Prophylaxis against gallstone formation with ursodeoxycholic acid in patients participating in a very-low-calorie diet program

The effects of ursodeoxycholic acid on cardiometabolic risk factors: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Chronic diseases such as obesity, hypertension, and metabolic syndrome are major health concerns worldwide. Ursodeoxycholic acid (UDCA) is a bile acid that is naturally produced in the liver and has been used for the treatment of various liver disorders. In this systematic review and meta-analysis, we investigated how UDCA might affect inflammation, blood pressure, and obesity.

METHODS

Five major databases were searched from inception to August 2024. The investigated outcomes included body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α). A random effect was carried out to estimate pooled weighted mean difference (WMD) with 95% confidence intervals (CI). The registration code is CRD42023428064.

RESULTS

Of the 7912 articles in the initial search, 12 were included in the systematic review and meta-analysis. UDCA consumption significantly decreased BMI (WMD: -0.29 kg/m2, 95% CI: -0.58, -0.01, P = 0.044), and DBP (WMD: -2.16 mmHg, 95% CI: -3.66, -0.66, P = 0.005). It also increased SBP (WMD: 5.50 mmHg, 95% CI: 3.65, 7.35, P < 0.001); however, it was not associated with weight loss (WMD: -0.3 kg, 95% CI: -1.3, 0.71, P = 0.561). Our systematic review showed that UDCA consumption has no effect on IL-6 and TNF-α.

CONCLUSION

This systematic review and meta-analysis suggest that UDCA supplementation may improve BMI and DBP, whereas it may increase SBP and have no effect on weight or inflammation. Further long-term and well-designed RCTs are needed to further assess and confirm these results.

The Efficacy of a Combination of Milk Thistle, Artichoke, and Green Tea in the Treatment of Biliary Sludge: An Interventional Prospective Open Study

Background: In Western countries, 10–20% of adults have gallstones, of which about 1–3% of patients are symptomatic for biliary colic. The treatment with ursodeoxycholic acid is debated. Silymarin is emerging nowadays as a natural substance with choleretic and beneficial properties, useful in the case of gallbladder sludge. Aim: The aim of our study was to evaluate the efficacy of supplementation with a mix of natural compounds (milk thistle 150 mg, artichoke 150 mg, and green tea 150 mg) in patients affected by biliary sludge in reducing biliary colic and biliary sludge and improving lipid profiles after 3 months of treatment compared to a control group. Patients and Methods: This was an interventional open study on 65 consecutive adult patients (23 M/42 F; mean age 61.0 ± 18.7 years) affected by biliary sludge without indication for surgery, admitted to the Internal Medicine Department of San Carlo di Nancy Hospital Rome. Forty patients were treated with milk thistle 150 mg, artichoke 150 mg, and green tea 150 mg, 2 capsules/day for three months, and followed up for abdominal ultrasound, the frequency of occurrence of biliary colic, and blood tests. Twenty-five control group patients were followed up for abdominal ultrasound, the frequency of occurrence of biliary colic, and blood tests after 3 months. Results: In Group A, we observed a disappearance of biliary sludge in 32.4% (12/37) of patients compared to 8.7% in the control group (p < 0.05). In 32.4% of treated patients, we report a reduction in biliary sludge. There were no side effects during treatment. In both groups, we registered a significant reduction in transaminases and gamma-glutamyl transferase (γ-GT) (p < 0.05). No significant modification of the lipid profile was observed. Conclusions: The treatment with a mix of natural compounds (milk thistle, artichoke, and green tea) in patients affected by symptomatic biliary colic resulted in efficacy and safety in reducing biliary sludge, biliary colic, and transaminases levels after three months of treatment. The limitations of this study include a small number of patients and the absence of long-term follow up after the end of treatment.

Gallstones: Prevention, Diagnosis, and Treatment

Gallstones are common and affect up to 20% of the general adult population and >20% of them will develop symptoms or complications of cholelithiasis. The high risk of gallbladder stone formation can be reduced by ursodeoxycholic acid in the case of significant weight reduction resulting from diet or bariatric surgery. Laparoscopic cholecystectomy is indicated for symptomatic gallstones, as the risk of recurrence or complications increases over the course of the disease. Biliary colic is treated with nonsteroidal anti-inflammatory drugs and spasmolytics; opioids can also be used in cases of severe acute pain. Acute cholecystitis represents a common complication of gallbladder stones and a cholecystectomy should be performed early electively, i.e., within 24 hours of admission to hospital. Symptomatic bile duct stones are primarily treated endoscopically. Immediate anti-infective therapy is mandatory in acute cholangitis. Although knowledge on the genetics and pathophysiology of gallstones has increased, current treatment algorithms remain predominantly invasive, based on interventional endoscopy and surgery. Future efforts should focus on novel strategies to prevent the development of gallstones.

Gallstone Disease and Its Correlation With Thyroid Disorders: A Narrative Review

Over the years, several studies have revealed an important link between thyroid disorders and gallstone disease. According to these studies, hypothyroidism and hyperthyroidism are associated with cholesterol gallstone disease. This association between thyroid hormone disorders and cholesterol gallstone disease is due to the importance of thyroid hormones on cholesterol synthesis, bile functioning and content, and gallbladder motility. Several genes and receptors have been found on the thyroid gland, liver, and gallbladder to verify this association. These genes affect thyroid hormone secretion, lipid metabolism, and bile secretion. Defects in these various gene expression and protein functions lead to bile duct diseases. Other causes that lead to cholesterol gallstone disease are supersaturation of the bile with cholesterol and impaired gallbladder motility, which leads to bile stasis. This article has discussed these factors in detail while highlighting the association between thyroid hormones and cholesterol gallstone disease.

Prevention of Gallstones After Bariatric Surgery using Ursodeoxycholic Acid: A Narrative Review of Literatures

Obesity by itself is a factor in the development of gallstone disease, and periods of weight loss after bariatric surgery further increase the risk of gallstone formation. In patients with obesity, hypersecretion of cholesterol may increase the risk of gallstone formation, which is approximately five-fold higher than that in the general population. The incidence of gallstone formation after bariatric surgery is 10-38% and often associated with a proportional increase in the risk of developing biliary complications. Routine postoperative administration of ursodeoxycholic acid (UDCA) is recommended to prevent gallstone formation. Several randomized trials have indicated that UDCA can effectively prevent gallstones and reduce the risk of cholecystectomy after bariatric procedures. The effective daily dose of UDCA in each study ranged from 500 to 1,200 mg, and it may be considered at least during the period of rapid weight loss (first 3-6 months postoperatively) to decrease the incidence of symptomatic gallstones.

Management of biliary stones in bariatric surgery

Morbidly obese and post-bariatric surgery patients are at increased risk for biliary stones formation. The complications related to biliary stones may impose complexity on their management. This study aimed to review the management of biliary conditions in obese and bariatric patients. In this study, a narrative review was performed of the medical, surgical, and endoscopic procedures for the management of biliary stones and their related complications. Knowing the main prophylactic and therapeutic interventions options is essential for clinicians to properly manage the biliary stones in patients candidates or submitted to bariatric surgery.

Incidence and risk factors for de novo cholelithiasis after bariatric surgery

INTRODUCTION

Obesity and rapid weight loss after bariatric surgery (BS) are risk factors for the development of cholelitiasis. The aim of this study is to know the incidence of the de novo symptomatic cholelitiasis (DNSC) after BS and to analyze the risk factors for its development.

METHODS

Single-centre retrospective observational study of patients undergoing BS between January 2010 and December 2017. The incidence of DNSC has been studied and sex, age, comorbilities, surgical tecnique, initial BMI and percentage of excess BMI lost (%EBMIL) at 6th, 12th and 24th postoperative months have been analyzed.

RESULTS

Among the 415 patients who underwent BS, 280 have been studied since they were not previously cholecystectomized and had a preoperative negative abdominal ultrasound. Twenty-nine developed DNSC (10,35%), with a remarkably higher increase in cumulative incidence during the first postoperative year (CI 5%, IC 95% 2,4-7,6). A higher percentage of excess BMI lost at the 6, 12 and 24 postoperative months was statistically significantly correlated with an increased risk of DNSC.

CONCLUSIONS

Incidence of DNSC and cholecystectomy after BS are relatively high, mainly during rapid weight loss period and even more the higher the percentage of excess BMI lost is. Concomitant cholecystectomy during BS in case of preoperative cholelithiasis regardless of symptoms and the use of ursodeoxycholic acid during the period of greater risk for DNSC development are two therapeutic options to consider.

Gallstone Formation Follows a Different Trajectory in Bariatric Patients Compared to Nonbariatric Patients

Since obese patients form cholesterol gallstones very rapidly after bariatric surgery, in patients who did not form gallstones during preceding years, we hypothesized that gallstone formation follows a different trajectory in bariatric patients compared to nonbariatric patients. We therefore analyzed the lipid composition of gallbladder bile derived from 18 bariatric gallstone patients and 17 nonbariatric gallstone patients (median (IQR) age, 46.0 (28.0-54.0) years; 33 (94%) female) during laparoscopic cholecystectomy using an enzymatic and lipidomics approach. We observed a higher concentration of total lipids (9.9 vs. 5.8 g/dL), bile acids (157.7 vs. 81.5 mM), cholesterol (10.6 vs. 5.4 mM), and phospholipids (30.4 vs. 21.8 mM) in bariatric gallstone patients compared to nonbariatric gallstone patients. The cholesterol saturation index did not significantly differ between the two groups. Lipidomics analysis revealed an interesting pattern. Enhanced amounts of a number of lipid species were found in the gallbladder bile of nonbariatric gallstone patients. Most striking was a fivefold higher amount of triglyceride. A concomitant ninefold increase of apolipoprotein B was found, suggesting secretion of triglyceride-rich lipoproteins (TRLs) at the canalicular pole of the hepatocyte in livers from nonbariatric gallstone patients. These findings suggest that gallstone formation follows a different trajectory in bariatric patients compared to nonbariatric patients. Impaired gallbladder emptying might explain the rapid gallstone formation after bariatric surgery, while biliary TRL secretion might contribute to gallstone formation in nonbariatric patients.

Excess Body Weight and Gallstone Disease

Background

Approximately one fifth of adults are diagnosed with gallstones worldwide. Of these, around 25% develop gallstone disease (indicated by the presence of symptoms) and undergo cholecystectomy.

Summary

The risk of gallstones is influenced by a combination of genetic and lifestyle factors, such as excess body weight. In fact, body mass has been demonstrated to be a major risk factor for symptomatic gallstones. Rapid weight loss can also initiate a prolithogenic state and further increase the likelihood of either gallstone formation or existing gallstones becoming symptomatic; however, sensible weight loss strategies can mitigate this risk. This review discusses the role of excess body weight and the risk of gallstone disease, as well as the options available for the prevention of symptomatic gallstones.

Key Messages

Healthy weight loss diets combined with regular physical activity can promote successful weight loss and weight maintenance and reduce the risk of gallstones. Should rapid weight loss be required for health reasons or be expected, e.g., after bariatric surgery, prophylactic ursodeoxycholic acid during the period of weight reduction has been demonstrated to reduce the incidence of gallstones formation or symptomatic gallstone occurrence. The recent German guidelines on gallstones recommend simultaneous cholecystectomy during bariatric surgery but only for those with preexisting symptomatic stones.

A rare complication of cholecystolithiasis: perforation of the gallbladder

Common complications of cholelithiasis include gallbladder inflammation, cholangitis, and acute pancreatitis. On the other hand, rare complications include gallbladder carcinoma, gallstone ileus, Mirizzi syndrome and gallbladder perforation. Some patients with cholecystitis do not require hospitalization. It is of key importance for proper further diagnosis and treatment to remember about the possible complications of cholecystitis, especially in oligosymptomatic patients. Therefore, ultrasound examinations in patients with a history of gallbladder stones should be performed with appropriate care. Ultrasound should be performed carefully in patients with a history of cholecystolithiasis, especially those oligosymptomatic, bearing in mind that there are some rare complications of this highly common clinical entity.

Statement on additional scientific evidence in relation to the essential composition of total diet replacement for weight control

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to revise the Opinion on the essential composition of total diet replacements for weight control (TDRs) regarding the minimum content of linoleic acid (LA) and alpha-linolenic acid (ALA) and the maximum content of magnesium (Mg). Through a comprehensive literature search, human studies were retrieved reporting on LA and ALA concentrations in adipose tissue (AT), on weight loss and gallstone formation following TDR consumption and on diarrhoea after supplemental Mg intake. The distribution of the amount of LA and ALA release from AT during weight loss when consuming TDRs was estimated using statistical simulations. Using the fifth percentile, the coverage of the adequate intake (AI) for both FA was estimated. For the risk of developing diarrhoea when consuming TDRs with an Mg content of 350 mg/day, four cross-over studies using 360-368 mg Mg/day were reviewed. The Panel concludes that (1) there is no need to add LA to TDRs, as the amount released from AT during weight loss when consuming TDRs is sufficient to cover the AI for LA; (2) a minimum of 0.8 g/day ALA is needed in TDRs in order to meet the AI for ALA; (3) the minimum fat content of TDRs of 20 g/day as derived in the Panel's previous opinion is proposed to be maintained until the availability of further evidence, given the considerable uncertainty as to the amount of fat required for reducing the risk of gallstone formation; and (4) the likelihood that Mg-induced diarrhoea occurs at a severity that may be considered of concern for overweight and obese individuals consuming TDRs is low when the total maximum Mg content in TDRs is 350 mg/day.

Incidence and risk factors for de novo cholelithiasis after bariatric surgery

INTRODUCTION

Obesity and rapid weight loss after bariatric surgery (BS) are risk factors for the development of cholelitiasis. The aim of this study is to know the incidence of the de novo symptomatic cholelitiasis (DNSC) after BS and to analyze the risk factors for its development.

METHODS

Single-centre retrospective observational study of patients undergoing BS between January 2010 and December 2017. The incidence of DNSC has been studied and sex, age, comorbilities, surgical tecnique, initial BMI and percentage of excess BMI lost (%EIMCP) at 6th, 12th and 24th postoperative months have been analyzed.

RESULTS

Among the 415 patients who underwent BS, 280 have been studied since they were not previously cholecystectomized and had a preoperative negative abdominal ultrasound. Twenty-nine developed DNSC (10.35%), with a remarkably higher increase in cumulative incidence during the first postoperative year (5%, 95% CI 2,4-7,6). A higher percentage of excess BMI lost at the 6, 12 and 24 postoperative months was statistically significantly correlated with an increased risk of DNSC.

CONCLUSIONS

Incidence of DNSC and cholecystectomy after BS are relatively high, mainly during rapid weight loss period and even more the higher the percentage of excess BMI lost is. Concomitant cholecystectomy during BS in case of preoperative cholelithiasis regardless of symptoms and the use of ursodeoxycholic acid during the period of greater risk for DNSC development are two therapeutic options to consider.

Gallstone formation due to rapid weight loss through hyperthyroidism

Background Cholesterol metabolism has dramatically changed under hyperthyroid status. However, a combination of hyperthyroidism and cholecystolithiasis is very rare. Case presentation We report a case of cholelithiasis accompanied by hyperthyroidism in a 13-year-old girl who had recently lost 13 kg of weight (from 53 to 40 kg) in 1 month without loss of appetite. Ultrasonography showed multiple hyperechoic areas with acoustic shadowing in the gallbladder. Thyroid function tests showed that her serum free triiodothyronine (T3) and thyroxine (T4) levels were elevated and the thyroid-stimulating hormone level was decreased. In addition, serum thyrotropin receptor antibody and thyroid-stimulating antibody were detected. The final diagnosis was cholelithiasis with Graves' disease. Thiamazole ingestion was started immediately after the diagnosis, and laparoscopic cholecystectomy was performed 33 days after hospitalization. Conclusions Massive and sudden weight loss could be a risk factor for gallstone formation in children. In addition, hyperthyroidism has the potential to promote cholelithiasis via cholesterol metabolism.

No common denominator: Plant-based diets and treatment-induced neuropathy of diabetes

Treatment-induced neuropathy of diabetes is a poorly understood and underestimated iatrogenic complication of aggressive glycemic control in individuals suffering from diabetes. Symptoms, including severe neuropathic pain and autonomic dysfunction, usually follow an abrupt improvement in glycemic control. The latter is usually triggered by pharmacotherapy, however, treatment-induced neuropathy of diabetes (TIND) has also been associated with severe dietary restriction. Dietary modifications are of paramount importance in the treatment of type 2 diabetes. Hereby, calorie restriction and fasting diets as well as plant-based diets enjoy uninterrupted popularity. While cases of TIND have been reported with (very) low calorie diets, a case of TIND in the context of a whole-food plant-based diet has not been published to the best of my knowledge. Is this a simple coincidence or is there potentially a reason behind it? The hypothesis presented in this paper is that whole-food plant-based diets and TIND do not share a common denominator. Both evidence in support and evidence against this, admittedly, speculative hypothesis, is presented in this manuscript. A special focus is put on HbA1c dynamics with plant-based diets and reduced medication needs.

The Role of Diet in the Pathogenesis of Cholesterol Gallstones

Cholesterol gallstone disease is a major health problem in Westernized countries and depends on a complex interplay between genetic factors, lifestyle and diet, acting on specific pathogenic mechanisms. Overweigh, obesity, dyslipidemia, insulin resistance and altered cholesterol homeostasis have been linked to increased gallstone occurrence, and several studies point to a number of specific nutrients as risk- or protective factors with respect to gallstone formation in humans. There is a rising interest in the identification of common and modifiable dietetic factors that put the patients at risk of gallstones or that are able to prevent gallstone formation and growth. In particular, dietary models characterized by increased energy intake with highly refined sugars and sweet foods, high fructose intake, low fiber contents, high fat, consumption of fast food and low vitamin C intake increase the risk of gallstone formation. On the other hand, high intake of monounsaturated fats and fiber, olive oil and fish (ω-3 fatty acids) consumption, vegetable protein intake, fruit, coffee, moderate alcohol consumption and vitamin C supplementation exert a protective role. The effect of some confounding factors (e.g., physical activity) cannot be ruled out, but general recommendations about the multiple beneficial effects of diet on cholesterol gallstones must be kept in mind, in particular in groups at high risk of gallstone formation.

Similarities and differences between biliary sludge and microlithiasis: Their clinical and pathophysiological significances

The terms biliary sludge and cholesterol microlithiasis (hereafter referred to as microlithiasis) were originated from different diagnostic techniques and may represent different stages of cholesterol gallstone disease. Although the pathogenesis of biliary sludge and microlithiasis may be similar, microlithiasis could be preceded by biliary sludge, followed by persistent precipitation and aggregation of solid cholesterol crystals, and eventually, gallstone formation. Many clinical conditions are clearly associated with the formation of biliary sludge and microlithiasis, including total parenteral nutrition, rapid weight loss, pregnancy, organ transplantation, administration of certain medications, and a variety of acute and chronic illnesses. Numerous studies have demonstrated complete resolution of biliary sludge in approximately 40% of patients, a cyclic pattern of disappearing and reappearing in about 40%, and progression to gallstones in nearly 20%. Although only a minority of patients with ultrasonographic demonstration of biliary sludge develop gallstones, it is still a matter of controversy whether microlithiasis could eventually evolve to cholesterol gallstones. Biliary sludge and microlithiasis are asymptomatic in the vast majority of patients; however, they can cause biliary colic, acute cholecystitis, and acute pancreatitis. Biliary sludge and microlithiasis are most often diagnosed ultrasonographically and bile microscopy is considered the gold standard for their diagnosis. Specific measures to prevent the development of biliary sludge are not practical or cost-effective in the general population. Laparoscopic cholecystectomy offers the most definitive therapy on biliary sludge. Endoscopic sphincterotomy or surgical intervention is effective for microlithiasis-induced pancreatitis. Ursodeoxycholic acid can effectively prevent the recurrence of solid cholesterol crystals and significantly reduce the risk of recurrent pancreatitis.

Incidence and Treatment of Bile Stones After Liver Transplant

OBJECTIVES

Although the incidence of bile stones after liver transplant is rare (2%-6%), various complications can occur, including recurrent cholangitis, biliary strictures, graft loss, and patient mortality.

MATERIALS AND METHODS

We retrospectively evaluated bile stone incidence, pathogenesis, and treatment in 352 liver transplant recipients, comparing demographics, transplant indication, blood lipid profile, bile reconstruction technique, postoperative complications, time of diagnosis, and treatment regimens.

RESULTS

Of 352 recipients, 18 had bile stones, with 13 of these patients (72.2%) receiving duct-to-duct bile reconstruction, 17 having biliary complications before bile stone development, 7 (38.9%) having biliary stricture, 6 (33.3%) having biliary leakage, 4 (22.2%) having biliary strictures secondary to biliary leakage, and 7 (38.9%) having hepatic artery complications early posttransplant. Previous biliary complications and recurrent cholangitis significantly increased bile stones. Incidence in patients with triglyceride levels > 250 mg/dL was significantly different from those with levels at < 250 mg/dL. Cold ischemia time was significant in those with and without bile stones (P = .001). Three patients (16%) were treated by endoscopic tools, with others (15/18, 84%) treated via percutaneous procedures.

CONCLUSIONS

Bile stone risk can be greater in those with previous biliary complications, hepatic artery problems, long cold ischemia time, and high cholesterol levels. It can be successfully treated by endoscopic and percutaneous techniques.

Role of the gastroenterologist in the management of the obese patient

Obesity is a highly prevalent disease worldwide, and one in which gastroenterologists can play an important role. Some digestive diseases are more common in obese patients, and preoperative evaluation may be required in some cases. Additionally, bariatric surgery can lead to digestive complications in the short and long term that require intervention, and endoscopic treatment can be an important factor in weight loss. The aim of this review is to highlight the role of the gastroenterologist in the management of obese patients who are either scheduled for or have undergone surgical or endoscopic treatment for obesity.

Medical management of obesity: a comprehensive review

Obesity has reached epidemic proportions, accounting for increased morbidity, disability, health care expenditures, and mortality. Certain metabolic and comorbid conditions disproportionately affect women. Unfortunately, nonsurgical options for treatment are limited. Knowledge accrued over the past 2 decades regarding physiological and hormonal determinants of weight regulation has contributed to growing evidence regarding efficacious behavioral, dietary, and pharmacologic treatments. In this review, the biology of excess adiposity is summarized in the context of a shifting paradigm, approaching obesity as a chronic metabolic disease. Relevant updates are discussed regarding long-term lifestyle approaches and novel drug therapies, with attention to some issues specific to women.

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.

Obesity and the risk and prognosis of gallstone disease and pancreatitis

Obesity is a risk factor for the formation of cholesterol gallstones and exposes patients to increased risk of gallstone-related complications and cholecystectomy. Rapid weight loss achieved by very low calorie diets or bariatric surgery is also a risk factor for cholelithiasis in obese patients, and therapy should take into account the higher prevalence of gallstones, the possibility of more frequent complications and the need for prophylactic treatment with oral ursodeoxycholic acid during weight loss. Obesity is also frequent in children and adolescents, and the burden of cholesterol cholelithiasis is increasing in this population. The chance to develop acute pancreatitis and the severity of the disease are higher in obese subjects because of specific pathogenic factors, including supersaturated bile and crystal formation, rapid weight loss, and visceral obesity. All health policies aimed at reducing the incidence of obesity worldwide will decrease the incidence of gallstones and gallstone-related complications. The pathophysiological scenarios and the therapeutic implications for obesity, gallstone disease, and pancreatitis are discussed.

Ursodeoxycholic acid and diets higher in fat prevent gallbladder stones during weight loss: a meta-analysis of randomized controlled trials

BACKGROUND & AIMS

The prevalence of gallstones is increasing in association with the obesity epidemic, but rapid weight loss also increases the risk of stone formation. We conducted a systematic review of the efficacy of strategies to prevent gallbladder stones in adults as they lose weight.

METHODS

Randomized controlled trials of nonsurgical strategies to prevent gallstones were identified by electronic and manual searches. Our final analysis included 13 trials, comprising 1836 participants undergoing weight loss through dieting (8 trials) or bariatric surgery (5 trials). The trials compared ursodeoxycholic acid (UDCA) or high-fat weight loss diets with control interventions. We performed random-effects meta-analyses and evaluated heterogeneity and bias with subgroup, sensitivity, regression, and sequential analysis.

RESULTS

UDCA reduced the risk of ultrasound-verified gallstones compared with control interventions (risk ratio, 0.33; 95% confidence interval [CI], 0.18-0.60; number needed to treat, 9). This effect was significantly larger in trials of diets alone (risk ratio, 0.17; 95% CI, 0.11-0.25) than in trials of patients who underwent bariatric surgery (risk ratio, 0.42; 95% CI, 0.21-0.83) (test for subgroup differences, P =.03). UDCA reduced the risk of cholecystectomy for symptomatic stones (risk ratio, 0.20; 95% CI, 0.07-0.53). Diets high in fat content also reduced gallstones, compared with those with low fat content (risk ratio, 0.09; 95% CI, 0.01-0.61). The meta-analyses were confirmed in trials with a low risk of bias but not in sequential analysis. No additional beneficial or harmful outcomes were identified.

CONCLUSIONS

On the basis of a meta-analysis of randomized controlled trials, during weight loss, UDCA and/or higher dietary fat content appear to prevent formation of gallstones.

Risk of symptomatic gallstones and cholecystectomy after a very-low-calorie diet or low-calorie diet in a commercial weight loss program: 1-year matched cohort study

Background:

Concern exists regarding gallstones as an adverse event of very-low-calorie diets (VLCDs; <800 kcal per day).

Objective:

To assess the risk of symptomatic gallstones requiring hospital care and/or cholecystectomy in a commercial weight loss program using VLCD or low-calorie diet (LCD).

Design:

A 1-year matched cohort study of consecutively enrolled adults in a commercial weight loss program conducted at 28 Swedish centers between 2006 and 2009. A 3-month weight loss phase of VLCD (500 kcal per day) or LCD (1200–1500 kcal per day) was followed by a 9-month weight maintenance phase. Matching (1:1) was performed by age, sex, body mass index, waist circumference and gallstone history (n=3320:3320). Gallstone and cholecystectomy data were retrieved from the Swedish National Patient Register.

Results:

One-year weight loss was greater in the VLCD than in the LCD group (−11.1 versus −8.1 kg; adjusted difference, −2.8 kg, 95% CI −3.1 to −2.4; P<0.001). During 6361 person–years, 48 and 14 gallstones requiring hospital care occurred in the VLCD and LCD groups, respectively, (152 versus 44/10 000 person–years; hazard ratio, 3.4, 95% CI 1.8–6.3; P<0.001; number-needed-to-harm, 92, 95% CI 63–168; P<0.001). Of the 62 gallstone events, 38 (61%) resulted in cholecystectomy (29 versus 9; hazard ratio, 3.2, 95% CI 1.5–6.8; P=0.003; number-needed-to-harm, 151, 95% CI 94–377; P<0.001). Adjusting for 3-month weight loss attenuated the hazard ratios, but the risk remained higher with VLCD than LCD for gallstones (2.5, 95% CI 1.3–5.1; P=0.009) and became borderline for cholecystectomy (2.2, 95% CI 0.9–5.2; P=0.08).

Conclusion:

The risk of symptomatic gallstones requiring hospitalization or cholecystectomy, albeit low, was 3-fold greater with VLCD than LCD during the 1-year commercial weight loss program.

Endoscopic ultrasonography in patients with elevated carbohydrate antigen 19-9 of obscure origin

AIM: To evaluate the efficacy of endoscopic ultrasonography (EUS) in patients with elevated carbohydrate antigen (CA) 19-9 levels of obscure origin.

METHODS: Patients who had visited Pusan National University Hospital because of elevated serum CA 19-9 levels, between January 2007 and December 2009, were retrospectively enrolled. EUS had been performed on all subjects, in addition to routine blood tests, endoscopy, abdominal computed tomography (CT) and other clinical exams, which had not revealed any abnormal findings suggestive of the origin of the elevated CA 19-9 levels.

RESULTS: Of the 17 patients, gallbladder sludge was detected in 16 patients (94.1%) and common bile duct sludge was observed in 3 patients (17.6%). After the administration of ursodeoxycholic acid to 12 of the patients with gallbladder sludge, CA 19-9 levels normalized in 6 of the patients after a median of 4.5 mo.

CONCLUSION: EUS is a useful diagnostic method for patients with elevated CA 19-9 levels of obscure origin, even if the reason for abnormal levels of this serum marker cannot be determined through prior examinations, including abdominal CT.

Weight loss and dropout during a commercial weight-loss program including a very-low-calorie diet, a low-calorie diet, or restricted normal food: observational cohort study

BACKGROUND

The effectiveness of commercial weight-loss programs consisting of very-low-calorie diets (VLCDs) and low-calorie diets (LCDs) is unclear.

OBJECTIVE

The aim of the study was to quantify weight loss and dropout during a commercial weight-loss program in Sweden (Itrim; cost: $1300/€1000; all participants paid their own fee).

DESIGN

This observational cohort study linked commercial weight-loss data with National Health Care Registers. Weight loss was induced with a 500-kcal liquid-formula VLCD [n = 3773; BMI (in kg/m(2)): 34 ± 5 (mean ± SD); 80% women; 45 ± 12 y of age (mean ± SD)], a 1200-1500-kcal formula and food-combination LCD (n = 4588; BMI: 30 ± 4; 86% women; 50 ± 11 y of age), and a 1500-1800-kcal/d restricted normal-food diet (n = 676; BMI: 29 ± 5; 81% women; 51 ± 12 y of age). Maintenance strategies included exercise and a calorie-restricted diet. Weight loss was analyzed by using an intention-to-treat analysis (baseline substitution).

RESULTS

After 1 y, mean (±SD) weight changes were -11.4 ± 9.1 kg with the VLCD (18% dropout), -6.8 ± 6.4 kg with the LCD (23% dropout), and -5.1 ± 5.9 kg with the restricted normal-food diet (26% dropout). In an adjusted analysis, the VLCD group lost 2.8 kg (95% CI: 2.5, 3.2) and 3.8 kg (95% CI: 3.2, 4.5) more than did the LCD and restricted normal-food groups, respectively. A high baseline BMI and rapid initial weight loss were both independently associated with greater 1-y weight loss (P < 0.001). Younger age and low initial weight loss predicted an increased dropout rate (P < 0.001). Treatment of depression (OR: 1.4; 95% CI: 1.1, 1.9) and psychosis (OR: 2.6; 95% CI: 1.1, 6.3) were associated with an increased dropout rate in the VLCD group.

CONCLUSION

A commercial weight-loss program, particularly one using a VLCD, was effective at reducing body weight in self-selected, self-paying adults.

Gallstone disease: current therapeutic practice

Most asymptomatic gallstone carriers require no therapy. Laparoscopic cholecystectomy is the best definitive therapy for symptomatic gallstone disease. Selective laparoscopic cholecystectomy can provide secondary prevention of symptoms and complications in certain instances (in a complex clinical setting such as sickle cell disease or to prevent gallbladder carcinoma from developing in those at risk with large gallstones or with a calcified gallbladder). Primary prevention is unproven but focuses on early identification and risk alteration to decrease the possibility of developing gallstones. Ursodeoxycholic acid has a limited role for stone dissolution but can prevent stone development in severe obesity during rapid weight reduction with diet or after bariatric surgery. Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy represents the therapeutic cornerstone for managing severe pancreatitis and cholangitis.

Risk of biliary complications in bariatric surgery

Gallstones are commonly observed after rapid weight loss, particularly after bariatric surgery. Preventive measures of gallstone formation and potential related complications are still debated. This study aimed to propose a standardized strategy according to the results of the literature. Thus, preventive measures should be determined according to patient status (evaluated clinically and by routine ultrasound) and the type of bariatric surgery. Cholecystectomy should be performed in patients with symptomatic gallstones irrespective of the planned operation, or for asymptomatic gallstones during a gastric by-pass. In other settings, ursodesoxycholic acid should be given postoperatively for 6 months.

Hereditary liver disease: gallstones

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

Impact of food on hepatic clearance of patients after endoscopic sphincterotomy

BACKGROUND

The recurrence rate of common bile duct stones (CBDS) is around 3-21% after treatment by endoscopic sphincterotomy (ES). Fatty meal has been shown to improve hepatic clearance in both patients with intact gallbladder and post-cholecystectomy after ES. This study tested the effects of different kinds of food on hepatic clearance by using quantitative cholescintigraphy (QC) in patients after ES.

METHODS

Forty-seven patients after ES with abnormal QC were enrolled in our study. Complete ablation of sphincter function was confirmed by sphincter of Oddi manometry. Fasting QC was done in every patient shortly after normalization of liver function, and then followed with low-fat and fatty-meal QC. Each of the 47 subjects was observed for the effect on hepatic clearance at 3 different levels of treatments (diets and fasting). Additionally, possible factors responsible for recurrent CBDS were investigated by means of logistic regression.

RESULTS

Both fatty and low-fat meals could significantly improve hepatic clearance compared with fasting in most patients after ES. But the response to food types was individualized. All patients tolerated the meals well. There was no significant relationship between the recurrence of CBDS and sex, age, intact gallbladder and presence of juxtapapillary diverticulum, CBD size, and improvement in hepatic clearance (> or = 5%) by food.

CONCLUSION

Both fatty and low-fat meals improved hepatic clearance in most of the patients with CBDS after ES, but the response to meals was individualized. Therefore, there is no need to restrict the amount of fat intake for patients who have undergone ES.

Risk factors and outcomes in post-liver transplantation bile duct stones and casts: A case-control study

Bile duct stones and casts (BDS) after liver transplantation are associated with significant morbidity. Risk factors for BDS formation and the efficacy of treatment in liver transplant recipients have not been systematically studied. The aim of this study was to evaluate potential risk factors for the formation of BDS in patients post-liver transplant. A case-control study of consecutive liver transplant recipients at a university hospital from 1989 to 2007 was performed to identify risk factors for BDS formation. Cases included all liver transplant recipients with BDS, excluding those with concurrent t-tubes or biliary stents. Controls were chosen randomly from the total liver transplant population matched for year of transplantation. Pre- and post-OLT risk factors were analyzed with univariate and multivariate analyses. There were 49 cases and 101 controls over an 18-year-period (1289 liver transplants performed) with an incidence of 3.8% for BDS. In the cases, the median time to BDS diagnosis was 613 days from time of transplant. The controls had a median follow-up of 1530 days. Use of ursodeoxycholic acid was protective (P = 0.005), whereas bile duct pathology (P = 0.003), total cholesterol >/= 200 mg/dL (P = 0.008), and triglyceride >/= 150 mg/dL (P = 0.008) were significant risk factors for BDS formation. Endoscopic retrograde cholangiopancreatography (ERCP) was technically successful in all cases with resolution or improvement of liver chemistries in 59% (29) of patients. In conclusion, significant risk factors for forming BDS included bile duct pathology and elevated total cholesterol and triglyceride levels. Ursodeoxycholic acid had a significant effect in preventing the development of posttransplant BDS and should be used in those that are at increased risk. ERCP is a safe and effective diagnostic and therapeutic modality for these patients.

Almost routine prophylactic cholecystectomy during laparoscopic gastric bypass is safe

BACKGROUND

Morbidly obese patients are at high risk to develop gallstones, and rapid weight loss after bariatric surgery further enhances this risk. The concept of prophylactic cholecystectomy during gastric bypass has been challenged recently because the risk may be lower than reported earlier and because cholecystectomy during laparoscopic gastric bypass may be more difficult and risky.

METHODS

A review of prospectively collected data on 772 patients who underwent laparoscopic primary gastric bypass between January 2000 and August 2007 was performed. The charts of patients operated before 2004 were retrospectively reviewed regarding preoperative echography and histopathological findings.

RESULTS

Fifty-eight (7.5%) patients had had previous cholecystectomy. In the remaining patients, echography showed gallstones or sludge in 81 (11.3%). Cholecystectomy was performed at the time of gastric bypass in 665 patients (91.7%). Gallstones were found intraoperatively in 25 patients (3.9%), for a total prevalence of gallstones of 21.2%. The age of patients with gallstones was higher than that of gallstone-free patients (43.5 vs 38.7 years, p<0.0001). Of the removed specimens, 81.8% showed abnormal histologic findings, mainly chronic cholecystitis and cholesterolosis. Cholecystectomy was associated with no procedure-related complication, prolonged duration of surgery by a mean of 19 min (4-45), and had no effect on the duration of hospital stay. Cholecystectomy was deemed too risky in 59 patients (8.3%) who were prescribed a 6-month course of ursodeoxycolic acid.

CONCLUSION

Concomitant cholecystectomy can be performed safely in most patients during laparoscopic gastric bypass and does not prolong hospital stay. As such, it is an acceptable form of prophylaxis against stones forming during rapid weight loss. Whether it is superior to chemical prophylaxis remains to be demonstrated in a large prospective randomized study.

Combined endoscopic and ursodeoxycholic acid treatment of biliary cast syndrome in a non-transplant patient

A 76-year-old diabetic man underwent cholecystectomy for gangrenous calculous cholecystitis. His postoperative course was complicated by the development of Candida albicans esophagitis necessitating antifungal therapy, and total parenteral nutrition (TPN) for 15 d. Seven weeks after cholecystectomy, he presented with cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated extrahepatic filling defects. Despite endoscopic extraction of a biliary cast, cholestasis remained unchanged. Oral administration of ursodeoxycholic acid (UDCA), 750 mg/d, resulted in normalization of liver function tests. We, therefore, propose for the first time, combined endoscopic plus UDCA treatment for the management of biliary cast syndrome.

Ursodeoxycholic acid in the prevention of gallstone formation after bariatric surgery: a meta-analysis

BACKGROUND

Rapid weight loss increases risk for gallstone formation. Prophylactic cholecystectomy is difficult. Several small trials have shown that ursodeoxycholic acid (UDCA) may prevent gallstone formation after bariatric surgery. The aim of this study is to assess the efficacy and safety of UDCA in the prevention of gallstone formation after bariatric surgery.

METHODS

Electronic databases, including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Australasian Medical Index, LILACS, and HERDIN, were searched. Reference lists of trials selected by the above electronic searching were also searched. Authors of the retrieved trials and pharmaceutical companies were also contacted for other trials, published and unpublished. A meta-analysis of all randomized, double-blind, placebo-controlled prospective trials comparing UDCA and placebo was performed.

RESULTS

Five RCTs including 521 patients were assessed. Random effects meta-analysis showed a significant reduction of gallstone formation (RR 0.43, 95% confidence interval 0.22-0.83), with 8.8% of those taking UDCA developing gallstones compared to 27.7% for placebo. Although this meta-analysis is heterogeneous with I(2) of 61.9%, the directions of the effect are all consistently in favor of UDCA (p=0.01). A meta-analysis on the adverse effects could not be performed because the studies did not report them in a way to make the analysis possible.

CONCLUSIONS

UDCA can prevent gallstone formation after bariatric surgery.

Is routine cholecystectomy indicated for asymptomatic cholelithiasis in patients undergoing gastric bypass?

BACKGROUND

The purpose of this study was to evaluate the natural history of patients undergoing Roux-en-Y gastric bypass (RYGBP) with known asymptomatic cholelithiasis in whom prophylactic cholecystectomy was not performed at the time of surgery.

METHODS

The records of 144 consecutive patients from a single year experience in RYGBP surgery at the University of California, Davis Medical Center were reviewed. Patients undergoing RYGBP were routinely screened for cholelithiasis by ultrasound. Patients who did not have cholecystectomy were managed with ursodiol for 6 months postoperatively.

RESULTS

13 males (9.0%) and 131 females (91%) underwent RYGBP. The mean age was 43 years (SD 8.55), and mean BMI was 46 kg/m2 (SD 6.5). The comorbidities of our patient population included diabetes (14%), hypertension (48%), gastroesophageal reflux disease (50%), dyslipidemia (35%), obstructive sleep apnea (31%), and musculoskeletal complaints (69%). 22 patients were diagnosed with cholelithiasis by ultrasonography preoperatively. 9 of these patients (41%) were symptomatic and underwent concurrent cholecystectomy and RYGBP. The remaining 13 patients (59%) had asymptomatic cholelithiasis preoperatively but did not undergo cholecystectomy at the time of surgery. Only one of these asymptomatic patients eventually developed symptoms necessitating cholecystectomy at up to 1 year follow-up.

CONCLUSIONS

Our data suggest that it may not be absolutely indicated to perform prophylactic cholecystectomy at the time of RYGBP surgery for asymptomatic cholelithiasis. We believe that this phenomenon needs to be further studied in a randomized trial.

Obesity management

Because obesity is associated with an increased risk of multiple health problems, it is important for gastroenterologists and all health care providers routinely to identify, evaluate, and treat patients for obesity in the course of daily practice. Therapy for obesity always begins with lifestyle management and may include pharmacotherapy or surgery. Setting an initial weight loss goal of 10% over 6 months is a realistic target, followed by long-term management.

Gallbladder Management during Laparoscopic Roux-en-Y Gastric Bypass Surgery: Routine Preoperative Screening for Gallstones and Postoperative Prophylactic Medical Treatment are Not Necessary

In the bariatric surgery literature, the optimum approach to the gallbladder is controversial. Recommendations range from concomitant cholecystectomy to selective screening and postoperative medical prophylaxis. At our institution, we have taken a highly selective approach where patients are not routinely screened for gallstones, nor are they medically treated postoperatively with bile salts. We have reviewed our experience with this approach. From January 2003 to January 2005, 407 laparoscopic Roux en Y gastric bypasses were performed at UCLA and postoperative outcomes were collected into a prospective database. Exclusion criteria included previous cholecystectomy, a follow-up period less than 6 months, or incomplete records. One hundred ninety-nine patients were included in the study. With a mean follow up period of 17.8 months, 12 (6%) patients required cholecystectomy for gallstone-induced pathology. Laparoscopic removal was performed in 11 (92%) patients. Indications for surgery included acute cholecystitis in five (2.5%) patients, gallstone pancreatitis in two (1%) patients, and biliary colic alone in another five (2.5%) patients. The incidence of symptomatic gallstones requiring cholecystectomy after laparoscopic Roux en Y gastric bypass is low. These results are similar to those from institutions where routine preoperative screening and prophylactic postoperative medical therapy is used. Routine preoperative screening or medical prophylaxis may not be necessary.

The evolution of very-low-calorie diets: an update and meta-analysis

OBJECTIVE

Very-low-calorie diets (VLCDs), providing <800 kcal/d, have been used since the 1970s to induce rapid weight loss. Previous reviews of the literature have disagreed concerning the relative efficacy of VLCDs vs. conventional low-calorie diets (LCDs) for achieving long-term weight loss.

RESEARCH METHODS AND PROCEDURES

We sought to update findings on the clinical use, safety, and efficacy of VLCDs and to perform a meta-analysis of randomized trials that compared the long-term efficacy of LCDs and VLCDs. Original research articles were retrieved by a Medline search and from prior reviews of VLCDs. Trials were included only if they were randomized comparisons of LCDs and VLCDs and included a follow-up assessment at least 1 year after maximum weight loss. Data were abstracted by both authors regarding: duration of VLCD, total length of treatment, attrition, short- and long-term weight loss, changes in weight-related comorbidities, and adverse effects.

RESULTS

Six randomized trials were found that met inclusion criteria. VLCDs, compared with LCDs, induced significantly greater short-term weight losses (16.1 +/- 1.6% vs. 9.7 +/- 2.4% of initial weight, respectively; p = 0.0001) but similar long-term losses (6.3 +/- 3.2% vs. 5.0 +/- 4.0%, respectively; p > 0.2). Attrition was similar with VLCD and LCD regimens.

DISCUSSION

VLCDs did not produce greater long-term weight losses than LCDs. In the United States, the use of liquid meal replacements as part of a 1000 to 1500 kcal/d diet may provide an effective and less expensive alternative to VLCDs. In Europe, VLCDs are used with less intensive medical supervision than in the United States, which reduces the cost of this approach.

Weight loss and long-term follow-up of severely obese individuals treated with an intense behavioral program

OBJECTIVE

To review weight loss and maintenance for severely obese individuals enrolled in intensive behavioral weight loss program using very-low or low-energy diets.

DESIGN

Chart review of consecutively treated patients between 1995 and 2002 seen at three weight loss centers.

SUBJECTS

One thousand five hundred and thirty one patients with severe obesity (>or=40 kg/m(2)) treated in three cities ('Study Group'). Of these, 1100 completed the 12-week core curriculum ('Completer Group'). Weight loss >or=100 lbs (>45 kg) was seen in 268 patients ('100-Pound Group').

MEASUREMENTS

Charts were reviewed for baseline characteristics, weekly weights, follow-up weights and side effects.

RESULTS

In the Study Group, average weight loss+/-s.e. for 998 women was 23.9+/-0.6 kg (18.5% of initial body weight (IBW)) and for 533 men was 36.0+/-1.0 kg (22.5%) over 30 weeks. For Completers, average weight loss for women was 30.8+/-0.6 kg (23.9%) and for men was 42.6+/-1.1 kg (26.7%) over 39 weeks. In the 100-Pound Group, average weight loss for women was 58.2+/-1.2 kg (41.5%) in 65 weeks and for men was 65.7+/-1.5 kg (37.5%) in 51 weeks. Side effects, assessed in 100 patients losing >45 kg, were mild to moderate in severity. Severe adverse events unrelated to the diet were noted in 5% of patients and during weight loss 1% had elective cholecystectomies. Follow-up weights were available for 86% of Completers at an average of 72 weeks with average maintenance of 23 kg or 59% of weight loss; follow-up weights were available for 94% of the 100-Pound Group at an average of 95 weeks with average maintenance of 41 kg or 65% of weight loss maintained.

CONCLUSIONS

Intensive behavioral treatment with meal replacements is a safe and effective weight-loss strategy for selected severely obese individuals.

Gallstone disease: Microlithiasis and sludge

'Sludge' is the solid material which results from the slow settling of particles dispersed in a liquid medium. Biliary sludge in the gallbladder can be detected by transabdominal ultrasonography, and the typical echoes derive mainly from pigment precipitates mixed with cholesterol crystals. A portion of biliary sludge contains comparatively large particles (1-3 mm) called microliths, the formation of which is an obligatory intermediate step in the development of all types of gallstone. Microlithiasis and sludge in bile may cause colicky pain, cholecystitis, cholangitis, and acute pancreatitis, and are thus of clinical relevance. In these patients treatment follows the guidelines of symptomatic gallstone disease, and strategies include long-term application of ursodeoxycholic acid, endoscopic papillotomy, or preferably laparoscopic cholecystectomy.

Gallstone disease: Primary and secondary prevention

Several risk factors for cholesterol gallstone formation in the general population have been identified. There is a strongly increased risk of gallstone disease during prolonged fasting, rapid weight loss, total parenteral nutrition, and somatostatin(-analogue) treatment. The annual risk of biliary colic and gallstone complications in asymptomatic gallstone carriers has been investigated sparsely. In asymptomatic and symptomatic gallstone carriers, treatment with the hydrophilic bile salt ursodeoxycholic acid (UDCA) has been claimed to reduce the risk of biliary colic and gallstone complications such as acute cholecystitis and acute pancreatitis. Also, prophylactic cholecystectomy could be beneficial in certain subgroups of asymptomatic gallstone carriers. However, randomized, double-blind, placebo-controlled trials are lacking. In this review, strategies for the prevention of gallstone formation in the general population and in high-risk conditions are dealt with. Also, strategies for the prevention of biliary colic and gallstone complications in asymptomatic and symptomatic gallstone carriers are discussed.