Evaluation of gallbladder motility in patients with liver cirrhosis: relationship to gallstone formation

Associations of gallbladder and gallstone parameters with clinical outcomes in patients with cirrhosis

Background

Morphologic changes in the gallbladder and gallstones are common in cirrhotic patients, but their associations with outcomes of cirrhotic patients are unclear.

Methods

We retrospectively enrolled 206 cirrhotic patients and measured their gallbladder length and width, gallbladder wall thickness, presence of gallstones, and gallstones’ length and width in axial contrast-enhanced computed tomography (CT) images. X-tile software was utilized to calculate the optimal cutoff values of these parameters for evaluating survival and hepatic decompensation events in the cirrhosis group. Their associations with survival were explored by Cox regression analyses and Kaplan–Meier curve analyses. Their associations with hepatic decompensation events were evaluated by competing risk analyses and Nelson-Aalen cumulative risk curve analyses where death was a competing event.

Results

Cirrhotic patients with gallbladder length < 72 mm had a significantly higher cumulative survival rate than those with a length of ≥ 72 mm (P = 0.049 by log-rank test), but gallbladder width, gallbladder wall thickness, presence of gallstones, and gallstones’ length and width were not significantly associated with survival (P = 0.10, P = 0.14, P = 0.97, P = 0.73, and P = 0.73 by log-rank tests, respectively). Cirrhotic patients with gallbladder wall thickness < 3.4 mm had a significantly lower cumulative rate of hepatic decompensation events than those with a wall thickness of ≥ 3.4 mm (P = 0.02 by Gray’s test), but gallbladder length and width, presence of gallstones, and gallstones’ length and width were not significantly associated with hepatic decompensation events (P = 0.15, P = 0.15, P = 0.54, P = 0.76, and P = 0.54 by Gray’s tests, respectively).

Conclusion

Changes in gallbladder length and gallbladder wall thickness, rather than gallstone parameters, may be in parallel with the long-term outcomes of cirrhotic patients.

Analysis of risk factors for the increased incidence of gallstone caused by hepatectomy: A retrospective case-control study

Background

An increased risk of gallstones has been observed in patients undergoing hepatectomy. This study attempted to analyze the risk factors for gallstones after hepatectomy.

Methods

From January 2013 to December 2016, clinical data of 1,452 eligible patients who underwent hepatectomy were consecutively reviewed. According to the imaging, including gallbladder ultrasound, computerized tomography, and magnetic resonance imaging, all patients were divided into the gallstone group and the nongallstone group. Univariate and multivariate logistic regression analyses were performed to select indicators associated with gallstone formation among patients after hepatectomy.

Results

In the total sample of included patients, there were 341 patients with gallstones and 1,147 patients without gallstones. The incidence of gallstones was 23.5% (341/1,452). The incidence of gallstones in the primary liver cancer group was higher than that in the benign liver tumor group (25.7% vs. 18.9%, P = 0.004). Univariate and multivariate logistic regression analyses showed that female gender, high body mass index, tumor located in S5, and severe postoperative complication were factors related to gallstones in patients with benign liver tumors after hepatectomy. In addition, Child-Pugh B, low albumin, liver cirrhosis, and transcatheter arterial chemoembolization (TACE) after recurrence were factors related to gallstones in patients with primary liver cancer after hepatectomy.

Conclusions

Hepatectomy increased the risk of gallstones in benign or malignant liver tumors, especially when the tumor was located in S5. TACE further increased the risk of gallstones in patients with postoperative recurrence.

Gallstone Disease in Cirrhosis-Pathogenesis and Management

Gallstones are more common in patients with cirrhosis of the liver, and the incidence increases with severity of liver disease. Pigment stones are the most frequent type of gallstones (GSs) in cirrhotics, and majority remain asymptomatic. Hepatitis C virus infection and nonalcoholic fatty liver disease are the underlying etiologies of liver diseases that most often associated with GSs. Multiple altered mechanisms in cirrhosis such as chronic hemolysis due to hypersplenism, reduced bile acid synthesis and transport, decreased cholesterol secretion, decreased apolipoprotein A-I and A-II secretion, gallbladder hypo-motility, autonomic dysfunction, and portal hypertension collectively lead to increased risk of lithogenesis. Asymptomatic GSs should be followed up closely and offered laparoscopic cholecystectomy once symptomatic in Child-Pugh class A and B patients. The model for the end-stage liver disease score is the best predictor of the outcome after cholecystectomy. In patients of Child-Pugh class C, conservative or minimally invasive approaches should be used to treat complications of GSs.

Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery?

Acute cholecystitis and several gallbladder stone-related conditions, such as impacted common bile duct stones, cholangitis, and biliary pancreatitis, are common medical conditions in daily practice. An early cholecystectomy or drainage procedure with delayed cholecystectomy is the current standard of treatment based on published clinical guidelines. Cirrhosis is not only a condition of chronically impaired hepatic function but also has systemic effects in patients. In cirrhotic individuals, several predisposing factors, including changes in the bile acid composition, increased nucleation of bile, and decreased motility of the gallbladder, contribute to the formation of biliary stones and the possibility of symptomatic cholelithiasis, which is an indication for surgical treatment. In addition to these predisposing factors for cholelithiasis, systemic effects and local anatomic consequences related to cirrhosis lead to anesthesiologic risks and perioperative complications in cirrhotic patients. Therefore, the treatment of the aforementioned biliary conditions in cirrhotic patients has become a challenging issue. In this review, we focus on cholecystectomy for cirrhotic patients and summarize the surgical indications, risk stratification, surgical procedures, and surgical outcomes specific to cirrhotic patients with symptomatic cholelithiasis.

Right posteroinferior bile duct angulation correlates with bile duct stone occurrence in patients with hepatolithiasis

PURPOSE

This study aimed to examine the correlation between right posteroinferior bile duct (RPBD) angulation and the occurrence of bile duct stones in patients with hepatolithiasis.

METHODS

Patients presenting with hepatolithiasis in our hospital from January 2011 to July 2016 were divided into two groups according to whether their RPBD was affected by stones. A statistical analysis for the relevant factors associated with bile duct stone formation in the RPBD was performed.

RESULTS

The binary logistic regression results showed that stenosis of the right hepatic duct [odds ratio (OR): 7.313; 95% confidence interval (CI) 4.131-12.945)] and the angle of the RPBD (OR 0.896; 95%CI 0.877-0.916) were risk factors associated with the formation of RPBD stones. Further, the receiver operating characteristic curve indicated that, when the angle of the RPBD was less than 44.58°, stones were able to form more easily in the RPBD.

CONCLUSION

The occurrence of bile duct stones is well correlated with sharp bile duct angulation.

Frequency of gallstones and mean BMI in decompensated cirrhosis

Introduction

The aim of the study was to determine the frequency of gallstones in patients with decompensated cirrhosis and to know about mean Body mass index (BMI) in patients of decompensated cirrhosis i.e End stage liver disease (ESLD) with and without gallstones.

Methods

it is a cross sectional descriptive study, conducted at the department of Hepato-gastroenterology, Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1^st August 2014 to 28 February 2015. Two hundred patients were enrolled from outpatient clinics of Hepato-gastroenterology that fulfilled the defined selection criteria. Questionnaire was filled for data collection. SPSS version 20.0 was used to analyze data. Mean value of age and BMI was calculated by mean ± S.D. values. Mean ± SD was also calculated for BMI in patients with and without gallstones. Stratification of the age, gender, and liver disease severity were done and chi-Square test was applied. p-values less than 0.05 considered statistically significant.

Results

Two hundred consecutive patients were enrolled among them 112(56%) were male. Mean age was 46.89 ± 11.9, BMI 23.59 ± 4.7 and CTP score was 9.7 ± 1.9. Most of the patient had Child class 'B' cirrhosis 102(51%), most common etiology was found to be Hepatitis C 133 (66.5%), cholelithiasis was found in 59(29.5%), sludge in 36 (18%) and both stone and sludge in 24(12%) of the cases. Advanced liver disease that is, more CTP score and child class 'C' was associated with increased frequency of gall stone formation (p-value = 0.012), and advancing age on age stratification (p-value = 0.024) however no relation was observed with increase BMI, gender, ethnicity, cause or duration of disease in this population.

Conclusion

Gallstone formation is associated with advanced stage of cirrhosis and hepatitis C Virus related CLD, contrary to the established risk factors, no relation of gender or BMI was found in decompensated liver disease.

Effects of gender and age on prevalence of cholelithiasis in patients with chronic HCV infection: A community-based cross-sectional study in an HCV-hyperendemic area

This study investigated the effects of age and gender on the prevalence of cholelithiasis in patients with chronic HCV infection.Demographic and clinical data of 8489 subjects (3671 males, 4818 females; mean age 47.5 years) receiving township-wide health examinations between September 2012 and August 2013 were analyzed. The main endpoint was prevalence of cholelithiasis. Risk factors (age, gender, body mass index, concomitant diseases, lifestyle, laboratory parameters, and HCV status) were evaluated. Univariate and multivariate logistic regression analyses were performed to identify associations between cholelithiasis and variables.Cholelithiasis was more prevalent among HCV subjects than non-HCV subjects (females: 8.1% vs 4.2%; males: 9.1% vs 3.9%; both P < .001); rates ranged from 5.6% to 8.3% in females and 4.7% to 10.6% in males. HCV status and age were associated with cholelithiasis occurrence (OR = 2.17 for HCV vs non-HCV; OR = 2.44, 3.54 for age 45-55, and >55 vs <45 years; all P < .05). Multivariate analysis showed a significant association between cholelithiasis and age/sex interaction terms (OR = 0.517 for age >55 vs <45 for sex; P = .011). Cholelithiasis prevalence was significantly associated between age and sex interaction terms but not anymore if considering positive HCV status. All noninvasive tests for liver fibrosis were associated with cholelithiasis but only fibrosis-4 index was significantly associated (OR = 1.28, P = .019).Age, gender, and HCV infection are associated with increased risk and prevalence of cholelithiasis. After age of 55 years, cholelithiasis is more prevalent among HCV-positive males than females. Females of age 55 and more may be protected against cholelithiasis as sex hormones decrease.

Hepatitis C Virus Infection Increases Risk of Gallstone Disease in Elderly Chinese Patients with Chronic Liver Disease

We investigated possible links between the etiology of liver disease and gallstone risk in Chinese patients with chronic liver disease (CLD). We compared the outcomes of 267 Chinese CLD patients with gallstones and those of a control group of 1,015 CLD patients without gallstones. Logistic regression analyses adjusting for demographic features and other gallstone risk factors revealed that liver cirrhosis increased the risk of gallstone development twofold [adjusted odds ratio (AOR); 95% confidence interval (95% CI): 2.343 (1.710–3.211)]. HCV infection increased gallstone risk 1–2-fold [AOR; 95% CI: 1.582 (1.066–2.347)] higher than did HBV infection. Multivariate analyses of the risk of developing gallstones in patients with liver cirrhosis after an HCV or HBV infection yielded an estimated AOR (95% CI) of 1.601 (1.063–2.413) in patients with an HCV infection. In elderly patients with CLD (≥60 years of age), gallstone risk also increased significantly after an HCV infection [AOR (95% CI): 2.394 (1.066–5.375)]. HCV infection, older age, and liver cirrhosis significantly correlate with an increased risk of gallstone development in Chinese patients with CLD. HCV infection further increases this risk in both patients with liver cirrhosis and in elderly CLD patients (≥60 years of age).

Outcome Analysis of Patients with Gallstone Disease Receiving Cholecystectomy: A Population-Based Cohort Study

BACKGROUND/AIMS

Cholecystectomy is generally performed to treat patients with gallstone disease (GSD) in clinical practice. The present study aimed to investigate whether type 2 diabetes mellitus (T2DM) may influence the overall survival of GSD patients.

METHODS

The National Health Insurance Research Database, a population-based registry data in Taiwan, was used to identify GSD patients from 2001 to 2008. The risk of cancers and effects of T2DM on the overall survival of GSD patients receiving cholecystectomy were estimated by hazards ratios (HRs) and 95% CIs using the Cox proportional hazard model.

RESULTS

Among 392,028 eligible GSD patients, 81,971 underwent cholecystectomy, whereas 310,057 did not. After cholecystectomy, the HR for developing cancer was 1.14. The HR for the overall survival was 0.74-fold lower for patients who underwent cholecystectomy than that for patients who did not. GSD patients without T2DM who underwent cholecystectomy (0.78-fold lower risk) had a longer survival, whereas those with T2DM had shorter survival (1.64-fold higher risk without cholecystectomy and 1.13-fold higher risk with cholecystectomy) compared with those without T2DM who did not undergo cholecystectomy.

CONCLUSIONS

Our major findings suggest that T2DM may worsen the prognosis of GSD patients after cholecystectomy, which provides useful insight into the treatment of T2DM among GSD patients in clinical settings.

Hepatitis C Virus Infection Is Positively Associated with Gallstones in Liver Cirrhosis

AIM

To elucidate the prevalence and risk factors of gallstone disease (GD) among patients with liver disease and explore their association with the aetiology and severity of hepatic injury.

METHODS

We analysed 4,832 subjects of hepatic injury induced by one of the following aetiologies: hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, excessive alcohol consumption. The risk factors significantly associated with GD were analysed using stepwise logistic regression analysis, the influence of aetiology and severity of liver disease on the prevalence of GD were assessed by multiple logistic regression analysis adjusting for confounding factors.

RESULTS

Three thousand forty eight patients were of positive HBV surface antigen alone with a prevalence of GD of 18.6%, 526 were tested as positive Anti-HCV alone with a prevalence of GD of 22.4%, and 1,258 were identified with excessive alcohol consumption patterns with a prevalence of GD of 13.5%. In each aetiological category, the prevalence of GD increased by age. Stepwise logistic regression analysis showed that age, female, low-density lipoprotein-cholesterol (LDL-Cho), family history of GD, HBV infection, HCV infection, chronic hepatitis and cirrhosis were independent factors associated with GD. After adjusting for age, LDL-Cho and family history of GD, the prevalence of gallstone disease was significantly associated with HCV-related cirrhosis in both genders, HBV-related cirrhosis in males and alcohol-related cirrhosis in females compared with patients with less severe liver disease [corrected]. After adjusting for gender, age, LDL-Cho and family history of GD, patients with HCV-related cirrhosis (OR 2.66, 95% CI 1.49-3.84) but not HBV-related cirrhosis (OR 1.52, 95% CI 0.73-1.82) were more likely to have GD compared with alcohol-related cirrhosis.

CONCLUSION

HCV infection is positively associated with gallstone formation especially in those with cirrhosis patients.

Gallstones in Patients with Chronic Liver Diseases

With prevalence of 10-20% in adults in developed countries, gallstone disease (GSD) is one of the most prevalent and costly gastrointestinal tract disorders in the world. In addition to gallstone disease, chronic liver disease (CLD) is also an important global public health problem. The reported frequency of gallstone in chronic liver disease tends to be higher. The prevalence of gallstone disease might be related to age, gender, etiology, and severity of liver disease in patients with chronic liver disease. In this review, the aim was to identify the epidemiology, mechanisms, and treatment strategies of gallstone disease in chronic liver disease patients.

Does Gallbladder Wall Thickening of Cirrhotic Patients Increase the Risk of Formation of Gallstones?

The objective of this study was to investigate whether gallbladder wall thickening in cirrhotic patients adds risk to the formation of gallstones. In this retrospective study, 259 patients with cirrhosis resulting from hepatitis B or hepatitis C were included (152 men, 107 women; mean ± SD, age 48.8 ± 11.4 years [range, 29–77 years]) and compared with 300 healthy participants comprising the control group. All participants had a standard abdominal sonographic assessment. The prevalence of gallstones in cirrhotic patients with and without gallbladder wall thickening was studied, and the distribution of gallstones and gallbladder wall thickening in different Child-Pugh classes was compared. The prevalence of gallstones in cirrhotic patients, cirrhotic patients with and without gallbladder wall thickening, and healthy participants was 27.4%, 28.8%, 13.0%, and 5.3%, respectively. The prevalence of gallstones in cirrhotic patients with gallbladder wall thickening was not significantly higher than in those without gallbladder wall thickening ( P > .05). Gallbladder wall thickening occurred with a higher frequency in Child-Pugh B and C patients, and normal thickness of the gallbladder wall was seen more frequently in Child-Pugh A patients ( P < .05). Gallstones were found more frequently in Child-Pugh A and C patients ( P < .05). In conclusion, gallbladder wall thickening in cirrhotic patients does not significantly add any risk for the formation of gallstones.

Impaired gallbladder motility and the effect of metformin therapy in patients with polycystic ovary syndrome

OBJECTIVE

  Impaired gallbladder (GB) emptying is a well-documented contributor to gallstone formation. The aim of this study was to evaluate GB motility in patients with polycystic ovary syndrome (PCOS).

METHODS

  The study population consisted of 36 PCOS patients and 20 healthy controls. GB volume was calculated using the ellipsoid formula (π/6 × L × D × W) after three-dimensional measurements were made by ultrasound [length (L), width (W) and depth (D)]. Following the determination of fasting GB volume (V0), patients were given a standard liquid meal. GB volume measurement was then repeated after 10, 20, 30, 40, 50, 60, 75 and 90 min. Gallbladder ejection fraction (GBEF) was calculated after each measurement. PCOS patients were re-evaluated after a 12-week course of metformin therapy at a dose of 1000 mg/day.

RESULTS

  Mean baseline GB volume (V0) was significantly higher in the patient group compared to the control group (27·2 ± 12·5 cm(3) vs 13·3 ± 7·0 cm(3) , P < 0·001). While baseline GBEF values were similar between groups, increases in GBEF were significantly lower in the PCOS group starting from 20 min after consumption of a standard test meal. A 12-week course of metformin therapy resulted in significant improvements in GB volume and GBEF values with a reversal of metabolic and hormonal abnormalities.

CONCLUSION

  For the first time in the literature, we managed to demonstrate impaired GB motility in patients with PCOS. Metformin therapy not only improves the metabolic and hormonal imbalances associated with PCOS but also has a positive influence on GB motility.

Hepatitis C virus infection is a risk factor for gallstone disease: a prospective hospital-based study of patients with chronic viral C hepatitis

We evaluated the prevalence and the risk factors for gallstone disease in patients with chronic hepatitis C infection. We investigated 453 consecutively admitted patients with chronic infection with hepatitis C virus (HCV) (cirrhosis excluded) and 879 patients without liver disease (October 2006-April 2007). Gallstone disease was diagnosed if gallstones were present at ultrasonography or if there had been a previous cholecystectomy. Variables evaluated were age, gender, gallstone heredity, body mass index, waist circumference, parity, serum lipids, fatty liver, arterial hypertension, diabetes mellitus and metabolic syndrome (International Diabetes Federation criteria). Informed consent was obtained from all patients. We found that 88 of 453 (19%) patients with chronic HCV hepatitis (age 50.1 +/- 11.7 years) and 153 of 879 (17%) controls (age 60.6 +/- 12.6 years) had gallstone disease (GD). Abdominal obesity (OR = 2.108, 95% CI 1.287-3.452) and steatosis (OR = 3.699, 95% CI 2.277-6.008) were risk factors for GD in HCV patients. Gallstone heredity, dyslipidaemia, type 2 diabetes mellitus and metabolic syndrome increased the risk for GD in controls vs HCV patients. Our study shows that even HCV patients with chronic hepatitis but not cirrhosis have an increased prevalence of gallstones. Compared with controls, gallstones are present in HCV patients at a younger age and are associated with central obesity and liver steatosis, but not with gallstone heredity, dyslipidaemia, diabetes mellitus or metabolic syndrome. Although we could not establish a temporal relationship, the association between HCV infection and gall stone disease is real and appears to be causally linked, at least in predisposed individuals (obese and with liver steatosis).

The prevalence and risk factors for gallstone disease

Gallstone disease is one of the most prevalent gastrointestinal disorders. In addition, the costs associated with the diagnosis and treatment of gallstone disease have been rapidly increasing. The etiology and pathogenesis of gallstone disease remains incompletely understood. Gallstone formation may result from a complex interaction of genetic and environmental factors. This article reviews the prevalence and risk factors associated with gallstone disease. Understanding the pathogenesis of gallstone disease could lead to the development of better therapeutic and preventive strategies for dealing with this disease.

Ultrasonographic study of gallbladder wall thickness and emptying in cirrhotic patients without gallstones

Background and Aim. Gallbladder wall thickening and impaired contractility are currently reported in cirrhotic patients and often related to portal hypertension and hepatic failure. The purpose of this work was to evaluate, by ultrasonographic method, gallbladder wall thickness and gallbladder emptying after a standard meal in normal subjects and in patients with compensated liver cirrhosis without gallstones. Methods. Twenty-three patients with Child-Pugh class A liver cirrhosis and twenty healthy controls were studied. Gallbladder wall thickness (GWT), gallbladder fasting volume (FV), residual volume (RV), and maximum percentage of emptying (%E) were calculated. Measurements of mean portal velocity, portal vein flow, and serum albumin were performed too. Statistical analysis was assessed by Student's “t test” for unpaired data. Results. GWT was 0.60 ± 0.22 cm in cirrhotic patients and 0.21 ± 0.06 cm in controls (P < .0001). FV and RV were, respectively, 37.8 ± 3.7 cm³ and 21.8 ± 3 cm³ in cirrhotic patients, 21.9 ± 4.2 cm³ and 4.6 ± 2.2 cm³ in healthy volunteers (P < .0001). %E was smaller in cirrhotics (42.6 ± 7.8) as compared to controls (80.3 ± 7.2; P < .0001). Conclusions. In patients with compensated liver cirrhosis without gallstones gallbladder wall thickness is increased whereas its contractility is reduced. These early structural and functional alterations could play a role in gallstone formation in more advanced stages of the disease.

Coordinate regulation of gallbladder motor function in the gut-liver axis

Gallstones are one of the most common digestive diseases with an estimated prevalence of 10%-15% in adults living in the western world, where cholesterol-enriched gallstones represent 75%-80% of all gallstones. In cholesterol gallstone disease, the gallbladder becomes the target organ of a complex metabolic disease. Indeed, a fine coordinated hepatobiliary and gastrointestinal function, including gallbladder motility in the fasting and postprandial state, is of crucial importance to prevent crystallization and precipitation of excess cholesterol in gallbladder bile. Also, gallbladder itself plays a physiopathological role in biliary lipid absorption. Here, we present a comprehensive view on the regulation of gallbladder motor function by focusing on recent discoveries in animal and human studies, and we discuss the role of the gallbladder in the pathogenesis of gallstone formation.

HCV infection is a risk factor for gallstone disease in liver cirrhosis: an Italian epidemiological survey

We assessed the prevalence of gallbladder disease (i.e. gallstones plus cholecystectomy) among patients with liver disease and its association with the severity and aetiology of hepatic injury. Subjects, referred to 79 Italian hospitals, were enrolled in a 6-month period. The independent effect of the severity and aetiology of liver disease on gallstone disease prevalence was assessed by multiple logistic regression analysis. Overall, 4867 subjects tested anti-hepatitis C virus (HCV) positive alone, 839 were hepatitis B virus surface antigen (HBsAg) alone, and 652 had an excessive alcohol intake. The prevalence of gallstone disease was 23.3% in anti-HCV-positive patients, 12.4% in HBsAg positive and 24.2% in subjects reporting excessive alcohol intake, respectively. Gallstone disease prevalence increased by age in each aetiological category. The proportion of patients with gallstone disease who had a cholecystectomy was the highest in HCV+ subjects. After adjusting for the confounding effect of age and body mass index, compared with patients with less severe liver disease, subjects with HCV-related cirrhosis, but not those with alcohol-related cirrhosis, were more likely to have gallstone disease. Subjects with HCV-related cirrhosis (OR 2.13, 95% CI: 1.38-3.26) were more likely to have gallstone disease when compared with those with HBV-related cirrhosis. HCV infection is a risk factor for gallstone disease. In Italy, the high prevalence of HCV infection among cirrhotic patients has important implications, as cholecystectomy in these subjects is associated with high risk of morbidity and mortality.

Biliary tract cancer and stones in relation to chronic liver conditions: A population-based study in Shanghai, China

Biliary tract cancers are relatively rare but fatal tumors. Apart from a close link with gallstones and cholangitis, risk factors for biliary tract cancer are obscure. Chronic liver conditions, including liver cirrhosis, have been linked to a higher risk of biliary tract cancer. In a population-based case-control study conducted in Shanghai, China, we investigated the relationships of a history of chronic hepatitis and liver cirrhosis as well as a family history of liver cancer with biliary tract cancer risk. The study included 627 patients with biliary tract cancers (368 gallbladder, 191 bile duct and 68 ampulla of Vater), 1,037 patients with biliary stones (774 gallbladder stones and 263 bile duct stones) and 959 healthy subjects randomly selected from the population. Bile duct cancer was associated with self-reports of chronic liver conditions, including a history of chronic hepatitis (OR = 2.0, 95% CI 0.9-4.4), liver cirrhosis (OR = 4.7, 95% CI 1.9-11.7) and a family history of primary liver cancer (OR = 2.0, 95% CI 1.0-3.9). The excess risk persisted after adjustment for gallstones and were more pronounced among subjects without gallstones (OR = 5.0, 95% CI 1.3-20.0 and OR = 4.9, 95% 2.0-12.2, respectively). History of liver conditions was also associated with an excess of biliary stones (OR = 1.9, 95% CI 1.2-3.0). No association was found for cancers of the gallbladder and ampulla of Vater. A history of chronic hepatitis and cirrhosis may be risk factors for extraheptic bile duct cancer. Given that chronic infection with hepatitis B virus (HBV) is the most common cause of liver disease in China, serologic markers of HBV need to be measured in future studies to examine the link between HBV and bile duct cancer.

Factors influencing the prevalence of gallstones in liver cirrhosis

BACKGROUND AND AIMS

To investigate the prevalence of gallstone disease in Chinese patients with liver cirrhosis and to identify risk factors for cholelithiasis.

METHODS

Blood samples were tested and ultrasonographic examination of the upper abdomen was conducted to observe the prevalence of gallstones in 90 compensated cirrhotic patients (Child-Pugh A), 180 decompensated cirrhotic patients (Child-Pugh B, C) and 300 controls. Risk factors for gallstone formation (age, sex, pregnancy, family history) and the characteristics of liver cirrhosis (Child class, inside diameter of portal vein), and gallbladder (wall thickness) were assessed.

RESULTS

Gallstones were found more often in cirrhotic patients (23.7%) than in controls (7.33%, P < 0.001). The prevalence of gallstones in decompensated cirrhotic patients was higher than that of the compensated cirrhotic patients (P < 0.001). Advanced age, female sex, family history of gallstones, gallbladder wall thickness 4 mm or greater and inside diameter of portal vein 13 mm or greater were significantly associated with gallstone disease in patients with liver cirrhosis. Multivariate analysis revealed that age (P < 0.001), sex (P = 0.0005) and thickness (4 mm or greater) of the gallbladder wall (P = 0.0064) were independently associated with gallstone disease in such patients.

CONCLUSIONS

This study confirms the high prevalence of cholelithiasis in liver cirrhosis. Age and sex are risk factors for gallstones and gallbladder wall thickness could be an additional risk factor for the development of gallstone in patients with liver cirrhosis.

Gallstone disease: Symptoms and diagnosis of gallbladder stones

The clinical aspects and the diagnostic features of gallstone disease are described. The natural history of silent gallstones is overviewed, and the risk of developing symptoms and complications is also discussed. The importance of colicky pain as a specific gallstone symptom is highlighted, and the role of both laboratory tests and diagnostic investigations for differential diagnosis is discussed. Finally, we describe the diagnostic features of gallbladder stone disease, including indications, sensitivity, specificity, and limitations of different test investigations under special circumstances.

Prevalence of gallbladder disease among persons with hepatitis C virus infection in the United States

Although cirrhosis is a known risk factor for gallstones, little is known about gallbladder disease (GBD) in individuals with hepatitis C virus (HCV) infection. We determined the association between chronic HCV infection and GBD in a representative sample of adults in the United States. Data on HCV infection and GBD were available for 13,465 persons 20 to 74 years of age who participated in the Third National Health and Nutrition Examination Survey. The presence of GBD (gallstones or cholecystectomy) was determined using abdominal ultrasonography, and HCV infection was assessed via a positive HCV antibody test and a positive HCV RNA test. Overall, 1.6% of adults (95% CI, 1.1-2.1) had chronic HCV infection and 12.5% (95% CI, 11.3-13.7) had GBD. After adjusting for potential confounding variables, the odds of gallstones (OR = 3.20; 95% CI, 1.08-9.45) and cholecystectomy (OR = 4.57; 95% CI, 1.57-13.27) among HCV-positive men was significantly higher compared with HCV-negative men. In contrast, the adjusted odds of gallstones (OR = 2.55; 95% CI, 0.58-11.25) and cholecystectomy (OR = 0.70; 95% CI, 0.21-2.37) among HCV-positive women was not significantly higher. The odds of GBD increased significantly with the severity of liver disease as assessed via elevated serum bilirubin levels and low levels of serum albumin and platelets. In conclusion, chronic HCV infection was strongly associated with GBD among men but not women in the United States, and GBD was more common in adults with severe liver disease.

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Risk factors for symptomatic gallstones in patients with liver cirrhosis: a case-control study

OBJECTIVES

Liver cirrhosis is a well-documented risk factor for the formation of gallstones. In cirrhotic patients, gallstones are almost always "silent," and surgery is rarely required. When indicated (symptoms or complications), cholecystectomy implies a high morbidity risk in these patients, especially in the advanced stages of cirrhosis. The aim of this study was to estimate the risk factors for symptom development in cirrhotic patients with gallstones to identify the subgroup of patients at risk of undergoing surgery.

METHODS

A total of 140 patients with liver cirrhosis and gallstones were studied: 97 with asymptomatic and 43 with symptomatic gallstone disease. The risk factors for gallstone formation (age, gender, family history, parity, obesity, diabetes mellitus, hyperlipoproteinemia) and the characteristics of liver cirrhosis (etiology, duration, Child class, hypersplenism), gallstones (duration, number, size), and gallbladder (size, wall thickness) were assessed in all patients. In 12 patients (four symptomatic, eight asymptomatic), gallbladder emptying was also evaluated by ultrasound. The association of asymptomatic and symptomatic gallstones with all these parameters was statistically evaluated by Student's t, Mann-Whitney, and chi(2) tests, as well as by means of multiple logistic regression. The causal relationship between these characteristics and gallstone symptoms was also examined by means of the KDD (knowledge discovery from databases) method, with an algorithm for learning Bayesian networks.

RESULTS

Advanced age, female gender, viral etiology of cirrhosis, family history of gallstones, and duration of gallstone disease were significantly associated with symptomatic gallstone disease. The number or size of gallstones and the size or emptying of the gallbladder did not differ in symptomatic versus asymptomatic patients. Male gender and alcoholic cirrhosis were inversely correlated with symptom presence. In the multivariate analysis, family history (p = 0.0098) and advanced age (p = 0.0422) were positively correlated and male gender (p = 0.0049) and alcoholic etiology of cirrhosis (p = 0.0116) negatively correlated with symptom presence. These relationships (except for age) were also evidenced by the KDD method.

CONCLUSIONS

The risk of gallstones becoming symptomatic is significantly lower in men and in alcoholic cirrhosis. In cirrhotic women, and especially in the presence of a positive family history and of advanced age, the risk of developing symptoms and undergoing surgery was significantly greater.

Choledocholithiasis in the Setting of Portal Hypertension

The successful management of biliary lithiasis in patients with cirrhosis depends on the degree of liver dysfunction. Patients with Child-Pugh class A or B hepatic reserve have excellent prognoses. Endoscopic spincterotomy is first-choice treatment for cirrhotic patients with choledocholithiasis. Endoscopic sphincterotomy can be performed in patients with Child-Pugh class A, B, or C hepatic function. Medical treatment with contact solvents is contraindicated in patients with pigment stones or calcified stones.