Cholecystectomy does not significantly increase the risk of fatty liver disease

Impact of cholecystectomy on the gut-liver axis and metabolic disorders

Cholecystectomy is considered as a safe procedure to treat patients with gallstones. However, epidemiological studies highlighted an association between cholecystectomy and metabolic disorders, such as type 2 diabetes mellitus and metabolic dysfunction-associated steatotic liver disease (MASLD), independently of the gallstone disease. Following cholecystectomy, bile acids flow directly from the liver into the intestine, leading to changes in the entero-hepatic circulation of bile acids and their metabolism. The changes in bile acids metabolism impact the gut microbiota. Therefore, cholecystectomized patients display gut dysbiosis characterized by a reduced diversity, a loss of bacteria producing short-chain fatty acids and an increase in pro-inflammatory bacteria. Alterations of both bile acids metabolism and gut microbiota occurring after cholecystectomy can promote the development of metabolic disorders. In this review, we discuss the impact of cholecystectomy on bile acids and gut microbiota and its consequences on metabolic functions.

Liver Fibrosis and Cirrhosis in Patients with Non-alcoholic Fatty Liver with and without History of Cholecystectomy: A Pilot Study

Background

Non-alcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases in the world. Previous studies revealed that cholecystectomy may be considered a risk factor for the development of NAFLD. The aim of this study was to compare the amount of liver fibrosis, determined by elastography, between patients with NAFLD with and without a history of cholecystectomy.

Methods

In this descriptive-analytical cross-sectional study, 50 patients with NAFLD were divided into two groups: one with a history of cholecystectomy and the other without. No significant differences were found between these two groups in terms of age or sex distribution. Liver fibrosis was measured for all patients using an elastography imaging system. Subsequently, the data related to liver fibrosis, along with the demographic information of the patients, were statistically analyzed using SPSS software version 22.

Results

The mean elastography score in all patients was 10.66±12.18 kPa (the elasticity scale ranging from 3.80 to 66.40 kPa). The group with a history of cholecystectomy had a significantly higher mean elastography score (13.39±16.20 kPa) compared with the group without cholecystectomy (7.93±4.99 kPa) (P=0.02). Additionally, there was a significant positive correlation between body mass index (BMI) and the mean elastography score in the group of patients with a history of cholecystectomy.

Conclusion

The mean elastography score of patients with NAFLD with a history of cholecystectomy was approximately twice as high as that of non-cholecystectomy patients.

Cholecystectomy and risk of liver disease: a systematic review and meta-analysis of 27 million individuals

BACKGROUND

There is still a lack of knowledge on the association between cholecystectomy and liver disease. This study was conducted to summarize the available evidence on the association of cholecystectomy with liver disease and quantify the magnitude of the risk of liver disease after cholecystectomy.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched systematically from database inception to January 2023 to identify eligible studies that evaluated the association between cholecystectomy and the risk of liver disease. Meta-analysis was conducted to obtain a summary odds ratio (OR) and 95% confidence interval (CI) using a random-effects model.

RESULTS

We identified 20 studies with a total of 27 320 709 individuals and 282 670 liver disease cases. Cholecystectomy was associated with an increased risk of liver disease (OR: 1.63, 95% CI: 1.34-1.98). In particular, cholecystectomy was found to be significantly associated with a 54% increased risk of nonalcoholic fatty liver disease (OR: 1.54, 95% CI: 1.18-2.01), a 173% increased risk of cirrhosis (OR: 2.73, 95% CI: 1.81-4.12), and a 46% increased risk of primary liver cancer (OR: 1.46, 95% CI: 1.18-1.82).

CONCLUSIONS

There is an association between cholecystectomy and the risk of liver disease. Our results suggest that strict surgical indications should be implemented to reduce unnecessary cholecystectomy. Additionally, the routine assessment of liver disease is necessary for patients with a history of cholecystectomy. More prospective large-sample studies are required for better estimates of the risk.

Gallstone disease and nonalcoholic fatty liver disease in patients with type 2 diabetes: a cross-sectional study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) and gallstone disease (GSD) often coexist in the general population owing to shared risk factors. This study explored the relationship between NAFLD and GSD in patients with type 2 diabetes.

METHODS

We conducted a retrospective cross-sectional analysis of 4325 patients with type 2 diabetes. GSD and NAFLD were confirmed using ultrasonography. GSD was defined as either asymptomatic gallstones or previous cholecystectomy, and each was analyzed separately.

RESULT

There was no significant difference in the prevalence of GSD between patients with and without NAFLD (23.8% vs. 21.2%, P = 0.15). After case-control matching (1:1) of baseline data such as age, sex, duration of diabetes, and HbA1c between patients with and without NAFLD, there was still no significant difference in the prevalence of GSD (25.5% vs. 23.6%, P = 0.15). The prevalence of NAFLD in patients with asymptomatic gallstones was lower than that of patients without GSD (38.6% vs. 47.3%, P < 0.001), whereas the prevalence in those who had undergone cholecystectomy was much higher (61.2% vs. 47.3%, P < 0.001). The ratio of cholecystectomy to asymptomatic gallstone in patients with or without NAFLD was 1.97 and 0.79, respectively. The rate of cholecystectomy was higher in the patients with NAFLD than in those without NAFLD (15.8% vs. 9.3%, P < 0.001), consistent with the result after case-control matching (17.3% vs. 11.2%, P < 0.001). Multivariate logistic regression analysis, after adjusting for numerous potential confounding factors, revealed that GSD (OR = 1.241, 95%CI: 1.036-1.488, P = 0.002) and cholecystectomy (OR = 1.946, 95%CI: 1.546-2.445, P < 0.001) were both strongly associated with NAFLD. However, asymptomatic gallstone (OR = 0.663, 95%CI: 0.513-0.856, P = 0.002) seemed to be negatively correlated with NAFLD.

CONCLUSIONS

The prevalence of GSD was similar in patients with type 2 diabetes with and without NAFLD. The higher proportion of cholecystectomy and lower proportion of asymptomatic gallstones in patients with NAFLD suggests that NAFLD may increase the risk of complications of GSD.

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.

Cholecystectomy and risk of metabolic syndrome

The gallbladder physiologically concentrates and stores bile during fasting and provides rhythmic bile secretion both during fasting and in the postprandial phase to solubilize dietary lipids and fat-soluble vitamins. Bile acids (BAs), major lipid components of bile, play a key role as signaling molecules in modulating gene expression related to cholesterol, BA, glucose and energy metabolism. Cholecystectomy is the most commonly performed surgical procedure worldwide in patients who develop symptoms and/or complications of cholelithiasis of any type. Cholecystectomy per se, however, might cause abnormal metabolic consequences, i.e., alterations in glucose, insulin (and insulin-resistance), lipid and lipoprotein levels, liver steatosis and the metabolic syndrome. Mechanisms are likely mediated by the abnormal transintestinal flow of BAs, producing metabolic signaling that acts without gallbladder rhythmic function and involves the BAs/farnesoid X receptor (FXR) and the BA/G protein-coupled BA receptor 1 (GPBAR-1) axes in the liver, intestine, brown adipose tissue and muscle. Alterations of intestinal microbiota leading to distorted homeostatic processes are also possible. According to this view, cholecystectomy, via BA-induced changes in the enterohepatic circulation, is a risk factor for the metabolic abnormalities and becomes another “fellow traveler” with, or another risk factor for the metabolic syndrome.

Cholecystectomy Causes Ultrasound Evidence of Increased Hepatic Steatosis

BACKGROUND

Cholecystectomy might contribute to the development of hepatic steatosis through metabolic changes. The biologic alteration of the enterohepatic circulation of bile acids and the alteration of the metabolic activity of bile acid that follows cholecystectomy may contribute to hepatic steatosis. This prospective study was conducted to clarify the possibility of steatosis development after cholecystectomy.

METHODS

From October 2013 to July 2014, 82 consecutive patients with a presumptive diagnosis of gallbladder disease were cholecystectomized. Liver parenchymal steatosis was measured using ultrasound and the hepatic steatosis index.

RESULTS

In all 82 patients, the hepatic steatosis index was found to be significantly correlated with the US fatty liver grade (Spearman's correlation r (2) = 0.331, P < 0.001). A total of 62 patients were followed up for 3 months. Comparison with the initial grade showed that 12 (18.5 %) patients had worsened from normal to mild (n = 10), from mild to moderate (n = 1), and from mild to severe (n = 1). The other patients stayed at their initial grade except one patient who improved (from moderated to mild). Analysis of laboratory findings showed that white blood cell count, aspartate transaminase, alanine transaminase level, and total bilirubin level were decreased. However, serum albumin and high-density lipoprotein cholesterol levels significantly increased.

CONCLUSIONS

Hepatic steatosis significantly developed 3 months after cholecystectomy. Therefore, cholecystectomy might be considered a risk factor for hepatic steatosis, but the relationship should be confirmed with long-term follow-up from a large group of patients.

Significant Association Between Gallstone Disease and Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Gallstone disease (GD) and nonalcoholic fatty liver disease (NAFLD) are common digestive disorders worldwide. Both conditions share certain risk factors including obesity, insulin resistance and diabetes. Several epidemiologic studies have reported the relationship between these two conditions.

AIM

We conducted a systematic review and meta-analysis to characterize the association between GD and NAFLD.

METHODS

A comprehensive search of the databases MEDLINE and EMBASE was performed from inception through November 2015. The inclusion criterion was the observational studies' assessment of the association between GD and NAFLD in adult participants. Pooled odds ratio (OR) and 95 % confidence interval (CI) were calculated using a random-effects model.

RESULTS

Data were extracted from 12 observational studies (9 cross-sectional studies, 1 case-control study and 2 cohort studies). The pooled OR of NAFLD in patients who had GD was 1.55 (95 % CI 1.31-1.82). The statistical between-studies heterogeneity (I (2)) was 64 %. The association remained significant when limited to cohort studies with pooled OR 1.33 (95 % CI 1.14-1.55, I (2) = 0 %).

CONCLUSION

Our meta-analysis demonstrated that GD is significantly associated with NAFLD. Further prospective studies exploring the underlying mechanism of this association should be pursued.