Epidemiology of gallstone disease in Argentina: prevalences in the general population and European descendants

The association between hypertension and the risk of gallstone disease: a cross-sectional study

Background

To explore the association between hypertension and the risk of gallstone disease.

Methods

We collected the data about the subjects receiving physical examination. Gallstone disease was diagnosed by abdominal ultrasound. Multivariable logistic regression was used to study the association between blood pressure and the risk of gallstone disease. SPSS version 23.0 was used for statistical analysis, and two-tailed P < 0.05 was defined as statistically significant.

Results

A total of 318,403 people were included in the study and 171,276 (53.8%) of them were men and 147,127 (46.2%) were women. Among them, 27,463 (8.6%) were diagnosed with gallstone disease on ultrasound examination, with 12,452 (3.9%) cases of gallstones and 15,017 (4.7%) cases of cholecystectomy. Multivariable logistic regression showed that hypertension was significantly associated with the risk of gallstone disease (OR = 1.05; 95% CI: 1.02–1.10; P = 0.03) and gallstones (OR = 1.12; 95% CI: 1.06–1.19; P < 0.01) and the association between hypertension and gallstone disease was stronger in women than in men. However, hypertension was not significantly correlated with cholecystectomy (OR = 0.99; 95% CI: 0.95–1.04; P = 0.85). Additionally, results showed that with the severity of hypertension increased, the risk of gallstone disease was also marked elevated (P for trend < 0.001).

Conclusions

The gallstone disease was prevalent and hypertension is significantly associated with the gallstone disease risk with a significant dose–response association. This study showed that the association between hypertension and cholecystectomy was not statistically significant, maybe hypertension correlated with gallstones but not with symptomatic gallstone disease which would require cholecystectomy.

A Mitochondrial DNA Variant Elevates the Risk of Gallstone Disease by Altering Mitochondrial Function

BACKGROUND AND AIMS

Gallstone disease (cholelithiasis) is a cholesterol-related metabolic disorders with strong familial predisposition. Mitochondrial DNA (mtDNA) variants accumulated during human evolution are associated with some metabolic disorders related to modified mitochondrial function. The mechanistic links between mtDNA variants and gallstone formation need further exploration.

METHODS

In this study, we explored the possible associations of mtDNA variants with gallstone disease by comparing 104 probands and 300 controls in a Chinese population. We constructed corresponding cybrids using trans-mitochondrial technology to investigate the underlying mechanisms of these associations. Mitochondrial respiratory chain complex activity and function and cholesterol metabolism were assessed in the trans-mitochondrial cell models.

RESULTS

Here, we found a significant association of mtDNA 827A>G with an increased risk of familial gallstone disease in a Chinese population (odds ratio [OR]: 4.5, 95% confidence interval [CI]: 2.1-9.4, P=1.2×10-4). Compared with 827A cybrids (haplogroups B4a and B4c), 827G cybrids (haplogroups B4b and B4d) had impaired mitochondrial respiratory chain complex activity and function and activated JNK and AMPK signaling pathways. Additionally, the 827G cybrids showed disturbances in cholesterol transport and accelerated development of gallstones. Specifically, cholesterol transport through the transporter ABCG5/8 was increased via activation of the AMPK signaling pathway in 827G cybrids.

CONCLUSIONS

Our findings reveal that mtDNA 827A>G induces aberrant mitochondrial function and abnormal cholesterol transport, resulting in increased occurrence of gallstones. The results provide an important biological basis for the clinical diagnosis and prevention of gallstone disease in the future.

The association between osteoporotic hip fractures and actinic lesions as a biomarker for cumulative sun exposure in older people-a retrospective case-control study in Argentina

The aim of this study was to analyze the association between the presence of actinic lesions (solar keratosis and non-melanoma skin cancer) and osteoporotic hip fractures in older patients. Both pathologies are common conditions in this age group. Since cumulative sun exposure is difficult to quantify, the presence of actinic lesions can be used to indirectly analyze the association between ultraviolet radiation and osteoporotic hip fractures. This was an observational case-control study. We reviewed the centralized medical records of patients with hip fracture (cases, n = 51) and patients with other diseases hospitalized in the same institution and period (controls, n = 59). The mean age of the patients was 80 ± 8.3 years (range 50-103 years). Differences in maternal hip fracture history were found between cases and controls (14.8 and 8 %, respectively; p = 0.047). Falls history in the past year was higher in cases than in controls (p < 0.0001). Actinic lesions were observed in 32.7 % of patients (prevalence rate 23.5 % in cases, 40.7 % in controls; p = 0.04). When considering patients with actinic lesions, controls have a higher FRAX score compared with cases. Although sun exposure is recommended for bone health, it represents a risk factor for actinic lesions. The presence of actinic lesions may indicate a lower osteoporotic hip fracture risk. A balance between adequate lifetime sun exposure and protection against its adverse effects is required for each patient, in the context of geographic location.

The Lowest Prevalence of Cholelithiasis in the Americas - An Autopsy-based Study

OBJECTIVES

This study used autopsy to evaluate the prevalence of cholelithiasis and its associated risk factors in a population of healthy, young subjects who suffered a violent or natural death.

METHODS

This study is a prospective evaluation of autopsies of 446 individuals from 2011 to 2013 in Brazil. Of that sample, 330 (74%) subjects died from violent deaths and 116 (26%) died naturally. The presence of biliary calculi, previous cholecystectomy, gender, age, ethnicity, body mass index (BMI) and alcohol use were evaluated.

RESULTS

In the natural death group, 6.9% (95% CI 3.39 to 13.28) (3.08% of the male subjects and 11.76% of the female subjects) exhibited evidence of gallbladder disease. In the violent death group, only 2.12% (95% CI 0.96 to 4.43) (2.17% of the male subjects and 1.85% of the female subjects) of the subjects exhibited evidence of gallbladder disease. Age was correlated with the prevalence of gallbladder disease, but BMI was correlated with only gallbladder disease in the natural death group.

CONCLUSIONS

This population has the lowest prevalence of cholelithiasis in the Americas. Dietary habits, physical activity, ethnicity, alcohol consumption and genetic factors may be responsible for this low prevalence.

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.

Black bile of melancholy or gallstones of biliary colics: historical perspectives on cholelithiasis

Barely 130 years after its first description, cholecystectomies are among the most commonly performed surgeries in the USA. The success of this operation with subsequent technical improvements, such as laparoscopic approaches, caused a paradigm shift in the management of gallstone disease. However, symptoms persist in 10-40 % of successfully operated patients. Reviewing monographs, textbooks, and articles published during the last 300 years, several important factors emerge as likely contributors to limited or poor treatment responses. Early on, clinicians recognized that cholelithiasis is quite common and thus often an incidental finding, especially if patients present with vague or atypical symptoms. Consistent with these observations, patients with such atypical symptoms are less likely to benefit from cholecystectomy. Similarly, lasting improvements are more reliably seen in patients with symptoms of presumed biliary origin and documented gallstones compared to individuals without stones, an important point in view of increasing rates of surgery for biliary dyskinesia. While cholelithiasis can cause serious complications, the overall incidence of clinically relevant problems is so low that prophylactic cholecystectomy cannot be justified. This conclusion corresponds to epidemiologic data showing that the rise in elective cholecystectomies decreased hospitalizations due to gallstone disease, but was associated with a higher volume of postoperative complications, ultimately resulting in stable combined mortality due to gallstone disease and its treatment. These trends highlight the tremendous gains in managing gallstone disease, while at the same time reminding us that the tightening rather than expanding indications for cholecystectomy may improve outcomes.

Incidence of and potential risk factors for gallstone disease in a general population sample

BACKGROUND

Several epidemiological studies have been published, but there are few reports on relations between gallstone incidence, symptomatology and risk factors.

METHODS

Of 621 randomly selected individuals aged 35-85 years in a general population who had been screened previously with ultrasonography and found to have no gallbladder stones, 503 (81.0 per cent) were re-examined after a minimum interval of 5 years. At baseline and re-examination, heredity for gallstone disease was explored and body mass index, digestive symptoms including abdominal pain, quality of life, alcohol and smoking habits, use of non-steroidal anti-inflammatory drugs and oestrogen, parity and blood lipid levels were recorded.

RESULTS

Forty-two (8.3 per cent) of the 503 subjects developed stones. Subjects were followed for a total of 3025.8 person-years, yielding an incidence for newly developed gallstones of 1.39 per 100 person-years. A positive association for gallstone development was found only for length of follow-up and plasma low-density lipoprotein-cholesterol levels at baseline. Weekly alcohol consumption was inversely related to gallstone development.

CONCLUSION

The incidence of gallstones in this population was 1.39 per 100 person-years. Gallstone development was related to length of follow-up and LDL-cholesterol levels, and inversely related to alcohol consumption.

The prevalence of gallbladder stones is higher among patients with chronic kidney disease in Taiwan

The pathogenesis of gallstone disease is multifactorial. Few studies have focused on gallbladder stones in the chronic kidney disease population in Taiwan. We conducted the current study to determine the prevalence of gallbladder stones in populations with and without chronic kidney disease.This was a hospital-based, cross-sectional study. We retrospectively analyzed the patients receiving periodic health examinations at 1 medical center in Taiwan from 2001 to 2004. In all, 4773 patients were enrolled in the study. Chronic kidney disease was defined as a glomerular filtration rate less than 60 mL/min per 1.73 m by the Modification of Diet in Renal Disease formula. Odds ratio (OR) and 95% confidence intervals (CI) were expressed using a multivariate logistic regression analysis.We studied 2686 men (56.3%) and 2087 women (43.7%). The mean age was 49.1 +/- 12.2 years (range, 20-87 yr). The prevalence of gallbladder stones was 13.1% in the group of patients with chronic kidney disease and 4.9% in the group of patients without chronic kidney disease (p < 0.001). After controlling for the other covariates, multivariate logistic regression analysis showed that increasing age (aged 40-64 yr vs. 20-39 yr, OR = 3.06, 95% CI = 1.81-5.15; and > or =65 yr vs. 20-39 yr, OR = 6.13, 95% CI = 3.42-10.98), chronic kidney disease (OR = 1.58, 95% CI = 1.01-2.47), body mass index > or =27 kg/m (OR = 1.39, 95% CI = 1.02-1.91), metabolic syndrome (OR = 1.45, 95% CI = 1.08-1.94), and cirrhosis (OR = 4.23, 95% CI = 1.25-14.29) were significantly related to gallbladder stone disease.The prevalence of gallbladder stones in patients with chronic kidney disease is significantly higher than in those without chronic kidney disease. Our findings suggest that increasing age, chronic kidney disease, body mass index > or =27 kg/m, metabolic syndrome, and cirrhosis are the related factors for gallbladder stone formation.

Gallbladder cancer worldwide: geographical distribution and risk factors

Gallbladder cancer is a relatively rare neoplasm that shows, however, high incidence rates in certain world populations. The interplay of genetic susceptibility, lifestyle factors and infections in gallbladder carcinogenesis is still poorly understood. Age-adjusted rates were calculated by cancer registry-based data. Epidemiological studies on gallbladder cancer were selected through searches of literature, and relative risks were abstracted for major risk factors. The highest gallbladder cancer incidence rates worldwide were reported for women in Delhi, India (21.5/100,000), South Karachi, Pakistan (13.8/100,000) and Quito, Ecuador (12.9/100,000). High incidence was found in Korea and Japan and some central and eastern European countries. Female-to-male incidence ratios were generally around 3, but ranged from 1 in Far East Asia to over 5 in Spain and Colombia. History of gallstones was the strongest risk factor for gallbladder cancer, with a pooled relative risk (RR) of 4.9 [95% confidence interval (CI): 3.3-7.4]. Consistent associations were also present with obesity, multiparity and chronic infections like Salmonella typhi and S. paratyphi [pooled RR 4.8 (95% CI: 1.4-17.3)] and Helicobacter bilis and H. pylori [pooled RR 4.3 (95% CI: 2.1-8.8)]. Differences in incidence ratios point to variations in gallbladder cancer aetiology in different populations. Diagnosis of gallstones and removal of gallbladder currently represent the keystone to gallbladder cancer prevention, but interventions able to prevent obesity, cholecystitis and gallstone formation should be assessed.

Mechanisms of disease: the genetic epidemiology of gallbladder stones

Cholelithiasis is one of the most prevalent and most expensive gastroenterologic diseases. It belongs to the group of complex metabolic disorders that affect humans, and its critical pathogenic mechanisms are not well defined. As a result, primary or secondary prevention strategies are sparse, and the only effective treatment is cholecystectomy. Here we provide an update on the molecular pathogenesis of gallbladder stones, evidence supporting the hypothesis that genetic factors are key elements predisposing to gallstones, and progress in human genetic studies of cholesterol stones. Data from recent identical twin, family and linkage studies provide conclusive evidence for a strong genetic component to gallstone disease. Furthermore, epidemiologic studies in at-risk populations indicate that gallstone formation is caused by multiple environmental influences and common genetic factors and their interactions. By contrast, monogenic subtypes of cholelithiasis, such as ATP-binding-cassette transporter deficiencies, appear to be rare. The summary of human association studies illustrates that distinct common gene variants might contribute to gallstone formation in different ethnic groups. The characterization of lithogenic genes in knockout and transgenic mice and the identification of many gallstone-susceptibility loci in inbred mice provide the basis for studies of the corresponding genes in patients with gallstones. The transfer of findings from mouse genetics to the bedside might lead to new strategies for individual risk assessment and reveal novel molecular targets for prevention and medical therapies.

Incidence of hip fractures in the city of Rosario, Argentina

In order to determine the incidence of hip fractures (HFx) in the city of Rosario, Argentina, (population, about 900,000), all HFx admitted to 26 medical centers from August 2001 to July 2002 were surveyed. Exclusion criteria were pathological fractures, violent trauma, and fractures in patients living outside urban limits. Demographical data were obtained from the 2001 national census, and the 1991 national census with projections made by the city's statistics department. In the study period, there were 763 HFx in persons aged 50 or older (608 in women and 155 in men). The annual incidence among inhabitants over the age of 50 years was 290 per 100,000 (405 for women, and 137 for men; female/male ratio: 2.96). In the population aged 65 or older, the global incidence was 646 per 100,000 (847 for women, and 343 for men; ratio: 2.47). The mean age (+/-SD) of fractured patients was 79.5+/-9.2 years; median age was 81 years (range: 50-104). Fractured men were younger (76.2+/-9.8 years vs 80.7+/-8.3 years; p <0.0001) and leaner (body mass index [BMI], 24.5+/-3.0 kg/m(2) vs 26.0+/-2.8 kg/m(2); p <0.0001) than fractured women. Most fractured patients either had normal BMI (35%) or were overweight (BMI, 25.1-30.0 kg/m(2); 47.5%). The incidence of fractures increased exponentially with advancing age. Relative risks of HFx (females/males) were calculated for each decade of life; the risk in individuals below the age of 69 was the same in both sexes; in those aged 70 or more the risk was significantly higher among women. Parental origin of fractured patients was mainly Spanish or Italian, reflecting the city's ethnic composition. Most fractures (72.5%) occurred in houses; 20% in apartments, and 7.5% in nursing homes. HFx were trochanteric in 54.4% of cases. Female patients with trochanteric fractures were older than those with cervical ones (80.0+/-9.4 years vs 78.2+/-11.4 years; p <0.01); their weights and BMIs did not differ significantly. The majority of HFx were treated surgically (91.8%); in-hospital mortality was 1.4%. In conclusion, incidence rates of HFx were somewhat higher in Rosario than those found in two other cities of central Argentina one decade earlier.

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES

Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy.

METHODS

Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations.

RESULTS

Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (<or=5 mm) gallstones (5,000 patients, 67% females, 45 yr old, 10-yr follow-up) indicates that life-years may be gained or lost by cholecystectomy, depending on incidence and mortality of pancreatitis.

CONCLUSIONS

Small gallstones are associated with pancreatitis. Prophylactic cholecystectomy may lead to gain or loss of life-years in patients with small stones, depending on incidence and mortality of pancreatitis.

Construction of two instruments for the presumptive detection of post-menopausal women with low spinal bone mass by means of clinical risk factors

The objective of this investigation was the design of two instruments based on clinical risk factors for the presumptive detection of post-menopausal women with spinal BMD<2.5 S.D. below average (LBMD). We investigated the association of 20 risk factors (RF) with LBMD in a series of 131 women. According to current densitometric criteria, subjects were classified as normals (N=33); osteopenics (N=53) and osteoporotics (N=45). Normals and osteopenics were taken as a single group because only 'nulliparity' and 'personal fractures' exhibited significant differences between these groups. A logistic regression attempting to identify which factors were associated with osteopenia showed a poor fit (pseudo R(2)=0.289). Univariate unconditional logistic regression analysis was used to calculate odd ratios (ORs) and their 95% CI for all RF. Those with associated P-values <0.100 were included in a multivariate logistic regression analysis to obtain the odds ratios (OR) adjusted by the effects of the others. The variables with not significant beta coefficients were eliminated, producing a reduced model. BMI (<25 kg/m(2)), calcium intake (<1.2g/day), menopause (>10 years), and the simultaneous occurrence of kyphosis and personal fractures showed significant association with low bone mass at the lumbar spine and their effect was additive. Fitting of the data to the model was assessed with the Hosmer-Lemeshow test (P=0.926) The area under the ROC curve is 0.833 (95% CI=0.757-0.909). The following equation calculates the probability of having low spinal bone mass: The sensitivity, specificity and area under the ROC curve were defined. The point of maximum specificity and sensitivity derived from the ROC curve, has a probability of 0.409. With such a cut-off point, the equation has a sensitivity of 73%, specificity 79%, positive predictive value 65% and negative predictive value 85%. The second instrument associates very low lumbar bone mass with the number of risk factors accumulated per patient. At baseline, all subjects had four RFs: they were, women, white, post-menopausal, and with no previous exposure to estrogens. With six additional RFs the presumptive diagnosis of LBMD has a specificity of 99%, positive predicting value 94% and false positives 6.5%. The area under the curve in a ROC graph was 0.826 (95% CI=0.747-0.914). Comparing present instruments with others in the literature, it is concluded that each population require its own algorithm for the presumptive detection of subjects with low bone mass. The algorithm should be reassessed periodically if the characteristics of the population or its social-economic conditions change.

Genetic background of cholesterol gallstone disease

Cholesterol gallstone formation is a multifactorial process involving a multitude of metabolic pathways. The primary pathogenic factor is hypersecretion of free cholesterol into bile. For people living in the Western Hemisphere, this is almost a normal condition, certainly in the elderly, which explains the very high incidence of gallstone disease. It is probably because the multifactorial background genes responsible for the high incidence have not yet been identified, despite the fact that genetic factors clearly play a role. Analysis of the many pathways involved in biliary cholesterol secretion reveals many potential candidates and considering the progress in unraveling the regulatory mechanisms of the responsible genes, identification of the primary gallstone genes will be successful in the near future.

Morphological and demographic associations of biliary symptoms in subjects with gallstones: findings from a population-based survey in Rosario, Argentina

BACKGROUND

Gallstone disease is a frequently encountered disorder in subjects living in Rosario. The reasons for the presence or absence of symptoms are unknown.

AIMS

To determine associations between biliary symptoms and ultrasonographic features of gallbladder and gallstones.

SUBJECTS

A random study was conducted on 1,173 subjects, inhabitants of 20 years and older, in the city of Rosario, Argentina.

METHODS

High-resolution abdominal ultrasound examinations were performed. Biliary pain was defined based on previously published definitions.

RESULTS

Gallstones were found in 149 subjects (101 female, 48 male) of whom 51% of females and 35% of males with cholelithiasis were symptomatic. Mean age was 53 years in symptomatic and 55 in asymptomatic subjects. Gallbladder size was normal in 97% of symptomatic and in 96% of the asymptomatic participants. There were no significant differences between the groups as far as concerns size and gallstone number. Impacted stones were observed in 10% of symptomatic and in none of the asymptomatic subjects (p<0.01).

CONCLUSIONS

Subjects' age and gender, gallstones size and number, as well as ultrasonographic features of gallbladder and biliary tract did not differ significantly between symptomatic and asymptomatic subjects. Only impacted stones were significantly more frequent in symptomatic subjects.