Cholelithiasis and dietary risk factors: an epidemiologic investigation in Vidauban, Southeast France. General Practitioner's Group of Vidauban

Cholesterol cholelithiasis: part of a systemic metabolic disease, prone to primary prevention

Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones.

The Role of Diet in the Pathogenesis of Cholesterol Gallstones

Cholesterol gallstone disease is a major health problem in Westernized countries and depends on a complex interplay between genetic factors, lifestyle and diet, acting on specific pathogenic mechanisms. Overweigh, obesity, dyslipidemia, insulin resistance and altered cholesterol homeostasis have been linked to increased gallstone occurrence, and several studies point to a number of specific nutrients as risk- or protective factors with respect to gallstone formation in humans. There is a rising interest in the identification of common and modifiable dietetic factors that put the patients at risk of gallstones or that are able to prevent gallstone formation and growth. In particular, dietary models characterized by increased energy intake with highly refined sugars and sweet foods, high fructose intake, low fiber contents, high fat, consumption of fast food and low vitamin C intake increase the risk of gallstone formation. On the other hand, high intake of monounsaturated fats and fiber, olive oil and fish (ω-3 fatty acids) consumption, vegetable protein intake, fruit, coffee, moderate alcohol consumption and vitamin C supplementation exert a protective role. The effect of some confounding factors (e.g., physical activity) cannot be ruled out, but general recommendations about the multiple beneficial effects of diet on cholesterol gallstones must be kept in mind, in particular in groups at high risk of gallstone formation.

Association between diet and gallstones of cholesterol and pigment among patients with cholecystectomy: a case-control study in Korea

BACKGROUND

The prevalence of cholesterol gallstones is high in Western populations, while pigment gallstones are common in Asian populations. Dietary factors are suggested to be associated with gallstone risk, but their relationship with gallstone type has not been evaluated. This study investigated the association between diet and risk of cholesterol gallstone or pigment gallstone in a Korean population whose dietary pattern and type of gallstone were changed during the last 30 years.

METHODS

Patients with cholesterol (n = 40) and pigment (n = 59) gallstones were recruited after laparoscopic cholecystectomy and were compared with those of age- and sex-matched controls without gallstones (n = 99). Dietary intakes were assessed by trained dietitians using a semi-quantitative food frequency questionnaire. Multinomial logistic regression analysis was performed to calculate odds ratios and 95% confidence intervals to examine the associations between diet and risk for type of gallstones adjusted by potential confounders.

RESULTS

Patients with cholesterol gallstone consumed more lipid, animal lipid, beef, pork, and fried food than those with pigment gallstones and control, while patients with pigment gallstone consumed more carbohydrate and noodles than patients with cholesterol gallstone and control. In multinomial logistic regression analysis using control as reference group, dietary pattern with high consumption of beef, pork, and fried food was associated with risk of cholesterol gallstones, while there was no association between the risk of pigment gallstone and dietary pattern. In addition, control consumed more alcohol than patients with cholesterol and pigment gallstones.

CONCLUSIONS

The present study suggested consumption of fat from meat and fried foods increased the risk of cholesterol gallstone, and intake of carbohydrate from noodles increased the risk of pigment gallstone.

Beyond Ischemic Heart Disease: Are There other Health Benefits from Drinking Alcohol?

Evidence is growing that alcohol consumption confers health benefits beyond protection from ischemic heart disease. We review this evidence with regard to cerebrovascular disease, peripheral vascular disease, diabetes, cholelithiasis (gallstones), cognitive functioning, and stress reduction and subjective psychosocial benefits. Other possible benefits are briefly considered. The weight of evidence suggests that low-level alcohol consumption offers some protection against ischemic stroke. The evidence that moderate alcohol consumption protects against diabetes and gallstones is also fairly strong. The possibility of other health benefits cannot be dismissed. For all the conditions considered, more research is indicated. The application of more appropriate statistical techniques, studies of patterns of drinking, and experimental approaches to delineating underlying mechanisms should enable firmer conclusions to be drawn. A better understanding of both the benefits and the risks of alcohol use for individuals and populations will facilitate the development of appropriate program and policy interventions to promote health.

Dietary fat and protein intake are not associated with incident biliary sludge and stones during pregnancy

BACKGROUND

Dietary composition can cause insulin resistance, elevated serum lipid levels, and obesity, all of which predispose to gallstone formation. The effects of dietary fat (including individual fatty acids) and protein on gallstone formation are controversial. The aim of this study was to examine the effects of dietary fat and protein intake on incident gallstone disease during pregnancy, a high-risk time for stone formation.

METHODS

We prospectively studied 3070 pregnant women who underwent serial gallbladder ultrasound examinations during pregnancy and at 4-6 weeks postpartum. All women had at least 2 study ultrasounds for comparison. A semi-quantitative food frequency questionnaire was completed by subjects in the early third trimester. Multivariate logistic regression was performed to assess the risk of incident gallbladder disease across quartiles of intake of total fat, individual fatty acids (polyunsaturated, monounsaturated, saturated, and total trans-fatty acids, as well as cholesterol), protein, and protein subtype (animal or vegetable based).

RESULTS

The cumulative incidence of new biliary sludge/stones or progression of baseline sludge to stones was 10.2% by 4-6 weeks postpartum. There was no association between total dietary fat (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.64-2.18 comparing lowest and highest quartiles) or protein intake (OR, 0.83; 95% CI, 0.44-1.22 comparing lowest and highest quartiles) and incident gallbladder disease. There was also no association between individual fatty acids or protein subtype and gallbladder disease.

CONCLUSIONS

Neither total nor subtype of dietary fat or protein was associated with incident biliary stone or sludge formation in this cohort of pregnant women.

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.

Alteration of sphingolipid metabolism and pSTAT3 expression by dietary cholesterol in the gallbladder of hamsters

Cholesterol and sphingolipids are major lipid constituents of the plasma membrane and have been implicated in a number of human diseases, such as atherosclerosis, fatty liver, diabetes mellitus, coronary heart disease, and hypertension. However, the relationship between cholesterol and sphingolipid metabolism has not been investigated. The purpose of this study was to determine whether dietary cholesterol would induce the alteration of sphingolipid metabolism in hamsters. Hypercholesterolemia was induced in hamsters by placing them on an experimental diet containing 0.5% cholesterol plus 0.5% choline chloride for 8 and 12 weeks. The serum profile of the hamsters showed that the administration of cholesterol increased the levels of total cholesterol, LDL cholesterol, and triglycerides as well as the activities of GOT and GPT. The levels of ceramide and sphingosine-1-phosphate (So-1-P) were remarkably elevated by 6-fold, respectively, in the bile juice of cholesterol-fed hamsters. Interestingly, the levels of iNOS and GFAP were increased in the gallbladders of cholesterol-fed hamsters. In addition, the immunostaining of pSTAT3 was increased on the gallbladder epithelium after cholesterol feeding. These results suggest that sphingolipid metabolism may be regulated in the bile juice during cholesterol feeding and may be a potential target for the treatment of hypercholesterolemia-induced diseases.

Macronutrients and insulin resistance in cholesterol gallstone disease

Cholelithiasis is a major source of digestive morbidity worldwide. Cholesterol stones account for the majority of gallstones in the United States and other Western countries. The pathogenesis of cholesterol gallstone disease is multifactorial with key factors including cholesterol supersaturation of bile, altered biliary motility, and nucleation and growth of cholesterol crystals. Increasing evidence suggests that many, but not all, causative factors of cholesterol gallstones are related to insulin resistance which, in association with obesity, has reached an epidemic level worldwide. Experimental studies show that hyperinsulinemia, a key feature of insulin resistance, may cause increased hepatic cholesterol secretion and cholesterol supersaturation of bile and gallbladder dysmotility, and thereby may enhance gallstone formation. Insulin resistance syndrome can be modified by environmental factors, including dietary factors. The impact of diet on insulin sensitivity is mediated by both dietary composition and its energy content. The contribution of specific dietary elements to the prevalence and incidence of cholesterol gallstone disease has been explored in animal and human studies. There is considerable evidence to suggest that different types of fatty acids, independent of the total amount of fat consumption, affect insulin sensitivity and cholesterol gallstone disease differently. The effects of salt intake, consumption of protein and carbohydrates, and alcohol drinking on insulin resistance are controversial. Additional intervention trials and controlled experimental feeding studies are needed to further clarify these relationships and to provide useful prophylactic and therapeutic strategies.

Reactive oxygen species and the hypomotility of the gall bladder as targets for the treatment of gallstones with melatonin: a review

Free radical-mediated damage of the gall bladder epithelium predisposes to the development of both gall bladder inflammation and gallstone formation, which often coexist. Melatonin, a pineal and gut secretory product, due to its antioxidant activity along with its effect on the aging gall bladder myocytes, inhibits gallstone formation. Melatonin reduces the biliary levels of cholesterol by inhibiting cholesterol absorption across the intestinal epithelium and by increasing the conversion of cholesterol to bile acids. The incidence of gallstones is increasing and is expected to rise dramatically with the increase in the longevity and the risk factors such as obesity. The change in the prevalence of cholelithiasis is associated with a proportionate rise in the incidence of cholangiocarcinoma. In an attempt to improve the quality of life of the rapidly increasing aging population, this article reviews up-to-date information on the pathophysiology of the gall bladder function and discusses the development of new therapies with potential good patient compliance and lower cost than the current treatments.

Long-chain saturated fatty acids consumption and risk of gallstone disease among men

BACKGROUND

Various saturated fatty acids have different effects on blood lipids and insulin secretion in experiments. The effect of long-term consumption of specific and different classes of saturated fatty acids on the risk of gallstone disease in humans is unknown.

METHODS

We prospectively studied consumption of saturated fatty acids and risk of gallstone disease in a cohort of 44,524 US men from 1986 to 2002. Intake of saturated fatty acids was assessed using a validated semiquantitative food frequency questionnaire. Newly diagnosed gallstone disease was ascertained biennially.

RESULTS

During 584,679 person-years of follow-up, we documented 2350 incident cases of gallstone disease, of which 1387 cases required cholecystectomy. Compared with men in the lowest quintile of dietary intake of long-chain saturated fats, after adjustment for age and other potential risk factors, the relative risk of gallstone disease for men in the highest quintile was 1.24 [95% confidence interval (CI), 1.02, 1.50, P for trend = 0.03], and the relative risk of cholecystectomy for men in the highest quintile was 1.41 (CI, 1.09, 1.82, P for trend = 0.008). Consumption of medium-chain saturated fatty acids or short-chain saturated fatty acids was unrelated to the risk.

CONCLUSIONS

Our results suggest that a higher consumption of long-chain saturated fatty acids may enhance the risk of gallstone disease in men.

Role of diet in cholesterol gallstone formation

BACKGROUND

There is a high prevalence of gallstone disease in Western countries as a consequence of genetic, biochemical, and environmental factors. Animal and clinical studies have explored the importance of dietary elements. Overwhelming but conflicting information has been reported about the relationship between specific dietary components and gallstone disease. Although the detailed biochemical pathways have been described in experimental models, human studies are mainly epidemiological.

METHODS

We performed a Medline search with the terms "diet", "gallstones", "cholesterol", "risk factors", including results from 1965 to 2006 and the author's personal library to review the relationship between dietary factors and cholesterol gallstone disease.

RESULTS

We identified over 150 references and present their results with respect to the author's criteria.

CONCLUSIONS

The best delineated relationship between cholesterol gallstones and diet was found in the studies that analyzed total calorie intake, refined sugars and fiber. The possible mechanisms are discussed in base of experimental studies.

Cholesterol gallstone disease

With a prevalence of 10-15% in adults in Europe and the USA, gallstones are the most common digestive disease needing admission to hospital in the West. The interplay between interprandial and postprandial physiological responses to endogenous and dietary lipids underscores the importance of coordinated hepatobiliary and gastrointestinal functions to prevent crystallisation and precipitation of excess biliary cholesterol. Indeed, identifying the metabolic and transcriptional pathways that drive the regulation of biliary lipid secretion has been a major achievement in the field. We highlight scientific advances in protein and gene regulation of cholesterol absorption, synthesis, and catabolism, and biliary lipid secretion with respect to the pathogenesis of cholesterol gallstone disease. We discuss the physical-chemical mechanisms of gallstone formation in bile and the active role of the gallbladder and the intestine. We also discuss gaps in our knowledge of the pathogenesis of gallstone formation and the potential for gene targeting in therapy.

Gallstone disease: Primary and secondary prevention

Several risk factors for cholesterol gallstone formation in the general population have been identified. There is a strongly increased risk of gallstone disease during prolonged fasting, rapid weight loss, total parenteral nutrition, and somatostatin(-analogue) treatment. The annual risk of biliary colic and gallstone complications in asymptomatic gallstone carriers has been investigated sparsely. In asymptomatic and symptomatic gallstone carriers, treatment with the hydrophilic bile salt ursodeoxycholic acid (UDCA) has been claimed to reduce the risk of biliary colic and gallstone complications such as acute cholecystitis and acute pancreatitis. Also, prophylactic cholecystectomy could be beneficial in certain subgroups of asymptomatic gallstone carriers. However, randomized, double-blind, placebo-controlled trials are lacking. In this review, strategies for the prevention of gallstone formation in the general population and in high-risk conditions are dealt with. Also, strategies for the prevention of biliary colic and gallstone complications in asymptomatic and symptomatic gallstone carriers are discussed.

Diet as a risk factor for cholesterol gallstone disease

Cholesterol gallstone disease is a common condition in western populations. The etiology is multifactorial with interaction of genetic and environmental factors. Obesity, aging, estrogen treatment, pregnancy and diabetes are consistently associated to a higher risk. A number of dietary factors have been involved in the pathogenesis of cholelithiasis. In this article we summarize several studies that have evaluated the role of diet as a potential risk factor for gallstone formation, including energy intake, cholesterol, fatty acids, fiber, carbohydrates, vitamins and minerals, and alcohol intake. Consumption of simple sugars and saturated fat has been mostly associated to a higher risk, while fiber intake and moderate consumption of alcohol, consistently reduce the risk. The association between cholesterol intake and gallstone disease has been variable in different studies. The effects of other dietary factors are less conclusive; additional studies are therefore necessary to clarify their relevance in the pathogenesis of gallstone disease. Recent discoveries of the role of orphan nuclear receptors in the regulation of fatty acid and hepatic cholesterol metabolism and excretion open new perspectives for a better understanding of the role of dietary constituents on cholesterol gallstone formation. KEY TEACHING POINTS: The etiology of cholesterol gallstone disease is multifactorial with interaction between genome and environment. It has been postulated that dietary constituents are important determinants for the formation of lithogenic bile. Intake of high energy, simple sugar and saturated fat favors gallstone formation. Fiber and moderate consumption of alcohol reduce the risk. The role of orphan nuclear receptors in the regulation of hepatic cholesterol metabolism and excretion open new leads for understanding the role of dietary constituents on cholesterol gallstone formation.

Development of symptoms and complications in individuals with asymptomatic gallstones

BACKGROUND

Gallbladder stones are common in the developed world. Complications of gallstones contribute substantially to healthcare costs and may be life threatening. The identification of individuals likely to develop complications would be of benefit in clinical practice as elective cholecystectomy could then be performed.

METHODS

Seven hundred and thirty-nine subjects aged 35-85 years from the general population were screened for gallbladder problems by ultrasonography and questionnaire assessment of putative risk factors and digestive symptoms. Gallstones, cholesterolosis or sludge in the gallbladder were diagnosed in 123 (16.3 per cent) of 739 subjects, 120 of whom were followed for a median of 87 (range 3-146) months to May 2003 or until treatment was required.

RESULTS

Fourteen patients were admitted to hospital and treated for gallstone-related complications or symptoms. The cumulative risk of being treated during the first 5 years after detection of asymptomatic gallstones was 7.6 per cent and there was no indication of this risk levelling off. There were no significant differences between treated and untreated subjects with regard to digestive symptoms or any of the risk factors monitored at the initial screening, although treated subjects were significantly younger than those who were not treated.

CONCLUSION

Nearly one in ten individuals with asymptomatic gallbladder stones in the general population may be expected to develop symptoms or complications that require treatment within 5 years. Age may be inversely related to the incidence of complications.

Alcohol consumption in relation to risk of cholecystectomy in women

BACKGROUND

Alcohol consumption has been linked to a lower risk of gallstone disease. However, the magnitude of the association is uncertain, and little is known about the relation of alcohol consumption patterns and individual types of alcoholic beverages to gallstone disease risk.

OBJECTIVE

We prospectively examined the association between alcohol intake and cholecystectomy, a surrogate for symptomatic gallstone disease, in a large cohort of women.

DESIGN

Women from the Nurses' Health Study who had no history of gallstone disease in 1980 (n = 80,898) were followed for 20 y. Alcohol consumption, which was measured every 2-4 y by food-frequency questionnaires, was used to predict subsequent cholecystectomy through multivariate analysis.

RESULTS

We ascertained 7831 cases of cholecystectomy. Relative to subjects who had no alcohol intake, subjects who had alcohol intakes of 0.1-4.9, 5.0-14.9, 15.0-29.9, 30.0-49.9, and >/=50.0 g/d had multivariate relative risks of cholecystectomy of 0.95, 0.86, 0.80, 0.67, and 0.62 (95% CI: 0.49, 0.79), respectively. Relative to subjects who never consumed alcohol, subjects who consumed alcohol 1-2, 3-4, 5-6, and 7 d/wk had multivariate relative risks of cholecystectomy of 0.94, 0.88, 0.87, and 0.73 (0.63, 0.84), respectively. All alcoholic beverage types were inversely associated with cholecystectomy risk, independent of consumption patterns (for quantity of alcohol consumed, P = 0.04, 0.001, and 0.003 for wine, beer, and liquor, respectively; for frequency of alcohol consumption, P = 0.01, 0.07, and <0.0001 for wine, beer, and liquor, respectively).

CONCLUSIONS

The intake of all alcoholic beverage types is inversely associated with the risk of cholecystectomy. Recommendations regarding the benefit of consuming moderate quantities of alcohol should be weighed against the potential health hazards.

Defining alcohol-related fatal medical conditions for social-cost studies in western societies: an update of the epidemiological evidence

OBJECTIVES

To elaborate a state-of-the-art list of alcohol-related fatal medical conditions for future social-cost studies in Western societies.

METHODS

Three major social-cost studies were compared with regard to their respective section on fatal health effects attributable to long-term as well as short-term use of alcohol. On discordant conditions, a systematic literature search was conducted in the Medline and ETOH databases.

RESULTS

There is no consensus between social-cost studies with respect to alcohol-related causes of mortality. Based on the recent epidemiological evidence on alcohol and health, this paper suggests an up-to-date list of fatal medical conditions for which the causal relationship has been established with sufficient scientific evidence. A further investigation is needed, however, to reestimate relative risks by meta-analysis.

CONCLUSIONS

Evaluating new epidemiological evidence regularly is necessary for the purpose of up-to-date social-cost studies.

Gallstones

This review summarizes the main advances made in the epidemiology, pathogenesis, and medical treatment of gallstone disease in the past year. Whether rapid weight reduction can precipitate gallstone formation is still debated. Phospholipase A(2)-II seems to play an interesting role in the pathogenesis of multiple cholesterol stone formation, and ursodeoxycholic acid may partially halt the formation of multiple cholesterol stones by mediating an anti-inflammatory effect on the gallbladder. Bacterial infections may contribute to gallstone formation, perhaps through secretion of biofilm. The combination of ursodeoxycholic acid and simvastatin for the resolution and prevention of gallstones is promising, but larger studies are needed.