Dietary intake and gallbladder disease: a review

Biliary adverse events in acromegaly during somatostatin receptor ligands: predictors of onset and response to ursodeoxycholic acid treatment

PURPOSE

Somatostatin receptor ligands (SRL) are the first-line medical treatment for acromegaly. Gallbladder alterations are one of most important SRL side effect, but according to some authors growth hormone hypersecretion itself is a risk factor for gallstones. This single center, longitudinal retrospective study evaluated the incidence and the predictors of biliary adverse events (BAE) in acromegaly during SRL therapy and their response to ursodeoxycholic acid (UDCA).

METHODS

91 acromegaly patients with indication to SRL were enrolled. Evaluations of acromegaly activity (GH, IGF-I, IGF-I/ULN) and metabolic profile were collected before starting treatment, yearly during follow-up and at BAE onset. In patients developing BAE we searched for predictors of UDCA effectiveness.

RESULTS

61.5% of patients developed BAE (58.9% cholelithiasis; 41.1% only sludge). IGF-I and IGF-I/ULN proved to be positive predictor of BAE, which occur about 5 years after SRL starting. None of metabolic markers proved to be associated with BAE. Only five patients (5.5%) underwent cholecystectomy for symptomatic cholelithiasis. 71% of patients started UDCA treatment, achieving regression of BAE in 60% of cases (88% in patients developing only sludge and 30% in patients affected by cholelithiasis, p < 0.001). BMI and obesity were negative predictors of UDCA efficacy. In 50% of the subjects BAE resolved after 36 months of therapy with a lower rate if cholelithiasis was present.

CONCLUSION

Biliary stone disease is a frequent SRL adverse event, although it is often symptomless. Ultrasound follow-up mainly in the first 5 years of therapy, early UDCA starting and proper lifestyle represent a valid strategy in their detection and management.

Advances in Risk Factors for Recurrence of Common Bile Duct Stones

Choledocholithiasis is a chronic common disease. The incidence of cholelithiasis is 5%-15%, of which 5%-30% are combined with Choledocholithiasis. Although endoscopic cholangiopancreatography (ERCP) + endoscopic sphincterotomy (EST) is the most common treatment procedure, which clearance rate is up to 95%, the incidence of recurrent choledocholithiasis was 4%-25%. The risk factors of recurrence after choledocholithiasis clearance are the focuses of current researches, which are caused by multiple factors. We first systematically summarize the risk factors of common bile duct stones (CBDS) recurrence into five aspects: first-episode stone related factors, congenital factors, biological factors, behavioral intervention factors, and the numbers of stone recurrence.

Diet and Risk of Cholecystectomy: A Prospective Study Based on the French E3N Cohort

OBJECTIVES

This study aimed to examine the relationship between diet and cholecystectomy risk, using three approaches, in a large French cohort.

METHODS

In a prospective cohort study in French women who completed a food-frequency questionnaire at baseline, we analyzed diet with three approaches: food groups, dietary patterns obtained by factor analysis, and the Mediterranean diet score. The primary outcome was cholecystectomy. We used Cox proportional hazards regression to assess the relationship between diet and cholecystectomy risk, adjusting for the main potential confounders.

RESULTS

During 1,033,955 person years of follow-up, we identified 2,778 incident cases of cholecystectomy. Higher intakes of legumes, fruit, vegetable oil, and wholemeal bread were associated with decreased cholecystectomy risk. Two dietary patterns were identified by factor analysis: "Western" (essentially processed meat, pizza, pies, high-alcohol beverages, French fries, sandwiches…) and "Mediterranean" (essentially fruits, vegetables, seafood, and olive oil). The "Mediterranean" pattern was inversely associated with cholecystectomy risk in the subgroup of postmenopausal women who ever used menopausal hormone therapy (hazard ratio for quartile 4 vs. 1=0.79, 95% confidence interval (CI): 0.65-0.95; P for linear trend=0.008). High adherence to the Mediterranean diet was associated with decreased risk of cholecystectomy (hazard ratio for a 6-9 score vs. 0-3=0.89, 95% CI: 0.80-0.99; P for linear trend=0.02).

CONCLUSIONS

Adherence to a diet rich in fruit, vegetables, legumes, and olive oil was associated with a reduction in cholecystectomy risk in French women. Further studies in different settings are requested.

Risk Factors for Cholelithiasis

Gallstone disease is one of the most common public health problems in the United States. Approximately 10%-20% of the national adult populations currently carry gallstones, and gallstone prevalence is rising. In addition, nearly 750,000 cholecystectomies are performed annually in the United States; direct and indirect costs of gallbladder surgery are estimated to be $6.5 billion. Cholelithiasis is also strongly associated with gallbladder, pancreatic, and colorectal cancer occurrence. Moreover, the National Institutes of Health estimates that almost 3,000 deaths (0.12% of all deaths) per year are attributed to complications of cholelithiasis and gallbladder disease. Although extensive research has tried to identify risk factors for cholelithiasis, several studies indicate that definitive findings still remain elusive. In this review, predisposing factors for cholelithiasis are identified, the pathophysiology of gallstone disease is described, and nonsurgical preventive options are discussed. Understanding the risk factors for cholelithiasis may not only be useful in assisting nurses to provide resources and education for patients who are diagnosed with gallstones, but also in developing novel preventive measures for the disease.

The relationship between different dimensions of alcohol use and the burden of disease-an update

BACKGROUND AND AIMS

Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs).

METHODS

Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others.

RESULTS

In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently.

CONCLUSIONS

Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

The relationship between different dimensions of alcohol use and the burden of disease-an update

BACKGROUND AND AIMS

Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs).

METHODS

Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others.

RESULTS

In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently.

CONCLUSIONS

Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

Vegetable protein intake is associated with lower gallbladder disease risk: Findings from the Women's Health Initiative prospective cohort

OBJECTIVE

This study aimed to measure associations between gallbladder disease and protein intake patterns, separated by quantity and type (vegetable vs. animal), among postmenopausal women.

METHODS

Analyses were based on 130,859 postmenopausal women enrolled from 1993 to 1998 at 40 U.S. clinical centers in the Women's Health Initiative clinical trials and observational study. Women were excluded if they reported a history of gallbladder disease prior to baseline. Cox proportional hazards regression models, adjusted for gallbladder disease risk factors, were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between energy-adjusted protein intake and gallbladder disease.

RESULTS

In this study sample, 8.1% of postmenopausal women self-reported incident gallbladder disease. In multivariate analysis, women in the highest quintile of energy-adjusted vegetable protein intake (>24.0g/d) had a lower risk of gallbladder disease (HR, 0.87; 95% CI, 0.81-0.93) as compared to women in the lowest quintile (<16.3g/d) (Ptrend<0.001). Total protein intake was modestly protective against gallbladder disease (Ptrend<0.021). Animal protein intake was not associated with gallbladder disease risk. The protective effect of vegetable protein held stable only for women without history of diabetes (HR, 0.86; 95% CI, 0.80-0.92) and without recent weight loss (HR, 0.88; 95% CI, 0.80-0.97).

CONCLUSIONS

Vegetable protein intake is inversely associated with gallbladder disease risk in our sample of postmenopausal women. In addition to weight management, healthcare providers could emphasize vegetable protein as an additional dietary modality to promote lower risk for gallbladder disease.

A nested case-control study on dietary fat consumption and the risk for gallstone disease

BACKGROUND

Gallstone disease (GD) incidence and prevalence rates differ between populations. Diet and lifestyle may be involved in GD development. To our knowledge, no study to date has evaluated quantitative data on diet when studying the relationship between fat consumption levels and GD in an Argentinean population. The present study aimed to assess the association between dietary fat intake and GD.

METHODS

A nested case-control study design was applied. Data were taken from subjects who participated in a previous cross-sectional study carried out in a random sample of asymptomatic people in Rosario, Argentina. Participants underwent a personal interview, and current weight and height, ancestor's ethnicity, and socio-economic status were recorded. Applying a food-frequency questionnaire and a food photography atlas, quantitative dietary data were estimated by combining the intake frequency, portion size and food composition. Logistic regression analysis was used to compute odds ratios and 95% confidence intervals adjusted by age, sex, ancestor's ethnicity, body mass index and daily total energy intake as potential confounders.

RESULTS

In total, 114 patients were studied (49 cases and 65 controls), without any statistically significant differences for age, sex, socio-economic status, body mass index and ancestry. The mean energy intake was higher in cases than in controls, and significant differences were found for dietary fat consumption. Obese or overweight people have a higher GD risk than subjects with normal weight. Increased GD risks were associated with high intakes of energy, total fat, and saturated and monounsaturated fatty acids.

CONCLUSIONS

According to our results, total fat, saturated and monounsaturated fatty acids high intakes are associated with increased GD risk.

Epidemiology of gallbladder disease: cholelithiasis and cancer

Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.

Somatostatin analogs and gallstones: a retrospective survey on a large series of acromegalic patients

CONTEXT

Development of gallstones (GS) is reported during the use of somatostatin analogs (SA) that are at present the mainstay for the medical treatment of acromegaly.

OBJECTIVE

To review the prevalence and clinical and biochemical correlates of GS in acromegalic patients.

DESIGN AND SETTING

Retrospective survey on hospital records in acromegalic patients followed up in the last 20 yr in tertiary referral centers.

PATIENTS

Four hundred and fifty-nine patients (272 females).

MAIN OUTCOME MEASURES

According to SA use and GS occurrence, patients were divided in 4 groups: 1) treated with SA without GS (SA+GS-), 2) GS developed while on SA (SA+GS+), 3) GS without SA use (SA-GS+), 4) neither GS nor SA (SA-GS-).

RESULTS

Patients were unevenly distributed in the 4 groups: 232, 125, 38, 64, respectively, pointing to a prevalence of GS in acromegaly of 8.3% at diagnosis with an additional 35% developing GS during SA. GS occurred after 3 months-18 yr (median 3 yr) of SA treatment, were diagnosed after symptoms in 17.6%, were associated to steatosis, ultrasound biliary dilation, and biochemical cholestasis, in 25.6%, 12.8%, and 4% of patients, respectively. Ursodehoxicolic acid was administered after GS occurrence, causing their dissolution in 39% of patients after 3-48 months (median 12). Cholecystectomy was performed in 16.8%of patients in group 2. At multivariate analysis obesity, dyslipidemia, and SA treatment were independent predictors of GS onset, whereas gender and age were not.

CONCLUSIONS

GS are a frequent occurrence in acromegalic patients treated with SA, may occur at any time, but are seldom symptomatic or prompt acute surgery. Obesity and dyslipidemia appear to play a major role in the occurrence of GS in acromegalic patients on SA treatment.

Calcium carbonate gallstones in children

BACKGROUND

In the United States, cholesterol stones account for 70% to 95% of adult gallstones and black pigment stones for most of the remainder. Calcium carbonate stones are exceptionally rare. A previous analysis of a small number of pediatric gallstones from the north of England showed a remarkably high prevalence of calcium carbonate stones. The aims of this study were to analyze a much larger series of pediatric gallstones from our region and to compare their chemical composition with a series of adult gallstones from the same geographic area.

METHODS

A consecutive series of gallbladder stones from 63 children and 50 adults from the north of England were analyzed in detail using Fourier transform infrared microspectroscopy. Demographic and clinical data were collected on all patients. The relative proportions of each major stone component were assessed: cholesterol, protein and calcium salts of bilirubin, fatty acids, calcium carbonate, and hydroxyapatite.

RESULTS

Thirty-nine (78%) adults had typical cholesterol stones, 7 (14%) had black pigment bilirubinate stones, and only 2 (4%) had calcium carbonate stones. In contrast, 30 (48%) children had black pigment stones, 13 (21%) had cholesterol stones, 15 (24%) had calcium carbonate stones, 3 (5%) had protein dominant stones, and 2 (3%) had brown pigment stones. In children, cholesterol stones were more likely in overweight adolescent girls with a family history of gallstones, whereas black pigment stones were equally common in boys and girls and associated with hemolysis, parenteral nutrition, and neonatal abdominal surgery. Calcium carbonate stones were more common in boys, and almost half had undergone neonatal abdominal surgery and/or required neonatal intensive care.

CONCLUSION

The composition of pediatric gallstones differs significantly from that found in adults. In particular, one quarter of the children in this series had calcium carbonate stones, previously considered rare. Geographic differences are not the major reason for the high prevalence of calcium carbonate gallstones in children.

Variation in the risk for liver and gallbladder cancers in socioeconomic and occupational groups in Sweden with etiological implications

OBJECTIVES

To examine the associations between socioeconomic/occupational factors and liver cancer at various anatomic sites (including primary liver, gallbladder and other cancers).

METHODS

We carried out a follow-up study on the economically active Swedish population, based on the Swedish Family-Cancer Database. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated in different social classes and occupations.

RESULTS

For primary liver cancer, farmers were at a decreased risk; increased risks were observed for male sales agents, journalists, seamen, waiters, cooks and female beverage manufacture workers. Similar patterns were observed for gallbladder cancer; workers employed as journalists, sales agents, cooks and stewards, and public safety workers showed increased risk. Only male transport workers showed increased risk of cancers in other parts.

CONCLUSIONS

Occupations with high consumption of alcohol and/or high prevalence of smoking associated with a risk of liver and gallbladder cancers. The present study suggests that the effects of socioeconomic factors on liver cancer of different subsites are similar; alcohol drinking is a risk factor of gallbladder cancer because of the covariation of primary liver and gallbladder cancers in occupational groups.

Lifestyle, parity, menstrual and reproductive factors and risk of gallbladder cancer

Together with thyroid cancer, cancer of the gallbladder is the only non-sex hormone-related cancer displaying a female preponderance, with incidence being 3-4 times more common among women. We carried out this study to evaluate the role of menstrual, reproductive and lifestyle factors in gallbladder carcinogenesis. A case-control study involving 64 newly diagnosed cases of gallbladder cancer and 101 cases of cholelithiasis was carried out. A detailed menstrual and reproductive history was illustrated beside detailed lifestyle history, in particular consumption of betel nut, tobacco and alcohol and smoking, odds ratio was calculated. Mean age of the patients with cancer was 51+/-1.2 years while it was 40.9+/-1.2 years for gallstones; 69% of cancer patients and 90% of gallstones patients were females. More than half of the cancer patients (53%) and 43% of the gallstone patients were illiterate. A past history of typhoid was present in 22% of cancer patients and 13% of gallstone patients, while 35% of cancer and 25% of gallstone patients were chewers, 18.1 and 9.9% were smokers, and 10% of cancer and 2% of gallstone patients consumed alcohol. Mean age of menarche was 13.4+/-1.2 years among female patients with cancer while it was 14.0+/-1.4 years for gallstone patients. Higher age at menarche (>13 years, OR 2.48, 95% confidence interval (CI) 1.16-5.3), higher number of childbirths(>3 births, OR 3.92; 95% CI 1.4-10.3), higher number of pregnancies (>3 pregnancies, OR 6.66, 95% CI 1.8-23.4), and higher age at last childbirth (>25 years, OR 2.97, 95% CI 1.04-8.5) were found to have significantly higher risk of developing gallbladder cancer. In conclusion, tobacco chewing and smoking are associated with increased odds of gallbladder cancer. Similarly early menarche, late menopause, multiple pregnancies and childbirth increased the risk of gallbladder cancer.

Risk factors for gallbladder cancer: a reappraisal

Carcinoma of the gallbladder has a very unusual geographical distribution with pockets of high incidence seen in Chile, Poland, India, Japan and Israel; it occurs rarely in the rest of the world. It is a common malignancy in the Western Bihar and Eastern Uttar Pradesh regions of India. Patients present with extremes of clinical symptoms, indicating benign biliary diseases on the one hand and incurable malignant disease on the other. Laboratory and roentgenographic data tend to confirm the clinical diagnosis of the advanced incurable disease at presentation, in most cases. Various aetiopathological agents have been proposed but none has stood the test of time. In this article, we have reviewed the aetiopathological agents proposed from time to time over the past two centuries, with special emphasis on the developments made in the last 25 years.