Gallstone disease: Symptoms and diagnosis of gallbladder stones

Quantitative phase analysis and molecular structure of human gallstones using synchrotron radiation X-ray diffraction and FTIR spectroscopy

Human gallstones are the most common disorder in the biliary system, affecting up to 20 % of the adult population. The formation of gallstones is primarily due to the supersaturating of cholesterol in bile. In order to comprehend gallstone disease in detail, it is necessary to have accurate information about phase identification and molecular structure. Different types of gallstone samples were collected from the Middle East area after surgical operations including; cholesterol, pigment, and mixed gallstones. To estimate the basic information about the stone formation and the pathophysiology of cholelithiasis as well as to classify the collected human gallstones, attenuated total reflection Fourier transform Infrared spectrometry (ATR-FTIR) was used to analyze the different gallstone structures in the wavenumber range from 400 to 4000 cm-1. Calcium bilirubinate was specified by the bands at 1662 cm-1, 1626 cm-1, and 1572 cm-1, while cholesterol rings were designated by the bands at 1464, 1438, 1055, and 1022 cm-1. It can be assumed that all samples consist of mixed gallstones based on the doublets at 1375 cm-1 and 1365 cm-1. The levels of calcium bilirubin and various minerals varied among the analyzed samples, indicating the heterogeneity in their composition and suggesting potential implications for gallstone formation. Based on the quantitative phase analysis using synchrotron radiation X-ray diffraction (SR-XRD), two phases of anhydrous cholesterol as a major content and one phase of monohydrate cholesterols as trace content represent the main components of most of the gallstones. Additional phases of calcium carbonate in the form of calcite, vaterite, aragonite, and bilirubinate were also quantified. According to the outcomes of the FTIR and the SR-XRD measurements, there exists a statistical correlation between the different types of chemical constituents of the gallstones.

Single-Stage Laparoscopic Common Bile Duct Exploration and Cholecystectomy Versus Two-Stage Endoscopic Stone Extraction Followed by Laparoscopic Cholecystectomy for Patients With Cholelithiasis and Choledocholithiasis: A Systematic Review

Gallbladder stones with common bile duct (CBD) stones can be managed by a single-stage laparoscopic approach with transcystic or transcholedochal CBD exploration and cholecystectomy or a two-stage approach with endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction followed by laparoscopic cholecystectomy. Comparative outcomes between these approaches remain controversial. The objective was to compare single-stage laparoscopic CBD exploration and cholecystectomy versus two-stage ERCP stone removal followed by laparoscopic cholecystectomy for clearance of CBD stones, complications, length of stay, and costs. We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for randomized trials and observational studies comparing outcomes of interest between single and two-stage approaches. Meta-analyses using random effects models were conducted. Seven studies with 382 patients were included. The single-stage approach achieved higher stone clearance rates (OR: 1.53, 95% CI: 1.12-2.08) with a shorter length of stay (mean duration: 3.5 days, 95% CI: -5.1 to -1.9 days) compared to the two-stage method. No significant difference was seen in complication rates (45% vs 40%, p=0.43) or costs ($19,000 vs $18,000, p=0.34). For patients with gallbladder and CBD stones, single-stage laparoscopic CBD exploration with cholecystectomy appears superior for stone clearance while comparable in safety and cost to a two-stage approach. Further randomized trials are warranted.

Plasma metabolomics and proteomics reveal novel molecular insights and biomarker panel for cholelithiasis

BACKGROUND

Cholelithiasis is a gastrointestinal disease that is associated with the highest socioeconomic cost. A diagnosis of cholelithiasis based on clinical features is significantly limited, and direct molecular insights into cholelithiasis and the relationship between cholelithiasis and clinical biochemical parameters are unclear.

OBJECTIVES

Uncovering direct molecular insights into cholelithiasis and the relationship between cholelithiasis and clinical biochemical parameters. Identifying sensitive and specific biomarkers for this disease.

METHODS

Parallel metabolomic and proteomic analyses of plasma from cholelithiasis patients (CPs) and healthy control individuals (HCs) without cholelithiasis were performed using ultrahigh-performance liquid chromatography-tandem mass spectrometry. A multimodule coexpression network analysis and integrated machine learning methods, including least absolute shrinkage and selection operator, random forest, and support vector machine, were used for bioinformatic analyses. An independent cohort and the cross-validation of the combination of two cohorts were used to evaluate the diagnostic performance of the panel.

RESULTS

Arachidonic acid metabolism was significantly different between the CP and HC groups. Glyceraldehyde-3-phosphate dehydrogenase, actin beta, phosphoglycerate mutase 1, Enolase 1, Myeloperoxidase, and actin alpha 1 were identified as potential proteins related to cholelithiasis. The correlation between the merged modules and clinical biochemical tests was calculated. A diagnostic panel composed of four candidate biomarkers, including 3-oxotetradecanoic acid, 12-hydroxydodecanoic acid, hemoglobin subunit delta (HBD), and fibrinogen beta chain (FGB), was proposed based on three modules that were significantly associated with cholelithiasis. The classification according to the diagnostic panel detected CPs with an area under the curve (AUC) of 0.955. External validation in an independent cohort resulted in similar accuracy (AUC=0.995).

CONCLUSIONS

This study provided some direct molecular insights into cholelithiasis by showing the differences in plasma metabolic and protein profiles between CPs and HCs and presented a potential biomarker panel with two metabolites (3-oxotetradecanoic acid, 12-hydroxydodecanoic acid) and two proteins (HBD, FGB) for predicting cholelithiasis. We also explored the potential correlation of clinical biochemical parameters with combined modules. These findings may provide some reference for the diagnosis of cholelithiasis in clinical practice.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

The Natural History of Asymptomatic Gallstones: A Longitudinal Study and Prediction Model

BACKGROUND & AIMS

Despite the high prevalence of asymptomatic gallstones (AGs), there are limited data on their natural history. We aimed to determine the rate of symptom development in a contemporary population, determine factors associated with progression to symptomatic gallstones (SGs), and develop a clinical prediction model.

METHODS

We used a retrospective cohort design. The time to first SG was shown using Kaplan-Meier curves. Multivariable competing risk (death) regression analysis was used to identify variables associated with SGs. A prediction model for the development of SGs after 10 years was generated and calibration curves were plotted. Participants were patients with AGs based on ultrasound or computed tomography from the general medical population.

RESULTS

From 1996 to 2016, 22,257 patients (51% female) with AGs were identified; 14.5% developed SG with a median follow-up period of 4.6 years. The cumulative incidence was 10.1% (±0.22%) at 5 years, 21.5% (±0.39%) at 10 years, and 32.6% (±0.83%) at 15 years. In a multivariable model, the strongest predictors of developing SGs were female gender (hazard ratio [HR], 1.50; 95% CI, 1.39-1.61), younger age (HR per 5 years, 1.15; 95% CI, 1.14-1.16), multiple stones (HR, 2.42; 95% CI, 2.25-2.61), gallbladder polyps (HR, 2.55; 95% CI, 2.14-3.05), large stones (HR, 2.03; 95% CI, 1.80-2.29), and chronic hemolytic anemia (HR, 1.90; 95% CI, 1.33-2.72). The model showed good discrimination (C-statistic, 0.70) and calibration.

CONCLUSIONS

In general medical patients with AGs, symptoms developed at approximately 2% per year. A predictive model with good calibration could be used to inform patients of their risk of SGs.

Risk factors for gallstone disease onset in Japan: Findings from the Shizuoka Study, a population-based cohort study

In the research literature on factors associated with gallstones, large population-based cohort studies are rare. We carried out a study of this type to explore risk factors for the onset of gallstones. This study included Japanese participants aged 40-107 years who were followed prospectively from January 2012 to September 2020 using a dataset composed of two individually linked databases, one containing annual health checkup records and the other containing medical claims for beneficiaries of the National Health Insurance System and the Medical Care System for Elderly in the Latter Stage of Life in Shizuoka Prefecture, Japan. Among the 611,930 participants in the analysis set, 23,843 (3.9%) were diagnosed with gallstones during the observational period (median [max]: 5.68 [7.5] years). Multivariate analysis revealed that risk of gallstone disease was increased by male sex, cerebrovascular disease, any malignancy, dementia, rheumatic disease, chronic pulmonary disease, hypertension, and H. pylori-infected gastritis. These findings provide essential insights into the etiology of cholelithiasis and may contribute to efforts to reduce the incidence of the disease.

Diagnosis and Treatment of Acute Pancreatitis

The pancreas is a glandular organ that is responsible for the proper functioning of the digestive and endocrine systems, and therefore, it affects the condition of the entire body. Consequently, it is important to effectively diagnose and treat diseases of this organ. According to clinicians, pancreatitis—a common disease affecting the pancreas—is one of the most complicated and demanding diseases of the abdomen. The classification of pancreatitis is based on clinical, morphologic, and histologic criteria. Medical doctors distinguish, inter alia, acute pancreatitis (AP), the most common causes of which are gallstone migration and alcohol abuse. Effective diagnostic methods and the correct assessment of the severity of acute pancreatitis determine the selection of an appropriate treatment strategy and the prediction of the clinical course of the disease, thus preventing life-threatening complications and organ dysfunction or failure. This review collects and organizes recommendations and guidelines for the management of patients suffering from acute pancreatitis.

Gallstone Disease and Bacterial Metabolic Performance of Gut Microbiota in Middle-Aged and Older Patients

Background

Gallstone disease (GSD) is more commonly presented in aged people.

Purpose

The purpose of the study was to explore the insights of metabolic performance of bacterial species from gut microbiota as well as the clinical background in middle-aged and elderly patients with GSD.

Patients and Methods

This is an observational study concerning 120 research participants. Of those, 90 patients with symptomatic GSD addressed for cholecystectomy, average age 59.83 ± 15.32 years: 45 with cholesterol rich gallstones (CGSs), 45 with pigment gallstones (PGSs) and 30 healthy controls joined this observational study. Clinical examination, lab work-ups, upper and lower digestive video-endoscopies, abdominal ultrasound/CT and gallbladder motility assessment by Dodd’s method were performed. Overall stool dysbiosis (DB) was assessed as 1 = minor, 2 = mild, 3 = severe, species being identified by matrix-assisted laser desorption ionization method. Stool samples from dysbiotic patients were analyzed by a next generation sequencing method with operational taxonomic unit identification.

Results

Patients with GSD presented with a significant high range of overall gut DB (p < 0.0001) when compared with controls. Those with CGSs compared with those having PGSs displayed significant clinical differences related to elderly age, lifestyle and diet particularities, obesity, dyslipidemia, nonalcoholic fatty liver disease, hypertension, type 2 diabetes mellitus or impaired glucose tolerance, as well as motility disturbances of gallbladder with a decrease of the ejection fraction. Significant increase of overall DB range and alterations of several functional bacterial species with a decrease of butyrate, lactate, acetate/propionate and methane producers, mucin degrading bacteria, biodiversity index of microbiota, as well as an increase of lipopolysaccharide positive bacteria were significantly present in patients with CGSs.

Conclusion

Middle-aged and elderly patients with GSD and a clinical background characterized by particular lifestyle, metabolic and gallbladder motility issues displayed significant modifications of biodiversity, overall gut DB and alterations of several functional bacterial species, with a decrease of their metabolic performance.

Dyspepsia and Gut Microbiota in Female Patients with Postcholecystectomy Syndrome

BACKGROUND

Gallstone disease (GSD) represents one of the most frequent digestive disorders, highly reported in female gender. The purpose of the study was to explore the clinical and gut microbiota particularities of female patients with postcholecystectomy syndrome (PCS) and the possible relationship between gut dysbiosis (DB) and abdominal complaints.

PATIENTS AND METHODS

In total, 129 female participants: 104 outpatients divided into two equal groups, 52 PCS (+), 52 PCS (-) and 25 healthy controls were consecutively enrolled in this observational study. Patients underwent clinical examination with assessment of pain, bloating, transit disturbances, abdominal ultrasound/computer tomography/magnetic resonance imaging/endoscopic retrograde cholangiopancreatography, upper and lower digestive endoscopies. Laboratory work-ups and stool microbiology assessments were performed for all study participants (patients and controls). Stool microorganisms were identified by matrix-assisted laser desorption ionization - time-of-flight- mass spectrometry and in patients with DB also by next-generation sequencing.

RESULTS

Older age, complicated gallstones disease, associated conditions like diabetes mellitus/impaired glucose tolerance and irritable bowel syndrome were significantly present in PCS (+) group, as well as sedentary lifestyle and diets characterized by a low fiber intake (p<0.0001). PCS (+) patients displayed significant differences related to the incidence and severity of overall gut microbiota DB, decreased H index of biodiversity and the unbalanced Firmicutes/Bacteroidetes (F/B) ratios by comparison to the PCS (-) group (p<0.0001). Strong positive correlations of the severity of overall DB with bloating and the intestinal habit disorders, as well as of F/B ratios to all abdominal symptoms were noted.

CONCLUSION

PCS in female patients was associated with older age, sedentary lifestyle, specific dietary habits, history of complicated gallstone disease, diabetes mellitus/impaired glucose tolerance and irritable bowel syndrome, as well as gut microbiota particularities. Overall DB and unbalanced F/B ratios were strongly correlated to abdominal complaints.

Immediate acupuncture with GB34 for biliary colic: protocol for a randomised controlled neuroimaging trial

INTRODUCTION

As the main manifestation of gallstone disease, biliary colic (BC) is an episodic attack that brings patients severe pain in the right upper abdominal quadrant. Although acupuncture has been documented with significance to lead to pain relief, the immediate analgesia of acupuncture for BC still needs to be verified, and the underlying mechanism has yet to be covered. Therefore, this trial aims first to verify the immediate pain-alleviation characteristic of acupuncture for BC, then to explore its influence on the peripheral sensitised acupoint and central brain activity.

METHODS AND ANALYSIS

This is a randomised controlled, paralleled clinical trial, with patients and outcome assessors blinded. Seventy-two patients with gallbladder stone disease presenting with BC will be randomised into a verum acupuncture group and the sham acupuncture group. Both groups will receive one session of immediate acupuncture treatment. Improvements in patients' BC will be evaluated by the Numeric Rating Scale, and the pain threshold of acupoints will also be detected before and after treatment. During treatment, brain neural activity will be monitored with functional near-infrared spectroscopy (fNIRS), and the needle sensation will be rated. Clinical and fNIRS data will be analysed, respectively, to validate the acupuncture effect, and correlation analysis will be conducted to investigate the relationship between pain relief and peripheral-cerebral functional changes.

ETHICS AND DISSEMINATION

This trial has been approved by the institutional review boards and ethics committees of the First Teaching Hospital of Chengdu University of Traditional Chinese Medicine, with the ethical approval identifier 2019 KL-029, and the institutional review boards and ethics committees of the First People's Hospital of Longquanyi District, with the ethical approval identifier AF-KY-2020071. The results of this trial will be disseminated through peer-reviewed publications and conference abstracts or posters.

TRIAL REGISTRATION NUMBER

CTR2000034432.

Application of Point-of-Care Ultrasound for Family Medicine Physicians for Abdominopelvic and Soft Tissue Assessment

Point-of-care ultrasound (POCUS) improves both the sensitivity and specificity with which clinicians can make a variety of diagnoses at the bedside from abdominal aortic aneurysm to kidney stones. In outpatient clinics, urgent care centers, and emergency departments, where ultrasound imaging may be delayed by hours or even days, the use of POCUS can be very helpful. We believe that POCUS facilitates both the triage of patients and provides diagnostic information quickly. We hope to advance the use of POCUS in the primary care setting and have reviewed six sonographic topics where we believe ultrasound can be of immense assistance to the physician in the outpatient setting.

Predictive factors for developing acute cholangitis and/or cholecystitis in patients undergoing delayed cholecystectomy: A retrospective study

BACKGROUND

/Objective: We evaluated the risk of acute cholangitis and/or cholecystitis while waiting for cholecystectomy for gallstones.

METHODS

We retrospectively enrolled 168 patients who underwent cholecystectomy for gallstones after conservative therapy. We compared clinical data of 20 patients who developed acute cholangitis and/or cholecystitis while waiting for cholecystectomy (group A) with 148 patients who did not develop (group B). We investigated surgical outcomes and risk factors for developing acute cholangitis and/or cholecystitis.

RESULTS

Preoperatively, significant numbers of patients with previous history of acute grade II or III cholecystitis (55.0% vs 10.8%; p < 0.001) and biliary drainage (20.0% vs 2.0%; p = 0.004) were observed between groups A and B. White blood cell counts (13500/μL vs 8155/μL; p < 0.001) and C-reactive protein levels (12.6 vs 5.1 mg/dL; p < 0.001) were significantly higher in group A than in group B; albumin levels (3.2 vs 4.0 g/dL; p < 0.001) were significantly lower in group A. Gallbladder wall thickening (≥5 mm) (45.0% vs 18.9%; p = 0.018), incarcerated gallbladder neck stones (55.0% vs 22.3%; p = 0.005), and peri-gallbladder abscess (20.0% vs 1.4%; p = 0.002) were significantly more frequent in group A than in group B. A higher conversion rate to open surgery (20.0% vs 2.0%; p = 0.004), longer operation time (137 vs 102 min; p < 0.001), and higher incidence of intraoperative complications (10.0% vs 0%; p = 0.014) were observed in group A, compared with group B.

CONCLUSION

A history of severe cholecystitis may be a risk factor for acute cholangitis and/or cholecystitis in patients waiting for surgery; it may also contribute to increased surgical difficulty.

Evaluation of the CT Scan as the First Examination for the Diagnosis and Therapeutic Strategy for Acute Cholecystitis

BACKGROUND

The CT scan has supplanted the abdominal ultrasound for emergency examinations. A comparison of CT scan and ultrasound performance for the diagnosis and management of acute cholecystitis in acute care was proposed. The hypothesis is that the CT scan may be sufficient for the diagnosis of acute cholecystitis, which would allow faster progress to surgery.

METHODS

The retrospective study of consecutive patients operated for acute cholecystitis or gallbladder distension with pre-operative imaging within 48 h in one centre.

RESULTS

Between 2015 and 2017, a total of 341 cholecystectomies were performed in our centre. The analysis involved 120 patients. Ultrasound had better sensitivity than the CT scan, respectively, 79.4% [70.5-86.6] and 52.3% [42.5-62.1], but less specificity, with 61.5% [31.6-86.1] and 92.3% [64.0-99.8], respectively. However, there was a significant difference in favour of the CT scan for the diagnosis of complicated cholecystitis (p 0.004). The positive likelihood ratio of complicated cholecystitis is better at CT scan (7.8) [2.7-23.1] than in ultrasound (1.0) [0.1-9.7]. CT scan and ultrasound are equivalent for the diagnosis of acute cholecystitis, but CT scan is more efficient for the diagnosis of complicated cases (Youden index J 0.3 vs 0.001).

CONCLUSION

It is possible to place the surgical indication of cholecystectomy on the only data of the CT scan. We propose a decision-making algorithm that uses the CT scan to make the diagnosis and decide on emergency treatment for complicated cases or that allows us to propose a delayed surgery for simple cholecystitis.

The Role of Diabetes Mellitus in Diseases of the Gallbladder and Biliary Tract

BACKGROUND

The increasing prevalence of diabetes mellitus worldwide continues to pose a heavy burden. Though its gastrointestinal impact is appropriately recognized, the lesser known associations may be overlooked.

OBJECTIVE

We aim to review the negative implications of diabetes on the gallbladder and the biliary tract.

METHODS

A MEDLINE® database search of literature was conducted with emphasis on the previous five years, combining keywords such as "diabetes," "gallbladder," and "biliary".

RESULTS

The association of diabetes to the formation of gallstones, gallbladder cancer, and cancer of the biliary tract are discussed along with diagnosis and treatment.

CONCLUSION

Though we uncover the role of diabetic neuropathy in gallbladder and biliary complications, the specific individual diabetic risk factors behind these developments is unclear. Also, in addition to diabetes control and surgical gallbladder management, the treatment approach also requires further focus.

Surgical approach to a left-sided gallbladder

Biliary colic is a pain in the right upper quadrant or epigastrium thought to be caused by functional gallbladder spasm from a temporary obstructing stone in the gallbladder neck, cystic duct or common bile duct. A 56-year-old man presented with frequent episodes of typical biliary colic. At initial laparoscopy, the gallbladder was absent from its anatomic location. Further inspection revealed a left-sided gallbladder (LSGB), suspended from liver segment 3. Preoperative ultrasound, the most common imaging modality for symptomatic gallstones, has a low positive predictive value for detecting LSGB (2.7%). Laparoscopic cholecystectomy (LC) was delayed to attain additional imaging. A magnetic resonance cholangiopancreatography demonstrated the gallbladder left of the falciform ligament with the cystic duct entering the common hepatic duct from the left. The patient underwent an elective LC 8 weeks later. The critical view of safety is paramount to safe surgical dissection and could be safely achieved for LSGB.

Prevalence of dyspepsia in patients with cholecystolithiasis: a systematic review and meta-analysis

Cholecystolithiasis and functional gastrointestinal disorders are both highly prevalent in the industrialized world and may exist concomitantly. The presence of both conditions impedes identification of the source of symptoms, leading to a risk of ineffective cholecystectomies with lack of symptom resolution. We carried out a systematic review and meta-analysis to determine the prevalence of dyspepsia in patients with uncomplicated cholecystolithiasis. The electronic databases Medline, Embase, and Web of Science were searched for articles reporting the prevalence of dyspepsia in adults (≥18 years) with uncomplicated cholecystolithiasis. Pooled prevalence and 95% confidence interval were calculated. I statistics were used to determine heterogeneity and the Methodological Evaluation of Observational Research criteria were applied for quality assessment. The study was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Of the 1696 studies evaluated, 13 reported the prevalence of dyspepsia in a total of 1227 cholecystolithiasis patients seeking medical care. The pooled prevalence of dyspepsia in patients with cholecystolithiasis was 65.7% (95% confidence interval: 51-79%). However, heterogeneity was large across studies. Overall, three studies used validated diagnostic criteria. Variation in diagnostic measures significantly influenced the prevalence of dyspepsia. In conclusion, symptoms similar to those of functional gastrointestinal disorders are common in patients with cholecystolithiasis, obscuring the source of abdominal complaints. Tools to select patients who will benefit from cholecystectomy are paramount to prevent ineffective surgery.

Limy bile syndrome in a dog

A 11-year-old spayed female golden retriever was examined because of lethargy, anorexia, vomiting and abdominal pain. Plain abdominal radiography showed a uniform radiopacity of the gallbladder. Ultrasonography demonstrated hyperechoic material in the gallbladder lumen associated with an acoustic shadow and findings consistent with acute pancreatitis. Fine-needle aspiration of the bile revealed bacterial cholecystitis. Following cholecystectomy, it was apparent that the gallbladder was filled with a semi-solid, pasty-like greenish-brown material composed of 80% calcium carbonate, consistent with a diagnosis of 'limy bile'. After surgery and medical treatment, the dog's condition improved. Two months after discharge, the dog had fully recovered a good appetite and no relapse has been observed after 11 months of follow-up. To our knowledge, this is the first report of limy bile syndrome in a dog.

The Influence of Clinical and Patient-Reported Outcomes on Post-surgery Satisfaction in Cholecystectomy Patients

BACKGROUND

Patient-reported outcomes (PROMs) and post-operative satisfaction have become a growing focus of surgical outcome evaluation and are considered key components of the movement towards patient-centred care. The aim was to compare the association of traditional clinical outcome measures and PROMs with post-surgery satisfaction in cholecystectomy patients.

METHODS

Patients who had undergone elective or emergency cholecystectomy for gallstone disease were sent validated PROM questionnaires, and telephone follow-up was performed in all cases. Categorical data were compared with the Chi-square and Fisher's exact tests. Satisfaction was investigated using a "top-box" approach, and multivariable logistic regression was performed for factors significantly (p < 0.05) associated with satisfaction in univariable analyses.

RESULTS

A total of 234 patients underwent cholecystectomy between 1 March 2014 and 1 May 2014, and 147 patients (63%) completed the questionnaire. 104/147 (71%) reported being "very satisfied" with their surgical outcome. In univariable analyses, satisfaction showed significant association with an absence of hospital-recorded 30-day complications (OR = 4.11, 95% CI 1.29-13.84), but not re-attendance, readmission, or length of stay. In a multiple regression analysis, no traditional clinical outcome measures were associated with satisfaction. By contrast, self-perceived health (OR = 4.04, 95% CI 1.44-11.86), the absence of patient-reported wound pain (OR = 6.11, 95% CI 1.83-21.74), and a return to normal leisure activities (OR = 11.14, 95% CI 2.61-55.26) were associated with satisfaction.

CONCLUSION

PROMs are the major determinants of patient satisfaction following cholecystectomy. When assessing outcomes following cholecystectomy, the measurement of clinical outcomes alone is inadequate and should be supplemented by the use of PROMs.

Association Between Type I and II Diabetes With Gallbladder Stone Disease

Objective: To assess the association of type 1 diabetes (T1DM) and type 2 diabetes (T2DM) with the subsequent development of gallbladder stone disease (GSD). Setting: Cohort Study. Participants: We identified two study cohort groups to evaluate the association of T1DM and T2DM with the development of GSD. The first group comprised a T1DM cohort of 7015 patients aged ≤ 40 years and a non-diabetes cohort randomly matched with the study cohort (4:1). The second group comprised a T2DM cohort of 51,689 patients aged ≥20 years and a non-diabetes cohort randomly matched with the study cohort (1:1). All patients were studied from 1996 to the end of 2011 or withdrawal from the National Health Insurance program to determine the incidence of GSD. Results: Compared with patients without diabetes, those with T1DM had a decreased risk of GSD [adjusted hazard ratios (aHR) = 0.48, 95% confidence interval (CI) = 0.25-0.92]. Those with T2DM had an increased risk of GSD (aHR = 1.55, 95% CI = 1.41-1.69), after adjustment for age, sex, comorbidities, and number of parity. The relative risk of GSD in the T2DM cohort was higher than that in the non-diabetes cohort in each group of age, sex, and patients with or without comorbidity. However, the relative risk of GSD in the T1DM cohort was lower than that in the non-diabetes cohort only in the age group of 20-40 years. Conclusion: Our population-based cohort study reveals a strong association between T2DM and GSD. However, an inverse relationship exists between T1DM and GSD in patients aged 20-40 years.

Gallstones in childhood: etiology, clinical features, and prognosis

AIM

The aim of this study was to determine demographic and clinical features in children diagnosed with gallstones, risk factors for gallstone formation, the effectiveness of ursodeoxycholic acid therapy, and the course of the disease.

MATERIALS AND METHODS

Patients aged 0-18 years were followed up for at least 6 months after the diagnosis of gallstones with ultrasonography and were evaluated retrospectively. Patients were evaluated with respect to age, sex, presenting symptoms, BMI, facilitating factors, accompanying diseases, family history of gallstones, history of ceftriaxone use, laboratory tests, ultrasonography findings and follow-up, and therapeutic approaches and results.

RESULTS

The study was completed with 70 patients. Thirty-nine (55.7%) patients were females. The mean age of the patients was 9.3±5.29 (0.3-18) years. The mean age among females was statistically significantly higher than that among males (P=0.007).No risk factor for stone formation was encountered in 50% of cases, whereas a family history of gallstones was present in 17.1%. Use of ceftriaxone was present in 8.6% of cases, total parenteral nutrition in 10%, obesity in 5.7%, hereditary spherocytosis in 4.3%, and Down's syndrome in 4.3%. The probability of dissolution of stones was 3.6 times higher in patients with stone sizes up to 5 mm [odds ratio (OR): 3.65, P=0.020], 3.9 times higher in those aged younger than 2 years (OR: 3.92, P=0.021), and 13.9 times higher in those with a single stone (OR: 13.97, P=0.003).

CONCLUSION

Our findings show that unknown causes are still prevalent in stone formation and that ursodeoxycholic acid exerts no effect on stone dissolution; however, diagnosis at younger than 2 years of age, a single stone, and small size of stone are factors affecting dissolution.

Clinical practice guideline: management of acute pancreatitis

ABSTRACT

There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.

The association between gallstones and metabolic syndrome in urban Han Chinese: A longitudinal cohort study. Sci Rep. 2016;6:29937. [PMID: 27443986 PMCID: PMC4957232 DOI: 10.1038/srep29937]

The precise association between metabolic syndrome (MetS) and gallstone disease remains unclear in China. This study aimed to clarify the relationship between MetS and gallstone and evaluate whether counts of metabolic abnormalities had influence on gallstone disease. We fitted gender-specific generalized estimating equation (GEE) regression models with data from a large-scale longitudinal study over 6-year follow-up to elucidate the real association. This study included 18291 participants with 3 times repeated measures at least who were free from a prior history of gallstone disease and cholecystectomy. A total of 873 cases of gallstones occurred during 6-year follow-up. The incidence density of gallstone in the group of subjects with MetS was higher than the group without MetS (10.27 vs 5.79). The GEE analyses confirmed and clarified the association between MetS and gallstone disease in males (RR = 1.33, P = 0.0020), while this association was not significant in females (RR = 1.15, P = 0.4962). With numbers of metabolic syndrome components increasing, the risk of gallstone disease showed corresponding increasing in males. In conclusion, the associations of MetS and gallstone are different in males and in females. And the risk of gallstone disease increases with the number of components of MetS for males but not for females.

Gallstones

Gallstones grow inside the gallbladder or biliary tract. These stones can be asymptomatic or symptomatic; only gallstones with symptoms or complications are defined as gallstone disease. Based on their composition, gallstones are classified into cholesterol gallstones, which represent the predominant entity, and bilirubin ('pigment') stones. Black pigment stones can be caused by chronic haemolysis; brown pigment stones typically develop in obstructed and infected bile ducts. For treatment, localization of the gallstones in the biliary tract is more relevant than composition. Overall, up to 20% of adults develop gallstones and >20% of those develop symptoms or complications. Risk factors for gallstones are female sex, age, pregnancy, physical inactivity, obesity and overnutrition. Factors involved in metabolic syndrome increase the risk of developing gallstones and form the basis of primary prevention by lifestyle changes. Common mutations in the hepatic cholesterol transporter ABCG8 confer most of the genetic risk of developing gallstones, which accounts for ∼25% of the total risk. Diagnosis is mainly based on clinical symptoms, abdominal ultrasonography and liver biochemistry tests. Symptoms often precede the onset of the three common and potentially life-threatening complications of gallstones (acute cholecystitis, acute cholangitis and biliary pancreatitis). Although our knowledge on the genetics and pathophysiology of gallstones has expanded recently, current treatment algorithms remain predominantly invasive and are based on surgery. Hence, our future efforts should focus on novel preventive strategies to overcome the onset of gallstones in at-risk patients in particular, but also in the population in general.

Compliance with Evidence-Based Guidelines in Acute Pancreatitis: an Audit of Practices in University of Toronto Hospitals

Despite existing evidence-based practice guidelines for the management of acute pancreatitis, clinical compliance with recommendations is poor. We conducted a retrospective review of 248 patients admitted between 2010 and 2012 with acute pancreatitis at eight University of Toronto affiliated hospitals. We included all patients admitted to ICU (52) and 25 ward patients from each site (196). Management was compared with the most current evidence used in the Best Practice in General Surgery Management of Acute Pancreatitis Guideline. Fifty-six patients (22.6 %) had only serum lipase tested for biochemical diagnosis. Admission ultrasound was performed in 174 (70.2 %) patients, with 69 (27.8 %) undergoing ultrasound and CT. Of non-ICU patients, 158 (80.6 %) were maintained nil per os, and only 18 (34.6 %) ICU patients received enteral nutrition, commencing an average 7.5 days post-admission. Fifty (25.5 %) non-ICU patients and 25 (48.1 %) ICU patients received prophylactic antibiotics. Only 24 patients (22.6 %) with gallstone pancreatitis underwent index admission cholecystectomy. ERCP with sphincterotomy was under-utilized among patients with biliary obstruction (16 [31 %]) and candidates for prophylactic sphincterotomy (18 [22 %]). Discrepancies exist between the most current evidence and clinical practice within the University of Toronto hospitals. A guideline, knowledge translation strategy, and assessment of barriers to clinical uptake are required to change current clinical practice.

Management of gallstones and its related complications

The majority of gallstone patients remain asymptomatic; however, interest toward the gallstone disease is continuing because of the high worldwide prevalence and management costs and the development of gallstone symptoms and complications. For cholesterol gallstone disease, moreover, a strong link exists between this disease and highly prevalent metabolic disorders such as obesity, dyslipidemia, type 2 diabetes, hyperinsulinemia, hypertriglyceridemia and the metabolic syndrome. Information on the natural history as well as the diagnostic, surgical (mainly laparoscopic cholecystectomy) and medical tools available to facilitate adequate management of cholelithiasis and its complications are, therefore, crucial to prevent the negative outcomes of gallstone disease. Moreover, some risk factors for gallstone disease are modifiable and some preventive strategies have become necessary to reduce the onset and the severity of complications.

Delayed laparoscopic cholecystectomy increases the total hospital stay compared to an early laparoscopic cholecystectomy after acute cholecystitis: an updated meta-analysis of randomized controlled trials

BACKGROUND

The objective of this study was to review the available prospective, randomized, controlled trials to determine whether an early (ELC) or a delayed (DLC) approach to a laparoscopic cholecystectomy is associated with an increase in length of hospitalization after acute cholecystitis.

METHODS

Medline, the Cochrane Trials Register and EMBASE were searched for prospective, randomized, controlled trials (RCTs) comparing ELC versus DLC, published up to May 2014. A meta-analysis was performed using Review Manager 5.0.

RESULTS

Nine RCTs were included in a total of 617 who underwent ELC and 603 patients who underwent DLC after acute cholecystitis. The mean hospital stay was 5.4 days in the ELC group and 9.1 days in the DLC group. The meta-analysis showed a mean hospital stay significantly lower in the ELC group [medical doctor (MD) = 3.24, 95% confidence interval (CI) = 1.95-4.54, P < 0.001]. The major biliary duct injury rate in the ELC group was 0.8% (2/247) and 0.9% (2/223) in the DLC group. The meta-analysis showed no significant difference between the ELC and DLC groups [relative risk (RR) =0.96, 95%CI = 0.25-3.73, P = 0.950].

CONCLUSION

DLC is associated with a longer total hospital stay but equivalent morbidity as compared to ELC for patients presenting with acute cholecystitis. ELC would appear to be the treatment of choice for patients presenting with ELC.

Prior statin use and the outcomes in patients with first-attack acute pancreatitis: A retrospective cohort study

BACKGROUND

We investigated whether prior stain use before admission for a first-attack AP would reduce the severity and mortality rate of a first-attack of AP with a dose-response relationship.

METHODS

We conducted a retrospective cohort study from a tertiary medical center's database in Taiwan. We evaluated the dose-response relationship between statin use and the first-attack of AP by defining the daily dose (DDD). The cumulative DDD (cDDD) was calculated as the sum of the dispensed DDD of any specific statin. The outcome measures in our study included the hospital mortality rate, duration of hospitalization, Ranson's score, computed tomography severity index (CTSI), and C-reactive protein (CRP) level.

RESULTS

In our study, we enrolled 31 patients in statin group and 63 matched patients in control group. In the univariate analysis there was no significant difference between them with regard to the outcomes except the CTSI and serum calcium concentration. According to multivariate analysis the serum calcium concentration was significantly higher in the statin group, and the CTSI was lower in the statin group. In subgroup analysis we divided the statin group into two groups according to the cDDDs (<365days and >365days) and the results showed no significance in the demographic data, overall mortality rate, hospitalization days, CRP level, Ranson's score, or CTSI.

CONCLUSION

Our study rejected the hypothesis that statins have beneficial effects on the clinical outcomes of patients with a first-attack of AP. However we demonstrated that statins have a positive effect on the CTSI.

Morphologic factors of biliary trees are associated with gallstone-related biliary events

AIM: To determine the risk factors for gallstone-related biliary events.

METHODS: This retrospective cohort study evaluated magnetic resonance cholangiopancreatography images from 141 symptomatic and 39 asymptomatic gallstone patients who presented at a single tertiary hospital between January 2005 and December 2012.

RESULTS: Logistic regression analysis showed significant differences between symptomatic and asymptomatic patients with gallstones in relation to the number of gallstones, the angle between the long axis of the gallbladder and the cystic duct, and the cystic duct diameter. Multivariate analysis showed that the number of gallstones (OR = 1.27, 95%CI: 1.03-1.57; P = 0.026), the angle between the long axis of the gallbladder and the cystic duct (OR = 1.02, 95%CI: 1.00-1.03; P = 0.015), and the diameter of the cystic duct (OR = 0.819, 95%CI: 0.69-0.97; P = 0.018) were significantly associated with biliary events. The incidence of biliary events was significantly elevated in patients who had the presence of more than two gallstones, an angle of > 92° between the gallbladder and the cystic duct, and a cystic duct diameter < 6 mm.

CONCLUSION: These findings will help guide the treatment of patients with asymptomatic gallstones. Clinicians should closely monitor patients with asymptomatic gallstones who exhibit these characteristics.

Analysis of gallstone composition and structure in Jharkhand region

AIM

The aim of this study was to analyze gallstones structurally and chemically as this may help to direct the measures for its treatment.

METHODOLOGY

On the basis of morphology, 459 gallstones were categorized into pigmented, cholesterol, and mixed gallstones and analyzed for their chemical structure and composition. Elementary analysis was done with the help of inductively coupled plasma, optical emission spectrophotometry. Fourier transform infrared spectroscopy was used for compound analysis. The effects of thermal stability were analyzed by thermal gravimetric analysis (TGA). Statistical analysis was done to correlate gallstone composition with their shape and number in gallbladder.

RESULTS

Pigmented gallstones were predominant and generally occurred in multiple forms, cholesterol as solitaire and black pigmented as slug (χ (2) = 3.56; p < 0.001). Scanning electron microscopy showed the crystals of cholesterol in cholesterol gallstones while pigmented gallstones were more compact in structure. Both types of structure were seen in mixed stones while black pigmented stones were amorphous in nature. This difference in structures might be due to difference in chemical compositions. Cholesterol and mixed stones contained basically cholesterol, brown pigmented constituted bilirubin as a major component, and black stones differed from brown pigmented stones by the presence of Ca palmitate. Bilirubin and palmitate were thermally more stable than cholesterol; hence pigmented gallstones were thermally more stable than cholesterol gallstones, as seen in TGA study.

CONCLUSION

Pigmented gallstones were most common in this study of gallstones from the Jharkhand region.

Prevalence and Risk Factors of Asymptomatic Gallstone Disease in North-East Part of Bangladesh

Background

The study was designed to assess the prevalence of asymptomatic gallstone disease in North-East part of Bangladesh.

Materials and methods

Randomly selected asymptomatic persons, unknown to have gallstone disease, from both rural and urban areas were enrolled. They were subjected to abdominal ultrasonography and findings were recorded in a data sheet.

Results

Total 1,019 persons (316 males and 703 females) were examined. Age of them varied from 18 to 80 years with mean age of 37.22 years. Out of them, 61 (6%) persons were found to have gallstone. Among them, 14 were males and 47 were females. Both male and females of age below 40 years were more affected. Gallstone disease was found more commonly among housewives and middle class people. Among 61 patients with gallstone, seven were underweight (11.47%), 32 (52.45%) had normal weight and 22 (36.06%) were overweight, obese or extremely obese. But, this difference was not statistically significant (p = 0.894).

Conclusion

Prevalence of asymptomatic gallstone disease was found in 6% apparently healthy subjects of North-East part of Bangladesh. It was more prevalent among housewives and middle class group of population. It is also common among the people of age group below 40 years.

How to cite this article

Saha M, Nahar K, Hosen MMA, Khan MH, Saha SK, Shil BC, Rahman MH. Prevalence and Risk Factors of Asymptomatic Gallstone Disease in North-East Part of Bangladesh. Euroasian J Hepato-Gastroenterol 2015;5(1):1-3.

Surgically avertable burden of digestive diseases at first-level hospitals in low and middle-income regions

BACKGROUND

To quantify the burden of digestive diseases avertable by surgical care at first-level hospitals in low- and middle-income countries (LMICs).

METHODS

We examined 4 digestive diseases from the Global Burden of Disease (GBD) 2010 STUDY: Appendicitis, intestinal obstruction, inguinal and femoral hernia, and gallbladder and bile duct disease. Using demographic and epidemiologic data from the GBD 2010 STUDY, we calculated the potential decrease in burden of digestive diseases if quality surgical services were available universally and accessible at first-level hospitals. The lowest case fatality rates for each age and sex grouping from all GBD regions were assumed to reflect the best possible state of full surgical coverage and treatment. These best scenario rates were applied to the GBD 2010 results from all LMIC regions to estimate surgically avertable burden.

RESULTS

Overall, 4.8 million disability-adjusted life-years (DALYs) or 65% of burden related to the 4 digestive diseases are avertable potentially with first-level surgical care in LMICs. Sub-Saharan Africa has the greatest avertable burden in absolute DALYs (1.7 million) and avertable proportion (83%). Intestinal obstruction accounted for the largest portion of avertable burden among the 4 digestive diseases (2.2 million DALYs; 64% avertable).

CONCLUSION

Improving the capacity of surgical services at first-level hospitals is essential for averting the burden of digestive diseases in LMICs. Practicable strategies for scaling up surgical capacities in rural districts are available potentially, which must be given due attention.

Cost-effectiveness of elective laparoscopic cholecystectomy versus observation in older patients presenting with mild biliary disease

Our objective was to determine the probability threshold for recurrent symptoms at which elective cholecystectomy compared to observation in older patients with symptomatic cholelithiasis is the more effective and cost-effective option. We built a decision model of elective cholecystectomy versus observation in patients >65 presenting with initial episodes of symptomatic cholelithiasis that did not require initial hospitalization or cholecystectomy. Probabilities for subsequent hospitalization, emergency cholecystectomy, and perioperative complications were based on previously published probabilities from a 5 % national sample of Medicare patients. Costs were estimated from Medicare reimbursements and from the Healthcare Cost and Utilization Project. Utilities (quality-adjusted life years, QALYs) were obtained from established literature estimates. Elective cholecystectomy compared to observation in all patients was associated with lower effectiveness (-0.10 QALYs) and had an increased cost of $3,422.83 per patient at 2-year follow-up. Elective cholecystectomy became the more effective option when the likelihood for continued symptoms exceeded 45.3 %. Elective cholecystectomy was both more effective and less costly when the probability for continued symptoms exceeded 82.7 %. An individualized shared decision-making strategy based on these data can increase elective cholecystectomy rates in patients at high risk for recurrent symptoms and minimize unnecessary cholecystectomy for patients unlikely to benefit.

Obesity and the risk and prognosis of gallstone disease and pancreatitis

Obesity is a risk factor for the formation of cholesterol gallstones and exposes patients to increased risk of gallstone-related complications and cholecystectomy. Rapid weight loss achieved by very low calorie diets or bariatric surgery is also a risk factor for cholelithiasis in obese patients, and therapy should take into account the higher prevalence of gallstones, the possibility of more frequent complications and the need for prophylactic treatment with oral ursodeoxycholic acid during weight loss. Obesity is also frequent in children and adolescents, and the burden of cholesterol cholelithiasis is increasing in this population. The chance to develop acute pancreatitis and the severity of the disease are higher in obese subjects because of specific pathogenic factors, including supersaturated bile and crystal formation, rapid weight loss, and visceral obesity. All health policies aimed at reducing the incidence of obesity worldwide will decrease the incidence of gallstones and gallstone-related complications. The pathophysiological scenarios and the therapeutic implications for obesity, gallstone disease, and pancreatitis are discussed.

Symptomatic cholelithiasis and functional disorders of the biliary tract

Symptomatic cholelithiasis and functional disorders of the biliary tract present with similar signs and symptoms. The functional disorders of the biliary tract include functional gallbladder disorder, dyskinesia, and the sphincter of Oddi disorders. Although the diagnosis and treatment of symptomatic cholelithiasis are relatively straightforward, the diagnosis and treatment of functional disorders can be much more challenging. Many aspects of the diagnosis and treatment of functional disorders are in need of further study. This article discusses uncomplicated gallstone disease and the functional disorders of the biliary tract to emphasize and update the essential components of diagnosis and management.

Acute inflammatory surgical disease. Surg Clin North Am. 2014;94:1-30. [PMID: 24267493 DOI: 10.1016/j.suc.2013.10.008]

Infectious and inflammatory diseases comprise some of the most common gastrointestinal disorders resulting in hospitalization in the United States. Accordingly, they occupy a significant proportion of the workload of the acute care surgeon. This article discusses the diagnosis, management, and treatment of appendicitis, acute cholecystitis/cholangitis, acute pancreatitis, diverticulitis, and Clostridium difficile colitis.

Elective laparoscopic cholecystectomy for symptomatic uncomplicated gallstone disease: do the symptoms disappear?

BACKGROUND

Symptomatic gallstone disease is considered an indication for cholecystectomy. A considerable proportion of patients may experience persistent symptoms after surgery. The purpose of the present study was to find out the rate of symptom persistence after elective laparoscopic cholecystectomy (LC) performed for symptomatic uncomplicated gallstone disease and, in particular, to clarify whether the recurrence rate differs according to the severity of preoperative symptoms.

METHODS

During a 10-year period (1992-2001), 1,101 patients underwent elective LC at Turku City Hospital for Surgery. A questionnaire concerning the intensity of preoperative symptoms, persistence of symptoms postoperatively, and overall satisfaction with the outcome of the procedure was sent to patients. A total of 677 patients [mean age (range) 59 (21-94) years; 554 (83.1%) females] with uncomplicated gallstone disease returned the completed form.

RESULTS

Overall, 380 (57%) patients reported attacks of intense upper abdominal pain, and 287 (43%) reported episodic mild abdominal symptoms as the prevailing preoperative symptom. Two hundred and forty-eight (37%) patients continued to have abdominal symptoms after the operation. Among those with predominantly mild abdominal symptoms preoperatively, 119 (41%) reported the persistence of symptoms after the operation, while in the group with mainly severe upper abdominal pain attacks, 129 (33%) patients had recurrences (p = 0.052).

CONCLUSIONS

According to our data, more than one-third of patients with symptomatic uncomplicated gallstone disease experienced persistent symptoms after elective LC. Patients with mild preoperative symptoms seemed to have more recurrences than those with severe symptoms, although the difference was not statistically significant.

TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis

While referring to the evidence adopted in the Tokyo Guidelines 2007 (TG07) as well as subsequently obtained evidence, further discussion took place on terminology, etiology, and epidemiological data. In particular, new findings have accumulated on the occurrence of symptoms in patients with gallstones, frequency of severe cholecystitis and cholangitis, onset of cholecystitis and cholangitis after endoscopic retrograde cholangiopancreatography and medications, mortality rate, and recurrence rate. The primary etiology of acute cholangitis/cholecystitis is the presence of stones. Next to stones, the most significant etiology of acute cholangitis is benign/malignant stenosis of the biliary tract. On the other hand, there is another type of acute cholecystitis, acute acalculous cholecystitis, in which stones are not involved as causative factors. Risk factors for acute acalculous cholecystitis include surgery, trauma, burn, and parenteral nutrition. After 2000, the mortality rate of acute cholangitis has been about 10 %, while that of acute cholecystitis has generally been less than 1 %. After the publication of TG07, diagnostic criteria and severity assessment criteria were standardized, and the distribution of cases according to severity and comparison of clinical data among target populations have become more subjective. The concept of healthcare-associated infections is important in the current treatment of infection. The treatment of acute cholangitis and cholecystitis substantially differs from that of community-acquired infections. Cholangitis and cholecystitis as healthcare-associated infections are clearly described in the updated Tokyo Guidelines (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Gender-specific association of the interleukin 18 gene with symptomatic gallstone disease

BACKGROUND AND AIM

Symptomatic gallstone disease (SGSD) induced several inflammatory responses and affected extrahepatic bile ducts. Although the pathology and environmental risk factors of gallstone disease are well documented, immune or inflammatory responses in SGSD development are still inconclusive. Interleukin 18 (IL18) is a pro-inflammatory cytokine that plays an important role in immune, infectious, and inflammatory diseases because of the induction of interferon-γ. In this study, we investigated whether polymorphisms of the IL18 gene were associated with SGSD susceptibility.

METHODS

Genomic DNA was isolated from the whole blood samples of 445 patients with SGSD and 1121 gallstone-free controls. The IL18 rs549908T>G, rs5744247C>G, rs187238G>C, rs1946518T>G, and rs360719A>G polymorphisms were genotyped using predeveloped TaqMan allelic discrimination assay.

RESULTS

We found IL18 rs5744247G allele conferred protection against SGSD in female patients (odds ratio = 0.75, corrected P-value = 0.015). Haplotype analysis revealed that TGGTA protected females from SGSD development (odds ratio = 0.75, corrected P-value = 0.02).

CONCLUSIONS

Based on our findings, IL18 rs5744247C>G polymorphism could be a potential genetic marker to predict SGSD susceptibility in Han Chinese women.

Evidence-based current surgical practice: calculous gallbladder disease

BACKGROUND

Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations.

DISCUSSION

Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.

Water channel proteins in bile formation and flow in health and disease: when immiscible becomes miscible

An essential function of the liver is the formation and secretion of bile, a complex aqueous solution of organic and inorganic compounds essential as route for the elimination of body cholesterol as unesterified cholesterol or as bile acids. In bile, a considerable amount of otherwise insoluble cholesterol is solubilized by carriers including two other classes of lipids, namely phospholipid and bile acids. Formation of bile and generation of bile flow are driven by the active secretion of bile acids, lipids and electrolytes into the canalicular and bile duct lumens followed by the parallel movement of water. Thus, water has to cross rapidly into and out of the cell interior driven by osmotic forces. Bile as a fluid, results from complicated interplay of hepatocyte and cholangiocyte uptake and secretion, concentration, by involving a number of transporters of lipids, anions, cations, and water. The discovery of the aquaporin water channels, has clarified the mechanisms by which water, the major component of bile (more than 95%), moves across the hepatobiliary epithelia. This review is focusing on novel acquisitions in liver membrane lipidic and water transport and functional participation of aquaporin water channels in multiple aspects of hepatobiliary fluid balance. Involvement of aquaporins in a series of clinically relevant hepatobiliary disorders are also discussed.

Therapy of gallstone disease: What it was, what it is, what it will be

Cholesterol gallstone disease is a common clinical condition influenced by genetic factors, increasing age, female gender, and metabolic factors. Although laparoscopic cholecystectomy is currently considered the gold standard in treating patients with symptomatic gallstones, new perspectives regarding medical therapy of cholelithiasis are currently under discussion, also taking into account the pathogenesis of gallstones, the natural history of the disease and the analysis of the overall costs of therapy. A careful selection of patients may lead to successful non-surgical therapy in symptomatic subjects with a functioning gallbladder harboring small radiolucent stones. The classical oral litholysis by ursodeoxycholic acid has been recently paralleled by new experimental observations, suggesting that cholesterol-lowering agents which inhibit cholesterol synthesis (statins) or intestinal cholesterol absorption (ezetimibe), or drugs acting on specific nuclear receptors involved in cholesterol and bile acid homeostasis, might be proposed as additional approaches for treating cholesterol gallstones. In this review we discuss old, recent and future perspectives on medical treatment of cholesterol cholelithiasis.

Gallbladder selection for histopathological analysis based on a simple method: a prospective comparative study

INTRODUCTION

After a cholecystectomy, the current and traditional practice is to send each resected gallbladder to the pathologist for analysis. Some reports have suggested the possibility of selecting only those gallbladders that need to be analysed. The purpose of this study was to show a simple method for selecting which gallbladders should be sent to the pathologist.

METHODS

A prospective comparative study was carried out. Two 'tests' were performed in 150 patients to detect or rule out gallbladder cancer. The first test included the patient's variables and a macroscopic gallbladder analysis performed by the surgeon (MGAS). The second test was the analysis performed by the pathologist. The results were compared.

RESULTS

Of the 150 patients, 132 were women and 18 men; 130 were under 60 years old. One patient had inflammatory bowel disease, seven had changes on ultrasonography and in four cases intra-operative disturbances were observed. During the MGAS, disturbances were found in 30 patients. Eighty-one cases (54%) had at least one or more risk factors for gallbladder cancer.

Statin use and the risk of gallstone disease: a population-based case-control study

OBJECTIVE

The aim of this study was to investigate whether the use of statins was associated with a decreased risk of gallstone disease.

METHODS

We conducted a population-based case-control study in Taiwan. Cases consisted of all patients who were aged 50 years and older and had a first-time diagnosis of gallstone disease or cholecystectomy for the period between 2005 and 2009. The controls were matched to cases by age, sex and index date. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by using multiple logistic regression.

RESULTS

We examined 1014 gallstone disease cases and 1014 controls. The unadjusted ORs for any statin prescription was 1.06 (95% CI 0.86 to 1.29), and the adjusted OR was 1.14 (95% CI 0.90 to 1.43). Compared with no use of statins, the adjusted ORs were 1.05 (95% CI 0.72 to 1.54) for the group having been prescribed statins with cumulative defined daily doses (DDDs) below 41.53, 1.12 (95% CI 0.84 to 1.50) for the group with cumulative dose between 41.54 and 334.81 DDD, and 1.30 (95% CI 0.86 to 1.95) for the group with cumulative statin use of 334.81 DDDs or more.

CONCLUSIONS

This study does not provide support for a beneficial association between usage of statin and gallstone disease.