Cholelithiasis in ileostomy patients

Kinetics of primary bile acids in patients after proctocolectomy and ileal pouch-anal anastomosis

BACKGROUND

The high incidence of cholesterol gallstones in patients after proctocolectomy with ileal pouch-anal anastomosis (IPAA) may be due to an increased loss of bile acids. We aimed to evaluate the kinetics of the primary bile acids cholic acid (CA) and chenodeoxycholic acid (CDCA) in these patients.

METHODS

Pool sizes, synthesis rates, and fractional turnover rates of CA and CDCA were determined by combined capillary gas chromatography/isotope ratio mass spectrometry in serum samples after administration of [¹³C]CA and [¹³C]CDCA in 6 patients and 9 healthy volunteers.

RESULTS

In patients with IPAA, pool sizes of CA and CDCA were 11.5 (8.2-23.8) and 12.1 (6.7-20.1) µmol/kg, respectively, and were significantly lower than in healthy controls [36.0 (24-47) and 29.0 (21-42) µmol/kg, respectively; p < 0.05, each]. Fractional turnover rates of CA [1.19 (1.06-1.82) vs. 0.31 (0.13-0.54) per day] and CDCA [1.01 (0.50-1.63) vs. 0.23 (0.09-0.36) per day] were increased fourfold in patients with IPAA (p < 0.05, each). Synthesis rates of CDCA [10.2 (5.2-32.9) vs. 6.6 (2.7-10.5) µmol/kg per day, p = 0.05] and CA [15.1 (9.3-39.4) vs. 11.5 (3.1-20.5) µmol/kg per day, n.s.] tended to be higher in patients with IPAA than in controls.

CONCLUSION

The reduced pool size of primary bile acids may contribute to the high incidence of cholesterol gallstones in patients after proctocolectomy and IPAA.

Increased risk of asymptomatic gallstones in patients with ulcerative colitis

BACKGROUND/AIMS

The relationship between Crohn's disease and gallstones is established. However, the prevalence and risk factors for gallstones in patients with ulcerative colitis (UC) are not yet well understood. The aim of this study was to evaluate the prevalence and risk factors of gallstones in patients with UC.

METHODS

This study was a retrospective single center study. A total of 87 patients with UC and 261 healthy controls were enrolled. Age, sex, and body mass index were matched. To investigate risk factors, the extent of UC, duration of disease, number of hospital admissions, and number of steroid treatments in patients with UC were evaluated.

RESULTS

The prevalence of gallstones in patients with UC was 13.8%, whereas that in healthy controls was only 3.1% (P<0.001). For patients with UC, patients ≥50 years of age had a 3.6-times higher risk of gallstones compared to that in those <50 years of age, and the difference was statistically significant (odds ratio, 3.60; confidence interval, 1.03-12.61) in univariate analysis. There were no statistically significant disease-related risk factors for gallstones in UC patients.

CONCLUSIONS

This is the first study of gallstone prevalence in Korean UC patients. In this study, patients with UC had a higher prevalence of gallstones compared to that in well-matched healthy controls. Age seemed to be a possible risk factor, and more studies are needed. Further prospective, large-scale studies will be required to confirm the risk factors for gallstones in UC patients.

Gallbladder carcinoma in a pregnant patient with Crohn's disease complicated with gallbladder involvement

Primary gallbladder (GB) carcinoma and Crohn’s disease (CD) of the GB are individually rare. We present a case of a pregnant woman with CD found to have GB involvement and primary GB carcinoma. A 34-year-old female at 6 wk gestation with a 21 year history of CD of uncertain extent presented with 3 mo of diarrhea, urgency and abdominal pain. During work-up, she was found to have elevated transaminases and an abnormal alkaline phosphatase. Imaging revealed two gallbladder polyps both greater than 1 cm in size. Resection and histological evaluation was consistent with Crohn’s involvement of the GB, poorly differentiated adenocarcinoma of the GB with invasion through the muscularis propria and matted lymph nodes in the porta hepatis positive for metastatic carcinoma (stage pT2N1). Six cases of CD involving the GB, two cases of primary GB carcinoma in CD, and ten cases of cholangiocarcinoma in pregnancy have been published. This is the only case that describes all three factors. Common features in CD of the GB include acute cholecystitis, ileal involvement, and presence independent of active intestinal disease. Common features in CD patients with GB malignancy include younger age of detection, a long history of CD, extensive colonic and ileal involvement of disease, the absence of cholelithiasis, and pre-existing gallbladder disease (primary sclerosing cholangitis and gallbladder polyps). Pregnancy is specific to this case. The role of CD in the development of GB malignancy is not well understood nor is the contribution of pregnancy to the spread of disease. Chronic inflammation and immunosuppression compounded by hormonal influence is implicated.

Histopathological characterization of cholecystectomy specimens in patients with inflammatory bowel disease

BACKGROUND AND AIMS

Inflammatory bowel disease is associated with increased risk of cholelithiasis. However, the histologic patterns in gallbladders have not been extensively studied. This study is designed to characterize the histopathologic features of cholecystectomy specimens in inflammatory bowel disease patients, compared to a control group.

METHODS

Cholecystectomy specimens in 78 Crohn's disease patients and 50 ulcerative colitis patients were reviewed. These were compared with 93 cholecystomies from noninflammatory bowel disease patients of approximate age and sex. The pattern and extent of inflammation was noted.

RESULTS

Marked chronic cholecystitis was present in 12% of ulcerative colitis patients (P<0.05) and 10.3% of Crohn's disease patients (P>0.05), compared to 4.3% of the noninflammatory bowel disease control group. Eight percent of ulcerative colitis patients (P<0.05) and 2.6% of Crohn's disease patients (P>0.05) had acute serositis, compared to 0% of the noninflammatory bowel disease control. The third inflammatory pattern, nodular lymphoid aggregates, was significantly increased in Crohn's disease patients after adjusting for the effect of cholelithiasis. Nodular lymphoid aggregates were found in 21.2% of Crohn's disease patients and 9.7% of ulcerative colitis patients without cholelithiasis, compared to 5% of noninflammatory bowel disease controls without cholelithiasis, a statistically significant difference between the Crohn's disease and control groups (P<0.05).

CONCLUSIONS

Inflammatory bowel disease patients show similar inflammatory patterns in cholecystectomy specimens compared to the general population. However, two inflammatory patterns that occur more often in ulcerative colitis patients are marked chronic cholecystitis and acute serositis, while nodular lymphoid aggregates are more common in Crohn's disease patients.

Proctocolectomy and brooke ileostomy for chronic ulcerative colitis

Proctocolectomy and permanent ileostomy is an option for selected patients with ulcerative colitis. Current indications include the elderly, patients with poor anal continence, and those with malignant lesions of the low rectum. Advantages of this procedure are that it has fewer complications than an ileal pouch-anal anastomosis, it is a one-stage operation removing all the diseased mucosa, and it is a relatively straightforward operation. The operative technique is discussed.

Prevalence of cholelithiasis in patients with chronic inflammatory bowel disease

AIM: To investigate the effect of chronic inflammatory bowel disease (CIBD) specific risk factors for cholecystolithiasis, as duration and involvement pattern of the disease and prior surgery in patients with Crohn's disease (CD) and ulcerative colitis (UC).

METHODS: A total of 222 patients with CD (135 females, 87 males; average age, 35.8 ± 11.8 years; range 17-81 years) and 88 patients with UC (39 females, 49 males; average age, 37.2 ± 13.6 years; range 16-81 years) underwent clinical and ultrasound examinations. Besides age, sex and degree of obesity, patients? CIBD specific parameters, including duration and extent of disease and prior operations were documented and evaluated statistically using logistic regression.

RESULTS: The overall prevalence of gallbladder stone disease in patients with CD was 13% (n = 30). Only age could be shown to be an independent risk factor (P = 0.014). Compared to a collective representative for the general population in the same geographic region, the prevalence of cholecystolithiasis was higher in all corresponding age groups. Patients with UC showed an overall prevalence of gallbladder stone disease of only 4.6%.

CONCLUSION: Only age but not disease-specific factors such as duration and extent of disease, and prior surgery are independent risk factors for the development of cholecystolithiasis in patients with CIBD.

Gallstone formation and gallbladder bile composition after colectomy in dogs

A high prevalence of gallstones has been described in patients following colectomy. The aim of this study was to examine whether lithogenicity is attributed to colectomy. In the present study, changes in gallbladder bile composition and the mechanism of gallstone formation after colectomy were examined in dogs. Ten mongrel dogs underwent restorative proctocolectomy. Seven dogs which received sham operations served as controls. Over a 12-week postoperative period, samples of gallbladder bile, formed gallstones and serum were collected and analyzed. In 7 of the 10 (70%) colectomized dogs, gallstones were found in the gallbladder, while the control dogs had no stones. Macroscopically the gallstones were similar to black pigment stones observed in humans. Chemical analysis and Fourier transform-infrared spectroscopy examination revealed that the stones were composed mainly of sodium bilirubinate and proteins, with minor amounts of calcium salts and cholesterol. Significant increases in biliary pH and concentrations of ionized calcium and unconjugated bilirubin were observed in the gallbladder bile of the colectomy group compared with that of the control group. The total bile acid and total bilirubin concentrations were significantly decreased in the colectomy group. Cholesterol crystal nucleation did not occur. The inhibitory effect of gallbladder bile on calcium carbonate precipitation in an in vitro assay system was preserved even after colectomy. In conclusion, proctocolectomy increases the concentration of unconjugated bilirubin in gallbladder bile and induces pigment gallstones which are composed mainly of sodium bilirubinate and proteins since calcium ions and cholesterol are stabilized in dogs.

Effect of colectomy with ileo-anal anastomosis on the biliary lipids

Total colectomy with ileo-anal anastomosis is an effective treatment for ulcerative colitis and familial adenomatous polyposis. The absence of the colon and the coexistence of bile acid malabsorption may increase bile lithogenicity, but data on biliary lipid composition in patients with this operation is lacking. Our aim was to assess bile lithogenicity, bile composition and mass of biliary lipids within the gallbladder. We studied 11 patients with total colectomy and ileo-anal anastomosis and 16 healthy controls. We measured the percentage composition of conjugated bile acids and the masses within the gallbladder of the three main biliary lipids. This method, in contrast with measurement of cholesterol saturation index, can determine the cause of bile lithogenicity in terms of absolute modifications of the biliary lipids. There was no difference in the cholesterol saturation index between patients and controls. Colectomy patients had reduced masses of all three biliary lipids (medians and ranges, mmol): cholesterol 0.11 (0.03-0.24) vs. 0.36 (0.02-0.96), P < 0.02; bile acid 1.62 (0.75-5.21) vs. 3.95 (1.27-8.70), P < 0.01; phospholipids 0.35 (0.07-0.69) vs. 1.14 (0.14-3.00), P < 0.002. They also had reduced per cent deoxycholic acid: 3.8 (0.0-27.6) vs. 17.4 (6.4-44.7), P < 0.005, and increased percent cholic acid: 44.9 (23.3-71.4) vs. 34.3 (19.2-57.9), P < 0.05. We conclude that, despite having bile acid malabsorption, patients with colectomy and ileo-anal anastomosis have a normal cholesterol saturation index, caused by a concomitant reduction in the masses of all three biliary lipids. The reduced per cent biliary deoxycholic acid may help explain the reduced cholesterol and phospholipid masses in these patients. Total colectomy with ileo-anal anastomosis does not seem to predispose to the formation of cholesterol gallstones.

Gallstones and their composition in patients with ileoanal anastomosis

Cholelithiasis is known to occur in 15%-24.5% of proctocolectomized patients. However, the clinical features and chemical analysis of gallstones in these patients have not been reported. We describe two cases of cholelithiasis that developed in patients after proctocolectomy with ileoanal anastomosis. These patients had a high output of watery stools and more frequent bowel movements than the average for Japanese patients with ileoanal anastomosis. The chemical composition of the resected gallstones was 93.0% cholesterol and 80.9%, respectively, in the two patients, indicating that cholesterol gallstones are formed in patients with ileoanal anastomosis after proctocolectomy.

Rapid cholesterol nucleation time and cholesterol gall stone formation after subtotal or total colectomy in humans

Changes in biliary lipid composition, pH, ionised calcium, total and unconjugated bilirubin, and cholesterol nucleation time of gall bladder bile samples were examined in six patients who had undergone subtotal or total colectomy between five months and seven years previously, and values were compared with those in control patients with no gall stones. The colectomy group mainly comprised patients with ulcerative colitis and familial adenomatosis coli, in whom only a short length of the terminal ileum (mean (SEM) 2.25 (0.57) cm) had been resected. The reconstruction procedures were ileoanal anastomosis in two patients, terminal ileostomy in two, ileorectal anastomosis in one, and J shaped ileal pouch-anal anastomosis in one patient. The distributions of age, sex, and relative body weight were similar in the two groups. The gall bladder bile was lithogenic in the post colectomy group--these patients had a significantly increased cholesterol saturation index (p < 0.01) and rapid cholesterol nucleation time (p < 0.05) compared with the control group. A significant increase in the molar percentage of cholesterol and a decrease in that of total bile acid associated with significantly decreased secondary bile acids (p < 0.05) were observed in the post colectomy group. Gall stones formed in two of six patients after colectomy were cholesterol stones containing more than 80% cholesterol by dry weight. Total and unconjugated bilirubin, pH, and ionised calcium values were similar in the two groups. The results indicate that after total or subtotal colectomy the composition of gall bladder bile increases the risk of cholesterol gall stone formation.

Effect of colectomy on bile composition, cholesterol crystal formation, and gallstones in patients with ulcerative colitis

Bile composition and the presence of cholesterol crystals in bile were studied in bile samples obtained at the time of surgery in patients with ulcerative colitis. Some patients were sampled before colectomy and others at a second operation months to years after a colectomy. Patients in the precolectomy group were found to have bile composition similar to control patients without gallstones, and few had crystals in their bile. In the postcolectomy group, cholesterol concentrations were very high, all biles were supersaturated, and almost all patients had cholesterol crystals in their bile. These findings are similar to those found in persons with cholesterol gallstones. Twenty patients have been followed for at least 3 years after colectomy and to date three have formed cholesterol gallstones.

Bile composition after total proctocolectomy with interposed jejunal segment as neorectum

Changes of bile composition in gallbladder bile and serum chemistries were investigated in nine dogs after proctocolectomy and ileoanal anastomosis, using an interposed jejunal segment as a neorectum. A significant decrease in cholic acid and an increase in deoxycholic acid were observed 24 weeks after the operation, although there was no significant change of total bile acid and phospholipids in the bile. Concentration of cholesterol and cholesterol saturation index in bile increased after total proctocolectomy. Although serum triglyceride levels became lower compared with the nontreated control group, concentrations of total protein, serum cholesterol, total lipids, blood sugar, and electrolytes showed no significant difference. This operative procedure apparently did not impair intestinal absorption of bile acid, but did increase the biliary cholesterol saturation index.