Oral contraceptives, pregnancy, and endogenous oestrogen in gall stone disease--a case-control study

Acute Pancreatitis during and after Pregnancy: A Review

During pregnancy and in the post-partum period, several diseases may arise or become exacerbated. Acute pancreatitis is an inflammatory disease with an increasing incidence in Western countries. The incidence of acute pancreatitis during pregnancy is not different with respect to the general population, but this incidence increases in the first 2 years after delivery. Biliary sludge and stones are the most frequent aetiologies, followed by hypertriglyceridemia. Taking care of the mother and foetus through a potentially severe disease requires a team consisting of an obstetrician, a gastroenterologist, an anaesthesiologist, and a surgeon. It is necessary to monitor the health of the foetus/child and the mother during pregnancy, childbirth, and puerperium. The management of this care depends on the systemic and local complications, the severity of the acute pancreatitis, and the trimester of pregnancy. Some diagnostic tools and many drugs are not safe for foetuses, while interventional endoscopy and surgery have limitations and can only be used after an accurate evaluation of benefit/risk ratios. Despite these limitations, maternal mortality due to acute pancreatitis is low during pregnancy, mainly thanks to multidisciplinary approaches for these patients. A careful diet to prevent obesity, alcohol abstinence, routine serum triglyceride control, and breastfeeding for at least three months may prevent acute pancreatitis during and after pregnancy.

Gallstone and Gallbladder Disease: Biliary Tract and Cholangiopathies

Cholestatic liver diseases are named primarily due to the blockage of bile flow and buildup of bile acids in the liver. Cholestasis can occur in cholangiopathies, fatty liver diseases, and during COVID-19 infection. Most literature evaluates damage occurring to the intrahepatic biliary tree during cholestasis; however, there may be associations between liver damage and gallbladder damage. Gallbladder damage can manifest as acute or chronic inflammation, perforation, polyps, cancer, and most commonly gallstones. Considering the gallbladder is an extension of the intrahepatic biliary network, and both tissues are lined by biliary epithelial cells that share common mechanisms and properties, it is worth further evaluation to understand the association between bile duct and gallbladder damage. In this comprehensive article, we discuss background information of the biliary tree and gallbladder, from function, damage, and therapeutic approaches. We then discuss published findings that identify gallbladder disorders in various liver diseases. Lastly, we provide the clinical aspect of gallbladder disorders in liver diseases and ways to enhance diagnostic and therapeutic approaches for congruent diagnosis. © 2023 American Physiological Society. Compr Physiol 13:4909-4943, 2023.

Breastfeeding in Prevention of Postpartum Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) caused by gallstones has an increased rate of incidence in young women in the 2 years postpartum. Middle-aged women with longer periods of breastfeeding have less hospitalization for gallbladder disease.

AIM

To investigate whether breastfeeding or other variables may be associated with AP.

METHODS

We conducted a population-based case-control study among all Sicilian women of childbearing age, and we identified all women who delivered (2013-2016) and had AP within 2 years postpartum. We reviewed their medical records, and for each case we matched four women of the same age (± 5 years), without AP. Univariate and multivariate logistic regression was used to estimate the odds ratios (OR) with their confidence intervals (CI) to assess associations between AP and clinical determinants.

RESULTS

In the 74 women with AP and 298 controls at univariate analysis, > 6 months oral contraception history (p < 0.01; OR 3.30; 95% CI 1.33-8.16), previous biliary disease (p < 0.001; OR 5.90; 95% CI 1.98-17.57) and smoking (p = 0.035; OR 2.04; 95% CI 1.04-4.0) were predictors of AP; amenorrhea ≥ 3 months (p < 0.001; OR 0.34; 95% CI 0.19-0.59) and breastfeeding ≥ 3 months (p < 0.001; OR 0.07; 95% CI 0.03-0.14) were protective. At multivariate analysis, previous biliary disease (p = 0.011; OR 5.49; 95% CI 1.48-20.38) and breastfeeding ≥ 3 months (p < 0.001; OR 0.06; CI 95% 0.03-0.14) were associated with AP.

CONCLUSIONS

Women who breastfeed for at least 3 months and do not have a history of biliary disorders have reduced risk of developing AP in the 2 years after delivery.

Global burden of gallbladder and biliary diseases: A systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND AND AIM

Gallbladder and biliary diseases (GBDs) are one of the most prevalent medical issues in the digestive system. This study was designed to describe the characteristics of prevalence, death, and disability-adjusted life years (DALYs) of GBDs during 1990-2019 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019.

METHODS

Prevalence, death, and DALYs for GBDs in different locations, years, sex, and age groups were estimated using DisMod-MR 2.1 and a generic Cause of Death Ensemble Modeling approach. Countries and territories were categorized according to socio-demographic index (SDI) quintiles.

RESULTS

The prevalence cases (127 345 732 to 193 493 378), death cases (82 430 to 124 941), and DALYs (4 604 821 to 6 352 738) of GBDs increased from 1990 to 2019. However, the age-standardized rates of indicators decreased over the 30-year period (prevalence, 2851.84 to 2350.78 per 100 000 population; death, 2.40 to 1.65 per 100 000 population; DALYs, 106.76 to 78.25 per 100 000 population). In 2019, the high and middle-high SDI regions had higher age-standardized prevalence rates, the low SDI region had the highest age-standardized death rate, and the middle SDI region had the highest DALYs and age-standardized DALYs rate of GBDs. Being female, older age, and high body mass index were important risk factors for the burden of GBDs.

CONCLUSIONS

Globally, there were improvements in overall health with regard to GBDs over the 30 years. However, the prevention of GBDs should be promoted in middle, middle-high, and high SDI regions, while more medical resources should be provided to improve treatment levels in low SDI region.

Risk of Gynecological Cancers in Cholecystectomized Women: A Large Nationwide Cohort Study

Background: Gallstones affect women more frequently than men, and symptomatic gallstones are increasingly treated with surgical removal of the gallbladder (cholecystectomy). Breast, endometrial, and ovarian cancer share several risk factors with gallstones, including overweight, obesity, and exposure to female sex hormones. We intended to assess the association between cholecystectomy and female cancer risk, which has not been comprehensively investigated. Methods: We investigated the risk of female cancers after cholecystectomy leveraging the Swedish Cancer, Population, Patient, and Death registries. Standardized incidence ratios (SIRs) adjusted for age, calendar period, socioeconomic status, and residential area were used to compare cancer risk in cholecystectomized and non-cholecystectomized women. Results: During a median follow-up of 11 years, 325,106 cholecystectomized women developed 10,431 primary breast, 2888 endometrial, 1577 ovarian, and 705 cervical cancers. The risk of ovarian cancer was increased by 35% (95% confidence interval (CI) 2% to 77%) in the first 6 months after cholecystectomy. The exclusion of cancers diagnosed in the first 6 months still resulted in an increased risk of endometrial (19%, 95%CI 14% to 23%) and breast (5%, 95%CI 3% to 7%) cancer, especially in women cholecystectomized after age 50 years. By contrast, cholecystectomized women showed decreased risks of cervical (-13%, 95%CI -20% to -7%) and ovarian (-6%, 95%CI -10% to -1%) cancer. Conclusions: The risk of ovarian cancer increased by 35% in a just short period of time (6 months) following the surgery. Therefore, it is worth ruling out ovarian cancer before cholecystectomy. Women undergoing cholecystectomy showed an increased risk of breast and endometrial cancer up to 30 years after surgery. Further evaluation of the association between gallstones or gallbladder removal on female cancer risk would allow for the assessment of the need to intensify cancer screening in cholecystectomized women.

Acute Pancreatitis During and After Pregnancy: Incidence, Risk Factors, and Prognosis

BACKGROUND

Acute pancreatitis may complicate pregnancy and both are associated with gallstones, but its incidence is not well known.

AIMS

To validate hospital discharge records in diagnosing acute pancreatitis and gallstones and to evaluate acute pancreatitis incidence in non pregnant, pregnant and after delivery using hospital discharge records METHODS: We identified all hospital discharge records of hospitalized Sicilian women of childbearing age (2011-2016). We determined agreement between 300 hospital discharge records and hospital records in diagnosing acute pancreatitis and gallstones. Acute pancreatitis incidence, prognosis, and their relationship with age and gallstones were calculated in the three groups using hospital discharge records.

RESULTS

There was 92% and 88% agreement in diagnosing acute pancreatitis and gallstones between hospital discharge and hospital records. In non pregnant, 1,564 of 7,236,863 women-years (21.61/100,000 person-years) developed acute pancreatitis. During pregnancy, 34 of 226,492 women-years developed acute pancreatitis (20.02/100,000 person-years). Postpartum acute pancreatitis incidence was higher than non pregnant, only in the first 2 years with the peak in the first semester (95.4/100,000 person-years). The increased incidence of postpartum acute pancreatitis was associated with gallstones in youngest women (gallstones acute pancreatitis in women below 20 years old versus non pregnant: rate ratios 16.61; 95% CI 8.40-32.87).

CONCLUSIONS

Agreement in acute pancreatitis and gallstones diagnosis between hospital discharge and hospital records was accurate. Acute pancreatitis incidence was increased only in the first 2 years after delivery in young women with gallstones.

Risk Factors for Gallstones and Cholecystectomy: A Large-Scale Population-Based Prospective Cohort Study in Japan

INTRODUCTION

Studies investigating the risk of gallstones in the Japanese population are sparse. To our knowledge, this is the first prospective cohort study assessing risk factors of gallstones in Japan.

METHODS

A nationwide population-based prospective cohort of 112,109 men and women, aged 40-69 years, self-completed questionnaires at baseline regarding exposures to potential risk factors, between 1990 and 1994. The occurrence of gallstones and cholecystectomy for gallstones were ascertained from another questionnaire after 10 years. Odds ratios and the 95% confidence intervals were calculated using the multivariate logistic regression.

RESULTS

During the 10-year follow-up, 3,092 (5.0%) participants developed gallstones and 729 (1.2%) participants required cholecystectomy. Increasing age, high body mass index, and diabetes mellitus were associated with the risk of gallstones in both sexes. In men, weight gain or loss of >5 kg over the follow-up period and stress were associated with risk of gallstones, whereas alcohol intake was inversely associated with the risk. In women, weight gain of >5 kg during the follow-up period, smoking, menopause, and lipid-lowering drugs were associated with risk of gallstones, whereas late onset of menarche was inversely associated with risk of gallstones. The risk of cholecystectomy broadly reflected the risk of gallstones for both sexes respectively.

CONCLUSION

Risk factors for both gallstones and cholecystectomy for gallstones are multifactorial and differ between men and women. Novel findings in this study include an inverse association between late onset of menarche and gallstones, and an association between self-reported stress in men and gallstones.

Is the oral contraceptive or hormone replacement therapy a risk factor for cholelithiasis: A systematic review and meta-analysis

BACKGROUND

Association between exogenous estrogen intake and cholelithiasis risk has been reported in several epidemiological studies, including oral contraceptive (OC) and hormone replacement therapy (HRT), while the results were controversial. This study aimed to perform a comprehensive meta-analysis of this issue.

METHODS

PUBMED, EMBASE, and Cochrane library database were searched up to October 2016. Two reviewers independently extracted data from eligible studies, relative risks (RRs), and/or odds ratios (ORs) with 95% confidence intervals (95% CIs) for the highest versus lowest categories of intake were adopted. Either a fixed- or a random-effects model was adopted to estimate overall RRs or ORs. Besides, subgroup and publication bias analyses were applied to explain the heterogeneity. An original study was also conducted to verify our conclusion.

RESULTS

A total of 19 studies with approximately 556,620 participants were included in this meta-analysis. The pooled RR of cholelithiasis for the highest versus the lowest categories was 1.59 (95% CI: 1.44-1.75), indicating that exogenous estrogen was positive associated with the intake of exogenous estrogen. However, the pooled RR of OC intake and cholelithiasis risk was 1.19 (95% CI: 0.97-1.45), and the RR for HRT was 1.79 (95% CI: 1.61-2.00).

CONCLUSION

The HRT was positively associated with the cholelithiasis risk, and the OC will not increase the risk of cholelithiasis.

Determinants for gallstone formation - a new data cohort study and a systematic review with meta-analysis

OBJECTIVE

Only few determinants of gallstone formation have been identified in cohort studies. The aim was to identify further determinants for gallstones in a Danish cohort and to perform a meta-analysis of results from existing cohorts.

MATERIAL AND METHODS

Data from a cohort study was used. Gallstone incidence was assessed through repeated ultrasound examinations. Body mass index (BMI), blood pressure, self-rated health, lifestyle variables, blood lipids, and use of female sex hormones were measured at the baseline examination. Statistical analyses included logistic regression. Based on a prospective protocol, a systematic review of the literature was performed identifying all articles dealing with determinants of incident gallstones. Meta-analyses of comparable determinants were performed through fixed effect models.

RESULTS

Participants with no gallstones at baseline and with at least one re-examination were followed-up completely (mean 11.6 years, N = 2848). The overall cumulative incidence of gallstones was 0.60% per year. Independent positive determinants for incident gallstones were age, female sex, non-high density lipoprotein (non-HDL) cholesterol, and gallbladder polyps. In addition, BMI was positively associated in men. The systematic review additionally identified associations for comorbidities, parity, and dietary factors. Meta-analysis confirmed the significant associations for incident gallstones and age, female sex, BMI, and non-HDL cholesterol. No significant associations were found for blood pressure, smoking, alcohol consumption, HDL cholesterol, or triglycerides in meta-analyses.

CONCLUSIONS

Age, female sex, BMI, non-HDL cholesterol, and polyps are independent determinants for gallstone formation. Incident gallstones and the metabolic syndrome share common risk factors. More studies are needed for further exploration.

Vitamin-D Deficiency Is Associated with Gallbladder Stasis Among Pregnant Women

BACKGROUND

Pregnant women are at increased risk of gallbladder (GB) stasis, an important risk factor for gallstones (GS). In non-pregnant women, Vitamin-D deficiency (VDD) is associated with GB stasis, which improves on supplementation. Relationship of VDD with GB stasis among pregnant women is not known.

METHODS

This is a prospective study in tertiary care centre. Consecutive healthy pregnant women (12-16 weeks gestation) were enrolled. Serum 25(OH) vitamin-D was estimated, and levels <20 ng ml(-1) were considered as VDD. Risk factors and clinical features of VDD were assessed. Gallbladder ejection fraction (GBEF) was assessed by ultrasound after a standard fatty meal, and <40 % was defined as stasis. Statistical analysis was performed to assess relationship of GB stasis and vitamin-D levels and identify factors associated with VDD.

KEY RESULTS

Median serum vitamin-D in 304 women was 7.9 ng ml(-1) (IQR 5.7, 12). VDD afflicted 92 % of them. Women with VDD more often had GB stasis (20 % vs 0 %; p = 0.015) and had lower GBEF [53.7 ± 17 % vs 59 ± 10 %; p = 0.026] compared to those with normal vitamin-D. GBEF showed positive correlation with vitamin-D levels (r = 0.117; p = 0.042). Risk factors for low vitamin-D levels were urban residence (p = 0.001), lower sun-exposure time (p = 0.005), limited skin exposure (p < 0.001), higher BMI (p = 0.05) and higher socioeconomic status (p = 0.02). Vitamin-D deficiency was associated with low serum calcium (ρ = 0.457; p < 0.001).

CONCLUSIONS

Vitamin D deficiency is highly prevalent among pregnant Indian women. It is associated with GB stasis and lower GBEF. The risk factors for VDD were reduced sun exposure, inadequate dietary intake and urban lifestyle.

Cholesterol cholelithiasis in pregnant women: pathogenesis, prevention and treatment

Epidemiological and clinical studies have found that gallstone prevalence is twice as high in women as in men at all ages in every population studied. Hormonal changes occurring during pregnancy put women at higher risk. The incidence rates of biliary sludge (a precursor to gallstones) and gallstones are up to 30 and 12%, respectively, during pregnancy and postpartum, and 1-3% of pregnant women undergo cholecystectomy due to clinical symptoms or complications within the first year postpartum. Increased estrogen levels during pregnancy induce significant metabolic changes in the hepatobiliary system, including the formation of cholesterol-supersaturated bile and sluggish gallbladder motility, two factors enhancing cholelithogenesis. The therapeutic approaches are conservative during pregnancy because of the controversial frequency of biliary disorders. In the majority of pregnant women, biliary sludge and gallstones tend to dissolve spontaneously after parturition. In some situations, however, the conditions persist and require costly therapeutic interventions. When necessary, invasive procedures such as laparoscopic cholecystectomy are relatively well tolerated, preferably during the second trimester of pregnancy or postpartum. Although laparoscopic operation is recommended for its safety, the use of drugs such as ursodeoxycholic acid (UDCA) and the novel lipid-lowering compound, ezetimibe would also be considered. In this paper, we systematically review the incidence and natural history of pregnancy-related biliary sludge and gallstone formation and carefully discuss the molecular mechanisms underlying the lithogenic effect of estrogen on gallstone formation during pregnancy. We also summarize recent progress in the necessary strategies recommended for the prevention and the treatment of gallstones in pregnant women.

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.

Can the type of gallstones be predicted with known possible risk factors?: A comparison between mixed cholesterol and black pigment stones

BACKGROUND

Pathogenesis of gallstones (GS) is multifactorial and multiple genetic and environmental factors have been identified in different populations for different types of GS with varying prevalence. However the role of the each aetiological factor on the formation of mixed cholesterol and black pigment GS has not being addressed adequately. Hence in this study we attempted to compare known possible risk factors for mixed cholesterol and black pigment GS among two groups of patients with two types of GS.

METHODS

The study was done on a cohort of patients with symptomatic GS admitted to the Teaching Hospital Peradeniya, Sri Lanka over a period of 18 months. Clinical and epidemiological data and physical parameters of the patients were recorded and surgically removed GS were analyzed chemically and physically to identify the type of GS. In addition lipid profile was done in all the patients with normal serum bilirubin levels.

RESULTS

A total of 86 patients were included in the study. Mixed cholesterol GS was significantly common among females than males (χ2 test, p = 0.029). Mixed cholesterol GS was commonly seen among patients belonging to Moor ethnicity (χ2 test, p = 0.009). Majority of patients with mixed cholesterol GS had body mass index above 25 kg/m2 (χ2 test, p = 0.018). Black pigment GS were significantly common among patients with type II diabetes mellitus (Fisher's exact test, p = 0.035). Further all the patients with chronic haemolytic anaemia and alcoholic cirrhosis had black pigment GS. Age, family history, Fasting Blood Glucose, dyslipidaemia, lipid profile, parity and use of oral contraceptive pills in females, smoking and alcohol intake in males did not differ significantly among patients in the two groups.

CONCLUSION

Gender, ethnicity and body mass index can be used to predict the formation of mixed cholesterol GS and black pigment GS.

Biliary issues in the bariatric population

Biliary disease is common in the obese population and increases after bariatric surgery. This article reviews management of the gallbladder at the time of bariatric surgery, as well as imaging modalities in the bariatric surgery population and prevention of lithogenesis in the rapid weight loss phase. In addition, diagnosis and treatment options for biliary diseases are discussed, including laparoscopic-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography in the patient having bariatric surgery.

Assessment of characteristics of patients with cholelithiasis from economically deprived rural Karachi, Pakistan

Background

Gallstones have been regarded as one of the most expensive diseases in Gastroenterology, posing a great economic burden on developing nations. The majority of Pakistani people live in rural areas where healthcare facilities are not available or are very primitive. We aim to assess the characteristics among cholelithiasis patients from rural Karachi so that a prevention campaign can be launched in rural underprivileged settings to reduce the economic burden of this preventable disease.

Method

A total of 410 patients were included in the study after giving verbal consent as well as written consent. Variables such as age, weight, height, body mass index (BMI), blood pressure, waist circumference, number of children, monthly family income, number of siblings, and number of family members, were considered in this questionnaire. All data was analysed by SPSS ver. 16.0. Mean and standard deviation (SD) were calculated for continuous variables. Frequency and percentages were calculated for categorical variables.

Results

Nearly 85.4% of the participants were female. The mean ± S.D. for age was 43.8 ± 9.59. Nearly 61% of the patients were illiterate. All of our patients were from low socioeconomic status and their mean salary ± S.D. was 6915 ± 1992 PKR (1 US $ = 90.37PKR). 75% of them were smokers with mean consumption ± S.D. of 7.5 ± 10 cigarettes per day. Fibre in diet was not used by 83.65% of patients. 40.2% were living in combined families. 61% were living in purchased homes. A positive history of diabetes mellitus was given by 45.1%, family history of cholelithiasis by 61% and history of hypertension by 31.7% of subjects. Soft drink consumption was given by 45.1% of patients; while only 8.5% used snacked daily. Tea was consumed by 95.1% of the subjects. Daily physical activity for 30 minutes was reported by only 13.4% of participants.

Conclusion

In conclusion, rural dwellers from low socioeconomic strata are neglected patients and illiteracy further adds fuel to the fire by decreasing the contact with the health professionals. Assessment of the characteristics are very important because considering the great socio-economic burden, an intervention strategy in the form of mass media campaign as well as small group discussions in such rural areas can be formulated and applied to high risk populations to reduce the burden and complications of gallstone disease.

Serum organochlorine pesticide residues and risk of gallstone disease: a case-control study in Xiamen

PURPOSE

To investigate the association between serum organochlorine pesticide residues and risk of gallstone disease.

METHODS

A 1:1, pair-matched, case-control study was designed. Data from 150 patients with gallstones diagnosed by abdominal ultrasonography at a single hospital from June 2009 to June 2010 were collected. A total of 150 patients without gallstones during the same period at the same hospital were recruited as the control group. Capillary gas chromatography was employed to measure the serum concentrations of dichlorodiphenyltrichloroethane (DDT) and hexachlorocyclohexane (HCH) residues. Multiple-factor conditional logistic regression analysis was conducted to estimate the relative risk of gallstones in relation to organochlorine pesticide residues in serum.

RESULTS

The percentages of p,p'-DDD and o,p'-DDT in serum of patients were significantly higher than those in serum of controls. The p,p'-DDE, α-HCH, and δ-HCH residues in serum of patients were also significantly increased compared with those in serum of controls. Multiple-factor conditional logistic regression analysis showed that high levels of p,p'-DDE and p,p'-DDT residues were risk factors for gallstone disease.

CONCLUSIONS

A high level of organochlorine pesticide residues in serum is a potential risk factor for gallstone disease, which suggests that environmental exposure to organochlorine pesticides should be evaluated with respect to gallstone formation.

Risk factors in patients with hereditary gallstones in Chinese pedigrees

OBJECTIVE

We aimed to define the risk factors and to evaluate the impact of family background on the prevalence of gallstones in China.

SUBJECTS AND METHODS

Thirty-eight gallstone pedigrees were collected and a case-control study was conducted. This study consisted of 272 first-degree relatives and 201 non-first-degree relatives of index patients. The participants completed a questionnaire and underwent physical and ultrasonographic examinations. The risk factors examined included age, sex, body mass index (BMI), smoking status, alcohol consumption, pregnancy, fat content in dietary meat, history of gastrointestinal surgery, hypertension, hyperlipidemia, fatty liver, coronary heart disease and diabetes.

RESULTS

The prevalence of gallstones in first-degree and non-first-degree relatives of index patients was 38.2 and 10.9%, respectively. Age, pregnancy and BMI significantly differed between cases and controls (p < 0.05). The relative risks were: consumption of meat with a high fat content 1.4 (95% CI 1.1-1.8); hyperlipidemia 2.4 (95% CI 1.3-4.6); diabetes 1.9 (95% CI 1.1-3.2); fatty liver 4.9 (95% CI 1.0-24); coronary heart disease 2.5 (95% CI 1.7-3.9).

CONCLUSION

Data showed that age, overweight, more consumption of high-fat food, high frequency of pregnancy, fatty liver, hyperlipidemia, coronary heart disease and diabetes could increase the risk of gallstones in the first-degree relatives of index patients.

Cholecystitis in pregnancy

Biliary tract disease is a relatively uncommon, heterogenous disease in pregnancy. Specifically, acute cholecystitis can be especially difficult to recognize in pregnancy. However, once diagnosed, the initial management plan should be conservative and include antibiotic therapy. Subsequent management depends on the gestational age at diagnosis. Surgical therapy, when indicated, should not be delayed and a planned intervention during the second trimester appears to offer a better outcome than surgery performed under emergent conditions.

Reproductive factors and risks of biliary tract cancers and stones: a population-based study in Shanghai, China

BACKGROUND

Parity has been linked to gallbladder cancer and gallstones, but the effects of other reproductive factors are less clear.

METHODS

We examined 361 incident biliary tract cancer cases, 647 biliary stone cases, and 586 healthy women in a population-based study in Shanghai.

RESULTS

The effects of parity (odds ratios, OR(> or =3 vs 1 child)=2.0, 95% confidence interval (CI) 0.7-5.1), younger age at first birth (OR(per 1-year decrease)=1.2, 95% CI 0.99-1.6), and older age at menarche (OR(per 1-year increase)=1.4, 95% CI 1.1-1.8) on gallbladder cancer risk were more pronounced among women with stones, but the interactions were not significant.

CONCLUSION

Our results provide support for high parity, younger age at first birth, and late age at menarche in the development of gallbladder cancer, particularly among women with biliary stones.

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.

Risk factors for gallstone disease in a Thai population

Background

Gallstone disease (GSD) is a major public health problem that is associated with a number of risk factors.

Methods

We conducted a case–control study of 407 participants comprising 207 cases with GSD and 200 controls without GSD, as confirmed by ultrasonography. The participants completed a questionnaire and underwent physical and ultrasonographic examination. The risk factors examined were age, sex, BMI, use of oral contraceptives, diabetes mellitus, cirrhosis, thalassemia, dyspepsia, family history of gallstone disease, smoking status, alcohol consumption, and dietary history.

Results

BMI, fat content of dietary meat, and smoking were associated with GSD. When compared to participants with a BMI below 25, participants with a BMI of 25 or higher had a multivariate relative risk of 4.1 (95% CI, 2.5–6.7). Participants who consumed meat with moderate fat content or high fat content had respective relative risks of 2.5 and 2.9 (95% CI, 1.5–4.2 and 1.5–5.6), when compared to those who consumed meat with a low fat content. Also, the multivariate relative risk for former smokers, as compared to never smokers, was 2.4 (95% CI, 1.1–5.2).

Conclusions

High BMI, consumption of high-fat meat, and smoking were associated with gallstone disease.

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.

A high cholecystectomy rate in a cohort of Mexican American women who are postpartum at the time of oral contraceptive pill initiation

BACKGROUND

Opinions regarding the association between gallbladder disease and oral contraceptive (OCs) differ. The objective of this article is to quantify cholecystectomy rate among women initiating OCs.

STUDY DESIGN

Women under the age of 25 years were enrolled at four sites in a randomized trial evaluating initiation of OCs. Hospitalizations while enrolled were elicited during follow-up interviews, and medical records of women who underwent cholecystectomy were reviewed.

RESULTS

Of 757 women enrolled at University of Texas Southwestern Medical Center (UTSW), 8 underwent cholecystectomy, a rate of 25.3/1000 woman-years (95% CI=8.1, 42.5). All eight were Mexican American and postpartum when they initiated OCs. The expected rate is 4.2/1000 woman-years for U.S. women aged 15-44.

CONCLUSIONS

Women enrolled at the UTSW site had an increased rate of cholecystectomy and were more likely to be postpartum and Mexican American than women enrolled at the other sites.

Menopausal hormone therapy and gallbladder disease: the Study of Health in Pomerania (SHIP)

OBJECTIVE

Several studies suggest that oral menopausal hormone therapy (MHT) is associated with an increased risk of gallbladder disease. It has been hypothesized that nonoral MHT may reduce the risk of cholelithiasis. The objective of the present study was to analyse the association between (1) use of life-time MHT (ever use) and gallbladder disease and (2) nonoral use of MHT and gallbladder disease.

DESIGN

Cross-sectional study using population-based data from the Study of Health in Pomerania (SHIP).

POPULATION

The study population included 994 postmenopausal women, aged 40-79 years. The subgroup of current oral and nonoral MHT users comprised 139 women.

METHODS AND MEASUREMENTS

Sociodemographic, medical and reproductive characteristics were based on computer-assisted personal interviews, and selected laboratory parameters were analysed. Gallbladder disease was defined by either a prior history of cholecystectomy or the presence of current sonographically diagnosed gallstones. Data analyses consisted of descriptive, bivariable and multivariable procedures. We performed Poisson regression with Huber/White standard errors to investigate the association between ever use, current nonoral use of MHT and gallbladder disease.

RESULTS

We found no significant association between ever use of MHT and gallbladder disease and sonographically diagnosed gallstones in fully adjusted analyses. Women who used MHT had a significantly higher risk for cholecystectomy compared to nonusers. There was no association between nonoral use of MHT and gallbladder disease.

CONCLUSIONS

Our analyses do not lend support to the hypothesis that use of MHT is associated with gallbladder disease.

Gallstone disease

Gallstone disease is one of the most prevalent gastrointestinal diseases with a substantial burden to health care systems that is supposed to increase in ageing populations at risk. Aetiology and pathogenesis of cholesterol gallstones still are not well defined, and strategies for prevention and efficient nonsurgical therapies are missing. This review summarizes current concepts on the pathogenesis of cholesterol gallstones with focus on the uptake and secretion of biliary lipids and special emphasis on recent studies into the genetic background.

Cholecystectomy and endometrial cancer: a marker of long-term elevated estrogen exposure?

Excess hormones, both endogenous and exogenous, are implicated in the etiology of endometrial cancer. We considered whether having had gallstones or a cholecystectomy (surgery to remove the gallbladder), which are more common in women who are obese and who use exogenous hormones, might be a marker for high lifetime levels of estrogen. We conducted a population-based study of endometrial cancer cases and community controls in women aged 40-79 years. Participants completed an interviewer-administered questionnaire that elicited exposures prior to diagnosis or reference date, including history of gallstones and cholecystectomy, as well as reproductive history, lifetime body mass, smoking, postmenopausal hormone (PMH) use, and other risk factors. Compared to controls, cholecystectomy was associated with a 50% increased risk of developing endometrial cancer (odds ratio = 1.5 [1.1-2.0]). The relationship appeared to depend upon PMH user status; the association was observed only among never hormone users. Body mass index did not appear to modify this relationship. Having a diagnosis of gallstones was also associated with endometrial cancer, although to a lesser magnitude. Although other etiologic factors may play a role in the relation between cholecystectomy and endometrial cancer, the current analysis suggests that this association is attributable, at least in part, to the sharing of hormonal risk factors.

Gender and gallstone disease

Gallstone disease is a common disorder all over the world. In the Western societies about 80 % of the gallstones are composed primarily of cholesterol. Several risk factors for gallstone formation have been identified. One of the most important risk factors is female gender. Rates of gallstones are two to three times higher among women than men. But this is primarily a phenomenon of the childbearing age. Pregnancy is also a major risk factor for gallstone formation. The risk is related to the number of pregnancies. Sex hormones are most likely to be responsible for the increased risk. Estrogen increases biliary cholesterol secretion causing cholesterol supersaturation of bile. Thus, hormone replacement therapy in postmenopausal women and oral contraceptives have also been described to be associated with an increased risk for gallstone disease. However, the effect of estrogen is dose-dependent and new oral contraceptives with a low estrogen dose do not seem to increase the rate of gallstone formation. The present article focuses on the mentioned risk factors associated with female sex hormones.

Risk factors associated with gallstone and biliary sludge formation during pregnancy

AIM

To define the risk factors in gallstone and sludge formation, and to investigate the incidence of gallstone and biliary sludge formation during pregnancy in a group of healthy pregnant women.

METHODS

Sixty-nine healthy pregnant women in early gestation and 28 nulliparous healthy controls were enrolled. Gallbladder volumes, gallbladder ejection fraction (GBEF), serum triglyceride and cholesterol levels were determined in both groups. In the pregnant group, repeated measurements were performed immediately after delivery and compared with initial levels. Risk factors, which are associated with gallstone and biliary sludge development during pregnancy, were determined by linear regression analysis.

RESULTS

No statistically significant difference was observed in the assessed parameters of pregnant women in early gestation and controls (both P > 0.05). In the pregnant group, gallstone and biliary sludge development during pregnancy were detected in 6.3% and 10.9% of cases, respectively. The detected parameters were significantly higher early after delivery than in early gestation, while GBEF was lower (both P < 0.001). Lower GBEF was the most significant factor (P < 0.001) associated with gallstone and sludge formation during pregnancy, while multiple childbirths was the other (P = 0.04).

CONCLUSION

Decrease in GBEF is the most significant risk factor for newly developed gallstone and sludge in pregnant women, while multiple childbirths is the other but less important risk factor.

Is there a link between oestrogen therapy and gallbladder disease?

Cholelithiasis is the most common form of benign gallbladder disease that results in major heath expenditure. Female sex hormones are causally related to cholesterol gallstone disease, which are more common in women than in men. The risk of development of cholelithiasis is further enhanced by the use of exogenous female sex hormones and by pregnancy. Oestrogens are used in oral contraceptives and in hormone replacement therapy (HRT). Oral contraceptives do not pose a greater risk for gallbladder disease. The findings from two randomised, controlled trials, the Heart and Oestrogen/Progestin Replacement Study and the Women's Health Initiative postmenopausal hormone trial, unequivocally confirm that oral oestrogen use in postmenopausal women is causally associated with gallbladder disease, and the magnitude of the effect is not influenced greatly by the presence or absence of progestins. A cautious approach should be observed when prescribing HRT. Women must be informed about the effect of oestrogen use on increased risk of benign gallbladder disease. HRT should be used in the lowest possible dose for the shortest possible time. Women harbouring asymptomatic gallstones should not receive oestrogens because of the possibility of developing cholecystitis.

Pregnancy is not a risk factor for gallstone disease: Results of a randomly selected population sample

AIM: To investigate the prevalence, risk factors, and selection of the study population for cholecystolithiasis in an urban population in Germany, in relation to our own findings and to the results in the international literature.

METHODS: A total of 2 147 persons (1 111 females, age 42.8 ± 12.7 years; 1 036 males, age 42.3 ± 13.1 years) participating in an investigation on the prevalence of Echinococcus multilocularis were studied for risk factors and prevalence of gallbladder stone disease. Risk factors were assessed by means of a standardized interview and calculation of body mass index (BMI). A diagnostic ultrasound examination of the gallbladder was performed. Data were analyzed by multiple logistic regression, using the SAS statistical software package.

RESULTS: Gallbladder stones were detected in 171 study participants (8.0%, n = 2 147). Risk factors for the development of gallbladder stone disease included age, sex, BMI, and positive family history. In a separate analysis of female study participants, pregnancy (yes/no) and number of pregnancies did not exert any influence.

CONCLUSION: Findings of the present study confirm that age, female sex, BMI, and positive family history are risk factors for the development of gallbladder stone disease. Pregnancy and the number of pregnancies, however, could not be shown to be risk factors. There seem to be no differences in the respective prevalence for gallbladder stone disease in urban and rural populations.

Gallbladder cancer: lessons from a rare tumour

Gallbladder cancer is a relatively rare form of malignancy about which our knowledge is scant. However, a unique combination of predisposing factors - including genetic predisposition, geographic distribution, female gender bias, chronic inflammation and congenital developmental abnormalities - makes this type of cancer unique and offers potential for understanding cancer pathogenesis in general. An understanding of how these risk factors contribute to the molecular basis of the disease is essential for understanding the origins of this unusual cancer.

Alterations in gallbladder emptying and bile retention in the absence of changes in bile lithogenicity in postmenopausal women on hormone replacement therapy

The role of female sex hormones in the pathogenesis of gallstones is well established. Pregnancy, contraceptive use, estrogen replacement therapy in postmenopausal women, and estrogen therapy in men for the treatment of prostatic carcinoma have been found to be associated with increased risk of cholesterol gallstones. Alterations in gallbladder emptying and in bile lithogenicity in postmenopausal women receiving hormone replacement therapy (HRT) have not been studied to date. The present study was undertaken to study the effect of HRT on gallbladder emptying and bile lithogenicity. Sixteen postmenopausal women were included in the study. None of the patients had gallstone disease and none had received prokinetic drugs, such as, erythromycin, metoclopramide, domperidone or cisapride, aspirin, and nonsteroidal antiinflammatory drugs. Gallbladder emptying (n = 16), bile microscopy (n = 7), cholesterol saturation index (CSI) (n = 7), and nucleation time (n = 7) were studied before and 3 months after HRT (conjugated estrogen, 0.625 mg, + medroxyprogesterone acetate, 2.5 mg, everyday). Fasting and residual volumes increased (fasting volume, 18.2 +/- 2.2 mL pre-HRT vs 27.6 +/- 3.2 mL post-HRT, P = 0.0003; residual volume, 3.9 +/- 0.6 mL pre-HRT vs 10.3 +/- 2.0 mL post-HRT, P = 0.00009) and ejection fraction decreased (78.2 +/- 2.5% pre-HRT vs 62.2 +/- 3.8% post-HRT; P = 0.0017) after 3 months of HRT. There was no change in CSI (2.32 +/- 0.36 pre-HRT vs 2.60 +/- 0.51 post-HRT; P = NS) or in nucleation time (19.0 +/- 1.2 days pre-HRT vs 17.6 +/- 1.3 days post-HRT; P = NS). None of the bile samples either pre-HRT or post-HRT showed cholesterol monohydrate crystals. Though impairment of gallbladder emptying occurs in the short term with HRT in postmenopausal women, there is no change in CSI and nucleation time.

Risk factors for cholelithiasis in pregnancy

This study was designed to examine the relationships of demographics, anthropometrics, prenatal physical activity, serum cholesterol, and nutrient intakes to symptomatic cholelithiasis (gallstone) occurrence in 128 northern plains pregnant women. Data collected at 14 and 26 weeks of pregnancy and 4 weeks after delivery, indicated 25.8% of the Native American and 8.3% of the Caucasian pregnant women experienced symptoms of cholelithiasis. Body mass indices (BMIs) were significantly higher in the pregnant women who experienced cholelithiasis than in those who did not have cholelithiasis, and prenatal physical activity was significantly lower in those same women. History of gallbladder disease (beta=.73; p=.001), BMI (beta=.33; p=.01), and prenatal physical activity (beta=-.20; p=.04) were predictive of increased occurrence of cholelithiasis during pregnancy.

Disease of the gallbladder and pancreas in pregnancy

Although maternal mortality and morbidity are substantially lower today than decades ago, perinatal mortality and morbidity secondary to gallbladder and pancreatic disease remain excessive. Improvements in perinatal mortality reflect improvements in neonatal intensive care because most of the morbidity stems from prematurity. Prompt recognition of cholelithiasis and pancreatitis and liberal hospitalization have been associated with a decline in poor outcomes. The decision to switch from medical to surgical management must be made individually, taking into account past history, gestational age, and the response of current disease to conservative therapy.

Association of obesity and type II diabetes mellitus as a risk factor for gallstones

Age, female sex, and obesity are well-known risk factors for gallstones; in contrast the possible role of type 2 diabetes mellitus (type-2 DM) is controversial. One reason for this discrepancy might be that type 2 DM is often accompanied by obesity. Therefore, the aim of this study was to evaluate the importance of obesity and of type 2 DM, separately and together, as risk factors for gallstones. In all, 203 obese patients with normal glucose tolerance (obese NGT), 446 obese patients with type 2 DM (obese type 2 DM), 269 lean patients with type 2 DM (lean type 2 DM) and 250 lean subjects with a normal glucose tolerance (lean NGT) were evaluated by ultrasonography for the presence of gallstones. At univariate analysis patients with gallstones (177) were older and were more frequently affected by both obesity and type 2 DM, and had higher triglycerides and fasting blood glucose levels. At multiple logistic regression analysis, only age and obesity, both in the presence or in absence of type 2 DM, were strongly associated with gallstones (P < 0.001); diabetes alone had a lower level of statistical significance (P = 0.07). These data suggest that obesity is a stronger risk factor for gallstones than type 2 DM.

Acute pancreatitis in the postpartum period: a population-based case-control study

OBJECTIVE

To determine relationships among pregnancy (during and postpartum), acute pancreatitis, and gallstones.

PATIENTS AND METHODS

In this retrospective population-based case-control study, we identified all 12- to 50-year-old Rochester, Minn, females diagnosed between 1976 and 1991 as having acute pancreatitis (cases). For each case, we matched 4 women of the same age (+/- 6 years) with no history of acute pancreatitis (controls). Acute pancreatitis was defined as associated with pregnancy if it occurred from 10 months prior to delivery to delivery and with the postpartum period if it occurred within 10 months of the date of delivery. Logistic regression was used to assess associations between pregnancy-related acute pancreatitis, age, gallstone occurrence, and alcohol use.

RESULTS

In a cohort of 61 women who developed acute pancreatitis and 244 controls, the relative risk for acute pancreatitis associated with pregnancy was 1.43 (95% confidence interval, 0.61-3.40). All 10 cases of acute pancreatitis associated with pregnancy occurred in the postpartum period. Gallstones were present in 6 of them compared with 13 of 51 women with non-pregnancy-related acute pancreatitis (P < .05). Women with postpartum-related pancreatitis were younger than those with non-pregnancy-related pancreatitis (mean, 28 vs 36 years; P < .05). Alcohol was not associated with pregnancy-related pancreatitis.

CONCLUSIONS

Acute pancreatitis during the postpartum period is not directly related to pregnancy but is associated with gallstones and occurs in younger women.

Smoking and hormone-related disorders

Through its antiestrogenic effect, cigarette smoking is linked to a variety of hormone-related disorders, both benign and malignant. Diseases that depend on this hormone for growth and development tend to be less common among smokers, such as endometrial cancer and uterine fibroids. Some normal, estrogen-dependent physiologic processes are affected by smoking, making osteoporosis and premature menopause more common among women who smoke. In other disorders, the link between sex hormone levels, cigarette smoking, and disease development is less clear.

Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy is one of the primary disorders of the liver that adversely affects maternal well-being and fetal outcome. Early identification of this condition, careful interdisciplinary monitoring, and prompt delivery at fetal maturity can improve outcomes in the mother and child. Although the cause is unclear, IHCP probably arises from a genetic predisposition for increased sensitivity to estrogens and progestogens and altered membrane composition and expression of bile ducts, hepatocytes, and canalicular transport systems. As a result, the elevations in maternal levels of bile acids and their molar ratios seen in healthy pregnancy rise further in IHCP patients. Also, as the normal fetal-to-maternal transfer of bile acids across the trophoblast is impaired, the excess bile acids with abnormal profiles accumulate and are toxic to the fetus. The management of IHCP is dictated by the increased risks of fetal distress, spontaneous preterm delivery, and sudden death, as well as by alleviating pruritus in the mother. These risks to the fetus rise progressively to delivery, regardless of serum levels of bile acids and ALT. Close monitoring of these markers is essential but does not prevent sudden fetal distress and death. Provision should be made to induce labor as soon as fetal lung maturity has been established. Ursodeoxycholic acid is the only therapy that has proven effective, albeit in small studies, in alleviating pruritus and restoring towards normal the abnormal profiles of bile acids and sulfated steroids in serum and other body fluids. Ursodeoxycholic acid seems to have no obvious adverse effects on the fetus, but experience is insufficient to draw conclusions regarding teratogenicity and prevention of adverse outcomes.

Gallstone prevalence in Germany: the Ulm Gallbladder Stone Study

The Ulm Gallbladder Stone Study is the first ultrasound-based epidemiologic survey of cholecystolithiasis in the former West Germany. A study population of 1116 blood donors (656 men, age 38.0 +/- 12.0 years; 460 women, age 34.1 +/- 11.2 years) at the Central Blood Bank of the German Red Cross in Ulm was examined between April 1994 and February 1995. Based on age, subjects were assigned to one of four groups (18-30, 31-40, 41-50, and 51-65 years). Following a structured interview of each study subject, an ultrasound examination was carried out and a blood sample obtained for laboratory study. Overall, 6.0% (95% (95% CI: 4.8%-7.6%) of all study subjects (5.8% of the men and 6.3% of the women) exhibited evidence of current or past gallbladder disease (cholelithiasis or history of cholecystectomy). The prevalence of gallbladder disease correlated positively with age, reaching a maximum of 13.7% (9.5-20.0) in the 51- to 65-year-old age group, and also correlated as with body mass index (BMI). Female subjects with previous full-term pregnancies showed a higher prevalence of cholelithiasis, but this difference was not statistically significant for age-adjusted analysis. Subjects with a family history of cholelithiasis were found to suffer from gallstones in 11.5% (8.0-16.7) of cases compared with 4.6% (3.4%-6.3%) of subjects without such family history. Autopsy studies conducted in Germany have shown the prevalence of gallstones to be about 13.1% in men and 33.8% in women. Our sonographic data are relatively low in comparison. This may be due, in part, to the specific selection characteristics inherent in retrospective autopsy studies, such as age distribution and the presence of other pathologic factors associated with increased risk for cholelithiasis. The Ulm data rank in the lower third of the prevalence range reported for European sonographic studies to date. Age, positive family history, and increased BMI all correlated positively with the prevalence of gallbladder disease (P < 0.05). For the study population as a whole, there was no gender-specific increased risk for the development of gallstones.

Risk factors for gallstone disease in Mexicans are similar to those found in Mexican-Americans

According to epidemiological studies, gallstone disease is a very common disease in Mexican-Americans and Mexicans. However, the major risk factors for cholelithiasis in Mexicans have not been identified. We designed a case-control study in a group of Mexican subjects with and without gallstone disease confirmed by ultrasound. These subjects were prospectively studied over a three-year period. Clinical and epidemiological data were collected by means of a questionnaire. A total of 1500 subjects were included in this study: 1000 with and 500 without gallstone disease. The major risk factor in both men and women was body mass index [odds ratio (OR) 1.64 and 1.96, respectively; P < 0.008 and 0.001]. In addition, parity was an important factor in women (OR 2.17, P < 0.001), whereas age was associated with gallstone disease in men (OR 1.43, P < 0.001). We found that body mass index, parity, and age were the principal risk factors for gallstone disease in this group of Mexican subjects. These results are similar to those found in Mexican-American populations.

Cholelithiasis induced in the Syrian hamster: evidence for an intramucinous nucleating process and down regulation of cholesterol 7 alpha-hydroxylase (CYP7) gene by medroxyprogesterone

This report reviews previously published studies from our laboratory and shows some recent morphological data obtained with scanning and transmission electron microscopy regarding gallstone formation and alteration of the gallbladder epithelium in the Syrian hamster model. Both male and female hamsters were treated with female sex steroids (estradiol alone, estradiol and medroxyprogesterone, medroxyprogesterone alone) during one month. The results show that the Syrian hamster is a good model to study bile changes, gallbladder structure changes, including gallstone formation, and the regulation of cholesterol metabolism at the molecular level. Arguments in favor of this animal model are presented and, during gallstone formation, epithelial cell changes, anionic mucus secretion, and formation of gallbladder luminal deposits can be demonstrated. Recent molecular biology observations related to the effect of female sex steroids on liver cholesterol 7 alpha-hydroxylase (CYP7) gene suggest that progestin alone or primed by estrogen down regulates CYP7 transcription and activity. In addition, progesterone in cell culture systems has been shown to enhance intracellular accumulation of free cholesterol by increasing its uptake and synthesis and by decreasing its esterification by inhibiting the activity of acylcoenzyme A: cholesterol acyltransferase. Non-esterified cholesterol is free to migrate to the extracellular spaces and may contribute to nucleation within the bile. It is suggested that these effects of progesterone on cholesterol metabolism combined with the CYP7 gene down regulation, physical changes in the mucus and the hypomotility of the gallbladder and biliary ducts result in hypersaturation of cholesterol in the bile which favors gallstone formation.

Gallbladder motility change in late pregnancy and after delivery

OBJECTIVES

The incidence of gallstone disease has increased recently in Korea and there seems to be an increased prevalence of gallstones when in association with pregnancy. Although the pathogenesis is incompletely defined, and altered motility of the gallbladder may contribute to the increased risk of gallstones during pregnancy.

METHODS

We measured gallbladder volume using real-time ultrasonography to find out the mechanism for the changes of gallbladder motility during late pregnancy. Eighteen pregnant women took the gallbladder ultrasonography during their last trimester of pregnancy and after delivery; gallbladder volume and ejection fraction were calculated in each patient.

RESULTS

Fasting gallbladder volumes increased significantly in the last trimester of pregnancy (25.28 +/- 14.26ml) compared with postpartum (17.44 +/- 5.82 ml) (p < 0.05). Gallbladder volumes measured after fatty meals showed more increment in pregnant women (10.13 +/- 7.19 ml) than in those after delivery (4.34 +/- 3.36 ml) (p < 0.005). A significantly reduced gallbladder ejection fraction was found in the pregnant group (60.56 +/- 18.80%) compared with those after delivery (77.48 +/- 13.37%) (p < 0.005).

CONCLUSION

Gallbladder motility in late pregnancy shows significant impairment compared with that in postpartum. Thus, we suggest that gallbladder hypomotility may occur during late pregnancy, and this impairment of gallbladder motility may play an important role in gallstone formation.

In vitro contractility of stimulated and non-stimulated human gallbladder muscle

In an attempt to define, more clearly, the nature of gallbladder contraction we obtained muscle strips from human gallbladder wall, removed at cholecystectomy. Samples were taken from various areas of the gallbladder to seek evidence of a dominant axis of contraction. The strips were stimulated with increasing concentrations of cholecystokinin-8 (CCK-8) and carbachol, and, to determine maximal contractile force, 0.25 M potassium chloride. No differences were seen between samples taken from the long-itudinal, circular and oblique axes. In a second series of experiments, samples were taken from the body and neck regions of the gallbladder. In these, it was seen that the samples from the body contracted more forcefully than those of the neck tissue and that they were more sensitive to carbachol stimulation. The difference in response to CCK-8 measured in the strips from the body and cystic duct/neck of the gallbladder cannot be explained by a difference in sensitivity to CCK-8, but is mainly due to the difference in the amount of muscle tissue present. Strips from the body are more sensitive to muscarinic stimulation that those from the neck. Overall, there is a functional difference in sensitivity between the body and neck which would serve to facilitate bile flow into the common bile duct during gallbladder contraction.

Oral contraceptive side effects: where's the beef?

The initial report is reviewed, as well as the results of subsequent investigations, and the current status of the following side effects attributed to the use of oral contraceptives: subjective symptoms such as mood and libido changes, also headache; melanoma; gallbladder disease; liver tumors, sickle cell disease exacerbation; teratogenesis; "post-Pill" amenorrhea; atherogenesis; and diminished carbohydrate tolerance. In many instances a cause-and-effect relationship appears to be incorrect or highly improbable. In other instances the side effects are clinically insignificant or so rare as to be of minimal importance. Yet they continue to be listed by various authorities as validated side effects or relative contraindications to oral contraceptive use. This, in turn, limits the access of many women to a highly effective form of contraception. This re-examination of past history is intended to modernize our concepts of the safety of this modality.

Gallbladder motility, gallstones, and the surgeon

Cholecystectomy is one of the commonest surgical procedures in the Western world, with more than half a million procedures performed annually in the United States alone. In recent years, studies of gallstone pathogenesis and gallbladder disease have increasingly focused on abnormal gallbladder motility in the pathogenesis of some, if not all, gallbladder conditions. The control of gallbladder motility is complex and depends on an intricate interplay of neural and hormonal factors. An understanding of the control of gallbladder motility is crucial to the understanding of the mechanisms of gallstone formation and may help to explain the failure to cure symptoms after cholecystectomy in up to one third of patients. The purpose of this article is to outline mechanisms controlling gallbladder motility, examine recent developments in our understanding of this complex process, and relate changes in motility to common disease conditions of the gallbladder. The role of altered motility in the pathogenesis of gallstones is discussed and the effects of commonly performed surgical procedures such as truncal vagotomy and cholecystectomy on upper gut physiology are reviewed.