Gall stones and gall bladder motility

Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment?

BACKGROUND

In patients with common bile duct stones (CBDS) and intact gallbladder, further management for the gallbladder after the CBDS clearance is still controversial. The relationship between gallbladder motility and the biliary complications were seldom discussed. Our study is to predict the subsequent biliary complications by gallbladder function test using fatty meal sonography (FMS) in patients with CBDS who had been treated by endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Patients with an intact gallbladder and CBDS after endoscopic clearance of bile duct were enrolled. Patients received a fatty meal sonography after liver function returned to normal. The fasting volume, residual volume, and gallbladder ejection fraction (GBEF) in FMS were measured. Relationships of patients' characteristics, gallbladder function and recurrent biliary complication were analyzed.

RESULTS

From 2011 to 2014, 118 patients were enrolled; 86 patients had calculus gallbladders, and 32 patients had acalculous gallbladders. After a mean follow- up of 33 months, 23 patients had recurrent biliary complications. Among 86 patients with calculus gallbladder, 15 patients had spontaneous clearance of gallbladder stones; 14 patients received cholecystectomy due to acute cholecystitis or recurrent colic pain with smooth postoperative courses. In the follow up period, six patients died of non-biliary causes. The GBEF is significant reduced in most patients with a calculus gallbladder in spite of stone color. Calculus gallbladder, alcohol drinking and more than one sessions of initial endoscopic treatment were found to be the risk factors of recurrent biliary complication.

CONCLUSIONS

Gallbladder motility function was poorer in patients with a calculus gallbladder, but it cannot predict the recurrent biliary complication. Since spontaneous clearance of gallbladder stone may occur, wait and see policy of gallbladder management after endoscopic treatment of CBDS is appropriate, but regular follow- up in those patients with risk factors for recurrence is necessary.

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.

Variants in motilin, somatostatin and their receptor genes and risk of biliary tract cancers and stones in Shanghai, China

Altered motility of the gallbladder can result in gallstone and cholecystitis, which are important risk factors for biliary tract cancer. Motilin (MLN) and somatostatin (SST) are known important modulators of gallbladder motility. To determine whether genetic variants in motilin, somatostatin, and their receptor genes are associated with the risk of biliary tract cancers and stones, nine tag-SNPs were determined in 439 biliary tract cancer cases (253 gallbladder, 133 extrahepatic bile duct and 53 ampulla of Vater cancer cases), 429 biliary stone cases, and 447 population controls in a population-based case–control study in Shanghai, China. We found that subjects with the MLNR rs9568169 AA genotype and SSTR5 rs169068 CC genotype were significantly associated with risk of extrahepatic bile duct cancer (OR = 0.49, 95% CI: 0.27–0.89; OR = 2.40, 95% CI: 1.13–5.13) compared to the major genotypes. MLN rs2281820 CT and rs3793079 AT genotypes had significantly increased risks of gallstones (OR = 1.52, 95% CI: 1.06–2.18; OR = 1.64, 95% CI: 1.20–2.25) compared to TT genotypes. Besides, haplotype analysis showed that MLN T-T-T haplotype (rs2281820–rs3793079–rs2281819) had a non-significantly elevated risk of gallstone (OR = 1.30, 95% CI: 0.91–1.86) compared with C-A-A haplotype. To the best of our knowledge, this is the first study to report an association between genetic polymorphisms in MLN, MLNR and their receptor genes and risk of biliary tract cancers and stones.

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We conduct a population-based case–control study of biliary tract diseases in China.

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We examine nine TagSNPs in gallbladder motility genes in this study.

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MLNR rs9568169 and SSTR5 rs169068 are related to extrahepatic bile duct cancer risk.

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MLN rs2281820 and rs3793079 are associated with gallstone risk.

Variants in CCK and CCKAR genes to susceptibility to biliary tract cancers and stones: a population-based study in Shanghai, China

BACKGROUND AND AIM

Altered motility of the gallbladder is associated with an increased risk of gallstones and can result in biliary tract cancers. Cholecystokinin (CCK) is an important modulator of gallbladder motility which functions by activating CCK type-A receptor (CCKAR). The aim of this study was to determine whether genetic variants in CCK and CCKAR are associated with the risk of biliary tract cancers and stones.

METHODS

We investigated the associations between nine single nucleotide polymorphisms in CCK and CCKAR in a population-based case-control study, including 439 biliary tract cancer cases (253 gallbladder, 133 extrahepatic bile duct, and 53 ampulla of Vater cancer cases), 429 biliary stone cases, and 447 population controls in Shanghai, China.

RESULTS

We found that women with the CCKAR rs1800855 AA genotype had an increased risk of gallbladder cancer (odds ratio = 2.37, 95% confidence interval (CI): 1.36-4.14) compared with subjects with the TT genotype, and remained significant after Bonferroni correction (P = 0.0056). Additionally, female carriers of the CCKAR haplotype C-T-C-T (rs2071011-rs915889-rs3822222-rs1800855) had a reduced risk of gallbladder cancer (odds ratio = 0.61, 95% confidence interval: 0.43-0.86) compared with those with the G-C-C-A haplotype; the association also remained significant after Bonferroni correction.

CONCLUSIONS

These findings suggest that variants in the CCKAR gene may influence the risk of gallbladder cancer in women. Additional studies are needed to confirm our findings.

Does impaired gallbladder function contribute to the development of Barrett's esophagus and esophageal adenocarcinoma?

INTRODUCTION

Esophageal adenocarcinoma is aetiologically associated with gastro-esophageal reflux, but the mechanisms responsible for the metaplasia-dysplasia sequence are unknown. Bile components are implicated. Impaired gallbladder function may contribute to duodenogastric reflux (DGR) and harmful GERD.

AIMS

This study aims to compare gallbladder function in patients with Barrett's esophagus, adenocarcinoma, and controls.

METHODS

Three groups of patients, all free of gallstone disease, were studied. Group 1: (n = 15) were normal controls. Group 2: (n = 15) were patients with >3-cm-long segment of Barrett's esophagus. Group 3: (n = 15) were patients with esophageal adenocarcinoma. Using real-time ultrasonography unit, gallbladder volume was measured in subjects following a 10-h fast. Ejection fraction was calculated before and after standard liquid meal and compared between the groups.

RESULTS

The mean percentage reduction in gallbladder volume was 50% at 40 min in the adenocarcinoma group compared with 72.4% in the control group (p < 0.001). At 60 min, gallbladder filling had recommenced in the control group to 64.1% of fasting volume while continuing to empty with further reduction to 63% in the Barrett's group and to 50.6% (p = 0.008) in the adenocarcinoma group. The mean gallbladder ejection fraction decreased progressively from controls to Barrett's to adenocarcinoma and was significantly lower in Barrett's group (60.9%; p = 0.019) and adenocarcinoma group (47.9%; p < 0.001) compared with normal controls (70.9%).

CONCLUSION

Gallbladder function is progressively impaired in Barrett's esophagus and adenocarcinoma. Gallbladder malfunction increases duodenogastric reflux, exposing the lower esophagus to an altered chemical milieu which, in turn, may have a role in promoting metaplasia-dysplasia-neoplasia sequence in the lower esophageal mucosa.

Independent effects of cardiorespiratory fitness, vigorous physical activity, and body mass index on clinical gallbladder disease risk

BACKGROUND AND AIMS

Incident self-reported physician-diagnosed clinical gallbladder disease was compared to BMI, body dimensions, physical activity (km/day run) and cardiorespiratory fitness (10 km race speed, meters per second [m/s]) in 29,110 male and 11,953 female runners.

METHODS

Physician-diagnosed gallbladder disease was reported by 166 men (0.57%) and 112 women (0.94%) during (mean +/- SD) 7.74 +/- 1.84 and 7.42 +/- 2.10 years of follow-up, respectively.

RESULTS

There was a progressive increase in age-adjusted risk with increasing BMI that accelerated sharply above 27.5 kg/m(2). Even among ostensibly healthy-weight women, the age-adjusted risk was significantly greater above 22.5 kg/m(2) vis-à-vis the leanest women (P= 0.04). Age-adjusted risk declined with increasing fitness in both sexes. Compared to the least fit men and women, men who ran faster than 4.75 m/s had 83% lower risk (75% lower when adjusted for km/day and BMI) and women who ran faster than 4 m/s had 93% lower risk (85% lower adjusted for km/day and BMI). The fittest men (> or =4.75 m/s) were at significantly less risk than men who ran <3.25 m/s (P < 0.003) and between 3.25 and 3.75 m/s (P= 0.03), and the fittest women (> or =4 m/s) were at significantly less risk than those who ran <2.8 m/s (P < 0.0001), between 2.8 and 3.2 (P= 0.0004), 3.2 and 3.6 (P= 0.002), and 3.6 and 4.0 m/s (P= 0.005). Adjustment for BMI accounted for more of the risk reduction associated with fitness in women than men. The risk for clinical gallbladder disease was also significantly related to usual running distance (men: P= 0.01; females: P= 0.008), which was attributable to the leanness of the longer-distance runners.

CONCLUSION

Clinical gallbladder disease risk was (a) concordantly related to BMI, (b) inversely related to usual running distance, and (c) inversely related to cardiorespiratory fitness independent of physical activity levels.

Lipase inhibition by orlistat: effects on gall-bladder kinetics and cholecystokinin release in obesity

BACKGROUND

Obese subjects are at risk of developing gallstones as a result of the obese state and during weight reduction.

AIM

To study whether orlistat, by lipase inhibition, impairs gall-bladder emptying, thus further predisposing weight-losing obese subjects to gallstone formation.

METHODS

Patients entering a randomized clinical trial of 1 month of diet, followed by treatment with placebo, 3 x 60 mg orlistat or 3 x 120 mg orlistat, underwent gall-bladder emptying studies measured by ultrasound. Meal-induced cholecystokinin release and gall-bladder emptying were investigated at the start, at randomization and after 1 and 12 months.

RESULTS

One month of dieting did not change gall-bladder emptying and cholecystokinin release. After 1 month, placebo treatment resulted in a decreased fasting volume of 11%, compared with increases of 26% and 47% with 60 and 120 mg orlistat, respectively. Gall-bladder emptying increased by 9% with placebo and decreased by 15% and 53% with 60 and 120 mg orlistat, respectively. Fasting cholecystokinin values and cholecystokinin release decreased significantly in the orlistat group. After 1 year, a persistent but attenuated effect of orlistat on gall-bladder emptying and cholecystokinin release remained. Three of 40 patients developed gallstones, two on placebo with major weight loss and one on 60 mg orlistat.

CONCLUSIONS

One month of lipase inhibition by orlistat significantly impaired gall-bladder motility, which persisted to some extent after 1 year. Obese subjects with diabetes or hyperlipidaemia, who are more at risk of gallstones, should be followed carefully.

Determinants of gallbladder kinetics in obesity

Obese subjects are at risk of developing gallstones both by being overweight and by reducing their body weight. The aim of the present study was to investigate factors related to disturbances in gallbladder emptying measured by ultrasound. Detailed information about weight loss attempts, age at onset of obesity, parity, presence of menopause, use of contraceptive or hormonal replacement drugs, and phase of menstrual cycle was obtained. Smoking habits, alcohol use, dietary intake, and physical activity were recorded. Body composition and fat distribution were assessed by anthropometry. Blood samples were taken for CCK, lipids, glucose, and insulin. Mean (SD) fasting gallbladder volume was 30.0 (12.6) ml. The residual volume was 12.5 (9.8) ml 90 min after a test meal. CCK levels increased from a basal 1.64 (0.8) pM to a peak value of 2.9 (1.0) pM. Fasting gallbladder volumes were closely related to residual and ejection volumes. Body weight and fasting insulin levels explained 35.2% of the variance in fasting volume, lean body mass and insulin explained 28.1% of the residual volume, and waist circumference 23.6% of the ejection volume. None of the other factors were related to gallbladder emptying. Subjects with the largest fasting gallbladders had the largest residual and least emptying gallbladders, scored the highest in every aspect of body size, composition, and fat distribution, and also had the highest insulin levels. Body weight, lean body mass, central fat distribution, and insulin levels were the main determinants of gallbladder kinetics. Fasting and residual gallbladder volumes were closely related and both determined by obesity and its metabolic complication of hyperinsulinemia.

Mechanisms of cisapride affecting gallbladder motility

Regulation of gallbladder motility is complex. Mechanisms via which cisapride may interact with gallbladder function are being reviewed. These are multiple and include direct effects on gallbladder and the sphincter of oddi, as well as indirect effects involving gastro-intestinal hormone levels, gastric emptying, gallbladder refilling, interdigestive migrating motor cycle (IMMC) and small intestinal transit. Effects, moreover, may vary according to dose, route and duration of cisapride administration, which may explain conflicting data so far with cisapride.

Review: pathogenesis of gallstones

The aim of this article is to review selected aspects of the pathogenesis of cholesterol-rich, gall-bladder stones (GBS)--with emphasis on recent developments in biliary cholesterol saturation, cholesterol microcrystal nucleation, statis within the gall-bladder and, particularly, on the roles of intestinal transit and altered deoxycholic acid (DCA) metabolism, in GBS development. In biliary cholesterol secretion, transport and saturation, recent developments include evidence in humans and animals, that bile lipid secretion is under genetic control. Thus in mice the md-2 gene, and in humans the MDR-3 gene, encodes for a canalicular protein that acts as a 'flippase' transporting phospholipids from the inner to the outer hemi-leaflet of the canalicular membrane. In the absence of this gene, there is virtually no phospholipid or cholesterol secretion into bile. Furthermore, when inbred strains of mice that have 'lith genes' are fed a lithogenic diet, they become susceptible to high rates of GBS formation. The precipitation/nucleation of cholesterol microcrystals from supersaturated bile remains a critical step in gallstone formation. methods of studying this phenomenon have now been refined from the original 'nucleation time' to measurement of cholesterol appearance/detection times, and crystal growth assays. Furthermore, the results of recent studies indicate that, in addition to classical Rhomboid-shape monohydrate crystals, cholesterol can also crystallize, transiently, as needle-, spiral- and tubule-shaped crystals of anhydrous cholesterol. A lengthy list of promoters, and a shorter list of inhibitors, has now been defined. There are many situations where GB stasis in humans is associated with an increased risk of gallstone formation--including iatrogenic stone formation in acromegalic patients treated chronically with octreotide (OT). As well as GB stasis, however, OT-treated patients all have 'bad' bile which is supersaturated with cholesterol, has excess cholesterol in vesicles, rapid microcrystal mulceation times and a two-fold increase in the percentage DCA in bile. This increase in the proportion of DCA seems to be due to OT-induced prolongation of large bowel transit time (LBTT). Thus LBTT is linearly related to (i) the percentage of DCA in serum; (ii) the DCA pool size; and (III) the DCA input or 'synthesis' rate. Furthermore, the intestinal prokinetic, cisapride, counters the adverse effects of OT on intestinal transit, and 'normalizes' the percentage of DCA in serum/bile. Patients with spontaneous gallstone disease also have prolonged LBTTs, more colonic gram-positive anaerobes, increased bile acid metabolizing enzymes and higher intracolonic pH values, than stone-free controls. Together, these changes lead to increased DCA formation, solubilization and absorption, Thus, in addition to the 'lithogenic liver' and 'guilty gall-bladder' one must now add the 'indolent intestine' to the list of culprits in cholesterol gallstone formation.

An evaluation of three-dimensional ultrasonography for the measurement of gallbladder volume

OBJECTIVE

Various three-dimensional ultrasonography systems have been developed. We estimated the accuracy of a three-dimensional ultrasonography system for measuring gallbladder volume and compared the results to the sum-of-cylinders method.

METHODS

In an in vitro study, 10 balloons of various shapes, sized 5-68 mL were scanned by real-time ultrasonography. In an in vivo study, we evaluated the gallbladder emptying of 14 healthy male volunteers after ingestion of two raw egg yolks. In both studies, volume measurement was performed by the three-dimensional ultrasonography method and the sum-of-cylinders method.

RESULTS

With the three-dimensional ultrasonography method, the mean difference between the measured volume and the true volume and the limits of agreement were smaller than those of the sum-of-cylinders method. Gallbladder volumes did not differ significantly with both ultrasound methods.

CONCLUSION

The three-dimensional ultrasonography method accurately determined gallbladder volumes.

A double-blind placebo-controlled study on the effects of omeprazole on gut hormone secretion and gastric emptying rate

BACKGROUND

The present study was designed to investigate whether an effect of omeprazole on gastric emptying is related to changes in the secretion of selected gut hormones.

METHODS

The studies were performed in healthy men after 10 days' treatment with 40 mg omeprazole daily/placebo. Food ingestion took place in a duodenal phase, I and the meal consisted of an omelette labelled with technetium Tc 99m, followed by 150 ml water labelled with indium In 111. Plasma concentrations of gastrin, cholecystokinin (CCK), and motilin were measured.

RESULTS

Pretreatment with omeprazole reduced gastric emptying rates. This applied to all variables and was most pronounced with regard to amounts of solid (median (95% confidence interval)) emptied at 180 min (71% (48 - 86) for omeprazole versus 96% (87 - 100) for placebo; P < 0.01). All median values of plasma gastrin concentrations from the omeprazole series were higher than the corresponding values from the placebo series, and omeprazole induced a tenfold increase in incremental integrated area (IIA, pmol/l x 180 min) of the gastrin concentration curve (5250 (2570 - 9680) versus 575 (240 - 1485); P < 0.01). New findings include a lower postprandial secretion of CCK in the omeprazole series, and consequently, a difference in total integrated area (TIA, pmol/l x 180 min) (88 (21 - 147) versus 217 (104 - 267); P < 0.05) and IIA (pmol/l x 180 min) (52 (2 - 142) versus 165 (104 - 195); P < 0.05), respectively; a difference in IIA-30 (pmol/l x 30 min) of plasma motilin concentrations (270 (140 - 595) (omeprazole) versus 460 (285 - 655); P < 0.05); and a direct relationship between the amounts of liquid emptied at 30 min and the corresponding TIA-30 of plasma motilin in the omeprazole (Rs = 0.677; P < 0.05) and the placebo series (Rs = 0.767; P < 0.05).

CONCLUSION

Pretreatment with 40 mg omeprazole daily decreases the gastric emptying rates and has a substantial influence on the secretion of gastrin, motilin, and CCK. The finding of an omeprazole-induced decrease in CCK release may have clinical implications. Further investigation into the possible effect of proton-pump inhibitors on biliary tract motility and cholesterol solubilization in gallbladder bile is warranted.

Exercise and gall bladder function

Epidemiological research has demonstrated protective effects of varying strength from physical activity against the risk for several chronic diseases such as coronary heart disease, hypertension, non-insulin-dependent diabetes mellitus and osteoporosis. Epidemiological studies have been supported by experimental research showing that exercise training improves coronary heart disease risk factors and other health-related factors. In contrast, the association between physical activity, exercise and gall stone disease has not yet been firmly established. This paper presents the theoretical role of aerobic exercise: (i) in the primary prevention of gall stone disease; and (ii) as a potential prokinetic agent in high risk gall stone disease groups. Primary risk factors in the pathogenesis of gall stone formation include cholesterol supersaturation in the solutes that precipitate from bile, hypernucleation (measured as "crystal appearance time') and finally hypomotility of the gall bladder which allows bile stasis and crystal formation. While the results of epidemiological studies suggest that physical activity may be inversely associated with gall stone disease, the mechanisms by which exercise may influence gall stone disease pathogeneses are poorly understood. In this paper the association between physical activity and exercise to gall bladder function and gall stone disease will be examined. Recommendations for future research and the implications for the primary prevention of gall stone disease will also be discussed.

Effects of colectomy on gallbladder motility in patients with ulcerative colitis

In order to gain insight into the possible mechanisms involved in gallstone formation in colectomized ulcerative colitis patients, we studied gallbladder motility by means of ultrasonography in three groups of subjects: controls (N = 40) and ulcerative colitis patients without (N = 30) and with (N = 20) colectomy. Impaired gallbladder emptying after a liquid fatty meal stimulus was observed in ulcerative colitis patients with colectomy compared with those obtained in ulcerative colitis patients without colectomy and controls (P = 0.001). The maximum percentage of gallbladder emptying also, was significantly lower (59.8%) than those seen in ulcerative colitis patients without colectomy (74.5%) and controls (77.8%) (P = 0.001). Diminished gallbladder emptying with ensuing stasis might be a contributory factor to the increased prevalence of gallstones in colectomized patients.

Evaluation of gallbladder volume and emptying with a novel three-dimensional ultrasound system: comparison with the sum-of-cylinders and the ellipsoid methods

To overcome the geometrical limitations of current methods to calculate gallbladder volume from two-dimensional sonographic images, we evaluated the accuracy and precision of a novel three-dimensional ultrasound system (3D). In vitro accuracy of 3D volumetry (10 mL to 55 mL) was 98.1 +/- 7.1% (mean+/-SD) with a mean difference of 0.7 mL between the measured and the true volume (p < 0.003). Compared with the sum-of-cylinders (SC) and the ellipsoid (EL) methods, 3D was characterized by a significantly smaller systematic bias and closer limits of agreement with the true volume. The variation coefficient was smallest with 3D (2.4%, p < 0.02) and largest with EL (4.2%). In vivo, gallbladder volumes were on average 1.4 mL (9%) smaller with 3D than with SC (p < 0.0001) and 2.4 mL (14%) larger with EL than with SC (p < 0.0001). 3D ultrasonography accurately measures gallbladder volume and emptying.

The effects of acute exercise on gallbladder function in an adult female population

It has been suggested that aerobic exercise influences gallstone disease pathogenesis through its effects on gallbladder motility. The purpose of the present investigation was to examine the effects of acute aerobic exercise on gallbladder emptying. Gallbladder function was evaluated, via cholescintigraphy, in 12 healthy females after undergoing two experimental trials [i.e., postprandial (P) and exercise + postprandial (E + P))]. In the E + P trial, 60 min after injection of 99mTc disofenin, subjects exercised for 30 min at 65.3 +/- 0.9%, (mean +/- SEM) of VO2 peak on a recumbent leg ergometer, and then ingested 8 oz of a liquid meal to promote gallbladder emptying. In the P trial the meal was administered at the same time relative to the E + P trial; however, for the 30 min prior to meal ingestion subjects remained in a resting supine position. Postprandial gallbladder ejection fraction (EF) was nonsignificantly higher in the E + P trial (49.4 +/- 5.1%) than in the P trial (46.6 +/- 6.7%). Results of this study also indicated that during a fasted state the gallbladder undergoes significant periods of spontaneous emptying both at rest EF = 25 +/- 5.6% (P < 0.02) and during exercise EF = 17 +/- 4.3% (P < 0.01). In conclusion, the results of this study indicate that 30 min of aerobic exercise at 65% of VO2 peak does not effect gallbladder motility in a healthy, premenopausal, female population.

Abnormal processing of the human cholecystokinin receptor gene in association with gallstones and obesity

BACKGROUND & AIMS

Cholesterol gallstone disease and obesity are often associated and share the potential, yet unreported, common etiology of cholecystokinin (CCK) dysfunction. While cloning the human CCK-A receptor complementary DNA (cDNA), we found predominance of a 262-base pair coding region deletion in a cDNA library prepared from a patient with this phenotype. The aim of this study was to determine the abundance, functional significance, and mechanism for generating this gene product.

METHODS

Relative abundance of CCK receptor gene products was determined using polymerase chain reaction and hybridization analysis. Constructs were expressed in COS cells and studied for radioligand binding and intracellular calcium responses. A human genomic clone for this receptor was sequenced, and the critical regions were compared with those of the patient.

RESULTS

Ninety-three percent of the patient's CCK receptor transcripts contained the 262-base pair deletion, whereas only 1.5% +/- 0.9% of control patients had the deletion. This encoded a receptor that did not bind or signal. The deletion corresponded with the third exon; however, this sequence and flanking introns were normal in the patient.

CONCLUSIONS

Abnormality of processing an apparently normal CCK receptor gene yields the predominant product with an absent third exon and encoding a nonfunctional receptor, probably reflecting a defective trans-acting splicing factor. An atypical lariat region in the third intron may explain the presence of small amounts of this product in control patients.

Effect of NSAIDs on gallbladder bile composition

Secretion of gallbladder mucin is an important step in gallstone pathogenesis. Previous studies have demonstrated that aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) can both inhibit gallbladder mucin secretion and prevent gallstone formation in animal models of cholesterol gallstone disease. The present study was performed to determine if chronic NSAID use was associated with a reduction in the mucin content or affected the lipid components of human gallbladder bile. Four groups of patients were identified retrospectively from a cohort of 230 morbidly obese patients who underwent gastric bypass surgery. The index group consisted of 18 patients who were found to have gallstones at gastric bypass surgery and had a history of chronic NSAID use. Three other patient groups were identified from the cohort by matching this index population for sex, race, and age according to the following criteria: (1) patients with gallstones who had not utilized NSAIDs, (2) patients without gallstones but with chronic NSAID use, and (3) patients without gallstones and without a history of NSAID use. Gallbladder bile was obtained from all patients by direct aspiration from the gallbladder at the time of surgery. Patients with gallstones had a significantly (P < 0.02) greater concentration of gallbladder mucin in their gallbladder bile compared to patients without gallstones (0.897 +/- 0.226 vs 0.173 +/- 0.039 mg/ml). Among gallstone patients, gallbladder mucin was reduced in those patients with a history of chronic NSAID use (1.18 +/- 0.43 vs 0.74 +/- 0.19 mg/ml).(ABSTRACT TRUNCATED AT 250 WORDS)

An early gallstone clearance following repeat piezoelectric lithotripsy

Piezoelectric extracorporeal litotripsy was performed in 128 symptomatic patients with radiolucent gall-bladder stones to assess the significance of disintegration in fragment clearance. Up to 10 repeat lithotripsy sessions were scheduled to achieve a fragment target size of < 3 mm. Fragmentation assessed by the size of the largest fragments after the last session was graded into three classes. I: sludge-like disintegration, 18%; II: < 3 mm (mean +/- s.d., 1.7 +/- 0.5 mm), 56%; and III: > or = 3 mm (3.3 +/- 0.6), 26%. All patients were initially subjected to lithotripsy alone. Bile acid dissolution therapy was started only when ultrasonography failed to show the evidence of decrease in the < 3 mm fragments during a 1 month follow up. Finally, 69 patients (54%) were treated by lithotripsy alone, and the remaining 59 received additional dissolution therapy at a mean period of 2.5 months after the initial lithotripsy. The rate of complete clearance in class I, II and III patients was 91, 42 and 10% at 6 months and 100, 68 and 49% at 18 months, respectively. Significant differences were noted between the three fragmentation grades (I vs II, III, P < 0.0001; II vs III, P < 0.02). The patients with complete clearance within 6 months were seen only in those treated by lithotripsy alone, while the majority (87%) of patients with complete clearance during the later period were seen in those treated by additional dissolution therapy. We conclude that a high degree of fragmentation appears to lead stones to an earlier period clearance, and reduce the need for dissolution therapy.