Gallstones at autopsy and cholecystectomy: a comparative study

Gallbladder cancer worldwide: geographical distribution and risk factors

Gallbladder cancer is a relatively rare neoplasm that shows, however, high incidence rates in certain world populations. The interplay of genetic susceptibility, lifestyle factors and infections in gallbladder carcinogenesis is still poorly understood. Age-adjusted rates were calculated by cancer registry-based data. Epidemiological studies on gallbladder cancer were selected through searches of literature, and relative risks were abstracted for major risk factors. The highest gallbladder cancer incidence rates worldwide were reported for women in Delhi, India (21.5/100,000), South Karachi, Pakistan (13.8/100,000) and Quito, Ecuador (12.9/100,000). High incidence was found in Korea and Japan and some central and eastern European countries. Female-to-male incidence ratios were generally around 3, but ranged from 1 in Far East Asia to over 5 in Spain and Colombia. History of gallstones was the strongest risk factor for gallbladder cancer, with a pooled relative risk (RR) of 4.9 [95% confidence interval (CI): 3.3-7.4]. Consistent associations were also present with obesity, multiparity and chronic infections like Salmonella typhi and S. paratyphi [pooled RR 4.8 (95% CI: 1.4-17.3)] and Helicobacter bilis and H. pylori [pooled RR 4.3 (95% CI: 2.1-8.8)]. Differences in incidence ratios point to variations in gallbladder cancer aetiology in different populations. Diagnosis of gallstones and removal of gallbladder currently represent the keystone to gallbladder cancer prevention, but interventions able to prevent obesity, cholecystitis and gallstone formation should be assessed.

Hepatobiliary ultrasound

The use of ultrasound technology in the emergency department(ED) is a recent and fast-growing phenomenon. Ultrasound is an extremely valuable tool for the evaluation of gallbladder (GB) dis-ease in the ED for several reasons: this disease is a common medical problem, cholecystitis can present in different ways clinically,the nature of the GB allows it to be well visualized by ultrasound,and ultrasound has many benefits and few complications associated with its use. This article reviews the focused examination of the GB, with specific attention to test characteristics (sensitivity,specificity, positive predictive value, and negative predictive value)when performed by emergency physicians in the ED.

Expression of bacterial beta-glucuronidase in human bile: an in vitro study

BACKGROUND

Bacterial beta-glucuronidase causes deconjugation of bilirubin diglucuronide resulting in the precipitation of calcium bilirubinate, which contributes to biliary sludge and stone formation. This process is attributed to enzyme activity produced by the aerobic enterobacteriaceae such as Escherichia coli and Klebsiella sp. The presence of Clostridium sp. was detected in 48 of 56 intrahepatic stones by using polymerase chain reaction techniques and cultured Clostridium perfringens from 14 of 18 unblocked biliary stents. Such bacteria are reported to produce beta-glucuronidase activity. The aim of this study was to determine the proportion of biliary bacteria isolated from pigment stones and stents that produce beta-glucuronidase and to compare the enzyme activity expressed by the different bacteria in human bile.

METHODS

A total of 202 bacteria were isolated from blocked and unblocked biliary stents and pigment ductal stones recovered from patients. Of these, 61 bacteria expressed beta-glucuronidase activity in brain heart infusion broth. These 61 bacteria were subsequently grown in human bile under aerobic or anaerobic conditions to the early stationary phase and assayed for beta-glucuronidase activity by using rho-nitrophenyl beta-D glucuronide as substrate. Results were normalized and reported as units of enzyme activity per milligram protein of the bacteria.

RESULTS

C. perfringens produced beta-glucuronidase enzyme activity that was 34-fold higher than that for E coli, Staphylococcus, Corynebacterium sp., Bacillus sp., Enterococcus sp., Acinetobacter sp., Streptococcus sp., and Klebsiella sp.

CONCLUSION

C. perfringens with its higher enzyme activity is more important in the deconjugation of bilirubin diglucuronide than E coli and Klebsiella sp.

Single and multiple cholesterol gallstones and the influence of bacteria

Single and multiple cholesterol gallstones constitute at least 80% of the gallstone population observed at cholecystectomy in Western countries. While supersaturation of bile with cholesterol is necessary for gallstone growth, the kinetic determinant of crystal nucleation is perhaps the critical factor leading to the incidence of gallstones. Nucleation involves aggregation of nidus-forming materials like pigment precipitates and mucus proteins. In combination with cholesterol precipitates and crystal formation, gallstone propagation is enhanced. Bacterial species may augment the process of nucleation and gallstone growth by contributing specific enzyme activities resulting in the formation of insoluble precipitates in bile, or by acting as a nidus upon which the deposition of cholesterol crystals may initiate gallstone formation. The utilization of Raman microscopic techniques permits detailed mapping of the distribution of the gallstone components leading to identification and characterization of the site of nucleation. This, when coupled to molecular genetic tools such as PCR DNA amplification, would permit elucidation of the role of bacteria in vivo gallstone propagation mechanisms.

Gallstones and gall bladder carcinoma

BACKGROUND

The present study reviewed the occurrence of gall bladder carcinoma in patients who underwent a cholecystectomy for gallstone disease.

METHODS

A retrospective study of demographical and clinical information for patients who underwent a cholecystectomy and operative cholangiogram for gallstones predominantly in three major hospitals located in the northern area of Melbourne was carried out.

RESULTS

Gall bladder carcinomas were observed in 14 patients (3.2%; 95% confidence interval (CI): 1.8-5.3%) consisting of 11 women and three men of median age 78.5 years (interquartile range: 77-81) from a series of 439 patients with a male-to-female ratio of 1-2. The results of the present study show that primary carcinoma of the gall bladder in this descriptive retrospective cohort was always associated with single or multiple cholesterol gallstones that were impacting on the gall bladder wall. Cholesterol 'solitaire' gallstones were ovoid in shape with diameters > 3 cm along their longest axis, whereas multiple cholesterol gallstones varied in size and number from two or three large stones (1-2 cm), to numerous smaller stones (variable size to 0.5 cm). No patient with gall bladder carcinoma had either brown or black pigment gallstones.

CONCLUSION

It is postulated that gall bladder carcinoma may be intimately associated with large or numerous cholesterol gallstones that in the first instance may interfere with the mechanical functioning of the gall bladder. The size as well as the number of gallstones present in the gall bladder may contribute significantly to the promotion of a gallstone filling defect of the gall bladder that may cause chronic mechanical damage to the gall bladder mucosa. The present report supports the hypothesis that gall bladder carcinoma is an age-dependent malignancy, present mostly in women, that may be intimately associated with long-standing benign gallstone disease of the gall bladder.

Abdominal ultrasonography

This article focuses on ultrasonographic examinations of the abdomen and important intra-abdominal pathology. The liver and biliary tree are discussed first, followed by the use of ultrasonography in diagnosing appendicitis, ascites, and bowel obstruction. Pyloric stenosis and intussusception, important pediatric intra-abdominal problems, are also discussed.

Cholecystectomy and right colon cancer in Puerto Rico

A case-control study was undertaken to evaluate the possible relationship between cholecystectomy and right colon cancer. Two hundred patients with adenocarcinoma of the cecum or ascending colon (diagnosed between 1984 and 1989) were compared with 200 matched neighborhood controls. Cholecystectomy history was obtained through interviews using structured questionnaires and subsequently validated from hospital records. A statistically significant association (odds ratio = 2.14) was found between right colon cancer and a history of prior cholecystectomy. The altered bile metabolism which occurs after removal of the gallbladder may have a carcinogenic effect on the right colon. Dietary habits of the colon cancer patients in our study were consistent with prior reports in the literature, showing that this group has a lower intake of vegetables and cereal fiber than the control population.

Bacteria and gallstone nucleation

This preliminary study reports for the first time that there might be a possible association between bacteria and the aetiology of some cholesterol calculi. The gall-bladder biles from 225 cholecystectomy patients underwent bacteriological and microscopic study. Cholesterol calculi from 13 patients (10.2%) were observed to be associated with gall-bladder bile profusely infected with at least one bacterial species that was shown to possess beta-glucuronidase activity, an enzyme that is thought to promote calcium bilirubinate precipitation in bile. Concomitantly, the associated gall-bladder bile was 'high' in calcium bilirubinate precipitation and the precipitate was also detected in the centre of the gallstones. Moreover, in approximately half of these patients (six of 13), the cholesterol gallstones' nuclear areas also contained calcium palmitate, which is also thought to be due to bacterial activity. The results also support the hypothesis that bacteria with active beta-glucuronidase (for example, Escherichia coli) can significantly influence the aetiology of brown pigment gallstones. In contrast, bacteria were observed to have no role in black pigment gallstone formation, as their associated gall-bladder biles were always observed to be sterile.

Klatskin tumours: a 20 year experience

The management of 27 patients who presented with cholangiocarcinoma of the hepatic confluence over the past 20 years is reviewed, and the dramatic changes, both in accuracy of diagnosis and modes of treatment, are documented. All 27 presented with jaundice, three underwent laparotomy only, four had a T-tube inserted, one had a straight transhepatic tube inserted, seven U-tubes were placed and four patients underwent surgical resection. More recently, seven patients were drained percutaneously and a further patient was treated by an endoscopic stent. There were six postoperative deaths. Of the 24 who received active treatment, the mean survival was 8 months with a range of 0-40 months. The advantages and disadvantages of the various methods of diagnosis and treatment are discussed. The possible role of radiotherapy and chemotherapy are reviewed briefly.

Large bowel cancer after cholecystectomy

In a large, population-based case control study of colorectal cancer, 65 of 715 patients and 57 of 727 control subjects had a previous cholecystectomy (chi-square = 0.6, relative risk 1.18, 95 percent confidence interval 0.81 to 1.70, p = 0.45). There was no statistically significant association between previous cholecystectomy and the risk of colorectal cancer, colon cancer, right colon cancer, any of the subsites of colon cancer, rectal cancer, age, or sex. Although there is some evidence from other studies of an association between previous cholecystectomy and right colon cancer in women, this may have resulted from confounding symptoms. Based on the present evidence, we believe that previous cholecystectomy is unlikely to be a risk factor for colorectal cancer.