recommended for its safety, the use of drugs such as ursodeoxycholic acid (UDCA) and the novel lipid-lowering compound, ezetimibe would also be considered. In this paper, we systematically review the incidence and natural history of pregnancy-related biliary sludge and gallstone formation and carefully discuss the molecular mechanisms underlying the lithogenic effect of estrogen on gallstone formation during pregnancy. We also summarize recent progress in the necessary strategies recommended for the prevention and the treatment of gallstones in pregnant women.

Black bile of melancholy or gallstones of biliary colics: historical perspectives on cholelithiasis

Barely 130 years after its first description, cholecystectomies are among the most commonly performed surgeries in the USA. The success of this operation with subsequent technical improvements, such as laparoscopic approaches, caused a paradigm shift in the management of gallstone disease. However, symptoms persist in 10-40 % of successfully operated patients. Reviewing monographs, textbooks, and articles published during the last 300 years, several important factors emerge as likely contributors to limited or poor treatment responses. Early on, clinicians recognized that cholelithiasis is quite common and thus often an incidental finding, especially if patients present with vague or atypical symptoms. Consistent with these observations, patients with such atypical symptoms are less likely to benefit from cholecystectomy. Similarly, lasting improvements are more reliably seen in patients with symptoms of presumed biliary origin and documented gallstones compared to individuals without stones, an important point in view of increasing rates of surgery for biliary dyskinesia. While cholelithiasis can cause serious complications, the overall incidence of clinically relevant problems is so low that prophylactic cholecystectomy cannot be justified. This conclusion corresponds to epidemiologic data showing that the rise in elective cholecystectomies decreased hospitalizations due to gallstone disease, but was associated with a higher volume of postoperative complications, ultimately resulting in stable combined mortality due to gallstone disease and its treatment. These trends highlight the tremendous gains in managing gallstone disease, while at the same time reminding us that the tightening rather than expanding indications for cholecystectomy may improve outcomes.

[Acute pancreatitis and pregnancy: Cases study and literature review]

OBJECTIVE

To describe issues associated with the diagnosis of acute pregnancy-associated pancreatitis.

MATERIALS AND METHODS

Retrospective study of cases presenting at our establishment from 2002 to 2012. These cases were defined on the basis of the association of abdominal pain, serum lipase levels three times normal values, or signs of pancreatitis on ultrasound scans carried out on women pregnant at the time of diagnosis. A retrospective analysis of the medical files of these patients was carried out, considering epidemiological and etiological criteria, the treatments administered and maternal/fetal fate.

RESULTS

We identified 10 cases during the study period, corresponding to an incidence of 1/1942. In 70% of cases, the patient was in the last three months of pregnancy. The pain was atypical in 70% of cases and ultrasound revealed biliary lithiasis in 30% of cases. None of the women died. In terms of neonatal morbidity, there were five preterm births, including one of an infant that died at the age of seven days. We then carried out a literature review, from which we determined the most appropriate course of action in cases of acute pancreatitis during pregnancy.

CONCLUSION

Pancreatitis should be considered in pregnant women with abdominal pains because this diagnosis is easy to confirm and maternal and fetal outcomes are essentially dependent on the early etiological management of this condition. Preterm birth is the predominant factor for neonatal morbidity.

Body mass index and biliary tract disease: a systematic review and meta-analysis of prospective studies

OBJECTIVE

To evaluate the association between body mass index (BMI, kg/m(2)) and incidence of biliary tract disease.

METHODS

We performed a systematic review and a meta-analysis of prospective studies by searching the database of PubMed and EMBASE published up to December 31, 2013. Outcome of interest was disease of biliary tract system (gallbladder, extrahepatic bile duct and Ampullar of Vater). We used a random-effects model to combine the study-specific relative risks (RRs) and 95% confidence intervals (95% CIs) from 22 prospective studies. We examined whether BMI was associated with a higher risk of biliary tract disease in a combined analysis.

RESULTS

The positive association was stronger for non-cancer biliary tract disease than biliary tract cancer; combined RRs (95% CIs) comparing the top with bottom categories were 1.40 (1.15-1.65) for biliary tract cancer and 2.75 (2.35-3.15) for non-cancer biliary tract disease (P for difference<0.001). For non-cancer biliary tract disease, combined RRs (95% CIs) comparing the top with bottom categories were 3.21 (2.48-3.93) for women and 2.01 (1.66-2.37) for men (P for difference=0.04).

CONCLUSION

Obesity is associated with higher risks of biliary tract cancer and, to a greater extent, non-cancer biliary tract disease.

Dietary fat and protein intake are not associated with incident biliary sludge and stones during pregnancy

BACKGROUND

Dietary composition can cause insulin resistance, elevated serum lipid levels, and obesity, all of which predispose to gallstone formation. The effects of dietary fat (including individual fatty acids) and protein on gallstone formation are controversial. The aim of this study was to examine the effects of dietary fat and protein intake on incident gallstone disease during pregnancy, a high-risk time for stone formation.

METHODS

We prospectively studied 3070 pregnant women who underwent serial gallbladder ultrasound examinations during pregnancy and at 4-6 weeks postpartum. All women had at least 2 study ultrasounds for comparison. A semi-quantitative food frequency questionnaire was completed by subjects in the early third trimester. Multivariate logistic regression was performed to assess the risk of incident gallbladder disease across quartiles of intake of total fat, individual fatty acids (polyunsaturated, monounsaturated, saturated, and total trans-fatty acids, as well as cholesterol), protein, and protein subtype (animal or vegetable based).

RESULTS

The cumulative incidence of new biliary sludge/stones or progression of baseline sludge to stones was 10.2% by 4-6 weeks postpartum. There was no association between total dietary fat (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.64-2.18 comparing lowest and highest quartiles) or protein intake (OR, 0.83; 95% CI, 0.44-1.22 comparing lowest and highest quartiles) and incident gallbladder disease. There was also no association between individual fatty acids or protein subtype and gallbladder disease.

CONCLUSIONS

Neither total nor subtype of dietary fat or protein was associated with incident biliary stone or sludge formation in this cohort of pregnant women.

Carbohydrate intake as a risk factor for biliary sludge and stones during pregnancy

BACKGROUND

High carbohydrate intake has been linked to insulin resistance, obesity, and abnormal serum lipid profiles-conditions which favor gallstone formation.

GOALS

The aim of this study was to evaluate the effect of dietary carbohydrate intake on incident gallbladder disease, defined as biliary sludge and stones, during pregnancy.

STUDY

We prospectively studied 3070 pregnant women who underwent serial gallbladder ultrasound during pregnancy and at 4 to 6 weeks postpartum. All women had at least 2 study ultrasounds for comparison. A semiquantitative food frequency questionnaire was completed by subjects in the early third trimester. Multivariate logistic regression was performed to assess the risk of incident gallbladder disease across quartiles total and individual carbohydrate and individual carbohydrates (starch, sucrose, galactose, fructose, and lactose) intake.

RESULTS

The cumulative incidence of gallbladder disease was 10.2% by 4 to 6 weeks postpartum. The risk of incident gallbladder disease during pregnancy was significantly higher among women in the highest quartile of total carbohydrate intake versus those in the lowest quartile (odds ratio 2.09, 95% confidence interval 1.02-4.27). High intake of fructose was associated with increased risk even after additional adjustment for total carbohydrate intake (odds ratio 2.18, 95% confidence interval 1.23-3.86, comparing highest with lowest quartile). No association was found between the intake of starch, sucrose, lactose, or galactose and the risk of incident gallbladder disease.

CONCLUSIONS

High consumption of total carbohydrate and fructose may increase the risk of developing gallbladder disease during pregnancy. Dietary modification during pregnancy might reduce gallstone incidence during this time period.

Epidemiology of gallbladder disease: cholelithiasis and cancer

Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.

Acute pancreatitis in pregnancy: an overview

Acute pancreatitis is rare in pregnancy but it is associated with increased incidence of maternal and fetal mortality. It should be considered in the differential diagnosis of upper quadrant abdominal pain with or without nausea and vomiting. The commonest identified causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. The main laboratory finding is increased amylase activity. Appropriate investigations include ultrasound of the right upper quadrant and measurement of serum triglycerides and ionized calcium. Management of gallstone pancreatitis is controversial, although laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) are often used and may be associated with lower complication rates. In hypertriglyceridemia-induced acute pancreatitis ω-3 fatty acids and even therapeutic plasma exchange can be used. We also discuss preventive measures.

Hereditary liver disease: gallstones

Gallstones are common in Western countries and due to pain and complications pose a substantial burden on health care systems. In general, cholesterol gallstones are distinguished from bilirubin gallstones. Bilirubin gallstones form if the ion product of unconjugated bilirubin and calcium in gallbladder bile exceeds the solubilisation capacities of mixed micelles and vesicles. Cholesterol gallstones develop if the amount of cholesterol in gallbladder bile exceeds the maximum concentration that is soluble at the given concentration of bile salts and phospholipids. In addition, cholesterol gallstone formation requires hypomotility of the gallbladder and a mucin gel as nucleation matrix for monohydrate crystals. The individual risk of gallstone formation is determined by interactions of lithogenic alleles of gallstone susceptibility genes and multiple environmental factors. For asymptomatic gallstones, expectant management is recommended, whereas an episode of gallstone-associated pain substantially increases the risk of complications such as cholecystitis, cholangitis and pancreatitis and therefore necessitates cholecystectomy.

BILIARY AND PANCREATIC DISEASE IN PREGNANCY

Pregnancy is a physiological condition that affects all organs. Diseases unrelated to pregnancy may present coincidentally during pregnancy or may be exacerbated by pregnancy, and may increase maternal and/or fetal morbidity or mortality. Compared with many other systems, the changes within the biliary tree and pancreas are relatively minimal. However, pregnancy is associated with an increased likelihood of cholelithiasis, which can have significant implications for the parturient.

Spontaneous gallbladder pathology in baboons

BACKGROUND

Gallbladder pathology (GBP) is a relatively uncommon, naturally occurring morbidity in both baboons and humans.

METHODS

A retrospective analysis was performed on 7776 necropsy reports over a 20 year period to determine the prevalence of baboon GBP.

RESULTS

Ninety-seven cases of GBP were identified, yielding a 20 year population prevalence of 1.25%. GBP is more common in adult female baboons, occurring with a female to male ratio of nearly 2:1. Among gallbladder pathologies, cholecystitis (35.1%) and cholelithiasis (29.9%) were the most prevalent abnormalities, followed by hyperplasia (16.5%), edema (15.5%), amyloidosis (5.2%), fibrosis (4.1%), necrosis (4.1%), and hemorrhage (1.0%).

CONCLUSION

Many epidemiologic similarities exist between GBP in baboons and humans suggesting that the baboon may serve as a reliable animal model system for investigating GBP in humans.

The effect of strict blood glucose control on biliary sludge and cholestasis in critically ill patients

BACKGROUND AND AIMS

Cholestatic liver dysfunction and biliary sludge are common problems in critically ill patients. No specific strategies have been described to prevent cholestasis and biliary sludge in the intensive care unit (ICU). We examined liver dysfunction and biliary sludge prospectively in a large medical long-stay ICU population and hypothesized that tight glycemic control with intensive insulin therapy (IIT) reduces cholestasis and biliary sludge.

METHODS

This study was a preplanned subanalysis of 658 long-stay (at least a fifth day) ICU patients out of a large randomized controlled trial (n = 1200), studying the effects of IIT on the outcome of medical critical illness. Patients were allocated to either IIT (glycemia 80-110 mg/dl) or conventional insulin therapy (CIT) requiring insulin above a glycemia of 215 mg/dl. Different patterns of liver dysfunction were studied based on daily blood sample analysis, and biliary sludge was evaluated by ultrasonography.

RESULTS

On admission, cholestasis was present in 17% of patients (n = 649), increasing to 20% on d 10 (n = 347), whereas ischemic hepatitis decreased from 3.4% (n = 588) to less than 1% (n = 328). IIT significantly decreased biliary sludge on d 5 (50.4 vs. 66.4%, P = 0.01; n = 250). The difference did not remain significant on d 10 (57.4 vs. 66.2%, P = 0.29; n = 136). IIT also lowered the cumulative risk of cholestasis (P = 0.03).

CONCLUSIONS

Cholestatic liver dysfunction and biliary sludge are very common during prolonged critical illness but are significantly reduced by IIT.

Liver disease in pregnancy

Liver diseases in pregnancy may be categorized into liver disorders that occur only in the setting of pregnancy and liver diseases that occur coincidentally with pregnancy. Hyperemesis gravidarum, preeclampsia/eclampsia, syndrome of hemolysis, elevated liver tests and low platelets (HELLP), acute fatty liver of pregnancy, and intrahepatic cholestasis of pregnancy are pregnancy-specific disorders that may cause elevations in liver tests and hepatic dysfunction. Chronic liver diseases, including cholestatic liver disease, autoimmune hepatitis, Wilson disease, and viral hepatitis may also be seen in pregnancy. Management of liver disease in pregnancy requires collaboration between obstetricians and gastroenterologists/hepatologists. Treatment of pregnancy-specific liver disorders usually involves delivery of the fetus and supportive care, whereas management of chronic liver disease in pregnancy is directed toward optimizing control of the liver disorder. Cirrhosis in the setting of pregnancy is less commonly observed but offers unique challenges for patients and practitioners. This article reviews the epidemiology, pathophysiology, diagnosis, and management of liver diseases seen in pregnancy.

Macronutrients and insulin resistance in cholesterol gallstone disease

Cholelithiasis is a major source of digestive morbidity worldwide. Cholesterol stones account for the majority of gallstones in the United States and other Western countries. The pathogenesis of cholesterol gallstone disease is multifactorial with key factors including cholesterol supersaturation of bile, altered biliary motility, and nucleation and growth of cholesterol crystals. Increasing evidence suggests that many, but not all, causative factors of cholesterol gallstones are related to insulin resistance which, in association with obesity, has reached an epidemic level worldwide. Experimental studies show that hyperinsulinemia, a key feature of insulin resistance, may cause increased hepatic cholesterol secretion and cholesterol supersaturation of bile and gallbladder dysmotility, and thereby may enhance gallstone formation. Insulin resistance syndrome can be modified by environmental factors, including dietary factors. The impact of diet on insulin sensitivity is mediated by both dietary composition and its energy content. The contribution of specific dietary elements to the prevalence and incidence of cholesterol gallstone disease has been explored in animal and human studies. There is considerable evidence to suggest that different types of fatty acids, independent of the total amount of fat consumption, affect insulin sensitivity and cholesterol gallstone disease differently. The effects of salt intake, consumption of protein and carbohydrates, and alcohol drinking on insulin resistance are controversial. Additional intervention trials and controlled experimental feeding studies are needed to further clarify these relationships and to provide useful prophylactic and therapeutic strategies.