Increased prevalence of subclinical hypothyroidism in common bile duct stone patients

[New Progress in Longitudinal Research on the Risk Factors for Cholelithiasis]

Cholelithiasis is a common disease of the digestive system. The risk factors for cholelithiasis have been reported and summarized many times in the published literature, which primarily focused on cross-sectional studies. Due to the inherent limitations of the study design, the reported findings still need to be validated in additional longitudinal studies. Moreover, a number of new risk factors for cholelithiasis have been identified in recent years, such as bariatric surgery, hepatitis B virus infection, hepatitis C virus infection, kidney stones, colectomy, osteoporosis, etc. These new findings have not yet been included in published reviews. Herein, we reviewed the 101 cholelithiasis-associated risk factors identified through research based on longitudinal investigations, including cohort studies, randomized controlled trials, and nested case control studies. The risk factors associated with the pathogenesis of cholelithiasis were categorized as unmodifiable and modifiable factors. The unmodifiable factors consist of age, sex, race, and family history, while the modifiable factors include 37 biological environmental factors, 25 socioenvironmental factors, and 35 physiochemical environmental factors. This study provides thorough and comprehensive ideas for research concerning the pathogenesis of cholelithiasis, supplying the basis for identifying high-risk groups and formulating relevant prevention strategies.

Co-Morbid Hypothyroidism and Liver Dysfunction: A Review

The liver and thyroid hormones interact at multiple levels to maintain homoeostasis. The liver requires large adequate amounts of thyroid hormones to execute its metabolic functions optimally, and deficiency of thyroid hormones may lead to liver dysfunction. Hypothyroidism has been associated with abnormal lipid metabolism, non-alcoholic fatty liver disease (NAFLD), hypothyroidism-induced myopathy, hypothyroidism-associated gallstones and occasionally, interferon-induced thyroid dysfunction. NAFLD remain an important association with hypothyroidism and further studies are needed that specifically compare the natural course of NAFLD secondary to hypothyroidism and primary NAFLD. Hepatic dysfunction associated with hypothyroidism is usually reverted by normalizing thyroid status. Large scale studies geared towards finding new and effective therapies, especially for NAFLD are needed. The clinician must be aware that there exists overlapping symptomatology between liver dysfunction and severe hypothyroidism which may make delay the diagnosis and treatment of hypothyroidism; this requires a high index of suspicion.

Sex-specific differences in the associations of metabolic syndrome or components with gallstone disease in Chinese euthyroid population

In euthyroid population, it is uncertain whether there is sex-specific difference in the associations of metabolic syndrome (MetS) or its components with gallstone disease (GSD); in general population, MetS increases the risk of GSD. This was a cross-sectional study to investigate the sex-specific difference in the prevalence of MetS according to GSD status and the associations of MetS or its components with GSD in Chinese euthyroid population. The total prevalence of GSD was 8.1% (6.5% in men and 11.0% in women, with a significant difference (p < 0.001)). The total presence of MetS was 10.7% (12.1% in men and 8.2% in women,with a significant difference (p = 0.001)). The age-adjusted odds ratio of MetS for GSD was 2.775 in men (p < 0.001), 2.543 in women (p = 0.007) and 2.503 in the oveall samples (p < 0.001). Univariate analysis revealed that fasting plasma glucose (FPG), high-density lipoprotein cholesterol (HDL-C) and thyroid-stimulating hormone (TSH) were associated with the prevalence of GSD. After adjustment for age, multivariate logistic regression analysis demonstrated that above three parameters were still significantly associated with the risk of GSD in general population; FPG and HDL-C but not TSH levels were significantly associated with the risk of GSD in men; and FPG and TSH levels but not HDL-C in women. Our study demonstrated that in euthyroid population, MetS appeared to be strongly associated with GSD regardless of sex, and FPG and TSH were two independent risk factors for GSD in men, while FPG and HDL-C in women.

A Review of Synchronous Findings of Hypothyroidism and Cholelithiasis

Cholelithiasis is considered to be the most common biliary pathology. They have been categorized into three types, which are pigment stones, cholesterol stones, and mixed types of stones with varying incidence. The condition may be asymptomatic for significantly long durations and in most cases, the presence of gall stones is an incidental finding. The patients may present with pain in the abdomen in stages of cholecystitis or advanced stages or cases of gall stones causing the obstruction. Gallbladder stones are formed through a very complex procedure with the contribution of numerous factors, where the main initiating step is supposed to be the development of a state wherein there is supersaturation of the bile, which in turn gives rise to accumulation and stasis of the bile and the development of gall stones. One of the factors is said to be the hypothyroid state. Hypothyroidism itself is a significantly common endocrine disorder that affects almost every nucleated cell in the body. There is decreased efficacy of the thyroid gland. The serum T3 and T4 levels might be found on the lower side whereas thyroid-stimulating hormone (TSH) values are found to be high. In some of the cases, though the T3 and T4 levels are maintained within the normal limits, the TSH shows raised values, which are labeled as subclinical hypothyroidism. The state of hypothyroidism may act upon the amount of bile secretion, the flow of bile into the intestines, cholesterol metabolism, and the action of the sphincter of Oddi. Studies have shown results pointing towards the correlation between these two factors. The basic mechanism behind the correlation between cholelithiasis and hypothyroidism is supposed to be due to the action of the hypothyroid state on the functioning of the sphincter of Oddi. The hypothyroid state is supposed to be decreasing the tendency of the sphincter of Oddi to relax, thus causing stasis of the bile, which over time leads to initiation of supersaturation of the bile and formation of gall stones. Both subclinical hypothyroidism and clinical hypothyroidism are found to be significantly common in patients having cholelithiasis. We, in this review article, have taken into consideration various studies which have been performed regarding this topic worldwide. The studies have been performed on individuals who are already diagnosed with either of these diseases and are then screened for the presence of the other disease included in this study. The degree of correlation varies according to the location of the stones and their sizes. Though various studies show varying results to some extent, overall almost all the studies show significant pieces of evidence of the correlation between cholelithiasis and hypothyroidism.

Clinical Profile and Evaluation of Outcomes of Symptomatic Gallstone Disease in the Senior Citizen Population

Background

There is a heavy burden of gallstone disease on the world’s population. The incidence and severity of symptomatic cholelithiasis increase with age. There is often a delay in presentation, leading to complicated disease, diagnostic delay, and increased morbidity. There is a paucity of studies on the presentation and management of cholelithiasis in elderly persons from the western part of India. This study aimed to observe the spectrum of presentation and management of symptomatic cholelithiasis in senior citizens.

Objectives 

The primary objective of this study was to describe the presentation, diagnosis and intraoperative findings of symptomatic gallstone disease (GSD) in patients aged over 60 years. The secondary objectives of this study were to find the association of GSD with age, sex, and comorbidities, including diabetes mellitus, hypertension, and thyroid disorders.

Methods

All patients above the age of 60 years presenting to the surgical outpatient and emergency departments from January 2020 to July 2021 with symptomatic GSD were included. Details of history, physical examination, blood investigations, and imaging of the abdomen (ultrasonography and Magnetic Resonance Cholangiopancreaticography, when indicated) were recorded. Patients were managed as per the advice of the treating consultant. Details of management and outcomes, including hospital stay, mortality, and morbidity, were noted. The descriptive data were organised into tables and percentages. The significance of various data and relationships between various variables was analysed using the Pearson chi-square test, Fischer exact test and scatter plots.

Results

A total of 76 patients were evaluated in this study, of which 73.7% were female. The mean age was 70.8 ± 1.7 years. The majority of patients (63.2%) were admitted through the outpatient department (OPD). The most common presenting complaint was abdominal pain (96.1%). Clinical jaundice was noted in 9.2%. Complicated Gall Stone Disease (GSD) was found more commonly in the female population (57.1%). Complicated GSD was more commonly found in patients with diabetes (p=0.075) and hypothyroidism (p=0.057). No association of age with intraoperative complications was noted (p = 0.446).

Conclusion

Senior citizens can present with both complicated and uncomplicated GSD. GSD, in the presence of hypothyroidism or diabetes mellitus, presents in a much more complicated form. Early surgical intervention in form of laparoscopic cholecystectomy can be beneficial to the patient if diagnosed with symptomatic gallstones. Patients of this age group need not be over investigated if a benign pathology is suspected.

Risk factors and management of primary choledocholithiasis: a systematic review

BACKGROUND

Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy.

METHODS

Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed.

RESULTS

A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches.

CONCLUSION

Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for young patients or those in good conditions.

The interplay between thyroid and liver: implications for clinical practice

A complex relationship exists between thyroid and liver in health and disease. Liver plays an essential physiological role in thyroid hormone activation and inactivation, transport, and metabolism. Conversely, thyroid hormones affect activities of hepatocytes and hepatic metabolism. Serum liver enzyme abnormalities observed in hypothyroidism may be related to impaired lipid metabolism, hepatic steatosis or hypothyroidism-induced myopathy. Severe hypothyroidism may have biochemical and clinical features, such as hyperammonemia and ascites, mimicking those of liver failure. Liver function tests are frequently abnormal also in hyperthyroidism, due to oxidative stress, cholestasis, or enhanced osteoblastic activity. Antithyroid drug-associated hepatotoxicity is a rare event, likely related mainly to an idiosyncratic mechanism, ranging from a mild hepatocellular damage to liver failure. Propylthiouracil-induced liver damage is usually more severe than that caused by methimazole. On the other hand, thyroid abnormalities can be found in liver diseases, such as chronic hepatitis C, liver cirrhosis, hepatocellular carcinoma, and cholangiocarcinoma. In particular, autoimmune thyroid diseases are frequently found in patients with hepatitis C virus infection. These patients, especially if thyroid autoimmunity preexists, are at risk of hypothyroidism or, less frequently, thyrotoxicosis, during and after treatment with interpheron-alpha alone or in combination with ribavirin, commonly used before the introduction of new antiviral drugs. The present review summarizes both liver abnormalities related to thyroid disorders and their treatment, and thyroid abnormalities related to liver diseases and their treatment.

The prevalence and correlation between subclinical hypothyroidism and gall stone disease in Baghdad teaching hospital

Background

Gall stones are the most common biliary pathology. Subclinical hypothyroidism is not a common problem in the population with thyroid disease, several explanations for a possible relation between hypothyroidism and lipid metabolism, gall stone formation proved that prevalence of gall stones is increased in patients with hypothyroidism disease.

Objective

To find the prevalence and correlation between the subclinical hypothyroidism and gall stone disease.

Methods

This cross-sectional study in Baghdad teaching hospital which done over the period of January 2015 till December 2015 where 103 patients presented with gall stones as an in and outpatients. All the patients were assessed and prepared for cholecystectomy by detailed history, clinical examination, thyroid function test and abdominal ultrasound.

Results

Among 103 patients, the majority them were in 36-50 years age group, 84 (81.6%) of them were females and 19 (18.4%) were males. Of the total number of patients, eight of them (7.8%) found to have subclinical hypothyroidism and 95 (92.2%) of them found to be euthyroid, most of patients in the subclinical hypothyroid group were showing female gender predominance with 81.6%. While the prevalence among males were found 18.4%, most patients with subclinical hypothyroidism were found to had positive family history (75%), and (25%) of them found to had negative family history.

Conclusion

There is gender specific relationship between subclinical hypothyroidism and gall stone disease as this study sharing statistically increasing in prevalence of the subclinical hypothyroidism among females in age group ≥ 40 years, positive family history, and single abdominal US gall stone. This subset of patients should be assessed for thyroid dysfunction.

Clinical aspects of thyroid function during ageing

Globally, populations are ageing at a rapid rate. The increase in the number of older citizens is accompanied by an increased prevalence of thyroid dysfunction, one of the most common disorders in older people. However, the diagnosis of thyroid dysfunction in older people is hindered by several factors, including the scarcity of thyroid dysfunction symptoms in older people. We describe the physiological changes in thyroid function that occur with increasing age, focusing on literature regarding changes in thyroid function test results in older populations. We also discuss treatment considerations for clinical and subclinical thyroid dysfunction according to international guidelines for older people. Finally, we discuss the relationship between variations in thyroid function and common diseases of old age including cardiovascular disease, osteoporosis, cognitive impairment, and frailty and suggest directions for future research.

Neonatal cholelithiasis in Down syndrome: Is hypothyroidism involved? A case-report

We report a 3-month-old male with Down syndrome (DS), prolonged jaundice and poor weight gain, that showed biliary lithiasis and undiagnosed congenital hypothyroidism (CH).CH should be considered in DS, especially in presence of gastrointestinal symptoms or malformations. Clinicians should be aware of the increased risk of gallstones in hypothyroid children with DS, even in neonatal age.

Laparoscopic common bile duct exploration and primary closure of choledochotomy after failed endoscopic sphincterotomy

BACKGROUND

The aim of this study is to evaluate the safety and feasibility of laparoscopic common bile duct exploration and primary closure of choledochotomy for the patients with common bile duct stones (CBDS) who failed in endoscopic sphincterotomy (EST).

METHODS

Between January 2007 and June 2012, a total of 78 patients who subjected to endoscopic retrograde cholangiopancreatography (ERCP) and EST, but failed in endoscopic stone extraction, were referred to us. The following day, laparoscopic cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and primary closure of choledochotomy were performed in all patients.

RESULTS

No intraoperative complications were experienced in the patients. 6 patients required conversion to open cholecystectomy due to impacted stones. The mean operative time was 145 min. The mean postoperative hospital stay was 6d. All the patients achieved successful stone clearance. 13 cases had slight bile leaks, which resolved spontaneously. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis, or cholangitis.

CONCLUSION

If it is performed by experienced laparoscopic surgeons, primary closure following immediate laparoscopic common bile duct exploration (LCBDE) is safe and feasible for patients with CBDS who fail in endoscopic stone extraction.

Menopause after a history of intrahepatic cholestasis of pregnancy

OBJECTIVE

Intrahepatic cholestasis of pregnancy is a hormone-provoked disorder that fades quickly after parturition. The aim of this study was to establish whether a history of intrahepatic cholestasis of pregnancy reduces the use of hormone therapy for menopausal symptoms and, irrespective of hormone therapy, whether intrahepatic cholestasis is associated with other health aspects after menopause.

METHODS

In 2010, questionnaires were sent to a cohort of women who delivered in Tampere University Hospital, Finland, from 1969 to 1988. The study population comprised postmenopausal women with a history of intrahepatic cholestasis of pregnancy (n = 189) and their controls (n = 416). The main outcome measures were the use of hormone therapy and other means of alleviating menopausal symptoms, and the diseases the women reported.

RESULTS

There were no differences in the use of hormone therapy between the two groups. Of the diseases reported, breast cancer, hepatobiliary diseases, and hypothyroidism were more frequent among women with a history of intrahepatic cholestasis of pregnancy, whereas cardiac arrhythmia was less frequent. With respect to other diseases, there were no differences.

CONCLUSIONS

A history of intrahepatic cholestasis of pregnancy does not reduce the use of hormone therapy. However, when physicians prescribe hormone therapy for these women, a history of intrahepatic cholestasis of pregnancy calls for attention in view of its association with gallstones.

Subclinical hypothyroidism: Controversies to consensus

Diagnoses of subclinicaal hypothyroidism (SCH) is biochemically made, when serum thyroid stimulating hormone (TSH) levels is elevated while free thyroid hormone levels are within normal reference range. SCH is diagnosed after excluding all other causes of elevated TSH levels. Symptoms of SCH may vary from being asymptomatic to having mild nonspecific symptoms. The risk of progression to overt hypothyroidism is related to number of factors including initial serum TSH concentration, presence of auto antibodies, family history and presence goiter. Various screening recommendations for thyroid function assessment are in practice. There are still controversies surrounding SCH and associated risk of various cardiovascular diseases (CVDs), pregnancy outcomes, neuropsychiatric issues, metabolic syndrome, and dyslipidemia. Consensus will require more large randomized clinical studies involving various age groups and medical condition, especially in developing countries. All these efforts will definitely improve our understanding of disease and ultimately patient outcomes.

Treatment of iron-deficiency anemia in patients with subclinical hypothyroidism

OBJECTIVE

Subclinical hypothyroidism is a health state that is associated with hypercholesterolemia, infertility, iron-deficiency anemia, and poor obstetric outcome. This article summarizes the results of a prospective clinical investigation of whether treatment of subclinical hypothyroidism and iron-deficiency anemia with a combination of levothyroxine plus iron salt would be superior to each treatment alone.

METHODS

In a randomized, double-blind, active-controlled trial, 60 patients with subclinical hypothyroidism and iron-deficiency anemia received iron salt+placebo (20 patients), levothyroxine+placebo (20 patients), or levothyroxine+iron salt (20 patients) for 3 months. Change from baseline (before) to end of study (after) in hemoglobin, ferritin, and thyroid-stimulating hormone levels were compared among groups.

RESULTS

The increase from baseline in hemoglobin and ferritin in the levothyroxine+iron group was superior to the other groups, in which a decrease in thyroid-stimulating hormone in the 2 groups that received levothyroxine was superior to the group treated with iron salt.

CONCLUSION

Subclinical hypothyroidism was investigated in iron-deficient patients with no acceptable response to iron salt alone. A combination of levothyroxine and iron salt is better than each one alone.

The underlying mechanisms: how hypothyroidism affects the formation of common bile duct stones-a review

For decades, one well-known risk factor for the development of gallbladder stones has been hypothyroidism. Recent studies have interestingly reported that the risk in particular for common bile duct (CBD) stones increases in clinical and subclinical hypothyroidism. There are multiple factors that may contribute to the formation and/or accumulation of CBD stones in hypothyroid patients, including decreased liver cholesterol metabolism, diminished bile secretion, and reduced sphincter of Oddi relaxation. This paper focuses on the mechanisms possibly underlying the association between hypothyroidism and CBD stones. The authors conclude that when treating patients with CBD stones or microlithiasis, clinicians should be aware of the possible hypothyroid background.

Health history after intrahepatic cholestasis of pregnancy

OBJECTIVE

To establish whether intrahepatic cholestasis of pregnancy (ICP) is associated with other diseases during a woman's lifetime.

DESIGN

Prospective controlled cohort study.

SETTING

University Hospital in Finland.

POPULATION

A total of 575 women with ICP and 1374 control women, all having delivered in 1969-1988. Questionnaires were sent to 544 ICP patients and 1235 control women. Responses were received from 1178 (66.4%).

METHODS

Questionnaire survey in autumn 2010.

MAIN OUTCOME MEASURES

Perceived health, symptoms and complaints, diseases diagnosed by a doctor and use of medicines.

RESULTS

No statistically significant differences were detected in perceived health. Differences in recent symptoms and complaints were small. Diagnoses made by a doctor showed higher frequencies in the ICP group than in control women for other hepatobiliary diseases, breast cancer and hypothyreosis. Diagnosed hypertension and high cholesterol requiring medication as well as cardiac arrhythmia were less frequent in the ICP group. Women in this group used antacid medicines more often than control women.

CONCLUSIONS

There were few differences between the ICP patients and control women except for a higher frequency of later hepatobiliary disease, breast cancer and hypothyreosis. Women with a history of ICP should be screened for hypothyreosis more readily than those without. The higher frequency of breast cancer warrants further research.

Bile duct stone procedures are more frequent in patients with hypothyroidism. A large, registry-based, cohort study in Finland

OBJECTIVE

Delayed bile flow may induce the formation/accumulation of common bile duct stones (CBDS). Bile flow is delayed in hypothyroidism, partly due to insufficient sphincter of Oddi relaxation. Patients with CBDS have higher incidences of clinical and subclinical hypothyroidism compared to healthy controls and gallbladder stone patients. The aim of this large registry-based study was to investigate the prevalence of CBDS in patients with diagnosed hypothyroidism compared to age-, sex- and living area-adjusted glaucoma (control) patients.

MATERIAL AND METHODS

Between 1987 and 2001, all patients with approved Special Medical Coverage (SMC) for hypothyroidism or glaucoma, and without other SMC approvals, were included. The glaucoma (control) cohort was adjusted for age, sex and area of residence. For each patient, onset of SMC, all prescription drugs and treatments for CBDS were noted.

RESULTS

A total of 14,334 patients in each group met the inclusion criteria. Thirty-three patients (0.23%) in the hypothyroidism cohort and 23 (0.16%) in the glaucoma cohort had been treated for CBDS (p = 0.018). The groups did not differ in the number of CBDS treatments before the diagnosis of hypothyroidism or glaucoma. However, after the diagnosis of hypothyroidism or glaucoma there were significantly more CBD stone patients in the hypothyroid cohort (n = 25) than in the glaucoma cohort (n = 14) (p < 0.05).

CONCLUSIONS

Diagnosed hypothyroidism is a significant risk factor for CBDS. We hypothesize that CBD stone formation begins during the untreated period and develops/matures even after the medication has been initiated, raising the question of the efficiency of treatment in this respect. When treating CBDS patients, one should be aware of the possible hypothyroid background.

Endocrine and liver interaction: the role of endocrine pathways in NASH

This article reviews evidence that causally links hormonal disorders with hepatobiliary disease, and gives particular focus to nonalcoholic steatohepatitis (NASH). The downstream mechanisms by which endocrine disturbances cause liver disease might be similar to those involved in the development of primary liver disease. Hypothyroidism, for example, might lead to NASH, cirrhosis and potentially liver cancer via the development of hyperlipidemia and obesity. Patients with growth hormone deficiency have a metabolic-syndrome-like phenotype that is also associated with the development of NASH. Polycystic ovary syndrome is a common endocrine disorder that is often associated with insulin resistance, the metabolic syndrome, altered levels of liver enzymes and the development of NASH. Recent findings support a role of dehydroepiandrosterone sulfate deficiency in the development of advanced NASH. In addition, adrenal failure is increasingly reported in patients with end stage liver disease and in patients who have received a liver transplant, which suggests a bidirectional relationship between liver and endocrine functions. Clinicians should, therefore, be aware of the potential role of endocrine disorders in patients with cryptogenic liver disease and of the effects of liver function on the endocrine system.