Cardiac complications caused by biliary diseases: A review of clinical manifestations, pathogenesis and treatment strategies of cholecardia syndrome

Global, Regional, National Burden of Gallbladder and Biliary Diseases From 1990 to 2021 and Forecasted Trends by 2040

BACKGROUND AND AIMS

Gallbladder and biliary diseases remain a major contributor to the causes of global disease burden. The study aims to provide updated estimates and projections of the global burden of gallbladder and biliary diseases from 1990 to 2021.

METHOD

We extracted age-standardised prevalence rate (ASPR), incidence rate (ASIR) and disability-adjusted life years rate (ASDR) from the 2021 Global Burden of Disease Study (GBD). We analysed the data by calculating the annual percentage change (EAPC) and stratified the data by sex, across 20 age groups, 21 GBD regions, 204 countries and territories, and five Socio-demographic Index (SDI) quintiles.

RESULT

The global burden remained grim, with a total number of 251 574 857 cases [95% uncertainty interval (UI): 215272108-293 541 994] and an ASPR of 2966.7 per 100 000 persons (95% UI: 2551.7-3447.6) in 2021. The ASIR was 865.4 per 100 000 persons (95% UI: 747.6-1000.8), with the ASDR of 91.7 per 100 000 persons (95% UI: 69.6-122.1). Regionally, Central Europe had both the highest ASPR and ASIR, while Central Latin America showed the highest ASDR. Globally, 35.9% of gallbladder and biliary diseases burden is attributed to high Body mass index (BMI) and 4.8% to smoking. It is projected that by 2040, the global burden of gallbladder and biliary diseases will rise slightly across these main indicators.

CONCLUSION

Although the global prevalence of gallbladder and biliary diseases has been declining over the past 32 years, the severe economic burden caused by it still exists, and there are huge differences between the levels of development of different regions and countries.

Global burden of gallbladder and biliary diseases (1990-2021) with healthcare workforce analysis and projections to 2035

BACKGROUND

Gallbladder and biliary tract diseases pose a significant global health burden, yet comprehensive analyses of their long-term epidemiological trends and future projections remain limited. This study aims to examine the temporal and spatial patterns of these diseases globally from 1990 to 2021, analyze healthcare workforce distribution relative to disease burden, and project the disease burden to 2035.

METHODS

Using data from the Global Burden of Disease Study 2021, we analyzed incidence, prevalence, disability-adjusted life years (DALYs), and mortality for gallbladder and biliary tract diseases. We employed the Estimated Annual Percentage Change (EAPC) to assess trends, decomposition analysis to identify drivers of change, health inequality analysis to evaluate distributional disparities, and the Bayesian Age-Period-Cohort (BAPC) model for projections to 2035. Additionally, we examined correlations between healthcare workforce density and disease burden across countries.

RESULTS

The global age-standardized incidence rate decreased by 12.84% from 1990 to 865.4 per 100,000 population in 2021, while the absolute number of cases increased by 60.11%. Age-standardized prevalence decreased by 13.31%, DALYs by 20.98%, and mortality by 28%. Decomposition analysis revealed that population aging contributed 95.37% and population growth 73.96% to the increase in global deaths, while epidemiological improvements offset 69.33% of this increase. High SDI regions had significantly higher disease burden, with Western Europe showing the highest prevalence (4,009.85 per 100,000). Our healthcare workforce analysis revealed substantial disparities; high-burden Honduras had only 48.3 health workers per 10,000 population (8.4 physicians), while Austria had 385.5 (45.6 physicians), despite similar disease prevalence. Health inequality increased between 1990 and 2021, with the concentration index for mortality rising from 0.24 to 0.31. By 2035, despite decreasing age-standardized rates, the absolute number of cases is projected to increase by 20.3%, DALYs by 26.1%, and deaths by 36.9%, primarily driven by demographic changes.

CONCLUSION

The increasing absolute burden of gallbladder and biliary diseases despite improvements in age-standardized rates necessitates targeted interventions. Health systems should implement enhanced screening programs for high-risk populations, expand surgical workforce capacity in underserved regions, develop region-specific clinical guidelines for early intervention, and adopt policies addressing modifiable risk factors such as obesity and diet. Strategic healthcare workforce planning is crucial, as our analysis revealed significant imbalances in both the density and composition of healthcare personnel relative to disease burden.

Utility of Serum Matrix Metalloproteinase-7 as a Biomarker in Cholestatic Infants with Congenital Heart Disease

BACKGROUND

Matrix metalloproteinase 7 (MMP-7) is a novel biomarker for diagnosis of biliary atresia (BA), the most common cholestatic liver disease in infancy. There is a pressing need to determine the utility of MMP-7 levels in infants with congenital heart disease (CHD) to avoid unnecessary invasive diagnostic procedures in this high-risk population. We investigated the utility of MMP-7 in discriminating BA from non-BA cholestasis in infants with CHD and whether MMP-7 elevation was present in infants requiring treatment for clinically significant PH.

METHODS

This is a single-center cross-sectional study including infants < 180 days of age with cholestasis and serum MMP-7 levels collected from 2019 to 2023. Demographic data and descriptive statistics were summarized with medians with interquartile ranges and frequencies with percentages. Median MMP-7 levels were assessed via Wilcoxon rank-sum test.

RESULTS

A total of 149 patients were included. Patients with CHD had significantly elevated MMP-7 levels relative to the non-CHD cohort (50 vs. 34 ng/mL, p = 0.009). Sub-analysis comparing infants with and without PH revealed significantly elevated median MMP-7 levels in those with clinically significant PH (125 vs. 39 ng/mL, p = 0.010). CHD patients with PH had greater median MMP-7 compared to CHD patients without PH (154 vs 43 ng/mL, p = 0.028).

CONCLUSION

Serum MMP-7 levels in infants with congenital heart disease with cholestasis (CHD-C) were significantly elevated compared to those with cholestasis alone. MMP-7 may help identify non-BA cholestatic infants who have concurrent clinically significant pulmonary hypertension. Larger, prospective studies are needed to validate this finding and establish CHD-specific MMP-7 cut-offs.

Utility of Serum Matrix Metalloproteinase-7 as a Biomarker in Cholestatic Infants with Congenital Heart Disease

Background

Matrix metalloproteinase 7 (MMP-7) is a novel biomarker for diagnosis of biliary atresia (BA), the most common cholestatic liver disease in infancy. There is a pressing need to determine the utility of MMP-7 levels in infants with congenital heart disease (CHD) to avoid unnecessary invasive diagnostic procedures in this high-risk population. We investigated the utility of MMP-7 in discriminating BA from non-BA cholestasis in infants with CHD and whether MMP-7 elevation was present in infants requiring treatment for clinically significant PH.

Methods

This is a single center cross sectional study including infants <180 days of age with cholestasis and serum MMP-7 levels collected from 2019-2023. Demographic data and descriptive statistics were summarized with medians with interquartile ranges and frequencies with percentages. Median MMP-7 levels were assessed via Wilcoxon rank-sum test.

Results

A total of 149 patients were included. Patients with CHD had significantly elevated MMP-7 levels relative to the non-CHD cohort (50 vs. 34 ng/mL, p=0.009). Sub-analysis comparing infants with and without PH revealed significantly elevated median MMP-7 levels in those with clinically significant PH (125 vs. 39 ng/mL, p=0.010). CHD patients with PH had greater median MMP-7 compared to CHD patients without PH (154 vs 43 ng/mL, p=0.028).

Conclusions

Serum MMP-7 levels in infants with CHD-C were significantly elevated compared to those with cholestasis alone. MMP-7 may help identify non-BA cholestatic infants who have concurrent clinically significant pulmonary hypertension. Larger, prospective studies are needed to validate this finding and establish CHD-specific MMP-7 cutoffs.

Cardioprotective Effects of Ursodeoxycholic Acid in Isoprenaline-Induced Myocardial Injury in Rats

Patients suffering from cholelithiasis have an increased risk of developing cardiovascular complications, particularly ischemic myocardial disease. Ursodeoxycholic acid (UDCA), already used in clinical practice for the treatment of cholelithiasis and related conditions, has proven antioxidative, anti-inflammatory, and cytoprotective effects. Therefore, the aim of this study was to investigate the cardioprotective effect of UDCA pre-treatment on isoprenaline-induced myocardial injury in rats. Male Wistar albino rats were randomized into four groups. Animals were pre-treated for 10 days with propylene glycol + saline on days 9 and 10 (control), 10 days with propylene glycol + isoprenaline on days 9 and 10 (I group), 10 days with UDCA + saline on days 9 and 10 (UDCA group), and 10 days with UDCA + isoprenaline on days 9 and 10 (UDCA + I group). UDCA pre-treatment significantly reduced values of high-sensitivity troponin I (hsTnI) and aspartate aminotransferase (AST) cardiac markers (p < 0.001 and p < 0.01, respectively). The value of thiobarbituric acid reactive substances (TBARS) was also decreased in the UDCA + I group compared to the I group (p < 0.001). UDCA also significantly increased glutathione (GSH) levels, while showing a tendency to increase levels of superoxide dismutase (SOD) and catalase (CAT). The level of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) expression, a key regulatory gene of inflammation, was diminished when UDCA was administered. A reduction of cardiac damage was also observed in the UDCA pre-treated group. In conclusion, UDCA pre-treatment showed a cardioprotective effect on isoprenaline-induced myocardial injury in rats, primarily by reducing oxidative stress and inflammation.

Effect of Bile on Hemodynamics and Blood Micro-Rheological Parameters in Experimental Models of Bilhemia

As a rare complication of liver injury and certain interventions, bile can enter the bloodstream depending on the pressure gradient, resulting in bilhemia. Its micro-rheological and hemodynamic effects are still unclear. We aimed to study these parameters in experimental bilhemia models. Under general anesthesia, via laparotomy, bile was obtained by gallbladder puncture from pigs and by choledochal duct cannulation from rats. In vitro, 1 µL and 5 µL of bile were mixed with 500 µL of anticoagulated autologous blood. The systemic effect was also assessed (i.v. bile, 200 µL/bwkg). Hemodynamic and hematological parameters were monitored, and red blood cell (RBC) deformability and aggregation were determined. RBC deformability significantly decreased with the increasing bile concentration in vitro (1 µL: p = 0.033; 5 µL: p < 0.001) in both species. The RBC aggregation index values were concomitantly worsened (1 µL: p < 0.001; 5 µL: p < 0.001). The mean arterial pressure and heart rate decreased by 15.2 ± 6.9% and 4.6 ± 2.1% in rats (in 10.6 ± 2.6 s) and by 32.1 ± 14% and 25.2 ± 11.63% in pigs (in 48.3 ± 18.9 s). Restoration of the values was observed in 45 ± 9.5 s (rats) and 130 ± 20 s (pigs). Bilhemia directly affected the hemodynamic parameters and caused micro-rheological deterioration. The magnitude and dynamics of the changes were different for the two species.