Gallbladder motor function, plasma cholecystokinin and cholecystokinin receptor of gallbladder in cholesterol stone patients

Serum cholecystokinin levels can be a predictive factor for difficult cholecystectomy: Decreased cholecystokinin receptor levels

BACKGROUND

Laparoscopic cholecystectomy (LC) is being performed frequently in general surgery practice. Estimation of difficult cholecystectomy is very important to take precautions against complications. Cholecystokinin (CCK) is an important enzyme for gall-bladder motility. CCK receptor is the target for CCK. Fibrosis and emptying problems of gallbladder are related with difficult cholecys-tectomies. We aimed to evaluate the association between plasma CCK and difficult cholecystectomy and try to explain the mechanism.

METHODS

Prospective cross-sectional study was conducted on a group of patients with cholelithiasis Patients who underwent elective cholecystectomy were classified into easy, difficult and very difficult preoperatively using LC difficulty scores. Pre-operative gallbladder empting ratios were measured by ultrasonography. Serum C-reactive protein, and postprandial serum CCK and pancreas polypeptide levels were measured before the operation. Operation data including operation times, adhesion scores, and complications were collected. Tissue CCK receptor levels and tissue fibrosis scores were obtained.

RESULTS

Easy, difficult, and very difficult LC (DLC) groups were consisted of 34, 28, and 8 patients, respectively. Gallbladder emp-tying was 60% in easy LC group, but 15% in very DLC group. Plasma CCK levels in easy group (37.4 pg/ml) were significantly lower than plasma CCK levels of difficult (58.6 pg/ml), and very difficult groups (66.23 pg/ml). Tissue CCK receptor levels of easy, difficult, and very difficult were 372.4, 178.3, and 144.1 ng/100 mg, respectively. Adhesion scores and fibrosis scores of very difficult group were significantly higher than other groups. Operation times were significantly longer in very difficult group. There were two conversions to open in very DLC group (25%).

CONCLUSION

CCK is a reliable parameter for determining the difficulty of LC. Decreased CCK receptor levels with fibrosis of gallbladder are the probably responsible mechanism.

Cholecystectomy reduces the severity of subsequent idiopathic acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common digestive system disease, and its incidence is increasing year by year. Although some clinical studies have indicated that cholecystectomy can reduce the risk of recurrent pancreatitis after acute biliary pancreatitis (ABP), it is not clear whether cholecystectomy would affect the severity of subsequent AP.

METHODS

In this study, we combined computed tomography scoring index (CTSI), bedside index for severity in AP (BISAP), and clinical manifestations grading of AP with propensity score matching (PSM), after correction for baseline confounding factors, to respectively explore the influence of cholecystectomy on the severity of subsequent pancreatitis in 527 AP patients.

RESULTS

The results showed that ABP (231/527) is more common in female patients and elderly patients (P < 0.001). Age, amylase, creatinine, blood urea nitrogen, and aspartate aminotransferase levels of patients with ABP at admission were higher than those of non-biliary pancreatitis (296/527), and the levels of albumin, hematocrit, and blood glucose were lower (P < 0.050). Further, compared with the unresected group (458/527), patients after cholecystectomy (69/527) had less white blood cells and higher level of albumin (P < 0.050). Patients had lower clinical manifestation grade (P = 0.019) and CTSI grade (P < 0.008) after cholecystectomy. After PSM correction, there was no difference in biochemical parameters between the cholecystectomy group and the non-cholecystectomy group, but differences in clinical manifestation grade (P = 0.039) and CTSI grade (P = 0.013) remained. We also found that cholecystectomy reduced the frequency of biliary pancreatitis (30.4% vs. 45.9%, P < 0.050). Finally, we found that cholecystectomy could reduce the severity of subsequent idiopathic AP.

CONCLUSION

Cholecystectomy could reduce the severity of subsequent idiopathic AP and the frequency of biliary pancreatitis.

Cholesterol gallstones: Focusing on the role of interstitial Cajal-like cells

Cholesterol gallstone (CG) is a common, frequent biliary system disease in China, with a complex and multifactorial etiology. Declined gallbladder motility reportedly contributes to CG pathogenesis. Furthermore, interstitial Cajal-like cells (ICLCs) are reportedly present in human and guinea pig gallbladder tissue. ICLCs potentially contribute to the regulation of gallbladder motility, and aberrant conditions involving the loss of ICLCs and/or a reduction in its pacing potential and reactivity to cholecystokinin may promote CG pathogenesis. This review discusses the association between ICLCs and CG pathogenesis and provides a basis for further studies on the functions of ICLCs and the etiologies of CG.

Gallbladder Stone Disease Is Associated with an Increased Risk of Migraines

Background: Several pathophysiological mechanisms are shared in both gallbladder stone disease (GSD) and migraines. We assessed the migraine risk for patients diagnosed with GSD. Methods: We identified 20,427 patients who were diagnosed with GSD between 2000 and 2011 from Taiwan’s National Health Insurance Research Database (NHIRD) as the study cohort. We randomly selected 81,706 controls from the non-GSD population with frequency matching by age and index year for the control cohort. All patient cases were followed until the end of 2011 to measure the incidence of migraines. Results: The cumulative incidence of migraines was greater in patients with GSD than in those without GSD (log-rank test: p < 0.001). The risk of migraine (3.89 vs. 2.30 per 10,000 person-years, adjusted hazard ratio (aHR) = 1.56, 95% confidence interval (CI) = 1.41–1.73) was greater for the GSD cohort than that for the non-GSD cohort. The risk of migraine increased with the time of follow-up after a diagnosis of GSD. The risk of migraine contributed by GSD was greater for all age groups. The risk of migraine for GSD patients with depression (aHR = 2.89, 95% CI = 2.21–3.77), anxiety (aHR = 2.07, 95% CI = 1.58–2.70), and coronary artery disease (CAD) (aHR = 2.05, 95% CI = 1.69–2.48) tended to be greater than that for GSD patients without depression (aHR = 1.54, 95% CI = 1.39–1.72), anxiety (aHR = 1.62, 95% CI = 1.46–1.81), and CAD (aHR = 1.65, 95% CI = 1.47–1.85), respectively. Compared with the patients without GSD, the risk of developing migraines was greater in those GSD patients either with (aHR = 1.39, 95% CI = 1.19–1.63) or without (aHR = 1.67, 95% CI = 1.48–1.88) cholecystectomy. Compared with the GSD patients that have not had a cholecystectomy, the risk of developing migraines was lower in the GSD patients that had a cholecystectomy (aHR = 0.83, 95% CI = 0.69–0.99). Conclusions: GSD is associated with an increased risk of migraines in the Taiwanese population, but the risk diminishes after a cholecystectomy. Furthermore, in the development of migraines, GSD is synergic with some migraine-associated comorbidities, such as CAD, depression, and anxiety. Further study is necessary to clarify whether GSD is a causal risk factor for migraine.

An update on the pathogenesis of cholesterol gallstone disease

PURPOSE OF REVIEW

Gallstone disease is a major epidemiologic and economic burden worldwide, and the most frequent form is cholesterol gallstone disease.

RECENT FINDINGS

Major pathogenetic factors for cholesterol gallstones include a genetic background, hepatic hypersecretion of cholesterol, and supersaturated bile which give life to precipitating cholesterol crystals that accumulate and grow in a sluggish gallbladder. Additional factors include mucin and inflammatory changes in the gallbladder, slow intestinal motility, increased intestinal absorption of cholesterol, and altered gut microbiota. Mechanisms of disease are linked with insulin resistance, obesity, the metabolic syndrome, and type 2 diabetes. The role of nuclear receptors, signaling pathways, gut microbiota, and epigenome are being actively investigated.

SUMMARY

Ongoing research on cholesterol gallstone disease is intensively investigating several pathogenic mechanisms, associated metabolic disorders, new therapeutic approaches, and novel strategies for primary prevention, including lifestyles.

Cholecystectomy as a risk factor of metabolic syndrome: from epidemiologic clues to biochemical mechanisms

Cholecystectomy has long been regarded as a safe procedure with no deleterious influence on the body. However, recent studies provide clues that link cholecystectomy to a high risk for metabolic syndrome (MetS). In the present review, we describe the epidemiologic evidence that links cholecystectomy to MetS. Various components of MetS are investigated, including visceral obesity, dyslipidemia, elevated blood pressure, impaired fasting glucose, and insulin resistance. The possible mechanisms that associate cholecystectomy with MetS are discussed on the basis of experimental studies.

Recent advances in understanding and managing cholesterol gallstones

The high prevalence of cholesterol gallstones, the availability of new information about pathogenesis, and the relevant health costs due to the management of cholelithiasis in both children and adults contribute to a growing interest in this disease. From an epidemiologic point of view, the risk of gallstones has been associated with higher risk of incident ischemic heart disease, total mortality, and disease-specific mortality (including cancer) independently from the presence of traditional risk factors such as body weight, lifestyle, diabetes, and dyslipidemia. This evidence points to the existence of complex pathogenic pathways linking the occurrence of gallstones to altered systemic homeostasis involving multiple organs and dynamics. In fact, the formation of gallstones is secondary to local factors strictly dependent on the gallbladder (that is, impaired smooth muscle function, wall inflammation, and intraluminal mucin accumulation) and bile (that is, supersaturation in cholesterol and precipitation of solid crystals) but also to "extra-gallbladder" features such as gene polymorphism, epigenetic factors, expression and activity of nuclear receptors, hormonal factors (in particular, insulin resistance), multi-level alterations in cholesterol metabolism, altered intestinal motility, and variations in gut microbiota. Of note, the majority of these factors are potentially manageable. Thus, cholelithiasis appears as the expression of systemic unbalances that, besides the classic therapeutic approaches to patients with clinical evidence of symptomatic disease or complications (surgery and, in a small subgroup of subjects, oral litholysis with bile acids), could be managed with tools oriented to primary prevention (changes in diet and lifestyle and pharmacologic prevention in subgroups at high risk), and there could be relevant implications in reducing both prevalence and health costs.

Effect of emodin on mobility signal transduction system of gallbladder smooth muscle in Guinea pig with cholelithiasis

OBJECTIVE

To study the effect of emodin on protein and gene expressions of the massagers in mobility signal transduction system of cholecyst smooth muscle cells in guinea pig with cholesterol calculus.

METHODS

The guinea pigs were randomly divided into 4 groups, such as control group, gall-stone (GS) group, emodin group and ursodeoxycholic acid (UA) group. Cholesterol calculus models were induced in guinea pigs of GS, emodin and UA groups by lithogenic diet, while emodin or UA were given to the corresponding group for 7 weeks. The histomorphological and ultrastructure change of gallbladder were detected by microscope and electron microscope, the content of plasma cholecystokinin (CCK) and [Ca²⁺]_i were analyzed successively by radioimmunoassay and flow cytometry. The protein and mRNA of Gsα, Giα and Cap in cholecyst cells were determined by western blotting and real time polymerase chain reaction (RT-PCR).

RESULTS

Emodin or UA can relieve pathogenic changes in epithelial cells and muscle cells in gallbladder of guinea pig with cholesterol calculus by microscope and transmission electron microscope. In the cholecyst cells of GS group, CCK levels in plasma and [Ca²⁺]_i decreased, the protein and mRNA of GS were down-regulated, the protein and mRNA of Gi and Cap were up-regulated. Emodin significantly decreased the formative rate of gallstone, improved the pathogenic change in epithelial cells and muscle cells, increased CCK levels in plasma and [Ca²⁺]_i in cholecyst cells, enhanced the protein and mRNA of Gs in cholecyst cells, reduced the protein and mRNA of Gi and Cap in cholecyst cells in guinea pig with cholesterol calculus.

CONCLUSION

The dysfunction of gallbladder contraction gives rise to the disorders of mobility signal transduction system in cholecyst smooth muscle cells, including low content of plasma CCK and [Ca²⁺]_i in cholecyst cells, abnormal protein and mRNA of Gs, Gi and Cap. Emodin can enhance the contractibility of gallbladder and alleviate cholestasis by regulating plasma CCK levels, [Ca²⁺]_i in cholecyst cells and the protein and mRNA of Gs, Gi and Cap.

Functions of the Gallbladder

The gallbladder stores and concentrates bile between meals. Gallbladder motor function is regulated by bile acids via the membrane bile acid receptor, TGR5, and by neurohormonal signals linked to digestion, for example, cholecystokinin and FGF15/19 intestinal hormones, which trigger gallbladder emptying and refilling, respectively. The cycle of gallbladder filling and emptying controls the flow of bile into the intestine and thereby the enterohepatic circulation of bile acids. The gallbladder also largely contributes to the regulation of bile composition by unique absorptive and secretory capacities. The gallbladder epithelium secretes bicarbonate and mucins, which both provide cytoprotection against bile acids. The reversal of fluid transport from absorption to secretion occurs together with bicarbonate secretion after feeding, predominantly in response to an adenosine 3',5'-cyclic monophosphate (cAMP)-dependent pathway triggered by neurohormonal factors, such as vasoactive intestinal peptide. Mucin secretion in the gallbladder is stimulated predominantly by calcium-dependent pathways that are activated by ATP present in bile, and bile acids. The gallbladder epithelium has the capacity to absorb cholesterol and provides a cholecystohepatic shunt pathway for bile acids. Changes in gallbladder motor function not only can contribute to gallstone disease, but also subserve protective functions in multiple pathological settings through the sequestration of bile acids and changes in the bile acid composition. Cholecystectomy increases the enterohepatic recirculation rates of bile acids leading to metabolic effects and an increased risk of nonalcoholic fatty liver disease, cirrhosis, and small-intestine carcinoid, independently of cholelithiasis. Among subjects with gallstones, cholecystectomy remains a priority in those at risk of gallbladder cancer, while others could benefit from gallbladder-preserving strategies. © 2016 American Physiological Society. Compr Physiol 6:1549-1577, 2016.

Prevention of gallbladder hypomotility via FATP2 inhibition protects from lithogenic diet-induced cholelithiasis

Gallstone disease is a widespread disorder costing billions for annual treatment in the United States. The primary mechanisms underlying gallstone formation are biliary cholesterol supersaturation and gallbladder hypomotility. The relative contribution of these two processes has been difficult to dissect, as experimental lithogenic diets cause both bile supersaturation and alterations in gallbladder motility. Importantly, there is no mechanistic explanation for obesity as a major risk factor for cholelithiasis. We discovered that lithogenic diets induce ectopic triacylglycerol (TAG) accumulation, a major feature of obesity and a known muscle contraction impairing condition. We hypothesized that prevention of TAG accumulation in gallbladder walls may prevent gallbladder contractile dysfunction without impacting biliary cholesterol saturation. We utilized adeno-associated virus-mediated knock down of the long-chain fatty acid transporter 2 (FATP2; Slc27A2), which is highly expressed by gallbladder epithelial cells, to downregulate lithogenic diet-associated TAG accumulation. FATP2-knockdown significantly reduced gallbladder TAG, but did not affect key bile composition parameters. Importantly, measurements with force displacement transducers showed that contractile strength in FATP2-knockdown gallbladders was significantly greater than in control gallbladders following lithogenic diet administration, and the magnitude of this effect was sufficient to prevent the formation of gallstones. FATP2-driven fatty acid uptake and the subsequent TAG accumulation in gallbladder tissue plays a pivotal role in cholelithiasis, and prevention of this process can protect from gallstone formation, even in the context of supersaturated bile cholesterol levels, thus pointing to new treatment approaches and targets.

Expression of CCK Receptors in Carcinoma Gallbladder and Cholelithiasis: A Pilot Study

BACKGROUND

Gastrin and cholecystokinin (CCK) receptors are trophic for various gastrointestinal malignancies. Their role in gallbladder cancer has not been widely studied.

OBJECTIVES

To identify expression of CCK-A and CCK-B receptors in the tissue and blood of patients suffering from carcinoma (CA) gallbladder and gallstone disease and to compare expression of CCK A and B receptors in the gall bladder tissue and blood of healthy individuals and patients of CA gallbladder, and gallstone diseases.

MATERIALS AND METHODS

Forty nine subjects of both genders were recruited, comprising of 22 patients of CA gall bladder, 19 cases of cholelithiasis and, 8 normal gallbladders obtained from patients operated for trauma of the biliary system or Whipple's procedure. RNA extraction and cDNA formation for CCK-A and CCK-B receptors were carried out. Real Time PCR was performed on cDNA and threshold cycle (Ct) value of each sample was obtained and ΔCt was calculated. Chi-square test for comparing two groups and ANOVA test for comparing multiple groups were applied and if p<0.05 then Dunnett-C test was performed.

OBSERVATION AND RESULTS

Both CCK-A and CCK-B receptors were expressed irrespective of its origin in all tissues and blood samples studied; be it normal, Cholelithiasis or CA gallbladder and there was no difference among them (p>0.05).

CONCLUSION

This preliminary study showed higher expression of CCK-A receptors in patients of cholelithiasis and decreased expression of CCK-A receptors in patients of CA gallbladder as compared to normal gallbladder although it did not rise to statistical significance.

Decreased expression of stem cell factor mRNA and protein in the gallbladders of guinea pigs fed on high cholesterol diet

OBJECTIVE

Sufficient evidence suggests that the c-kit protooncogene receptor and its ligand stem cell factor (scf) signal pathway play a crucial role in interstitial cells of Cajal (ICCs) development and maintenance of their phenotype. We aimed to determine the expressions of scf mRNA and scf protein in the gallbladders in guinea pigs fed on high cholesterol diet (HCD).

METHODS

The gallbladder and serum samples from 20 guinea pigs of HCD and from 20 guinea pigs of standard diet (StD) were used for this study. Serum lipid analysis was performed using standard laboratory procedure. Expression of scf mRNA was detected by reverse transcription polymerase chain reaction (RT-PCR), and expression of scf protein was detected by Western blot analysis.

RESULTS

Laboratory results showed serum total cholesterol (TC), low density lipoprotein (LDL) cholesterol , high density lipoprotein (HDL) cholesterol and triglyceride (TG) concentrations were significantly higher in the HCD group than in the StD group of guinea pigs (P < 0.001, respectively). Decreased expression of scf mRNA and protein were demonstrated in the HCD group compared with the StD group (P < 0.05 respectively).

CONCLUSION

The data indicates that the expression of scf mRNA and c-kit protein is significantly decreased in the gallbladders in guinea pigs of HCD.

Endogenous elevation of plasma cholecystokinin does not prevent gallstones

BACKGROUND

Regular gall bladder contraction reduces bile stasis and prevents gallstone formation. Intraduodenal administration of exogenous pancreatic secretory trypsin inhibitor-I (PSTI-I, also known as monitor peptide) causes cholecystokinin (CCK) secretion.

DESIGN

We proposed that stimulation of CCK release by PSTI would produce gall bladder contraction and prevent gallstones in mice fed a lithogenic diet. Therefore, we tested the effect of overexpression of rat PSTI-I in pancreatic acinar cells on plasma CCK levels and gall bladder function in a transgenic mouse line (TgN[Psti1]; known hereafter as PSTI-I tg).

RESULTS

Importantly, PSTI tg mice had elevated fasting and fed plasma CCK levels compared to wild-type (WT) mice. Only mice fed the lithogenic diet developed gallstones. Both fasting and stimulated plasma CCK levels were substantially reduced in both WT and PSTI-I tg mice on the lithogenic diet. Moreover, despite higher CCK levels PSTI-I tg animals developed more gallstones than WT animals.

CONCLUSIONS

Together with the previously observed decrease in CCK-stimulated gall bladder emptying in mice fed a lithogenic diet, our findings suggest that a lithogenic diet causes gallstone formation by impaired CCK secretion in addition to reduced gall bladder sensitivity to CCK.

Disruption of the murine protein kinase Cbeta gene promotes gallstone formation and alters biliary lipid and hepatic cholesterol metabolism

The protein kinase C (PKC) family of Ca(2+) and/or lipid-activated serine-threonine protein kinases is implicated in the pathogenesis of obesity and insulin resistance. We recently reported that protein kinase Cβ (PKCβ), a calcium-, diacylglycerol-, and phospholipid-dependent kinase, is critical for maintaining whole body triglyceride homeostasis. We now report that PKCβ deficiency has profound effects on murine hepatic cholesterol metabolism, including hypersensitivity to diet-induced gallstone formation. The incidence of gallstones increased from 9% in control mice to 95% in PKCβ(-/-) mice. Gallstone formation in the mutant mice was accompanied by hyposecretion of bile acids with no alteration in fecal bile acid excretion, increased biliary cholesterol saturation and hydrophobicity indices, as well as hepatic p42/44(MAPK) activation, all of which enhance susceptibility to gallstone formation. Lithogenic diet-fed PKCβ(-/-) mice also displayed decreased expression of hepatic cholesterol-7α-hydroxylase (CYP7A1) and sterol 12α-hydroxylase (CYP8b1). Finally, feeding a modified lithogenic diet supplemented with milk fat, instead of cocoa butter, both increased the severity of and shortened the interval for gallstone formation in PKCβ(-/-) mice and was associated with dramatic increases in cholesterol saturation and hydrophobicity indices. Taken together, the findings reveal a hitherto unrecognized role of PKCβ in fine tuning diet-induced cholesterol and bile acid homeostasis, thus identifying PKCβ as a major physiological regulator of both triglyceride and cholesterol homeostasis.

A relationship between migraine and biliary tract disorders: findings in two Swedish samples of elderly twins

OBJECTIVES

To investigate whether there is a relationship between the clinical occurrence of migraine and biliary tract disorders (BTD) and to study whether there is a genetic influence on such an association.

MATERIALS AND METHODS

The near lifetime morbidity for migraine and BTD was examined in two Swedish twin-samples: OCTO-Twin (149 MZ and 202 DZ pairs; 234 men, 468 women; 80 years of age or older at inclusion), and the GENDER study (249 unlike-sex DZ-pairs; 70-80 years of age at inclusion). The diagnosis of BTD was established by perusal of medical records from the last twenty years. The diagnosis of migraine was based on iterated questionnaires and personal interviews.

RESULTS

The odds ratio (OR) of BTD among OCTO-Twin subjects suffering from migraine was 3.5 (1.9-6.7) in monozygotic pairs and 1.7 (1.0-2.9) in dizygotic pairs The corresponding figures among the GENDER unlike-sex DZ-pairs was 2.7 (1.6-4.5). Migraine was associated with female sex and waist circumference.

CONCLUSIONS

There is a relationship between the occurrence of migraine and BTD, also when controlling for the fact that both disorders are more frequent in women. The association appears to be partly attributable to genetic influences.

Pathophysiological significance of gallbladder volume changes in gallstone diseases

AIM: To study the pathophysiological significance of gallbladder volume (GBV) and ejection fraction changes in gallstone patients.

METHODS: The fasting GBV of gallstone patients with acute cholecystitis (n = 99), chronic cholecystitis (n = 85) and non-gallstone disease (n = 240) were measured by preoperative computed tomography. Direct saline injection measurements of GBV after cholecystectomy were also performed. The fasting and postprandial GBV of 65 patients with gallstones and chronic cholecystitis and 53 healthy subjects who received health examinations were measured by abdominal ultrasonography. Proper adjustments were made after the correction factors were calculated by comparing the preoperative and postoperative measurements. Pathological correlations between gallbladder changes in patients with acute calculous cholecystitis and the stages defined by the Tokyo International Consensus Meeting in 2007 were made. Unpaired Student’s t tests were used. P < 0.05 was deemed statistically significant.

RESULTS: The fasting GBV was larger in late stage than in early/second stage acute cholecystitis gallbladders (84.66 ± 26.32 cm³, n = 12, vs 53.19 ± 33.80 cm³, n = 87, P = 0.002). The fasting volume/ejection fraction of gallbladders in chronic cholecystitis were larger/lower than those of normal subjects (28.77 ± 15.00 cm³vs 6.77 ± 15.75 cm³, P < 0.0001)/(34.6% ± 10.6%, n = 65, vs 53.3% ± 24.9%, n = 53, P < 0.0001).

CONCLUSION: GBV increases as acute cholecystitis progresses to gangrene and/or empyema. Gallstone formation is associated with poorer contractility and larger volume in gallbladders that contain stones.

Pathogenesis of cholesterol gallstone disease

Cholesterol gallstone disease is a common disorder with an incidence rate of about 10%. In recent years, the research on metabolic disorders involving the gut-liver axis and the relation between gallstone disease and metabolic syndrome is attracting more attention. This article focuses on the origin of biliary cholesterol, intestinal cholesterol absorption, regulation of gallbladder motility, cholesterol transporters and metabolic syndromes and their role in the pathogenesis of gallstone disease.

Gastrin, cholecystokinin and gastrointestinal tract functions in mammals

The aim of the present review is to synthesise and summarise our recent knowledge on the involvement of cholecystokinin (CCK) and gastrin peptides and their receptors in the control of digestive functions and more generally their role in the field of nutrition in mammals. First, we examined the release of these peptides from the gut, focusing on their molecular forms, the factors regulating their release and the signalling pathways mediating their effects. Second, general physiological effects of CCK and gastrin peptides are described with regard to their specific receptors and the role of CCK on vagal mucosal afferent nerve activities. Local effects of CCK and gastrin in the gut are also reported, including gut development, gastrointestinal motility and control of pancreatic functions through vagal afferent pathways, including NO. Third, some examples of the intervention of the CCK and gastrin peptides are exposed in diseases, taking into account intervention of the classical receptor subtypes (CCK1 and CCK2 receptors) and their heterodimerisation as well as CCK-C receptor subtype. Finally, applications and future challenges are suggested in the nutritional field (performances) and in therapy with regards to the molecular forms or in relation with the type of receptor as well as new techniques to be utilised in detection or in therapy of disease. In conclusion, the present review underlines recent developments in this field: CCK and gastrin peptides and their receptors are the key factor of nutritional aspects; a better understanding of the mechanisms involved may increase the efficiency of the nutritional functions and the treatment of abnormalities under pathological conditions.

Spontaneous gallbladder pathology in baboons

BACKGROUND

Gallbladder pathology (GBP) is a relatively uncommon, naturally occurring morbidity in both baboons and humans.

METHODS

A retrospective analysis was performed on 7776 necropsy reports over a 20 year period to determine the prevalence of baboon GBP.

RESULTS

Ninety-seven cases of GBP were identified, yielding a 20 year population prevalence of 1.25%. GBP is more common in adult female baboons, occurring with a female to male ratio of nearly 2:1. Among gallbladder pathologies, cholecystitis (35.1%) and cholelithiasis (29.9%) were the most prevalent abnormalities, followed by hyperplasia (16.5%), edema (15.5%), amyloidosis (5.2%), fibrosis (4.1%), necrosis (4.1%), and hemorrhage (1.0%).

CONCLUSION

Many epidemiologic similarities exist between GBP in baboons and humans suggesting that the baboon may serve as a reliable animal model system for investigating GBP in humans.

Gallbladder function and dynamics of bile flow in asymptomatic gallstone disease

AIM: To investigate the effects of gallbladder stones on motor functions of the gallbladder and the dynamics of bile flow in asymptomatic gallstone disease.

METHODS: Quantitative hepatobiliary scintigraphy was performed to detect the parameters of gallbladder motor function [gallbladder ejection fraction (GBEF), gallbladder visualization time (GBVT), gallbladder time to peak activity (GBT_max), gallbladder half emptying time (GBT_1/2), and transit time of bile to duodenum (TTBD)] in 24 patients with asymptomatic cholelithiasis who were diagnosed incidentally during routine abdominal ultrasonographic examination and 20 healthy subjects with normal gallbladder.

RESULTS: Even though there was no significant difference in the clinical and laboratory parameters between the patient and control groups, all parameters of gallbladder function except TTBD were found to differ significantly between the two groups. GBEF in the patient group was decreased (P = 0.000) and GBVT, GBT_max, GBT_1/2 in the patient group were longer (P = 0.000, P = 0.015, P = 0.001, respectively).

CONCLUSION: Our results showed that even if there were not any clinical and laboratory findings, gallbladder filling and emptying could be impaired in patients with gallstone disease.

Cholecystokinin receptor A gene polymorphism in gallstone disease and gallbladder cancer

BACKGROUND AND AIM

Gallbladder carcinoma (GBC) usually arises in the background of gallstone disease which may be causatively related to decreased gallbladder contractility. Cholecystokinin receptor A (CCK-AR) mediates signals resulting in gallbladder contraction. Deteriorating gallbladder contraction promotes gallstone formation. A common genetic polymorphism of CCK-AR may be causatively associated with the risk of gallstone and GBC. This study aimed to understand the association of CCK-AR Pst I polymorphism in gallstone disease with gallbladder cancer.

METHOD

This study included 165 gallstone patients, 139 GBC patients, and 190 healthy subjects. Genotyping was done using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method.

RESULTS

The frequency of the A1A1 genotype of CCK-AR was significantly higher in gallstone patients than healthy individuals (P = 0.008 odds ratio [OR] = 2.25, and 95% confidence interval [CI]:1.2-4.1). However, there was a significant difference in the frequency of A1A1 genotype when gallstone patients were compared to GBC patients (P = 0.041, OR = 0.49, and 95% CI: 0.3-0.9). On stratification of GBC patients according to presence or absence of gallstones, GBC patients without stones were compared to controls and GBC patients with stones were compared to stone patients; however, no significant differences in frequencies were observed.

CONCLUSION

The results suggest that the A1A1 genotype of CCK-AR is an independent genetic risk factor for gallstone disease and does not modulate the susceptibility of gallbladder cancer.

Cholecystokinin receptor positivity in children with chronic acalculous gallbladder dysfunction: a pilot study to investigate the etiology of chronic acalculous gallbladder dysfunction

BACKGROUND

The etiology of chronic acalculous gallbladder dysfunction (CAGD) is unknown. However, cholecystectomy is being performed as treatment, based on gallbladder (GB) ejection fraction studies. The aim of this study was to examine the pathology and immunohistology of GBs from children with CAGD.

METHODS

Children with a diagnosis of CAGD were identified. Control patients had their GB removed for nonbiliary indications. Immunoperoxidase staining was performed using rabbit antihuman cholecystokinin receptor (CCK-R) antibody. The pathologist was blinded to the study and controls.

RESULTS

Fifteen children were evaluated: 6 children with CAGD and 9 controls. All children with CAGD had abnormal cholecystokinin-stimulated nuclear imaging. Ejection fractions ranged from 8% to 30%. All patients reported resolution of symptoms on follow-up at 6 months. Histopathology of the GB was normal for both the controls and children with CAGD. Both control and CAGD GBs demonstrated positive staining for CCK-R in the vascular endothelium and smooth muscle. Mucosal epithelial staining was only observed in 5 of 6 of GBs of children with CAGD. In the sixth GB, the epithelium was too necrotic to assess.

CONCLUSIONS

In this pilot study, expression of CCK-Rs in the epithelial cells is noted in children with CAGD compared with controls. The significance of this finding requires further investigation.

The influence of gallbladder function on the symptomatology in gallstone patients, and the outcome after cholecystectomy or expectancy

The purpose of this study was to examine whether gallbladder function as assessed by a hepatobiliary scintigraphy was related to the symptomatology in gallstone patients and to the outcome 1 year after either cholecystectomy or watchful waiting. The study included 100 patients with uncomplicated gallstone disease. Fifty-six patients had a functioning gallbladder and 44 had a nonfunctioning gallbladder. Patients with a nonfunctioning gallbladder had significantly more vomiting and received more pain-killing injections during pain attacks. Otherwise, there were no differences in pain patterns or characteristics of dyspeptic symptoms in relation to gallbladder function. In patients with a functioning gallbladder, there were no significant differences between the group of patients with impaired and normal gallbladder function. Cholecystectomy was performed in 69 patients and at the 1-year follow-up; 22% continued to have pain attacks, but this was not related to the gallbladder function preoperatively. In 31 patients without cholecystectomy, 14 patients became asymptomatic within a 1-year follow-up. However, this was not related to gallbladder function. In conclusion, gallbladder function evaluated by a hepatobiliary scintigraphy was not related to the symptoms in gallstone patients, and was not related to the occurrence of symptoms after cholecystectomy or watchful waiting.

Cholecystokinin

PURPOSE OF REVIEW

The hormone cholecystokinin was discovered in 1928 because of its ability to induce gallbladder contraction. Since then, cholecystokinin has been shown to possess multiple functions in the gastrointestinal tract and brain. This review discusses several significant developments in cholecystokinin biology that show how it plays a role in gastrointestinal diseases, including control of appetite.

RECENT FINDINGS

Cholecystokinin was shown to induce satiety by interacting through CCK-1 receptors located in specialized regions of the hindbrain. Cholecystokinin also inhibits expression of orexigenic peptides in the hypothalamus and prevents stimulation of specialized neurons by ghrelin. In the pancreas, cholecystokinin increased the proliferation of insulin-producing beta cells and reduced insulin-induced hyperphagia. Elevated cholecystokinin levels decreased appetite and reduced intestinal inflammation caused by parasites and bacterial toxins.

SUMMARY

Understanding the mechanisms by which cholecystokinin regulates orexigenic pathways in the body may lead to strategies for controlling appetite-related disorders such as obesity and bulimia. The reduction of intestinal inflammation by dietary fats (by elevating cholecystokinin) suggests that the hormone plays an integrated role in regulating the ingestion and digestion of food that may be relevant to inflammatory diseases of the gastrointestinal tract.

The role of (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan in the management of biliary pain

OBJECTIVE

To assess the outcome of laparoscopic cholecystectomy on the basis of an abnormal provocative (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan for patients with typical biliary pain and normal trans-abdominal ultrasound (TUS) scan.

PATIENTS AND METHODS

Prospective data were collected for 1201 consecutive patients with typical biliary symptoms. Patients who were found to have a normal TUS and upper GI endoscopy subsequently underwent cholescintigraphy (HIDA scan). Patients with an abnormal HIDA scan, i.e.<40% ejection fraction with Sincalide (cholecystokinin octapeptide)--were offered cholecystectomy. Symptoms and histology were reviewed postoperatively.

RESULTS

In all, 48/1201 (4%) patients with typical biliary symptoms had a normal ultrasound and endoscopy; 35/48 patients had an abnormal provocative HIDA scan and all underwent laparoscopic cholecystectomy. Histology in all cases revealed chronic cholecystitis and 18 patients had sludge or microlithiasis within the gallbladder. At 6-week follow-up, 31 of the 35 patients were completely asymptomatic or improved. Furthermore, 79% of patients remained symptom-free or improved at a median follow-up of 28.5 months (range 4-70).

CONCLUSIONS

HIDA scan is a useful clinical tool as an adjunct to the diagnosis and management of patients who present with typical biliary pain and a normal TUS scan.

Role of CCK/gastrin receptors in gastrointestinal/metabolic diseases and results of human studies using gastrin/CCK receptor agonists/antagonists in these diseases

In this paper, the established and possible roles of CCK1 and CCK2 receptors in gastrointestinal (GI) and metabolic diseases are reviewed and available results from human agonist/antagonist studies are discussed. While there is evidence for the involvement of CCK1R in numerous diseases including pancreatic disorders, motility disorders, tumor growth, regulation of satiety and a number of CCK-deficient states, the role of CCK1R in these conditions is not clearly defined. There are encouraging data from several clinical studies of CCK1R antagonists in some of these conditions, but their role as therapeutic agents remains unclear. The role of CCK2R in physiological (atrophic gastritis, pernicious anemia) and pathological (Zollinger-Ellison syndrome) hypergastrinemic states, its effects on the gastric mucosa (ECL cell hyperplasia, carcinoids, parietal cell mass) and its role in acid-peptic disorders are clearly defined. Furthermore, recent studies point to a possible role for CCK2R in a number of GI malignancies. Current data from human studies of CCK2R antagonists are presented and their potential role in the treatment of these conditions reviewed. Furthermore, the role of CCK2 receptors as targets for medical imaging is discussed.

A genomewide search finds major susceptibility loci for gallbladder disease on chromosome 1 in Mexican Americans

Gallbladder disease (GBD) is one of the major digestive diseases. Its risk factors include age, sex, obesity, type 2 diabetes, and metabolic syndrome (MS). The prevalence of GBD is high in minority populations, such as Native and Mexican Americans. Ethnic differences, familial aggregation of GBD, and the identification of susceptibility loci for gallstone disease by use of animal models suggest genetic influences on GBD. However, the major susceptibility loci for GBD in human populations have not been identified. Using ultrasound-based information on GBD occurrence and a 10-cM gene map, we performed multipoint variance-components analysis to localize susceptibility loci for GBD. Phenotypic and genotypic data from 715 individuals in 39 low-income Mexican American families participating in the San Antonio Family Diabetes/Gallbladder Study were used. Two GBD phenotypes were defined for the analyses: (1) clinical or symptomatic GBD, the cases of cholecystectomies due to stones confirmed by ultrasound, and (2) total GBD, the clinical GBD cases plus the stone carriers newly diagnosed by ultrasound. With use of the National Cholesterol Education Program/Adult Treatment Panel III criteria, five MS risk factors were defined: increased waist circumference, hypertriglyceredemia, low high-density lipoprotein cholesterol, hypertension, and high fasting glucose. The MS risk-factor score (range 0-5) for a given individual was used as a single, composite covariate in the genetic analyses. After accounting for the effects of age, sex, and MS risk-factor score, we found stronger linkage signals for the symptomatic GBD phenotype. The highest LOD scores (3.7 and 3.5) occurred on chromosome 1p between markers D1S1597 and D1S407 (1p36.21) and near marker D1S255 (1p34.3), respectively. Other genetic locations (chromosomes 2p, 3q, 4p, 8p, 9p, 10p, and 16q) across the genome exhibited some evidence of linkage (LOD >or=1.2) to symptomatic GBD. Some of these chromosomal regions corresponded with the genetic locations of Lith loci, which influence gallstone formation in mouse models. In conclusion, we found significant evidence of major genetic determinants of symptomatic GBD on chromosome 1p in Mexican Americans.