Gallbladder contents and fasting gallbladder volumes during and after pregnancy

The global prevalence of gallstones in pregnancy: A systematic review and meta-analysis

Background

Gallstone disease is the second most common non-gynecological disease that may require surgical intervention during pregnancy. This study investigates the global prevalence of gallstones in pregnancy through a systematic review and meta-analysis.

Methods

A systematic review and meta-analysis of studies that reported the global prevalence of gallstones in pregnancy was conducted. PubMed, Scopus, Web of Science, Embase, ScienceDirect, and Google Scholar were searched for studies published up to September 2022.

Results

In a review of 31 studies with a sample size of 190,714 people, the I2 heterogeneity test showed high heterogeneity (I2 = 98.8%). Therefore, the random effects method was used to analyze the results. The prevalence of gallstones was reported as 3.6% (95% CI: 1.9-6.7%). The highest prevalence of gallstones by continent was reported in America, at 6.8% (95% CI: 4.2-10.8%). The Egger test showed no evidence of publication bias (p = 0.609).

Conclusion

Based on the results of this study, health policymakers should emphasize to the target community and the medical staff dealing with pregnant women the importance of screening for gallstones during pregnancy.

Endoscopy in Pregnancy: A Systematic Review

Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy.

Methods A systematic literature search was performed using PubMed. All original research articles with sample size > 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021.

Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (>95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (> 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy.

Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected.

Gallbladder diseases in pregnancy: Sonographic findings in an indigenous African population

Aim of the study

This study aimed to evaluate the prevalence of gallbladder disease in gravid Nigerian women and to elucidate any association with gravidity and ABO blood group.

Materials and Methods

This was a descriptive cross-sectional study of six hundred and fifty-six (656) pregnant women recruited from March 2015 to March 2016. Hemoglobin genotype and blood group were recorded and a sonographic examination was performed using Siemens ultrasound scanner. Statistical analysis was done using STATA software for Windows.

Results

Age had a significant association with the occurrence of gallbladder diseases (Likelihood ratio = 7.116, P = 0.03). Two (0.3%) pregnant women had biliary sludge, 11 (1.7%) had gallstones while 643 (98%) had normal gallbladders. Also, only one (9.1%) primigravida woman with gallstone was found in this study while 10 (90.9%) of the women with gallstones were multigravida. All the pregnant women who had gallstone(s) had blood group O. Of the two women with biliary sludge; one had blood group A while the other had blood group O.

Conclusions

The incidence of gallbladder disease increased with age in this study. There was a higher prevalence of gallstones than sludge in pregnancy. Also, the incidence of gallstones increased with the number of pregnancies among the women with gallstones. Attention should be paid to the gallbladder during abdominal sonography in pregnancy.

Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

AIM

To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography (ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.

METHODS

Systematic computerized literature search performed using PubMed with the key words “ERCP” and “pregnancy”. Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubMed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.

RESULTS

Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in non-pregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.

CONCLUSION

This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.

The Role of Placental Hormones in Mediating Maternal Adaptations to Support Pregnancy and Lactation

During pregnancy, the mother must adapt her body systems to support nutrient and oxygen supply for growth of the baby in utero and during the subsequent lactation. These include changes in the cardiovascular, pulmonary, immune and metabolic systems of the mother. Failure to appropriately adjust maternal physiology to the pregnant state may result in pregnancy complications, including gestational diabetes and abnormal birth weight, which can further lead to a range of medically significant complications for the mother and baby. The placenta, which forms the functional interface separating the maternal and fetal circulations, is important for mediating adaptations in maternal physiology. It secretes a plethora of hormones into the maternal circulation which modulate her physiology and transfers the oxygen and nutrients available to the fetus for growth. Among these placental hormones, the prolactin-growth hormone family, steroids and neuropeptides play critical roles in driving maternal physiological adaptations during pregnancy. This review examines the changes that occur in maternal physiology in response to pregnancy and the significance of placental hormone production in mediating such changes.

The deletion of the estrogen receptor α gene reduces susceptibility to estrogen-induced cholesterol cholelithiasis in female mice

Compelling evidence has demonstrated that estrogen is a critical risk factor for gallstone formation and enhances cholesterol cholelithogenesis through the hepatic estrogen receptor α (ERα), but not ERβ. To study the lithogenic mechanisms of estrogen through ERα, we investigated whether the deletion of Erα protects against gallstone formation in ovariectomized (OVX) female mice fed a lithogenic diet and treated with 17β-estradiol (E2) at 0 or 6μg/day for 56days. Our results showed that the prevalence of gallstones was reduced from 100% in OVX ERα (+/+) mice to 30% in OVX ERα (-/-) mice in response to high doses of E2 and the lithogenic diet for 56days. Hepatic cholesterol secretion was significantly diminished in OVX ERα (-/-) mice compared to OVX ERα (+/+) mice even fed the lithogenic diet and treated with E2 for 56days. These alterations decreased bile lithogenicity by reducing cholesterol saturation index of gallbladder bile. Immunohistochemical studies revealed that ERα was expressed mainly in the gallbladder smooth muscle cells. High levels of E2 impaired gallbladder emptying function mostly through the ERα and cholecystokinin-1 receptor pathway, leading to gallbladder stasis in OVX ERα (+/+) mice. By contrast, gallbladder emptying function was greatly improved in OVX ERα (-/-) mice. This markedly retarded cholesterol crystallization and the growth and agglomeration of solid cholesterol crystals into microlithiasis and stones. In conclusion, the deletion of Erα reduces susceptibility to the formation of E2-induced gallstones by diminishing hepatic cholesterol secretion, desaturating gallbladder bile, and improving gallbladder contraction function in female mice.

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.

Non-radiation endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis during pregnancy

Gallstone diseases are common during pregnancy. In most cases, patients are asymptomatic and do not require any treatment. However, choledocholithiasis, cholangitis, and gallstone pancreatitis may potentially become life-threatening for both mother and fetus and often require urgent intervention. Although endoscopic retrograde cholangiopancreatography (ERCP) has become the standard technique for removing common bile duct stones, it is associated with ionizing radiation that could carry teratogenic risk. Non-radiation ERCP (NR-ERCP) is reported to be effective without incurring this risk. Two techniques have been described to confirm bile duct cannulation: bile aspiration and image guidance. With bile aspiration, biliary cannulation is confirmed by applying suction to the cannula to yield bile, thus confirming an intrabiliary position. Image guidance involves using ultrasound or direct visualization (choledochoscopy) to confirm selective biliary cannulation or duct clearance. Once cannulation is achieved, the stones are removed using standard ERCP techniques and tools. Case series and retrospective studies have reported success rates of up to 90% for NR-ERCP with complication rates similar to standard ERCP. Pregnancy outcomes are not adversely affected by NR-ERCP, but whether the avoidance of radiation carries benefit for the baby is unknown. Prospective comparative trials are lacking. NR-ERCP is technically demanding and should be attempted only by skilled biliary endoscopists in properly equipped and staffed health-care institutions, in a multidisciplinary setting.

Serum organochlorine pesticide residues and risk of gallstone disease: a case-control study in Xiamen

PURPOSE

To investigate the association between serum organochlorine pesticide residues and risk of gallstone disease.

METHODS

A 1:1, pair-matched, case-control study was designed. Data from 150 patients with gallstones diagnosed by abdominal ultrasonography at a single hospital from June 2009 to June 2010 were collected. A total of 150 patients without gallstones during the same period at the same hospital were recruited as the control group. Capillary gas chromatography was employed to measure the serum concentrations of dichlorodiphenyltrichloroethane (DDT) and hexachlorocyclohexane (HCH) residues. Multiple-factor conditional logistic regression analysis was conducted to estimate the relative risk of gallstones in relation to organochlorine pesticide residues in serum.

RESULTS

The percentages of p,p'-DDD and o,p'-DDT in serum of patients were significantly higher than those in serum of controls. The p,p'-DDE, α-HCH, and δ-HCH residues in serum of patients were also significantly increased compared with those in serum of controls. Multiple-factor conditional logistic regression analysis showed that high levels of p,p'-DDE and p,p'-DDT residues were risk factors for gallstone disease.

CONCLUSIONS

A high level of organochlorine pesticide residues in serum is a potential risk factor for gallstone disease, which suggests that environmental exposure to organochlorine pesticides should be evaluated with respect to gallstone formation.

Clinical benefit of gluten-free diet in screen-detected older celiac disease patients

BACKGROUND

The utility of serologic screening for celiac disease is still debatable. Evidence suggests that the disorder remains undetected even in the older population. It remains obscure whether screening makes good or harm in subjects with long-standing gluten ingestion. We evaluated whether older subjects benefit from active detection and subsequent gluten free dietary treatment of celiac disease.

METHODS

Thirty-five biopsy-proven patients aged over 50 years had been detected by serologic mass screening. We examined the disease history, dietary compliance, symptoms, quality of life and bone mineral density at baseline and 1-2 years after the commencement of a gluten-free diet. Symptoms were evaluated by gastrointestinal symptom rating scale and quality of life by psychological general well-being questionnaires. Small bowel biopsy, serology, laboratory parameters assessing malabsorption, and bone mineral density were investigated.

RESULTS

Dietary compliance was good. The patients had initially low mean serum ferritin values indicating subclinical iron deficiency, which was restored by a gluten-free diet. Vitamin B12, vitamin D and erythrocyte folic acid levels increased significantly on diet. Celiac patients had a history of low-energy fractures more often than the background population, and the diet had a beneficial effect on bone mineral density. Alleviation in gastrointestinal symptoms was observed, even though the patients reported no or only subtle symptoms at diagnosis. Quality of life remained unchanged. Of all the cases, two thirds would have been diagnosed even without screening if the family history, fractures or concomitant autoimmune diseases had been taken carefully into account.

CONCLUSIONS

Screen-detected patients benefited from a gluten-free diet. We encourage a high index of suspicion and active case-finding in celiac disease as an alternative to mass screening in older patients.

Risks versus benefits of gastrointestinal endoscopy during pregnancy

Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.

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.

New insights into the molecular mechanisms underlying effects of estrogen on cholesterol gallstone formation

Epidemiological and clinical studies have found that at all ages women are twice as likely as men to form cholesterol gallstones, and this gender difference begins since puberty and continues through the childbearing years, which highlight the importance of female sex hormones. Estrogen is a crucial hormone in human physiology and regulates a multitude of biological processes. The actions of estrogen have traditionally been ascribed to two closely related classical nuclear hormone receptors, estrogen receptor 1 (ESR1) and ESR2. Recent studies have revealed that the increased risk for cholesterol gallstones in women vs. men is related to differences in how the liver metabolizes cholesterol in response to estrogen. A large number of human and animal studies have proposed that estrogen increases the risk of developing cholesterol gallstones by increasing the hepatic secretion of biliary cholesterol, which, in turn, leads to an increase in cholesterol saturation of bile. Furthermore, it has been identified that hepatic ESR1, but not ESR2, plays a major role in cholesterol gallstone formation in mice in response to high doses of 17beta-estradiol. The mechanisms mediating estrogen's action have become more complicated with the recent identification of a novel estrogen receptor, G protein-coupled receptor 30 (GPR30), a member of the seven-transmembrane G protein-coupled receptor superfamily. In this review, we provide an overview of the evidence for the lithogenic actions of estrogen through ESR1 and discuss the cellular and physiological actions of GPR30 in estrogen-dependent processes and the relationship between GPR30 and classical ESR1 on gallstone formation.

Lithogenesis and bile metabolism

Gallstone disease exacts a considerable financial and social burden worldwide leading to frequent physician visits and hospitalizations. Based on their composition, gallstones are categorized as cholesterol, black pigment, and brown pigment, with each category having a unique structural, epidemiologic, and risk factor profile. Cholesterol crystal formation requires the presence of one or more of the following: (a) cholesterol supersaturation, (b) accelerated nucleation, or (c) gallbladder hypomotility/bile stasis. Some risk factors for cholesterol stones include age, gender, genetics, obesity, rapid weight loss, and ileal disease. Generally, pigment stones are formed by the precipitation of bilirubin in bile, with black stones associated with chronic hemolytic states, cirrhosis, Gilbert syndrome, or cystic fibrosis, and brown stones associated with chronic bacterial or parasitic infections.

Psychoneurotic symptoms and alexithymia in coeliac disease

OBJECTIVE

Depression, psychological problems and the impairment of quality of life are reported to occur in untreated coeliac disease. Alexithymia ("no words for feelings") is associated with various gastrointestinal disorders. The aim of this study was to evaluate whether patients with coeliac disease suffer from psychoneurotic symptoms or alexithymia, and whether a gluten-free diet has an impact on the symptoms.

MATERIAL AND METHODS

The Crown-Crisp Experiential Index (CCEI) and its six subscales were applied to measure neurotic psychopathology, and the 20-item version of the Toronto Alexithymia Scale (TAS-20) and its 3-factor scales to measure alexithymia. The testing was carried out in 20 consecutive adult patients with biopsy-proven coeliac disease before and after one year of treatment on a gluten-free diet. The data were compared with those obtained earlier in non-coeliac Finnish subjects.

RESULTS

Somatic anxiety was higher in coeliac disease patients before the introduction of the gluten-free diet than after adhering to the diet. Otherwise, the diet had no significant impact on the CCEI scores. The patients were not suffering from alexithymia, but the TAS-20 score improved significantly during the follow-up. The scores did not differ from those published in the Finnish population.

CONCLUSIONS

Psychological problems were not common in adult coeliac disease patients. Gluten-free diet had only a minor influence on the symptoms. Common knowledge about coeliac disease and the readily available gluten-free products may have had an impact on these results.

The role of MR cholangiopancreatography in the evaluation of pregnant patients with acute pancreaticobiliary disease

This study aimed to determine the usefulness of MR cholangiopancreatography (MRCP) in the evaluation of pregnant patients with acute pancreaticobiliary disease and its additional value over ultrasound. MRI studies of pregnant patients who were referred because of acute pancreaticobiliary disease were included. MR images and patient charts were reviewed retrospectively to determine clinical outcome and the results of other imaging studies. 18 pregnant patients underwent MRCP because of right upper quadrant pain (n = 6), pancreatitis (n = 9), cholangitis (n = 1) or jaundice (n = 2). 15 patients were also evaluated with ultrasound. Biliary dilatation was detected in eight patients by ultrasound, but the cause of biliary dilatation could not be determined by ultrasound in seven patients. MRCP demonstrated the aetiology in four of these patients (choledocholithiasis (n = 1), Mirizzi syndrome (n = 1), choledochal cyst (n = 1) and intrahepatic biliary stones (n = 1)) and excluded obstructive pathology in the other four patients. MRCP was unremarkable in the seven patients who had no biliary dilatation on ultrasound. Three patients underwent only MRCP; two had choledocholithiasis and one cholelithiasis and pancreatitis. Choledocholithiasis diagnosed with MRCP (n = 3) was confirmed by endoscopic retrograde cholangiopancreatography. Mirizzi syndrome (n = 1) and a choledochal cyst (n = 1) were confirmed by surgery. The patients with normal MRCP (n = 12) and one patient with intrahepatic stones improved with medical treatment. MRCP appears to be a valuable and safe technique for the evaluation of pregnant patients with acute pancreaticobiliary disease. Especially when ultrasound shows biliary dilatation, MRCP can determine the aetiology and save the patient from unnecessary endoscopic retrograde cholangiopancreatography by excluding a biliary pathology.

Hepatic disorders mildly to moderately affected by pregnancy: medical and obstetric management

Hepatic, biliary, and pancreatic disorders are often complex and clinically challenging during pregnancy. Hepatic disorders can affect the pregnancy and vice versa. The differential diagnosis of hepatic diseases is particularly broad during pregnancy because it includes disorders related to, and unrelated to, pregnancy. This article discusses the physiologic effects of pregnancy on liver function; the differential diagnosis of hepatic findings during pregnancy; modifications of abdominal imaging and hepatobiliary endoscopic procedures during pregnancy; and the medical and obstetric management of hepatic, biliary, and pancreatic diseases that are mildly to moderately affected by pregnancy.

Coordinate regulation of gallbladder motor function in the gut-liver axis

Gallstones are one of the most common digestive diseases with an estimated prevalence of 10%-15% in adults living in the western world, where cholesterol-enriched gallstones represent 75%-80% of all gallstones. In cholesterol gallstone disease, the gallbladder becomes the target organ of a complex metabolic disease. Indeed, a fine coordinated hepatobiliary and gastrointestinal function, including gallbladder motility in the fasting and postprandial state, is of crucial importance to prevent crystallization and precipitation of excess cholesterol in gallbladder bile. Also, gallbladder itself plays a physiopathological role in biliary lipid absorption. Here, we present a comprehensive view on the regulation of gallbladder motor function by focusing on recent discoveries in animal and human studies, and we discuss the role of the gallbladder in the pathogenesis of gallstone formation.

Gender and gallstone disease

Gallstone disease is a common disorder all over the world. In the Western societies about 80 % of the gallstones are composed primarily of cholesterol. Several risk factors for gallstone formation have been identified. One of the most important risk factors is female gender. Rates of gallstones are two to three times higher among women than men. But this is primarily a phenomenon of the childbearing age. Pregnancy is also a major risk factor for gallstone formation. The risk is related to the number of pregnancies. Sex hormones are most likely to be responsible for the increased risk. Estrogen increases biliary cholesterol secretion causing cholesterol supersaturation of bile. Thus, hormone replacement therapy in postmenopausal women and oral contraceptives have also been described to be associated with an increased risk for gallstone disease. However, the effect of estrogen is dose-dependent and new oral contraceptives with a low estrogen dose do not seem to increase the rate of gallstone formation. The present article focuses on the mentioned risk factors associated with female sex hormones.

MR Imaging Evaluation of Acute Abdominal Pain During Pregnancy

MR imaging enables diagnosis of a variety of maternal diseases presenting as acute abdominal pain in pregnant patients. MR imaging is a valuable complement to ultrasound in the determination of the exact etiology of acute abdominal pain, and it is important for the radiologist to recognize the MR imaging appearance of common causes of acute abdominal pain during pregnancy. This article reviews the MR imaging technique and findings of various abnormalities causing acute abdominal pain in pregnant patients.

Risk factors associated with gallstone and biliary sludge formation during pregnancy

AIM

To define the risk factors in gallstone and sludge formation, and to investigate the incidence of gallstone and biliary sludge formation during pregnancy in a group of healthy pregnant women.

METHODS

Sixty-nine healthy pregnant women in early gestation and 28 nulliparous healthy controls were enrolled. Gallbladder volumes, gallbladder ejection fraction (GBEF), serum triglyceride and cholesterol levels were determined in both groups. In the pregnant group, repeated measurements were performed immediately after delivery and compared with initial levels. Risk factors, which are associated with gallstone and biliary sludge development during pregnancy, were determined by linear regression analysis.

RESULTS

No statistically significant difference was observed in the assessed parameters of pregnant women in early gestation and controls (both P > 0.05). In the pregnant group, gallstone and biliary sludge development during pregnancy were detected in 6.3% and 10.9% of cases, respectively. The detected parameters were significantly higher early after delivery than in early gestation, while GBEF was lower (both P < 0.001). Lower GBEF was the most significant factor (P < 0.001) associated with gallstone and sludge formation during pregnancy, while multiple childbirths was the other (P = 0.04).

CONCLUSION

Decrease in GBEF is the most significant risk factor for newly developed gallstone and sludge in pregnant women, while multiple childbirths is the other but less important risk factor.

Gallstone disease: Symptoms and diagnosis of gallbladder stones

The clinical aspects and the diagnostic features of gallstone disease are described. The natural history of silent gallstones is overviewed, and the risk of developing symptoms and complications is also discussed. The importance of colicky pain as a specific gallstone symptom is highlighted, and the role of both laboratory tests and diagnostic investigations for differential diagnosis is discussed. Finally, we describe the diagnostic features of gallbladder stone disease, including indications, sensitivity, specificity, and limitations of different test investigations under special circumstances.

Is coeliac disease screening in risk groups justified? A fourteen-year follow-up with special focus on compliance and quality of life

BACKGROUND

The benefits of serologic screening for coeliac disease in asymptomatic individuals are debatable.

AIM

To investigate dietary compliance, quality of life and bone mineral density after long-term treatment in coeliac disease patients found by screening in risk groups.

METHODS

The study comprised 53 consecutive screen-detected coeliac patients diagnosed 14 years (median) ago. Dietary compliance was assessed by interview, 4-day food record and serology. Quality of life was evaluated by the Psychological General Well-Being and SF-36 questionnaires, gastrointestinal symptoms by the Gastrointestinal Symptom Rating Scale and bone mineral density by dual-energy x-ray absorptiometry. Comparisons were made to 44 symptom-detected-treated coeliac patients, 110 non-coeliac subjects and the general population.

RESULTS

A total of 96% of screen-detected and 93% of symptom-detected coeliac patients adhered to a strict or fairly strict gluten-free diet. In screen-detected patients, quality of life and gastrointestinal symptoms were similar to those in symptom-detected patients or non-coeliac controls and bone mineral density was similar to that in the general population.

CONCLUSIONS

Long-term dietary compliance in screen-detected patients was good. Quality of life and bone mineral density were comparable with those in non-coeliac subjects and the general population. Active screening in coeliac disease risk groups seems to be reasonable rather than harmful.

Risk factors for cholelithiasis in pregnancy

This study was designed to examine the relationships of demographics, anthropometrics, prenatal physical activity, serum cholesterol, and nutrient intakes to symptomatic cholelithiasis (gallstone) occurrence in 128 northern plains pregnant women. Data collected at 14 and 26 weeks of pregnancy and 4 weeks after delivery, indicated 25.8% of the Native American and 8.3% of the Caucasian pregnant women experienced symptoms of cholelithiasis. Body mass indices (BMIs) were significantly higher in the pregnant women who experienced cholelithiasis than in those who did not have cholelithiasis, and prenatal physical activity was significantly lower in those same women. History of gallbladder disease (beta=.73; p=.001), BMI (beta=.33; p=.01), and prenatal physical activity (beta=-.20; p=.04) were predictive of increased occurrence of cholelithiasis during pregnancy.

Effect of an oats-containing gluten-free diet on symptoms and quality of life in coeliac disease. A randomized study

BACKGROUND

Evidence suggests the acceptability of oats in a gluten-free diet in coeliac disease. We investigated the impact of an oats-containing diet on quality of life and gastrointestinal symptoms.

METHODS

Thirty-nine coeliac disease patients on a gluten-free diet were randomized to take either 50 g of oats-containing gluten-free products daily or to continue without oats for 1 year. Quality of life was assessed using the Psychological General Well-Being questionnaire and gastrointestinal symptoms using the Gastrointestinal Symptom Rating Scale. Small-bowel mucosal villous architecture, CD3+, alphabeta+, gammadelta+ intraepithelial lymphocytes, serum endomysial and tissue transglutaminase antibodies were investigated.

RESULTS

Twenty-three subjects were randomized to the oats-containing diet and 16 to the traditional gluten-free diet. All adhered strictly to their respective diet. Quality of life did not differ between the groups. In general, there were more gastrointestinal symptoms in the oats-consuming group. Patients taking oats suffered significantly more often from diarrhoea, but there was a simultaneous trend towards a more severe average constipation symptom score. The villous structure did not differ between the groups, but the density of intraepithelial lymphocytes was slightly but significantly higher in the oats group. The severity of symptoms was not dependent on the degree of inflammation. Antibody levels did not increase during the study period.

CONCLUSION

The oats-containing gluten-free diet caused more intestinal symptoms than the traditional diet. Mucosal integrity was not disturbed, but more inflammation was evident in the oats group. Oats provide an alternative in the gluten-free diet, but coeliac patients should be aware of the possible increase in intestinal symptoms.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.

Gastrointestinal symptoms rating scale in coeliac disease patients on wheat starch-based gluten-free diets

BACKGROUND

A wheat starch-based gluten-free diet is widely adopted in the treatment of coeliac disease, even though the products contain trace amounts of gluten. The aim here was to establish whether such a diet sustains abdominal symptoms.

METHODS

The Gastrointestinal Symptom Rating Scale (GSRS) was applied to 58 coeliac disease patients on gluten-free diets and 110 non-coeliac controls. An estimate was made of daily dietary fibre and wheat starch-derived gluten. Psychological well-being was evaluated by a structured interview. Twenty-three coeliac patients consented to small-bowel biopsy.

RESULTS

The mean GSRS score in coeliac disease patients did not differ from that in control subjects. Poorer psychological well-being was associated with abdominal symptoms in coeliac patients, whereas the daily amount of wheat starch had no effect on GSRS score. Overall dietary compliance was good, and villous atrophy was found in only 2 out of 23 patients. The average fibre consumption, 13 g per day, was lower than recommended.

CONCLUSIONS

Wheat starch-based gluten-free products are well-tolerated in coeliac disease patients, provided that their diets are otherwise strict.

Clinical features of celiac disease today

The clinical spectrum of celiac disease has widened over the past decades. The condition is no longer a severe malabsorption syndrome. Instead, a typical celiac disease patient today has merely mild abdominal symptoms. Malabsorption can be subclinical or absent, and there is usually only moderate, if any, loss of weight. Simultaneously, the current prevalence has increased from 1:1,000 to 1:300 inhabitants, or even higher. Clinically silent celiac disease cases are being detected in increasing numbers since the introduction and widespread use of serologic screening tests. Symptoms of celiac disease can appear outside the intestine, a typical example being dermatitis herpetiformis. Gluten intolerance is no longer limited to overt villous atrophy. Inflammation without villous damage may be observed in genetically susceptible individuals. The term latent celiac disease is applied in situations where the patient has normal villous architecture while on a gluten-containing diet, but later develops small bowel villous atrophy compatible with celiac disease.

Gallstones

This review summarizes the main advances made in the epidemiology, pathogenesis, and medical treatment of gallstone disease in the past year. Whether rapid weight reduction can precipitate gallstone formation is still debated. Phospholipase A(2)-II seems to play an interesting role in the pathogenesis of multiple cholesterol stone formation, and ursodeoxycholic acid may partially halt the formation of multiple cholesterol stones by mediating an anti-inflammatory effect on the gallbladder. Bacterial infections may contribute to gallstone formation, perhaps through secretion of biofilm. The combination of ursodeoxycholic acid and simvastatin for the resolution and prevention of gallstones is promising, but larger studies are needed.