Hepatobiliary Complications of Chronic Intestinal Failure

Intestinal failure-associated liver disease is a multifactorial process that may occur in patients with chronic intestinal failure on long-term home parenteral nutrition. A very short gut, the lack of enteral feeding, recurrent sepsis, and parenteral overfeeding are major risk factors. Histologic changes include steatosis, steatohepatitis, cholestasis, fibrosis, and cirrhosis. Chronic cholestasis is common, but does not always progress to fibrosis and/or cirrhosis. Preventing harmful factors may dramatically decrease the risk of intestinal failure-associated liver disease. Advanced liver disease is an indication for intestinal and/or multivisceral transplantation. Biliary stone formation is frequent and mainly due to a lack of enteral feeding.

[Nutritional intervention in the control of gallstones and renal lithiasis]

INTRODUCTION

Cholelithiasis and kidney stones are frequent pathologies in developed countries. Gallstones can be pigmentary, cholesterol (75%) or mixed. Age, female sex, obesity, rapid weight loss, consumption of refined sugars, saturated fat, iron deficiency, vitamin D and low intake of fiber and vitamin C are factors associated with an increased risk of cholelithiasis. On the other hand, the intake of ω-3 fatty acids, oleic acid, calcium, magnesium, fiber, fruits and vegetables, dairy products, nuts, coffee, moderate consumption of alcohol, vitamin C supplements, physical exercise and a regular diet have a protective paper. The most frequent kidney stones are calcium oxalate followed by mixed ones (oxalate and calcium phosphate), struvite, uric acid and cystine. A high water intake is recommended (> 2.5 l / day), varying the type of recommended or unadvisable food depending on the type of calculus. In oxalic lithiasis it is recommended to reduce the consumption of meat, moderate that of spinach, Swiss chard, asparagus, chocolate and avoid excessive sodium intake. The administration of oxalate-degrading probiotics (Lactobacillus) may reduce intestinal absorption, although further studies are necessary to corroborate these results. In calcium phosphate acidifying diet is recommended and limit the consumption of coffee and tea. The prevention of uric calculus is based on hydration with alkalizing drinks and vegetarian diet, decreasing foods rich in purines (liver, kidney, fish eggs, anchovies, sardines and seafood) and in calculus of cystine diet is recommended alkalizing. Since the formation of struvite calculi is due to urinary infections, pharmacological treatment and the consumption of acidifying diets, moderation of the intake of phosphate-rich foods and limiting the contribution of fats and citrus fruits are necessary. The nutritional intervention is an effective measure in the prevention of biliary and renal lithiasis and prevent its recurrence.

Cholesterol cholelithiasis: part of a systemic metabolic disease, prone to primary prevention

Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones.

Exercising the hepatobiliary-gut axis. The impact of physical activity performance

BACKGROUND

Physical inactivity puts the populations at risk of several health problems, while regular physical activity brings beneficial effects on cardiovascular disease, mortality and other health outcomes, including obesity, glycaemic control and insulin resistance. The hepatobiliary tract is greatly involved in several metabolic aspects which include digestion and absorption of nutrients in concert with intestinal motility, bile acid secretion and flow across the enterohepatic circulation and intestinal microbiota. Several metabolic abnormalities, including nonalcoholic fatty liver as well as cholesterol cholelithiasis, represent two conditions explained by changes of the aforementioned pathways.

MATERIALS AND METHODS

This review defines different training modalities and discusses the effects of physical activity in two metabolic disorders, that is nonalcoholic fatty liver disease (NAFLD) and cholelithiasis. Emphasis is given to pathogenic mechanisms involving intestinal bile acids, microbiota and inflammatory status.

RESULTS

A full definition of physical activity includes the knowledge of aerobic and endurance exercise, metabolic equivalent tasks, duration, frequency and intensity, beneficial and harmful effects. Physical activity influences the hepatobiliary-gut axis at different levels and brings benefits to fat distribution, liver fat and gallbladder disease while interacting with bile acids as signalling molecules, intestinal microbiota and inflammatory changes in the body.

CONCLUSIONS

Several beneficial effects of physical activity are anticipated on metabolic disorders linking liver steatosis, gallstone disease, gut motility, enterohepatic circulation of signalling bile acids in relation to intestinal microbiota and inflammatory changes.

Recent advances in understanding and managing cholesterol gallstones

The high prevalence of cholesterol gallstones, the availability of new information about pathogenesis, and the relevant health costs due to the management of cholelithiasis in both children and adults contribute to a growing interest in this disease. From an epidemiologic point of view, the risk of gallstones has been associated with higher risk of incident ischemic heart disease, total mortality, and disease-specific mortality (including cancer) independently from the presence of traditional risk factors such as body weight, lifestyle, diabetes, and dyslipidemia. This evidence points to the existence of complex pathogenic pathways linking the occurrence of gallstones to altered systemic homeostasis involving multiple organs and dynamics. In fact, the formation of gallstones is secondary to local factors strictly dependent on the gallbladder (that is, impaired smooth muscle function, wall inflammation, and intraluminal mucin accumulation) and bile (that is, supersaturation in cholesterol and precipitation of solid crystals) but also to "extra-gallbladder" features such as gene polymorphism, epigenetic factors, expression and activity of nuclear receptors, hormonal factors (in particular, insulin resistance), multi-level alterations in cholesterol metabolism, altered intestinal motility, and variations in gut microbiota. Of note, the majority of these factors are potentially manageable. Thus, cholelithiasis appears as the expression of systemic unbalances that, besides the classic therapeutic approaches to patients with clinical evidence of symptomatic disease or complications (surgery and, in a small subgroup of subjects, oral litholysis with bile acids), could be managed with tools oriented to primary prevention (changes in diet and lifestyle and pharmacologic prevention in subgroups at high risk), and there could be relevant implications in reducing both prevalence and health costs.

Practice Patterns for Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography for Patients With Choledocholithiasis

BACKGROUND & AIMS

Cholecystectomy (CCY) after an episode of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction reduces recurrent biliary events compared to expectant management. We studied practice patterns for performance of CCY after ERCP for choledocholithiasis using data from 3 large states and evaluated the effects of delaying CCY.

METHODS

We conducted a retrospective cohort study using the ambulatory surgery, inpatient, and emergency department databases from the states of California (years 2009-2011), New York (2011-2013), and Florida (2012-2014). We collected data from 4516 patients hospitalized with choledocholithiasis who underwent ERCP. We compared outcomes of patients who underwent CCY at index admission (early CCY), elective CCY within 60 days of discharge (delayed CCY), or did not undergo CCY (no CCY), calculating rate of recurrent biliary events (defined as an emergency department visit or unplanned hospitalization due to symptomatic cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis), mortality, and cost by CCY cohort. We also evaluated risk factors for not undergoing CCY. The primary outcome measure was the rate of recurrent biliary events in the 365 days after discharge from index admission.

RESULTS

Of the patients who underwent ERCP for choledocholithiasis, 41.2% underwent early CCY, 10.9% underwent delayed CCY, and 48.0% underwent no CCY. Early CCY reduced relative risk of recurrent biliary events within 60 days by 92%, compared with delayed or no CCY (P < .001). After 60 days following discharge from index admission, patients with early CCY had an 87% lower risk of recurrent biliary events than patients with no CCY (P < .001) and patients with delayed CCY had an 88% lower risk of recurrent biliary events than patients with no CCY (P < .001). A strategy of delayed CCY performed on an outpatient basis was least costly. Performance of early CCY was inversely associated with low facility volume. Hispanic race, Asian race, Medicaid insurance, and no insurance associated inversely with performance of delayed CCY.

CONCLUSIONS

In a retrospective analysis of >4500 patients hospitalized with choledocholithiasis, we found that CCY was not performed after ERCP for almost half of the cases. Although early and delayed CCY equally reduce the risk of subsequent recurrent biliary events, patients are at 10-fold higher risk of recurrent biliary event while waiting for a delayed CCY compared with patients who underwent early CCY. Delayed CCY is a cost-effective strategy that must be balanced against the risk of loss to follow-up, particularly among patients who are ethnic minorities or have little or no health insurance.

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 diseases of digestive organs]

Obesity is non-infectious pandemic. Its association with cardiovascular pathology is especially widely discussed, but an overweight patient is actually polymorbid. An increase of body mass provides a pathogenetic basis for many diseases including those of digestive system This review deals with pathogenesis, clinical features, and treatment of gastroesophageal reflux disease, cholelithiasis and non-alcoholic fatty liver disease in obese patients. This pathology and its aggravation result from such pathophysiological processes as a rise in intra-abdominal pressure, excess adipokine, cholesterol and free fatty acid synthesis, activation of lipid peroxidation. Gastroesophageal reflux disease in obese patients has an atypical clinical course characterized by discrepancy between clinical, endoscopic and morphological features in oesophagus and frequent formation of Barrett's oesophagus. Cholelethiasis in obesity is fraught with further progress of the disease after prescription of low-fat diet. The risk of calculi formation can be reduced by prescription of ursodeoxycholic acid that produces both litholytic and hypolipidemic effects. Treatment of non-alcoholic fatty liver disease requires combined therapy with statins, insulin sensitizers, hepatoprotectors and adequate physical activity. Sustained remission of diseases of digestive organs is impossible without correction of body mass and their pharmacotherapy requires increasing doses of medicines and duration of their administration.

[Gallstone disease post-radical gastrectomy for gastric adenocarcinoma at the National Institute of Neoplastic Diseases, January 1990 to December 2000]

SUBJECT

To determinate the frecuency and the time of development of the gallbladder stones in gastrectomy post-operated patients with stomach adenocarcinoma at The National Cancer Institute in Lima, Peru.

METHODS

In an observational, descriptive and retrospective case series design, 148 patiens' files who underwent gastrectomy for stomach adenocarcinoma in the National Cancer Institue of Lima during 1990 and 2000, have been reviewed looking for the development of gallbladder stones.

RESULTS

A total de 148 patients were involved in this study. 29 of them (19.6%) develop gallbladder stones during the (x years of) follow up vs 119 (80.9%) . The mean age ot the 29 patients with gallbladder stones were 59.9 years ans 18 of them were female and 11 male.\The mean time of develop gallbladder stones was 3.1 years.According to the type of surgery, 14 patient wiht gallbladder stones underwent to subtotal gastrectomy and 15 to total gastrectomy.

CONCLUSIONS

The frecuency of gallbladder stones post gastrectomy in this study was 19.6%. The mean time of the develop and diagnosis of litiasis was 3.1 years.To perform the colecistectomy at the same time of the gastrectomy could be an important decision in patients with high risk of gallstones and gallbladder cancer.We need furthermore studies to have conclusions about the risk factors.

[Medico-statistical characteristics of the cholelithiasis in the Udmurt Republic]

THE AIM OF OUR INVESTIGATION: siuay me level or moroiaity or cnolelimiasis and its dynamic in adult and children population of Udmurt Republic.

MATERIALS AND METHODS

We used the materials of state statistic registration documentation. We took into account the average population of Udmurt Republic, data of cholrlithiasis morbidity and the quantity of registrated cases of disease. To reveal tendency of cholelithiasis morbidity we spent the regressive analysis with using of trend models.

THE RESULTS

We found that during analyzing period (2005-2009) common morbidity of cholelithiasis in Udmurt Republic exceeds the same data in Russian Federation. Morbidity of adult urban population is significantly higher than in rural population. The cholelithiasis morbidity increases at the age of 41-60 years. In children population we marked significant raising of primary cholelithiasis morbidity. CONCLUSION. It was revealed that cholelithiasis morbidity in Udmurt Republic remains high. Due to this information we have possibility to determine medical and prophylactic measures.

[Possibilities of using of crystal-optic qualities of bile in early diagnostic stage of cholelithiasis]

The aim of our investigation was to study the changes of bile morphology and possibilities of its using in early diagnostic stage of cholelithiasis. We spent the complex investigation of biochemical and crystal-optic qualities of bile in 207 patients with cholelithiasis stage I with different disease duration. The revealed crystal-optic morphotypes have selective morphology due to the bile lithogene level that allows to determine the disease duration and the bile instability to make in-time adequate profilactic.

[Point system in diagnostics of the gallbladder cholesterosis]

THE PURPOSE OF THE STUDY

Development of scoring systems of diagnostics of gallbladder cholesterolosis (GBC) on the grounds of clinical and laboratory-instrumental parameters determined in the general clinical practice.

MATERIAL AND METHODS

For development of the scoring systems, the methods of the logistic regression (LR) and artificial neuron networks (ANN) were used. The results of specially carried clinical observations of 124 patients, who had cholelithiasis with morphological confirmation of presence of GBC or chronic cholecystitis after planned cholecystectomy, were analysed.

THE RESULTS

The scoring systems of diagnostics of GBC have been created: the detailed scring system, subjected to 24 parameters (12 quantitative ones; 12 qualitative ones) and the diminished scring system subjected to 6 the most informative parameters (3 clinical ones, 3 ultrasonic signs). Using the detailed scoring system of diagnostics of GBC allowed to set a correct diagnosis in 83,8% cases, specificity of the method was 91.80%, sensitiveness--92.11%. Diminished scoring system provides the correct diagnostics of GBC in 68% cases, the model specificity--63.41%, sensitiveness--63.77%.

THE CONCLUSION

Using LR and ANN allowed to evaluate the influence of individual clinical and laboratory-instrumental parameters on probability of the GBC diagnosis. Developed scoring systems open new possibilities of the early diagnosing of this disease that enables to conduct the identical medication treatment in proper time, cut off clinical presentations and prevent the development of cholelithiasis.

[Effect of praziquantel and ursodeoxycholic acid therapy on bile lithogenicity in patients with opisthorchosis on the background of main variant of standard diet]

A total of 56 patients were examined. It is revealed that there is a significant increase of concentration of indirect bilirubin, cholesterol, albumins in cystic bile after monotherapy with praziquantel as compared to healthy persons. It is evidence of high bile lithogenicity, defined lower result of lithogenesis resolution after ongoing therapy (29%). Inclusion of ursodeoxycholic acid into anthelmintic therapy makes it possible to reach more significant litholitical effect of ongoing therapy (70,5%).

Predictors of gallstone formation after bariatric surgery: a multivariate analysis of risk factors comparing gastric bypass, gastric banding, and sleeve gastrectomy

BACKGROUND

Risk factors for gallstone formation in the general population have been well studied while those after weight reduction surgery are unknown. The aim of this study was to identify the risk factors for the development of symptomatic gallstones after bariatric surgery.

METHOD

Retrospective review was performed for patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), adjustable gastric banding (LAGB) or sleeve gastrectomy (LSG) between 2004 and 2006. Statistical evaluation was performed using a univariate and multivariate analysis. Risk factors, including age, gender, preoperative body mass index (BMI), BMI > 45 kg/m(2), diabetes mellitus, hyperlipidemia, types of operation, and weight loss >25% of original weight, were analyzed for their association with postoperative symptomatic gallstones formation.

RESULTS

670 laparoscopic RYGBP, 47 LAGB, and 79 LSG were performed in our institute. Preoperative gallbladder disease, as indicated by presence of gallstones or sludge on preoperative transabdominal ultrasound, or previous cholecystectomy, were found in 25.3, 14.9, and 30.4% of patients who subsequently had RYGBP, LAGB, and LSG, respectively. A total of 586 patients were included for analysis. Mean follow-up was 25.9 (range 12-42) months. Overall rate of symptomatic gallstone formation was 7.8% and mean time for its development was 10.2 (range 2-37) months. Incidence of symptomatic gallstones with complications as initial presentation was found in 1.9% of the patients. Logistic regression analysis showed that only postoperative weight loss of more than 25% of original weight was associated with symptomatic gallstones formation [B = 1.482, SE = 0.533, odds ratio 4.44, 95% confidence interval (CI) 1.549-12.498, p = 0.005].

CONCLUSIONS

Traditional risk factors for gallstone formation in the general population are not predictive of symptomatic gallstone formation after bariatric surgery. Weight loss of more than 25% of original weight was the only postoperative factor that can help selecting patients for postoperative ultrasound surveillance and subsequent cholecystectomy once gallstones were identified.

Effect of ezetimibe on the prevention and dissolution of cholesterol gallstones

BACKGROUND & AIMS

Cholesterol cholelithiasis is one of the most prevalent and most costly digestive diseases in developed countries and its incidence has increased markedly in Asian countries owing to the adoption of Western-type dietary habits. Because animal experiments showed that high efficiency of intestinal cholesterol absorption contributes to gallstone formation, we explored whether the potent cholesterol absorption inhibitor ezetimibe could prevent gallstones and promote gallstone dissolution in mice and reduce biliary cholesterol content in human beings.

METHODS

Male gallstone-susceptible C57L mice were fed a lithogenic diet and concomitantly administered with ezetimibe at 0, 0.8, 4, or 8 mg/kg/day for 8 or 12 weeks. Gallbladder biles and gallstones were examined by microscopy. Gallbladder emptying in response to cholecystokinin octapeptide was measured gravimetrically. Biliary lipid outputs were analyzed by physical-chemical methods. Cholesterol absorption efficiency was determined by fecal dual-isotope ratio and mass balance methods. Lipid changes in gallbladder biles of gallstone patients vs overweight subjects without gallstones were examined before (day 0) and at 30 days after ezetimibe treatment (20 mg/day).

RESULTS

Ezetimibe prevented gallstones by effectively reducing intestinal cholesterol absorption and biliary cholesterol secretion, and protected gallbladder motility function by desaturating bile in mice. Treatment with ezetimibe promoted the dissolution of gallstones by forming an abundance of unsaturated micelles. Furthermore, ezetimibe significantly reduced biliary cholesterol saturation and retarded cholesterol crystallization in biles of patients with gallstones.

CONCLUSIONS

Ezetimibe is a novel approach to reduce biliary cholesterol content and a promising strategy for preventing or treating cholesterol gallstones by inhibiting intestinal cholesterol absorption.

Complications vésiculaires après chirurgie bariatrique

With the increased incidence of obesity in the developed countries, and the failure of medical treatments, bariatric surgery has increased rapidly. Although laparoscopic gastroplasty is the most popular bariatric intervention in France, the gold standard tends to be the laparoscopic gastric bypass. The severe weight loss caused by this type of procedure induces specific middle or long term complications such as biliary lithiasis. In this literature we describe different physiopathological mechanisms of lithiasis after gastric bypass by coeliosurgery or gastroplasty, their diagnosis, and preventive treatment to avoid these complications.

Genetic predisposition to gallbladder stones

Geographic and ethnic differences in gallstone prevalence rates and familial clustering of cholelithiasis imply that genetic factors influence the risk of gallstone formation. Recently, twin, family, and linkage studies confirmed a genetic predisposition to the development of symptomatic gallstones. In rare instances, mutations in single genes confer a substantial risk for the formation of gallstones. However, in the majority of cases gallstones might develop as a result of lithogenic polymorphisms in several genes and their interactions with multiple environmental factors, rendering gallstones generally a complex genetic disorder. Some of the rare monogenic forms of cholelithiasis were unraveled but the lithogenic genes that increase the susceptibility to cholelithiasis in the majority of gallstone carriers remain elusive. Identification of these lithogenic genes will provide novel means of risk assessment, strategies for prevention, and targets for nonsurgical management of cholelithiasis, which currently is one of the most expensive digestive disorders.

[The prevention of hepatolithiasis and biliary stricture post choledochojejunostomy]

OBJECTIVE

To investigate the prevention of hepatolithiasis and biliary stricture post choledochojejunostomy using choledochoscopy technique and evaluate feasibility and efficacy of choledochojejunostomy and artificial valve of efferent loop in preventing reflux.

METHODS

To analyze the data of 47 patients with hepatolithiasis who had been operated with Roux-en-Y cholangiojejunostomy and artificial valve of efferent loop to prevent bilio-intestinal regurgitation. Of the patients, 19 were marked with silver nip at the jejunum export of bilio-intestinal anastomosis. The regurgitation, recurrence, anastomotic stricture and their managements after the surgery were investigated.

RESULTS

The bilio-intestinal regurgitation were found in 32 cases (32/47, 68.1%), it suggested that artificial valve could not prevent bilio-intestinal regurgitation efficiently. Two cases of hepatolithiasis recurred and were cured by sinus tract placement with the aid of silver nip mark under choledochoscope instead of re-operation. Of the 6 cases with anastomotic stricture, 5 cases were treated successfully with stone extraction, biliary stent dilatation under the percutaneous transhepatic cholangioscopy (PTCS) and the other one case died.

CONCLUSIONS

Silver nip mark provides safe and simple path for the cholangioscopy, it made the treatment of the recurrent biliary stricture and stone safe and brief, made the cholangioscopy play more important role in the hepatolithiasis, residual stone and biliary stricture. PTCS is mini-invasive, safe, simple and effective.

Nutritional and metabolic complications of bariatric surgery

Bariatric surgery is an effective treatment for patients with clinically severe obesity. In addition to significant weight loss, it is also associated with improvements in comorbidities. Unfortunately, bariatric surgery also has the potential to cause a variety of nutritional and metabolic complications. These complications are mostly due to the extensive surgically induced anatomical changes incurred by the patient's gastrointestinal tract, particularly with roux-en-Y gastric bypass and biliopancreatic diversion. Complications associated with vertical banded gastroplasty are mostly due to decreased intake amounts of specific nutrients. Macronutrient deficiencies can include severe protein-calorie malnutrition and fat malabsorption. The most common micronutrient deficiencies are of vitamin B12, iron, calcium, and vitamin D. Other micronutrient deficiencies that can lead to serious complications include thiamine, folate, and the fat-soluble vitamins. Counseling, monitoring, and nutrient and mineral supplementation are essential for the treatment and prevention of nutritional and metabolic complications after bariatric surgery.

[Inhibiting effects of recipe for dispersing stagnated liver qi to promote bile flow on cholesterol gallstone formation in guinea pigs]

OBJECTIVE

To explore the mechanism of the inhibiting effects of recipe for dispersing stagnated liver qi to promote bile flow (Danshijing Tablets) on cholesterol gallstone formation and provide experimental evidence for its clinical application.

METHODS

Eighty guinea pigs were randomly divided into 4 groups, which were normal control group, untreated group, ursodeoxycholic acid (UDCA)-treated group and Danshijing Tablets-treated group. The gallstones in guinea pigs were induced by high-cholesterol diet. UDCA and Danshijing Tablets were given orally to guinea pigs in the corresponding group respectively for seven weeks. Then the physical signs of the guinea pigs, the rates of gallstone formation and the histomorphological changes of the gallbladder were examined.

RESULTS

The behavior of guinea pigs in the Danshijing Tablets-treated group was obviously improved and the rate of gallstone formation was significantly decreased as compared with those in both untreated and UDCA-treated groups (P<0.05). The inflammation reaction of mucous membrane in gallbladder was evidently reduced in the Danshijing Tablets-treated group and its morphological appearance turned to be approximately normal.

CONCLUSION

Recipe for dispersing stagnated liver qi to promote bile flow may decrease gallstone formation. Its mechanism may be related to reducing pathologic changes in gallbladder tissues, which will reduce the damages of cholesterol to the smooth muscle in gallbladder and enhance the contractility of gallbladder.

[Effects of Shengqing Capsules on cholelithiasis-related genes in guinea pigs]

OBJECTIVE

To explore the molecular mechanisms of Shengqing Capsules in treating cholelithiasis.

METHODS

Sixty female guinea pigs were randomized into 3 groups: group I (fed with normal diet), group II (fed with low-protein diet) and group III (fed with low-protein diet and Shengqing Capsules). After six-week feeding, the gallstone formation and the expressions of bilirubin UDP-glucuronosyltransferase (B-UGT) mRNA and cholesterol 7alpha-hydroxylase (CYP7A1) mRNA were observed.

RESULTS

The proportions of stone-formed in groups I, II and III were 2/14, 9/12 and 4/14, respectively. There were significant differences among the three groups (P<0.05). The expressions of B-UGT and CYP7A1 mRNAs were higher in both group I and group III as compared with those in the group II (P<0.05).

CONCLUSION

Shengqing Capsules can reduce the rate of stone-formation, which may be due to its interference of metabolism of bilirubin and cholesterol and up-regulation of the expressions of B-UGT and CYP7A1 mRNAs.

[New approaches to cholelithiasis prevention in young patients]

The purpose of the study was to evaluate efficacy of poliphepan and hepabene as components of complex therapy in patients with chronic cholecystitis (CC). The subjects were 33 CC patients with biliary tract (BT) dyskinesia and biliar sludge. Application of the drugs led to significant improvement of clinical symptoms and the parameters of BT functional condition, as well as to decrease of bile lithogenicity and improvement of life quality.

[Use of essentiale and cholagogum in prevention of cholelithiasis in fat hepatosis with concomitant cholecystitis]

AIM

To assess efficacy of essentiale in combination with cholagogum in prevention of cholelithogenesis in patients with fat hepatosis (FH) and concomitant cholecystitis (CC).

MATERIAL AND METHODS

100 patients aged 31-60 years with FH and CC were examined using clinical, device and biochemical tests. The diagnosis was verified by the results of ultrasonography, computed and MR tomography. Fractionated duodenal tubing followed by biochemical examination of bile was conducted in all the patients.

RESULTS

Changes in physico-chemical properties of hepatic and vesical bile corresponding to stage I of cholelithiasis occurred in most of the examinees. Treatment with essentiale +cholagogum is clinically effective, improves functional condition of bile ducts and the liver, diminishes bile lithogenicity.

CONCLUSION

In fat hepatosis and concomitant cholecystitis, essentiale and cholagogum improve biochemical composition of bile, resulting finally in decreased risk of cholelithogenesis.

[Prevention and treatment of cholelithiasis by traditional Chinese medicine]

Cholelithiasis is one of the clinically common and frequently encountered diseases. In this paper, the Chinese Meteria Medica and prescriptions utilized to treat cholelithasis were discussed in four aspects. In addition, we discussed the clinical effect and mechanism of actions of these drugs in order to provide some reference for future drug development in this area.

Cholesterol synthesis inhibition distal to squalene upregulates biliary phospholipid secretion and counteracts cholelithiasis in the genetically prone C57L/J mouse

BACKGROUND AND AIMS

Newly synthesised cholesterol contributes poorly to biliary lipid secretion but may assume greater importance when the rate limiting enzyme 3-hydroxy-3-methylglutaryl-CoA reductase (HMGR) is upregulated. As this occurs in the gall stone susceptible C57L/J inbred mouse, we employed two cholesterol biosynthesis inhibitors, Tu 2208 and Ro 48-8071, potent inhibitors of squalene epoxidase and oxidosqualene-lanosterol cyclase, respectively, to assess their potential in preventing cholesterol cholelithiasis in the C57L/J mouse strain. Mice were fed a lithogenic diet comprising a balanced nutrient intake with 15% dairy fat, 1% cholesterol, and 0.5% cholic acid added.

METHODS

We determined gall stone phenotype, HMGR activity, biliary lipid secretion rates, and counterregulatory events in male C57L/J mice and gall stone resistant AKR treated with Tu 2208 (30-60 mg/kg/day) or Ro 48-8071 (30-100 mg/kg/day), while ingesting chow or the lithogenic diet.

RESULTS

Both agents reduced the gall stone prevalence rate from 73% to 17% in C57L/J mice, inhibited HMGR activity, and decreased hepatic cholesterol concentrations without appreciably influencing biliary cholesterol secretion. In C57L as well as AKR mice, both agents increased biliary phospholipid (which is mostly phosphatidylcholine) secretion rates and at the highest doses effectively reduced the biliary cholesterol saturation index.

CONCLUSIONS

Cholesterol biosynthesis inhibitors acting distally to squalene do not reduce biliary cholesterol secretion rates despite reductions in cholesterol biosynthesis and hepatocellular levels. However, they effectively prevent gall stone formation through stimulation of pathways that lead to enhanced biliary phospholipid secretion.

Phosphatidylcholine-enriched diet prevents gallstone formation in mice susceptible to cholelithiasis

Cholesterol gallstones affect approximately 10-15% of the adult population in North America. Phosphatidylcholine (PC) is considered to be the main cholesterol solubilizer in bile. This study examined the effect of a PC-enriched diet on gallstone incidence in mice susceptible to cholelithiasis. The result obtained showed that the feeding of a lithogenic (LG) diet for 4 weeks or 8 weeks resulted in cholesterol gallstone incidences of 47% and 89%, respectively. These gallstone incidences were either reduced or prevented when the LG diet was enriched with 2% or 6% PC, respectively. The cholesterol saturation index (CSI) was reduced only in mice fed with LG + 6% PC diet as compared with mice fed the LG diet alone. However, in all groups, the CSI was significantly higher than in mice fed Purina chow diet. The biliary anionic polypeptide fraction (APF) was significantly increased in mice fed the LG + 2% PC diet and was reduced in those fed with LG + 6% PC diet. In conclusion, prevention or delay of gallstone formation was not due to a consistent effect on biliary lipid composition, suggesting a direct effect of PC on cholesterol solubilization and/or the effect of an additional nonlipid biliary component such as APF.

Relation of coffee, green tea, and caffeine intake to gallstone disease in middle-aged Japanese men

A possible protective effect of coffee or caffeine intake in the formation of gallstones has been suggested in some epidemiological studies. We examined the relation of coffee, green tea, and caffeine intake to gallstone disease in middle-aged Japanese men, distinguishing known gallstones from unknown diagnosed gallstones. Study subjects were 174 cases of gallstones as determined by ultrasonography, 104 cases of postcholecystectomy, and 6889 controls of normal gallbladder in the total of 7637 men who received a health examination at four hospitals of the Self-Defense Forces (SDF). Of the 174 cases of prevalent gallstones, 50 had been aware of having gallstones. Previously diagnosed gallstones and postcholecystectomy were combined as known gallstone disease. The consumption of coffee and green tea was ascertained by a self-administered questionnaire, and caffeine intake was estimated. Statistical adjustment was done for body mass index, smoking, alcohol use, rank in the SDF, and hospital. Coffee and caffeine intake were associated each with a statistically significant increase in the prevalence odds of known gallstone disease, but unrelated to newly diagnosed gallstones. Adjusted odds ratios of known gallstone disease were 1.7 (95% confidence interval [CI] 1.1-2.8) for coffee consumption of five cups or more per day vs. no consumption and 2.2 (95% CI: 1.3-3.7) for caffeine intake of 300 mg/day or more vs. less than 100 mg/day. The consumption of green-tea showed no material association with either unknown gallstones or known gallstone disease. The findings do not support a hypothesis that coffee drinking may be protective against gallstone formation.

Intraoperative ultrasound and prophylactic ursodiol for gallstone prevention following laparoscopic gastric bypass

BACKGROUND

Previous studies have shown that ursodiol decreases gallstone formation from 32% to 2% following open gastric bypass, but no data exist on laparoscopic Roux-en-Y gastric bypass (LRYGB) using intraoperative ultrasound (IOUS) screening.

METHODS

LRYGB with IOUS were performed on 195 consecutive patients. Patients with gallstones underwent simultaneous cholecystectomy, and patients without gallstones were prescribed ursodiol, 300 mg twice daily, for 6 month. Follow-up survey and ultrasound.

RESULTS

Of 195 patients, 44 (23%) had had a prior cholecystectomy, 21 (11%) underwent a simultaneous cholecystectomy, 129 (66%) had gallbladders left intact, and one (0.5%) false negative IOUS was excluded. Of 69 patients with ultrasound and survey follow-up (mean, 10 months), 19 (28%) developed gallstones seven with symptoms), and 50 (72%) were gallstone free. Forty-one percent of patients were compliant with ursodiol. There was no difference in compliance between patients with and without gallstones. In patients with gallstones, all of the symptomatic patients were noncompliant, whereas none of the compliant patients developed symptoms. Medication side-effects occurred in 17 of 69 patients (25%).

CONCLUSIONS

IOUS during LRYGB efficiently screens for gallstones, and selective cholecystectomy followed by prophylactic ursodiol results in low morbidity. Improvements in compliance may lower the incidence of postoperative gallstone formation.

New strategies for the treatment of gallstone disease

BACKGROUND

Symptomatic gallstones are generally accepted as being the indication for cholecystectomy. Generally, severe abdominal pain in epigastrium and in the right upper abdominal quadrant, and lasting for more than 15 min, is thought to be caused by gallstones. However, many patients with other abdominal complaints undergo cholecystectomy and are satisfied with the outcome of surgery. Possible ways to improve the results of cholecystectomy are discussed.

METHODS

Review of previous work by the authors.

RESULTS

The introduction of laparoscopic cholecystectomy has even led to an increase in cholecystectomies; in a higher complication rate; and in increased costs of the treatment of gallstone disease. Because of faster recovery, 70% of symptomatic gallstone patients are able and willing to undergo laparoscopic cholecystectomy in day care. Cholecystectomy after sphincterotomy and stone extraction in patients who have stones in the gallbladder was demonstrated to prevent gallstone-related symptoms in at least 40% of patients. If the gallbladder had to be removed later for symptomatic disease, however, this did not result in a higher rate of conversions and complications. Because of shortage in operation capacity in The Netherlands, there is a considerable delay between the diagnosis of symptomatic stones and cholecystectomy. Better selection of patients for cholecystectomy will not only improve the results of cholecystectomy, it will also reduce the number of cholecystectomies and patients on waiting lists. Delay of cholecystectomy is associated with more complications, longer operative times, higher conversion rates to open cholecystectomy and prolonged hospitalization. The efficacy of the bile salt ursodeoxycholic acid in preventing gallstone-related pain attacks and complications in patients with contraindications for operation or waiting to undergo cholecystectomy should be investigated further, since two retrospective studies have demonstrated favourable outcomes for this strategy.

CONCLUSION

The results of cholecystectomy are likely to be improved by better selection of patients, prevention of delay of the procedure and possibly treatment with ursodeoxycholic acid.

[Basis for the use of a new galena-based substance from plants for prevention and treatment of cholelithic disease]

With the purpose of prevention and treatment of cholelithic disease, a new galena-based phytocomposition having the choleritic, cholekinetic, spasmolytic and hypocholesterolemic effects at the same time was administered to patients along with lithotripsy. Clinical manifestations of cholecystitis disappeared after a daily intake of the phytocomposition during 30 days in 96 patients out of 418 people having the diagnosis of cholelithic disease and high initial concentrations of?-lipoproteins and cholesterol in the blood serum. The level of lipids dropped reliably, and it became much easier to use the lithotripsy method. Due to the decrease of bile viscosity, it was possible to note easier elimination of fragments from the gallbladder. During the monotherapy with the galena-based phytocomposition, full litholisis of single (up to 30 mm) or multiple (up to 50% of the gallbladder volume) calculi was determined in seven patients out of 47 (17%) during the period from two to six months.

Coffee intake is associated with lower risk of symptomatic gallstone disease in women

BACKGROUND & AIMS

Metabolic studies have shown that coffee affects several hepatobiliary processes that are involved in cholesterol lithogenesis. We previously showed that coffee drinking was associated with a lower risk of symptomatic gallstone disease in men.

METHODS

We prospectively examined the association between coffee drinking and cholecystectomy, a surrogate of symptomatic gallstone disease, in a cohort of 80,898 women age 34-59 years in 1980 who had no history of gallstone disease. Coffee consumption and cholecystectomy were reported by participants on biennial mailed questionnaires.

RESULTS

During 20 years of follow-up to the year 2000, 7,811 women reported a cholecystectomy. Compared with women who consistently reported consuming no caffeinated coffee, the multivariate relative risks (adjusting for risk factors for gallstone disease) of cholecystectomy comparing increasing categories of consistent intake of caffeinated coffee (0, 1, 2-3, and > or =4 cups/day) were 1.0, 0.91, 0.78, and 0.72 (95% confidence interval comparing extreme categories, 0.62-0.84; P value of test for trend < 0.0001). Caffeine intake from beverages and dietary sources was also inversely associated with risk of cholecystectomy. The multivariate relative risks comparing increasing categories of caffeine intake (< or =25, 26-100, 101-200, 201-400, 401-800, and >800 mg/day) were 1.0, 1.03, 1.01, 0.94, 0.85, and 0.85 (95% confidence interval comparing extreme categories, 0.74-0.96; P value of test for trend < 0.0001). In contrast, decaffeinated coffee was not associated with risk.

CONCLUSIONS

These data suggest that consumption of caffeinated coffee may play a role in the prevention of symptomatic gallstone disease in women.

Effect of beta-muricholic acid on the prevention and dissolution of cholesterol gallstones in C57L/J mice

This study investigated whether beta-muricholic acid, a natural trihydroxy hydrophilic bile acid of rodents, acts as a biliary cholesterol-desaturating agent to prevent cholesterol gallstones and if it facilitates the dissolution of gallstones compared with ursodeoxycholic acid (UDCA). For gallstone prevention study, gallstone-susceptible male C57L mice were fed 8 weeks with a lithogenic diet (2% cholesterol and 0.5% cholic acid) with or without 0.5% UDCA or beta-muricholic acid. For gallstone dissolution study, additional groups of mice that have formed gallstones were fed chow with or without 0.5% beta-muricholic acid or UDCA for 8 weeks. One hundred percent of mice fed the lithogenic diet formed cholesterol gallstones. Addition of beta-muricholic acid and UDCA decreased gallstone prevalence to 20% and 50% through significantly reducing biliary secretion rate, saturation index, and intestinal absorption of cholesterol, as well as inducing phase boundary shift and an enlarged Region E that prevented the transition of cholesterol from its liquid crystalline phase to solid crystals and stones. Eight weeks of beta-muricholic acid and UDCA administration produced complete gallstone dissolution rates of 100% and 60% compared with the chow (10%). We conclude that beta-muricholic acid is more effective than UDCA in treating or preventing diet-induced or experimental cholesterol gallstones in mice.

Plasma leptin and the cholesterol saturation of bile are correlated in obese women after weight loss

Increased cholesterol secretion is a major alteration of biliary function in obese subjects Leptin is a regulator of food intake and is increased in plasma of subjects with low energy expenditure and high adiposity. We investigated the relationship between leptin and the cholesterol saturation of bile in obese women before and after weight reduction by energy restriction (5.02 MJ/d). We studied women (n = 14) with a body mass index (BMI) > or = 30 kg/m(2) who were 35.4 +/- 2.3 y old and who did not have a history of gallstones. They were studied by ultrasound to ensure absence of stones or sludge. BMI, gallbladder bile composition, plasma leptin, serum lipids and lipoproteins cholesterol levels were recorded at baseline and after 6 wk of weight reduction. There were decreases in BMI (33.9 +/- 3.1 to 31.1 +/- 3.6 kg/m(2), P < 0.0001) and leptin levels (16.7 +/- 9.7 to 10.0 +/- 6.7 micro mol/L, P < 0.05) during weight loss. After the experimental period, there were positive correlations between plasma leptin levels and BMI (r = 0.71, P < 0.004); leptin levels and the cholesterol saturation index (CSI) (r = 0.53, P < 0.05); the CSI and LDL cholesterol (r = 0.73, P < 0.003); and negative correlations between leptin levels and HDL cholesterol (r = -0.54, P < 0.05) and LDL cholesterol (r = -0.57, P < 0.03). We have shown relationships among HDL cholesterol, CSI and leptin. This could be useful in understanding the pathophysiology of cholesterol gallstone formation in obese people.

Diet and gallbladder cancer: a case-control study

Cancer of the gallbladder is rare but fatal, and has an unusual geographic and demographic distribution. Gallstones and obesity have been suggested as possible risk factors. As diet is known to influence both these factors, we carried out the present study to evaluate the possible role of diet in gallbladder carcinogenesis. A case-control study involving 64 newly diagnosed cases of gallbladder cancer and 101 cases of gallstones was carried out. The dietary evaluation was carried out by the dietary recall method based on a preset questionnaire developed specifically for the present study, keeping in mind the common dietary habits prevailing in this part of the world. Odds ratios (OR) and 95% confidence interval (CI) were calculated for various dietary items. A significant reduction in odds ratio was seen with the consumption of radish (OR 0.4; 95% CI 0.17-0.94), green chilli (OR 0.45; 95% CI 0.21-0.94) and sweet potato (OR 0.33; 95% CI 0.13-0.83) among vegetables, and mango (OR 0.4; 95% CI 0.16-0.99), orange (OR; 0.45; 95% CI 0.22-0.93), melon (OR 0.3; 95% CI 0.14-0.64) and papaya (OR 0.44; 95% 0.2-0.64) among fruits. A reduction in odds was also seen with the consumption of cruciferous vegetables, beans, onion and turnip, however the difference was not statistically significant. On the other hand, an increase in the odds was observed with consumption of capsicum (OR 2.2), beef (OR 2.58), tea (OR 1.98), red chilli (OR 1.29) and mutton (OR 1.2), however the difference was statistically not significant. In conclusion, the results of the present study show a protective effect of vegetables and fruits on gallbladder carcinogenesis, but red meat (beef and mutton) was found to be associated with increased risk of gallbladder cancer.

Position of the American Dietetic Association: health implications of dietary fiber

Dietary fiber consists of the structural and storage polysaccharides and lignin in plants that are not digested in the human stomach and small intestine. A wealth of information supports the American Dietetic Association position that the public should consume adequate amounts of dietary fiber from a variety of plant foods. Recommended intakes, 20-35 g/day for healthy adults and age plus 5 g/day for children, are not being met, because intakes of good sources of dietary fiber, fruits, vegetables, whole and high-fiber grain products, and legumes are low. Consumption of dietary fibers that are viscous lowers blood cholesterol levels and helps to normalize blood glucose and insulin levels, making these kinds of fibers part of the dietary plans to treat cardiovascular disease and type 2 diabetes. Fibers that are incompletely or slowly fermented by microflora in the large intestine promote normal laxation and are integral components of diet plans to treat constipation and prevent the development of diverticulosis and diverticulitis. A diet adequate in fiber-containing foods is also usually rich in micronutrients and nonnutritive ingredients that have additional health benefits. It is unclear why several recently published clinical trials with dietary fiber intervention failed to show a reduction in colon polyps. Nonetheless, a fiber-rich diet is associated with a lower risk of colon cancer. A fiber-rich meal is processed more slowly, which promotes earlier satiety, and is frequently less calorically dense and lower in fat and added sugars. All of these characteristics are features of a dietary pattern to treat and prevent obesity. Appropriate kinds and amounts of dietary fiber for the critically ill and the very old have not been clearly delineated; both may need nonfood sources of fiber. Many factors confound observations of gastrointestinal function in the critically ill, and the kinds of fiber that would promote normal small and large intestinal function are usually not in a form suitable for the critically ill. Maintenance of body weight in the inactive older adult is accomplished in part by decreasing food intake. Even with a fiber-rich diet, a supplement may be needed to bring fiber intakes into a range adequate to prevent constipation. By increasing variety in the daily food pattern, the dietetics professional can help most healthy children and adults achieve adequate dietary fiber intakes.

Apolipoprotein-E genotype and the risk of developing cholelithiasis following bariatric surgery: a clue to prevention of routine prophylactic cholecystectomy

BACKGROUND

Obesity and especially rapid weight loss following bariatric surgery are known risk factors for cholelithiasis. Since the risk may be high, prophylactic cholecystectomy has been advocated. Apolipoprotein (Apo) E, an important carrier protein in cholesterol metabolism and trafficking, is believed to play a role in gallstone pathogenesis. In particular, the Apo E4 allele has been suggested to be associated with cholesterol cholelithiasis. The aim of this study was to assess the incidence of postoperative cholelithiasis in our patient population and to determine a possible correlation with the Apo-E genotype.

METHODS

134 morbidly obese patients undergoing gastric restrictive surgery [laparoscopic assisted gastric banding (LAGB) or silastic ring vertical gastroplasty (SRVG)] had abdominal ultrasound before and 6 to 12 months after operation, to determine the presence of gallstones. None of the patients enrolled in the study had gallstones before surgery. They did not have a prophylactic cholecystectomy or receive bile salt treatment. Apo-E genotypes were determined by Polymerase Chain Reaction restriction enzyme analysis.

RESULTS

10 patients (7.5%) developed postoperative cholelithiasis. The incidence of cholelithiasis in each ApoE genotype was: E2/E3--1/20 (5%), E3/E3--3/91 (3%), E3/E4--6/21 (29%), and E4/E4--0/2. ApoE allele frequencies in the study population were identical to those of a healthy control population. The mean BMI dropped from 43.6 to 29.4 kg/m2.

CONCLUSIONS

The occurrence of postoperative gallstones was low in our population. However, in subjects with the Apo-E3/E4 genotype, the incidence is of practical significance. These data suggest that Apo-E genotyping may be useful in selecting patients for gallstone prevention (surgical or medical) when undergoing bariatric surgery. Further testing in larger patient populations may be able to give more definite guidelines in the future.

Gallbladder management in obesity surgery

BACKGROUND

In the 1980s, some surgeons recommended routine cholecystectomy for patients undergoing bariatric surgery. This was based on the high prevalence of gallstones in the obese and concern that rapid weight loss would increase the risk of gallbladder disease. Others recommended waiting for a lower weight and a definite need. With increasing prevalence and severity of obesity and increased use of gastric reduction surgery for weight control, it seemed appropriate to review the current standard of care for cholecystectomy. A survey was also made of ursodeoxycholic acid usage for prevention of gallstone formation.

METHODS

Data collected from active contributors for the 28th Report of the International Bariatric Surgery Registry (IBSR) were examined. Two questionnaires were also sent to members of the American Society for Bariatric Surgery (ASBS). The first (Q1) asked about the indications for cholecystectomy. The second (Q2) asked about ursodeoxycholic acid usage for prevention of gallstone formation during rapid weight loss following surgical treatment of obesity.

RESULTS

There has been an increase in concurrent cholecystectomy during the last 15 years. Some of this is due to a shift from simple gastric restrictive operations to gastric bypass with gastric restriction. When the most extensive bypass of intestine is used, as in distal Roux-en-Y gastric bypass (RYGBP-X) or biliopancreatic diversion with a duodenal switch (BPD-DS), all patients were reported to have undergone cholecystectomy. Only 30% of surgeons performing standard Roux-en-Y gastric bypass (RYGBP) remove normal-appearing gallbladders. Ursodeoxycholic acid is used to prevent gallstone formation in one-third of patients when a normal-appearing gallbladder is left in place.

CONCLUSIONS

Prophylactic cholecystectomy is left to the discretion of the surgeon when RYGBP is used. There has been an increase in cholecystectomy and malabsorptive operations during the last 15 years. When most of the small bowel is bypassed, all remaining gallbladders are removed. For patients with simple restriction operations, normal-appearing gallbladders are usually left in place. Urso-deoxycholic acid during rapid weight loss for prevention of gallstone formation is used in one-third of patients with remaining gallbladders.

[Cost-effectiveness analysis of a preventive program for gallbladder disease in Chile]

BACKGROUND

Chilean women have one of the highest mortality rates from gallstone disease in the world. There is no primary prevention for the disease and the benefits of prophylactic cholecystectomy in high risk groups have not been studied.

AIM

To analyze the cost and effectiveness of a screening program for gallbladder disease in the Chilean women population.

METHODS

A decision analytic model is used to compare lifetime cost and effectiveness of standard care with three screening strategies. The first two strategies consider "universal ultrasound screening" for all women 40 years old and laparoscopic cholecystectomy for those with gallstones ("elective intervention") or with calculous > or = 3 cm ("high risk intervention"). The third strategy is based on "selective screening" for obese women.

RESULTS

The lifetime probability of a 40 years old Chilean woman of dying from gallbladder disease is reduced by 70% in the universal screening/elective intervention, by 63% in the high risk intervention and by 18% in the selective screening strategy. Her lifetime expectancy increases by 5.25, 4.64 and 1.24 months respectively. The incremental cost-effectiveness ratio of each screening strategy is US$ 180, US$ 147 and US$ 481 respectively.

CONCLUSION

A screening program for gallbladder disease in a high risk population achieves significant benefits at a low incremental cost and acceptable cost-effectiveness.

Comparison of effects of cholecystokinin and erythromycin on bile chemistry and gallstone formation in aged guinea pigs

BACKGROUND

There has been considerable interest in gall bladder motility in recent years. We compared the effects of cholecystokinin (CCK) and erythromycin on bile chemistry and gallstone formation in aged guinea pigs.

METHODS

Two groups of guinea pigs (1-mo and 3-y old; n=40 each) were studied. Each group was divided into four subgroups of 10 animals each; one subgroup received lithogenic diet, one each received CCK or erythromycin daily in addition to lithogenic diet for 4 weeks, and one received normal diet. After 4 weeks, the presence of gallstones or sludge was recorded and bile composition including concentrations of bile acid, cholesterol, lecithin and protein concentrations was studied.

RESULTS

No gallstones were observed in the 1-mo-old animals. In the 3-year-old animals, 9 of 10 guinea pigs on lithogenic diet and 4 of 10 in each treatment subgroup and the normal diet subgroup developed gallstones. CCK and erythromycin had similar effects on bile chemistry and stone formation.

CONCLUSIONS

Aging increases the formation of gallstones in guinea pigs. Erythromycin is as effective as CCK in reducing gallstone formation by improving gall bladder motility.

Transgenic expression of cholesterol-7-alpha-hydroxylase prevents atherosclerosis in C57BL/6J mice

C57BL/6J mice are susceptible to atherosclerosis when fed a diet consisting of fat, cholesterol, and taurocholate. The susceptibility to diet-induced atherosclerosis is linked to a reduction in plasma high density lipoprotein (HDL). Diet-induced reduction of plasma HDL shows a physiological and a genetic correlation with repression of cholesterol-7-alpha-hydroxylase, the liver-specific enzyme that regulates the conversion of cholesterol into bile acids. To examine the hypothesis that the repression of cholesterol-7-alpha-hydroxylase is responsible for initiating the metabolic alterations leading to the formation of atherosclerosis and gallstones, we determined whether constitutive transgenic expression of cholesterol-7-alpha-hydroxylase in C57BL/6J mice would confer resistance to these 2 common human diseases. When fed the atherogenic diet, nontransgenic littermates, but not cholesterol-7-alpha-hydroxylase transgenic mice, accumulated cholesterol and cholesterol esters in their livers and plasma. Although the atherogenic diet caused a marked decrease in plasma HDL cholesterol in nontransgenic mice, HDL levels in transgenic mice remained relatively unchanged. Moreover, the ability of cholesterol-7-alpha-hydroxylase transgenic mice to maintain cholesterol and lipoprotein homeostasis completely prevented the formation of atherosclerosis and gallstones. These data establish the integral role that cholesterol-7-alpha-hydroxylase has in maintaining hepatic cholesterol homeostasis and, thus, in the susceptibility to the formation of gallstones and atherosclerosis.

Prevention of gallstone formation in morbidly obese patients undergoing rapid weight loss: results of a randomized controlled pilot study

INTRODUCTION

An increased risk of gallstone (GS) formation has been linked to obesity and to episodes of rapid and significant weight loss. Previous reports have suggested that bile salt therapy (ursodeoxycholic acid) or prostaglandin inhibition (ibuprofen) may prevent gallstone formation in this high-risk group. The purpose of this study was to investigate GS prevention following bariatric surgery.

DESIGN

Randomized double blind controlled trial.

METHODS

Sixty patients without gallstones preoperatively (gender, 9 male, 51 female; average preop wt, 349.6 lb; mean age, 38 years) were randomly assigned to receive urso (600 mg/day, n = 20), ibuprofen (600 mg/d, n = 20), or placebo (n = 20). At the time of standard open gastric bypass, intraoperative ultrasonography confirmed the absence of stones or microcalculi, and bile samples were collected via puncture of the gallbladder for bile lipid analysis. Following recovery and resumption of a bariatric diet, study medication was prescribed for the first 6 months postop. Gallbladder emptying and GS formation were assessed using ultrasonograms preop and at 3, 6, 9, and 12 months postop (gallbladder emptying following a high-fat liquid test meal was assessed preop, and at 3 and 6 months postop).

RESULTS

Forty-one (68.3%, 8 male, 33 female) of the original 60 patients completed all phases of the study (15 urso, 15 ibuprofen, 11 placebo). The average weight loss was 98.5 +/- 7.2 lb over the 12-month period following bariatric surgery. Twenty-nine (71%) of 41 patients who completed the study developed GS. Of those who formed stones, 12 (41%) developed symptomatic GS and 8/12 (67%) underwent cholecystectomy (4 refused operation). Preoperative gallbladder emptying studies showed no differences in emptying between groups (urso 29%, ibuprofen 32%, and placebo 30%). There was no correlation found between the cholesterol saturation index (CSI mean 205.15, range 67-360) and the incidence of GS. There was a statistical difference (P < 0.01) between the ursodeoxycholic acid group and the ibuprofen group with respect to the incidence of stone formation. There was correlation between weight loss (mean 99 lb, range 21-278 lb) and GS formation, in that patients who lost more weight had a greater tendency to form gallstones. Complete medical compliance was achieved in only 17/60 (28%) of patients originally enrolled.

CONCLUSIONS

This pilot study confirms the high incidence of gallstone formation (71% of assessed patients) associated with rapid weight loss in patients undergoing gastric bypass. Despite active enrollment in a supervised prevention trial, the two therapies investigated to reduce gallstone formation were not efficacious, likely because compliance with medical therapy was poor. These findings highlight the significant risk of gallstone formation in this patient cohort even when prevention strategies are utilized.

Effects of cisapride on gall bladder emptying, intestinal transit, and serum deoxycholate: a prospective, randomised, double blind, placebo controlled trial

BACKGROUND

Octreotide inhibits gall bladder emptying and prolongs intestinal transit. This leads to increases in the proportion of deoxycholic acid in, and cholesterol saturation of, gall bladder bile, factors that contribute to the pathogenesis of octreotide induced gall stones.

AIMS

To see if an intestinal prokinetic, cisapride, could overcome these adverse effects of octreotide and if so, be considered as a candidate prophylactic drug for preventing iatrogenic gall bladder stones.

METHODS

A randomised, double blind, placebo controlled, crossover design was used to examine the effects of cisapride (10 mg four times daily) on gall bladder emptying, mouth to caecum and large bowel transit times, and the proportions of deoxycholic acid and other bile acids, in fasting serum from: (i) control subjects (n=6), (ii) acromegalic patients not treated with octreotide (n=6), (iii) acromegalics on long term octreotide (n=8), and (iv) patients with constipation (n=8).

RESULTS

Cisapride had no prokinetic effect on the gall bladder. In fact, it significantly increased both fasting and postprandial gall bladder volumes. However, it shortened mouth to caecum (from 176 (13) to 113 (11) minutes; p<0.001) and large bowel (from 50 (3.0) to 31 (3.4) h; p<0.001) transit times. It also reduced the proportion of deoxycholic acid in serum from 26 (2.3) to 15 (1.8)% (p<0.001), with a reciprocal increase in the proportion of cholic acid from 40 (3.5) to 51 (3.8)% (p<0.01). There were significant linear relationships between large bowel transit time and the proportions of deoxycholic acid (r=0.81; p<0.001) and cholic acid (r=-0.53; p<0.001) in fasting serum. INTERPRETATION/SUMMARY: Cisapride failed to overcome the adverse effects of octreotide on gall bladder emptying but it countered octreotide induced prolongation of small and large bowel transit. Therefore, if changes in intestinal transit contribute to the development of octreotide induced gall bladder stones, enterokinetics such as cisapride may prevent their formation.

Benefits of sustained moderate weight loss in obesity

Over the last few years, weight loss has been recognised as a key factor in the control and prevention of coronary heart disease, hypertension, type 2 diabetes, hyperlipidaemia, cardiorespiratory failure and other chronic degenerative diseases. It has been shown that even a modest loss of 5% of initial body weight can reduce, eliminate or prevent these disorders in a large proportion of overweight patients. The early benefits of weight loss can be explained by the direct effects of a low calorie diet, but the long-term effects can only partially be attributed to diet, physical exercise or behavioural modifications. Long-term studies have shown that a sustained moderate weight loss of 10% improves glycemic control as a result of reduced insulin resistance, the better control or prevention of hypertension, increased HDL-and decreased LDL-cholesterol and VLDL triglycerides, improved diastolic function and the propagation of a cardiac stimulus that reduces the risk of ventricular arrhythmias. The health benefits of modest weight loss are particularly evident and useful when excess body fat is a major health hazard, as in the case of class III obesity (BMI > 40 kg/m2), which is often characterised by prevalent visceral fat accumulation. Baseline serum glucose, cholesterol, triglyceride, uric acid and blood pressure levels are usually higher in the upper body than is the case in peripheral obesity, and tend to decrease more in response to moderate weight loss. A therapeutic programme aimed at obtaining a gradual and moderate weight loss avoids the complications due to the rapid weight loss associated with inappropriate, unbalanced diets or even more harmful treatments. These complications include cholelithiasis and the subsequent risk of cholecystitis, lean body mass loss and a stable decrease in energy expenditure with a high probability of regaining weight (weight cycling syndrome). In conclusion, a large number of obese patients may be sensitive to a modest weight loss even without the achievement of ideal body weight. Sustained moderate weight loss by itself is definitely beneficial in obesity (especially "malignant" and "morbid" obesity), but also in diabetes, hypertension, hyperlipidaemia, cardiorespiratory diseases and other chronic degenerative diseases associated with any degree of excess body fat.