Short-term impact of air pollution, noise and temperature on emergency hospital admissions in Madrid (Spain) due to liver and gallbladder diseases

BACKGROUND

Very few epidemiological studies have explored the environmental and meteorological risk factors that influence liver diseases and gallbladder disorders, and no studies have addressed the specific case of Spain.

METHODS

This is a retrospective ecological study conducted during 2013-2018. We analysed emergency admissions in the central area of the Region of Madrid for the following causes: Liver and gallbladder diseases (L&GB) (ICD-10: K70-K81); disorders of gallbladder (DGB) (ICD 10: K80-K81); liver disease (LD) (ICD 10: K70-K77); alcoholic liver disease (ALD) (ICD-10: K70); viral hepatitis (VH) (ICD10:B15-B19); and hepatic failure, not elsewhere classified (HFNS) (ICD-10: K72). Independent variables used: meteorological (maximum daily temperature (Tmax in ⁰C), minimum daily temperature (Tmin in ⁰C), and relative humidity (RH in %)); chemical air pollution (8-hO3, NO2, PM10, PM2.5 in μg/m3); and noise pollution (equivalent level of daily noise (Ld in dB(A)). Transformed variables: extreme heat in degrees (Theat); wet cold (WC); and high ozone. We fitted Poisson models, negative binomials and zero-inflated Poisson controlled for seasonality, day of the week, holidays, trend, and autoregressive trend. Based on these models, the percentage of cases attributable to statistically significant risk factors was then estimated.

RESULTS

In L&GB emergency admissions daily noise is related to 4.4% (CI95%: 0.8 7.9) of admissions; NO2 to 2.9% (CI95%: 0.1 5.7) and wet cold to 0.2% (CI95%: 0.8 7.9). Heat wave temperature was only related to ALD. In addition, the wet cold association with L&GB is also related to HFNS attributing 1.0% (CI95%: 0.3 1.8) of admissions for this cause.

CONCLUSIONS

Daily noise and NO2 are associated with more than 7% of urgent L&GB admissions. Both pollutants, are mainly emitted by road traffic. A reduction of traffic in cities would result in a reduction of emergency admissions due to this cause.

Ceftriaxone-associated Pseudolithiasis in the Gallbladder and Bile Duct of an Elderly Patient

A 78-year-old man had been undergoing treatment with Cefamezin for pyogenic spondylitis. Because of complication of a urinary tract infection, the medication was switched to ceftriaxone (CTRX) 2 g/day. On day 18 after starting CTRX, the patient began experiencing abdominal pain. Computed tomography (CT) and endoscopic ultrasound led to the identification of calculi in the gallbladder and extrahepatic bile duct with a peculiar formation. We suspected CTRX-associated pseudo-cholecystolithiasis and pseudo-choledocholithiasis, although CT performed at admission had shown no such findings. Therefore, CTRX was discontinued. By day 17 after CTRX cessation, both the pseudo-cholecystolithiasis and pseudo-choledocholithiasis had disappeared.

Repeated Perforation of the Gallbladder in a Patient with Hepatocellular Carcinoma Receiving Lenvatinib

A 59-year-old man who was receiving lenvatinib as a third-line tyrosine kinase inhibitor to treat hepatocellular carcinoma and multiple bone metastases complained of general fatigue four months after starting lenvatinib. A blood examination showed unexpectedly elevated serum C-reactive protein (CRP) levels. Computed tomography (CT) revealed rupture of the gallbladder wall, indicating gallbladder perforation. After conservative treatment, the patient received lenvatinib again under informed consent; however, one month later, CT revealed repeated rupture of the gallbladder wall. Gallbladder perforation had again been induced by lenvatinib. For this reason, lenvatinib is strongly considered a causative drug for gallbladder perforation.

Tissue distribution and acute toxicity of silver after single intravenous administration in mice: nano-specific and size-dependent effects

BACKGROUND

Silver nanoparticles (AgNPs) are an important class of nanomaterials used as antimicrobial agents for a wide range of medical and industrial applications. However toxicity of AgNPs and impact of their physicochemical characteristics in in vivo models still need to be comprehensively characterized. The aim of this study was to investigate the effect of size and coating on tissue distribution and toxicity of AgNPs after intravenous administration in mice, and compare the results with those obtained after silver acetate administration.

METHODS

Male CD-1(ICR) mice were intravenously injected with AgNPs of different sizes (10 nm, 40 nm, 100 nm), citrate-or polyvinylpyrrolidone-coated, at a single dose of 10 mg/kg bw. An equivalent dose of silver ions was administered as silver acetate. Mice were euthanized 24 h after the treatment, and silver quantification by ICP-MS and histopathology were performed on spleen, liver, lungs, kidneys, brain, and blood.

RESULTS

For all particle sizes, regardless of their coating, the highest silver concentrations were found in the spleen and liver, followed by lung, kidney, and brain. Silver concentrations were significantly higher in the spleen, lung, kidney, brain, and blood of mice treated with 10 nm AgNPs than those treated with larger particles. Relevant toxic effects (midzonal hepatocellular necrosis, gall bladder hemorrhage) were found in mice treated with 10 nm AgNPs, while in mice treated with 40 nm and 100 nm AgNPs lesions were milder or negligible, respectively. In mice treated with silver acetate, silver concentrations were significantly lower in the spleen and lung, and higher in the kidney than in mice treated with 10 nm AgNPs, and a different target organ of toxicity was identified (kidney).

CONCLUSIONS

Administration of the smallest (10 nm) nanoparticles resulted in enhanced silver tissue distribution and overt hepatobiliary toxicity compared to larger ones (40 and 100 nm), while coating had no relevant impact. Distinct patterns of tissue distribution and toxicity were observed after silver acetate administration. It is concluded that if AgNPs become systemically available, they behave differently from ionic silver, exerting distinct and size-dependent effects, strictly related to the nanoparticulate form.

[CEFTRIAXONE-INDUCED GALLBADDER LITHIASIS IN CASE OF INTENSTINAL BACTERIAL INFECTIONS (CASE REPORTS)]

Ceftriaxone is a third generation cephalosporin antibiotic and is one of the most often applicable parenteral drug, which has wide antimicrobial activity range. According to the literature gall bladder lithiasis is a complication which is described in the first days of the treatment with this antibiotic. The cases are seen mostly as undergdiagnosed conditions when ultrasound examination is performed due to the abdominal colics. The aim of the study was to observe Cholelithiasis in ceftriaxone-treated patients. Last year few cases of Cholelithiasis were observed in Children's Infectious Diseases Hospital. All of them were related to the dysentery treatment with ceftriaxone. All of the cases of Cholelithiasis were diagnosed at the beginning of the antibiotic therapy (in first 2-3 days of hospitalization). Gall bladder concernments/sludge were found accidentally. Cholelithiasis in these cases was transitory and in 2 weeks ultrasound investigation revealed no calculi/sludge in the gall bladder. Further findings are supposed to be analyzed on a bigger number of the patients. It is necessary to follow up with gall bladder concernments till their absolute resolution.

Ceftriaxone-associated acute gallbladder enlargement - an unexpected diagnosis in the child with urinary tract infection

Biliary sludge and/or biliary pseudolithiasis occur in patients treated with ceftriaxone with prevalence of 3-57%. Biliary obstruction can be the cause of the acute gallbladder enlargement. It is a minor complication, that usually does not give clinical symptoms and resolves once the drug is discontinued. The authors present a case of a 5-month old boy treated for the acute pyelonephritis. Routine ultrasound, performed on the 5th day of treatment with ceftriaxone, showed gallbladder enlargement. In the consecutive studies small gallblader sludge was visible. Patient had no symptoms related to the gallbladder enlargement. Ultrasound performed 6 weeks from the drug discontinuation was completely normal.

CONCLUSIONS

Patients treated with ceftroiaxone should be monitored for biliary sludge and pseudolithiasis.

SIDE EFFECTS OF TUBERCULOSIS TREATMENT WITH FIXED-DOSE COMBINATIONS

This paper aimed to explore the therapeutic effect and safety of Fixed-dose Combinations (FDCs) on tuberculosis. A computer search was carried out to review the literature related to clinical randomized controlled trials (RCTs) and clinical controlled trails (CCTs) on the curative effect and safety of treating pulmonary tuberculosis with FDCs. The results demonstrated that, in the 22 studies examined, comparison of sputum negative conservation rate of treating smear-positive pulmonary tuberculosis with FDCs and single drug, the relative risk (RR) value and 95% confidence interval (CI) were 1.02 (1.01, 1.03) and 1.01 (1.00, 1.02), respectively, at the end of the 2nd month and 6th month (P<0.05), while comparison of the relapse rate within six months showed that RR value and 95% CI was 1.72 (0.98, 3.02) (P>0.05). No statistically significant differences were found between the two groups in total occurrence of the rates of side effects pertaining to skin reaction, gastrointestinal tract side reaction, occurrence rate of liver and gall side reaction or occurrence rate of drug withdrawal because of side effects (P>0.05). After sensitivity analysis, it was found that occurrence rate of gastrointestinal tract side effects and occurrence rate of liver and gall side effects were unstable. All the findings suggest that the curative effect of treating tuberculosis with FDCs is better than that of a single drug. More reliable evidence is required since the safety evaluation results are not stable.

Gallbladder and urinary tract precipitations associated with ceftriaxone therapy in children: a prospective study

The incidence and outcome of gallbladder and urinary tract complications in children receiving ceftriaxone therapy were evaluated prospectively. The subjects were given intravenous ceftriaxone, 100 mg/kg/day, in two divided doses infused over 20-30-minute periods, for 5-14 days. Serial abdominal ultrasonography revealed gallbladder and urinary tract precipitations in five of 35 children, three of whom had gallbladder pseudolithiasis, one gallbladder sludge and one gallbladder pseudolithiasis and urinary bladder sludge. The children who had gallbladder sludge and gallbladder pseudolithiasis with urinary bladder sludge had abdominal pain, nausea and vomiting. Three children remained symptom-free. The gallbladder precipitations were found after 4-9 days of ceftriaxone therapy, and resolved completely 7-19 days after the end of treatment. The urinary tract precipitation was found on the 5th day after cessation of ceftriaxone therapy and resolved 7 days later. Ceftriaxone-associated gallbladder pseudolithiasis, gallbladder sludge and urinary bladder sludge usually resolve spontaneously and physicians should be aware of these complications so as to avoid unnecessary therapeutic procedures.

[Evaluation of clinical effectiveness of treatment of hepatobiliary disorders in the negative effects of environmental factors in children]

303 children with the diagnosis "Hepatobiliary disorders of cystic duct or gall bladder" and "Sphincter Oddu's spasm" have been examined. After a profound children's examination, the data of objective survey, and also laboratory, biochemical, immune, functional rates (such as ultrasound survey, cardiointervalography) and findings of chemical-analytical survey of the toxics rate (such as aroma carbons, phenol, aldehydes, aliphatic alcohols) in biospheres of children's organisms were a nalysed. The evaluation of the effectiveness of children's hepatobilliary disorders'treatment in conditions of the environmentae negative factors' influence.

Oral contraceptives and the risk of gallbladder disease: a comparative safety study

BACKGROUND

Recent concerns have been raised about the risk of gallbladder disease associated with the use of drospirenone, a fourth-generation progestin used in oral contraceptives. We conducted a study to determine the magnitude of this risk compared with other formulations of oral contraceptives.

METHODS

We conducted a retrospective cohort study using the IMS LifeLink Health Plan Claims Database. We included women who were using an oral contraceptive containing ethinyl estradiol combined with a progestin during 1997-2009. To be eligible, women had to have been taking the oral contraceptive continuously for at least six months. We computed adjusted rate ratios (RRs) for gallbladder disease using a Cox proportional hazards model. In the primary analysis, gallbladder disease was defined as cholecystectomy; in a secondary analysis, it was defined as hospital admission secondary to gallbladder disease.

RESULTS

We included 2,721,014 women in the cohort, 27,087 of whom underwent surgical or laparoscopic cholecystectomy during the follow-up period. Compared with levonorgestrel, an older second-generation progestin, a small, statistically significant increase in the risk of gallbladder disease was associated with desogestrel (adjusted RR 1.05, 95% confidence interval [CI] 1.01-1.09), drospirenone (adjusted RR 1.20, 95% CI 1.16-1.26) and norethindrone (adjusted RR 1.10, 95% CI 1.06-1.14). No statistically significant increase in risk was associated with the other formulations of oral contraceptive (ethynodiol diacetate, norgestrel and norgestimate).

INTERPRETATION

In a large cohort of women using oral contraceptives, we found a small, statistically significant increase in the risk of gallbladder disease associated with desogestrel, drospirenone and norethindrone compared with levonorgestrel. However, the small effect sizes compounded with the possibility of residual biases in this observational study make it unlikely that these differences are clinically significant.

Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women: prospective cohort study

OBJECTIVE

To determine whether transdermal compared with oral use of hormone replacement therapy reduces the risk of gallbladder disease in postmenopausal women.

DESIGN

Prospective cohort study (Million Women Study).

SETTING

Women registered with the National Health Service (NHS) in England and Scotland.

PARTICIPANTS

1,001,391 postmenopausal women (mean age 56) recruited between 1996 and 2001 from NHS breast screening centres and followed by record linkage to routinely collected NHS hospital admission data for gallbladder disease.

MAIN OUTCOME MEASURES

Adjusted relative risk and standardised incidence rates of hospital admission for gallbladder disease or cholecystectomy according to use of hormone replacement therapy.

RESULTS

During follow-up 19 889 women were admitted for gallbladder disease; 17 190 (86%) had a cholecystectomy. Compared with never users of hormone replacement therapy, current users were more likely to be admitted for gallbladder disease (relative risk 1.64, 95% confidence interval 1.58 to 1.69) but risks were substantially lower with transdermal therapy than with oral therapy (relative risk 1.17, 1.10 to 1.24 v 1.74, 1.68 to 1.80; heterogeneity P<0.001). Among women using oral therapy, equine oestrogens were associated with a slightly greater risk of gallbladder disease than estradiol (relative risk 1.79, 1.72 to 1.87 v 1.62, 1.54 to 1.70; heterogeneity P<0.001) and higher doses of oestrogen increased the risk more than lower doses: for equine oestrogens >0.625 mg, 1.91 (1.78 to 2.04) v <or=0.625 mg, 1.76 (1.68 to 1.84); heterogeneity P=0.02; estradiol >1 mg, 1.68 (1.59 to 1.77) v <or=1 mg, 1.44 (1.31 to 1.59); heterogeneity P=0.003. The risk of gallbladder disease decreased with time since stopping therapy (trend P=0.004). Results were similar taking cholecystectomy as the outcome. Standardised hospital admission rates per 100 women over five years for cholecystectomy were 1.1 in never users, 1.3 with transdermal therapy, and 2.0 with oral therapy.

CONCLUSION

Gallbladder disease is common in postmenopausal women and use of hormone replacement therapy increases the risk. Use of transdermal therapy rather than oral therapy over a five year period could avoid one cholecystectomy in every 140 users.

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

OBJECTIVE

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

DESIGN

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

POPULATION

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

METHODS AND MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

Hepatic changes in the acute phase of streptozotocin (SZ)-induced diabetes in mice

We have reported the streptozotocin (SZ)-induced hepatic lesions in the subacute phase (4 to 12 weeks after the treatment), which are characterized by appearance of oncocytic hepatocytes, cytomegalic hepatocytes and bile duct hyperplasia. In this study, we focused on the acute phase (6 to 48 hours after the treatment) of the SZ-induced hepatic lesions of mice to clarify the onset of the hepatic alterations, especially before the induction of hyperglycemia. Livers were taken from 8-week-old Crj:CD-1 (ICR) male mice at 6, 12, 24, 36 and 48 hours after the 200 mg/kg b.w. of SZ-injection. SZ-induced hyperglycemia was noted at 36 and 48 hours after the treatment, but the hepatic changes including lipid peroxidation, mitochondrial swelling, peroxisome proliferation and inhibition of hepatocyte proliferation occurred before the elevation of the serum glucose levels. The present findings indicate the direct effects of SZ on hepatocytes rather than the secondary effects of diabetes, and certain correlations between the hepatocytic changes in the acute phase and those in the subacute one. In addition, ulcer and submucosal edema of the gallbladder were observed at 36 or 48 hours after the SZ-treatment, which can be a novel finding in SZ-treated animal.

Effect of estrogen therapy on gallbladder disease

CONTEXT

Estrogen therapy is thought to promote gallstone formation and cholecystitis but most data derive from observational studies rather than randomized trials.

OBJECTIVE

To determine the effect of estrogen therapy in healthy postmenopausal women on gallbladder disease outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Two randomized, double-blind, placebo-controlled trials conducted at 40 US clinical centers. The volunteer sample was 22,579 community-dwelling women aged 50 to 79 years without prior cholecystectomy.

INTERVENTION

Women with hysterectomy were randomized to 0.625 mg/d of conjugated equine estrogens (CEE) or placebo (n = 8376). Women without hysterectomy were randomized to estrogen plus progestin (E + P), given as CEE plus 2.5 mg/d of medroxyprogesterone acetate (n = 14,203).

MAIN OUTCOME MEASURES

Participants reported hospitalizations for gallbladder diseases and gallbladder-related procedures, with events ascertained through medical record review. Cox proportional hazards regression was used to assess hazard ratios (HRs) and 95% confidence intervals (CIs) using intention-to-treat and time-to-event methods.

RESULTS

The CEE and the E + P groups were similar to their respective placebo groups at baseline. The mean follow-up times were 7.1 years and 5.6 years for the CEE and the E + P trials, respectively. The annual incidence rate for any gallbladder event was 78 events per 10,000 person-years for the CEE group (vs 47/10,000 person-years for placebo) and 55 per 10,000 person-years for E + P (vs 35/10,000 person-years for placebo). Both trials showed greater risk of any gallbladder disease or surgery with estrogen (CEE: HR, 1.67; 95% CI, 1.35-2.06; E + P: HR, 1.59; 95% CI, 1.28-1.97). Both trials indicated a higher risk for cholecystitis (CEE: HR, 1.80; 95% CI, 1.42-2.28; E + P: HR, 1.54; 95% CI 1.22-1.94); and for cholelithiasis (CEE: HR, 1.86; 95% CI, 1.48-2.35; E + P: HR, 1.68; 95% CI, 1.34-2.11) for estrogen users. Also, women undergoing estrogen therapy were more likely to receive cholecystectomy (CEE: HR, 1.93; 95% CI, 1.52-2.44; E + P: HR, 1.67; 95% CI, 1.32-2.11), but not other biliary tract surgery (CEE: HR, 1.18; 95% CI, 0.68-2.04; E + P: HR, 1.49; 95% CI, 0.78-2.84).

CONCLUSIONS

These data suggest an increase in risk of biliary tract disease among postmenopausal women using estrogen therapy. The morbidity and cost associated with these outcomes may need to be considered in decisions regarding the use of estrogen therapy.

Alcohol consumption in relation to risk of cholecystectomy in women

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

[Clinical and biochemical aspects of the course of strawberry gallbladder]

The article is devoted to an infrequently diagnosed affection of the gallbladder--cholesterosis. The conclusion reached from the analysis of clinical, laboratory, biochemical findings is that the condition under consideration is more commonly seen among middle-aged and elderly persons; it runs a latent course that can be associated with cholelitiasis: the condition develops in the presence of obesity, abnormalities in carbohydrate and lipid metabolism. In cholesterosis, there takes place a decline in the motility-evacuatory function of the gallbladder and a disturbance in the biochemical composition of the bile.

Safety of implantable contraceptives for women: data from observational studies

Contraceptive implants are registered in over 60 countries and have been used by millions of women for three decades. This article reviews findings from observational studies on the safety of contraceptive implants and examines the risk of specific health outcomes. Fifty-five articles were reviewed, and the body of evidence for each health outcome was summarized. Available evidence suggests that contraceptive implants are safe and, overall, implant users do not experience adverse events at rates higher than women not using implants. With respect to specific outcomes, the evidence suggests no increased risks of pelvic inflammatory disease, decreased bone mineral density, anemia, thrombocytopenia, or death with implant use. The evidence was too limited to draw meaningful conclusions for neoplastic disease, cardiovascular events, and HIV/AIDS. Nonsignificantly elevated associations were reported for diabetes, serious mental disorders, and rheumatoid arthritis. Conditions for which risks were marginally, yet significantly, elevated were hypertension and gall bladder disease.

Hormone replacement therapy for prevention of coronary heart disease: current evidence

Postmenopausal estrogen replacement, with or without progestin therapy, has a generally favorable impact on lipids, improves endothelial function, and has anti-inflammatory and antioxidant effects. These properties should favorably impact coronary risk; indeed, epidemiologic studies have consistently associated hormone replacement therapy with reduced coronary risk. Nonetheless, the Heart & Estrogen/progestin Replacement Study (HERS), a randomized, placebo-controlled, secondary prevention trial of conjugated estrogen with progestin, found no overall reduction in coronary events among women assigned to active hormone treatment. This review explores the role of estrogen replacement among interventions intended to prevent coronary heart disease in the post-HERS era.

Early detection by ultrasound scan of severe post-chemotherapy gut complications in patients with acute leukemia

BACKGROUND AND OBJECTIVE

Acute leukemia patients may develop life-threatening gut complications after intensive chemotherapy. We evaluated the role of abdominal and pelvic ultrasound (US) examination in early detection of these complications.

DESIGN AND METHODS

A cohort of twenty adult acute leukemia patients undergoing intensive chemotherapy for remission induction entered the study. All chemotherapy regimens included cytarabine by continuous i.v. infusion for several days.

RESULTS

Three patients had severe gut complications: 2 cases of enterocolitis and 1 case of gall bladder overdistension in the absence of calculi. In all cases the abnormality was documented by US examination: US scan showed thickening of the intestinal wall (two cases), and gall bladder overdistension with biliary sludge (one case). Immediate medical care included bowel rest, a broad-spectrum antibiotic, antimycotic treatment, and granulocyte colony-stimulating factor. All patients recovered from the complication.

INTERPRETATION AND CONCLUSIONS

We believe that the favorable outcome obtained in our small series can be attributed to early diagnosis followed by appropriate treatment. Early recognition by US and immediate medical management can lead to complete recovery of severe intestinal complications in patients with acute leukemia undergoing intensive chemotherapy.

Sonography of gallbladder abnormalities in acromegaly patients following octreotide and ursodiol therapy: incidence and time course

PURPOSE

We studied the effects of octreotide and ursodiol on the gallbladders of patients with acromegaly.

METHODS

We performed gallbladder sonography in patients with acromegaly at various intervals during treatment. Group I (18 patients) was treated with subcutaneous injections of the somatostatin analogue octreotide. Group II (10 patients) was treated with ursodiol while receiving octreotide therapy.

RESULTS

Seventy-eight percent of patients receiving octreotide developed gallbladder abnormalities: sludge in 72% (13/18) and calculi in 39% (7/18). Ursodiol reversed the gallbladder abnormalities in 7 of 10 patients.

CONCLUSIONS

A majority of patients receiving octreotide develop gallbladder abnormalities. Ursodiol appears to reverse the abnormalities in most cases.

Ascorbic acid supplement use and the prevalence of gallbladder disease. Heart & Estrogen-Progestin Replacement Study (HERS) Research Group

To investigate the relation of ascorbic acid supplement use to gallbladder disease and cholecystectomy, we conducted a cross-sectional analysis of baseline from 2744 postmenopausal women, aged 44-79 years, enrolled in the Heart & Estrogen-progestin Replacement Study (HERS), a secondary coronary heart disease prevention trial. A total of 629 HERS participants (23%) reported a history of gallbladder disease. Of these, 508 (19%) also reported a history of cholecystectomy. In bivariate models, ascorbic acid supplement use was associated with a decreased prevalence of gallbladder disease [odds ratio (OR)=0.74; 95% confidence interval (CI), 0.57, 0.96] and a trend toward a decreased prevalence of cholecystectomy (OR=0.77; 95% CI, 0.58, 1.02). Because we detected significant interactions between ascorbic acid supplement use and alcohol consumption, multivariate analyses were performed stratified by drinking status. After adjustment for potential confounding variables, use of ascorbic acid supplements among drinkers was associated with a decreased prevalence of gallbladder disease (adjusted OR=0.50; 95% CI, 0.31, 0.81) and cholecystectomy (adjusted OR=0.38; 95% CI, 0.21, 0.67). Use of ascorbic acid supplements among non-drinkers was not significantly associated with either prevalence of gallbladder disease or cholecystectomy. Further study is necessary to confirm our findings and, specifically, to examine the combined effects of ascorbic acid and alcohol on cholesterol metabolism.

Lipidosis induced in the dog gallbladder by a direct 5-lipoxygenase inhibitor

The direct 5-lipoxygenase inhibitor L-739,010 was administered at a dose of 60 mg/kg/day per os to beagle dogs for 15 days. Histopathological examination of gallbladders from treated dogs showed epithelial vacuolation and submucosal infiltration by foamy macrophages that were positive for lipids in Sudan Black-and/or Oil Red O-stained sections. Scanning electron microscopic examination of gallbladder mucosa showed thickening of epithelial folds and multifocal epithelial membrane disruptions. Transmission electron microscopy confirmed these findings and showed mucosal epithelial cell lipid droplet accumulation and submucosal infiltration of macrophages filled with lipid droplets, myelin figures, heterophagosomes, and cholesterol clefts. These changes resembled those reportedly seen in the human gallbladder with cholesterolosis and/or chronic cholecystitis.

Oral contraceptives and the risk of gallbladder disease: a meta-analysis

OBJECTIVES

This study was designed to assess the risk of gallbladder disease due to oral contraceptive use by conducting a thorough literature review.

METHODS

Controlled epidemiologic studies published through March 1992 were systematically searched and evaluated. Of 25 studies (27 publications), 9 could stand the test of critical appraisal with respect to validity. Restriction to these studies was judged to circumvent publication bias at the same time.

RESULTS

Oral contraceptive use is associated with a slightly and transiently increased rate of gallbladder disease. The results of six selected studies in which asymptomatic women were screened for gallstones were strikingly similar. Pooling of these results yielded an odds ratio, for ever vs never oral contraceptive use, of 1.36. A dose-effect relationship was indicated, suggesting that modern low-dose oral contraceptives are safer than older formulas, but an effect cannot be excluded.

CONCLUSIONS

Considering the large efforts already devoted to this exposure-disease relationship, the probably weak effect, and the rapidly changing formulas of oral contraceptives, the authors suggest that the safety of new oral contraceptives be evaluated by studying bile saturation and biliary function rather than by waiting for gallbladder disease to develop.

Prospective study of the long-term effects of somatostatin analog (octreotide) on gallbladder function and gallstone formation in Chinese acromegalic patients

This article reports the changes in gallbladder function examined by ultrasonography in 20 Chinese patients with active acromegaly treated with sc injection of the somatostatin analog octreotide in dosages of 300-1500 micrograms/day for a mean of 24.2 +/- 13.9 months. During treatment with octreotide, 17 patients developed sludge, 10 had gallstones, and 1 developed acute cholecystitis requiring surgery. In all of 7 patients examined acutely, gallbladder contractility was inhibited after a single 100-micrograms injection. In 8 patients followed for 24 weeks, gallbladder contractility remained depressed throughout therapy. After withdrawal of octreotide in 10 patients without gallstones, 8 patients assessed had return of normal gallbladder contractility within 1 month. In 8 of the remaining 10 patients who developed gallstones during treatment, gallbladder contractility normalized in 5 patients (3 of whom has disappearance of their stones within 3 weeks), and remained depressed in 3 (2 of whom had stones present at 6 months). Our results suggest that the suppression of gallbladder contractility is the cause of the successive formation of bile sludge, gallstones, and cholecystitis during octreotide therapy in Chinese acromegalic patients. It is therefore very important to follow the changes of gallbladder function during long-term octreotide therapy of acromegalic patients.

Hepatobiliary complications of total parenteral nutrition

The relationships between various hepatobiliary disorders and the administration of total parenteral nutrition (TPN) were reviewed and, in particular, the role of TPN in their pathogenesis was critically evaluated. Several clinical and pathological entities including steatosis, steatohepatitis, cholestasis, and cholelithiasis have been commonly linked to TPN, and instances of chronic decompensated liver disease have been reported. However, it is concluded that it is often difficult to extricate the effects of TPN on hepatobiliary function from many other hepatotoxic factors that may be operative in these patients. Thus, whereas considerable evidence exists to support a role fro carbohydrate or calorie excess in TPN solutions in the pathogenesis of steatosis, a loss of enteric stimulation and not TPN per se may be the primary factor in the development of cholestasis, biliary sludge, and gallstones. The apparent predilection of infants to TPN-related cholestasis may be based on the relative immaturity of the neonatal biliary excretory system.

Proceedings of the discussion, "Tolerability and safety of Sandostatin"

Side effects of octreotide may be local, biochemical, gastroenterological, or endocrinological. Local pain at the injection site occurs frequently, but rarely lasts more than 15 minutes and often resolves with continued therapy and may be improved if the vial is warmed prior to injection. No long-term hematological or biochemical abnormalities have been described. Despite initial diarrhea in some patients, no change in circulating fat-soluble vitamins has been consistently reported. Antibodies to octreotide have been described, but are rare. Abdominal pain or diarrhea can occur at the beginning of therapy. These symptoms rarely persist and are minimal if the injections are timed between meals, but this may increase the incidence of gallstones. Gallstones occur with increased frequency. Gastritis has been described as being an invariable consequence of long-term treatment with octreotide. We have found the incidence to be increased in patients on octreotide, but this is not invariable. Hypoglycemia may be exacerbated in some patients with insulinoma because of glucagon suppression. Small numbers of patients on octreotide for acromegaly have developed hypoglycemic. Conversely, carbohydrate tolerance may temporarily worsen because of insulin suppression and rarely oral hypoglycemia drug therapy may become necessary. Most frequently, carbohydrate tolerance does not deteriorate. In some patients with acromegaly, pituitary tumor size may continue to increase despite continued therapy. Last, there is the theoretical risk of addiction to a compound which may act through opiate receptors and considerably alleviates headache in some patients with pituitary tumor. Overall, despite the multiplicity of theoretical side effects, the majority of patients tolerate octreotide well, with no serious untoward effects.

[Epigastric colic after ceftriaxone therapy]

The following article describes a girl with right upper quadrant abdominal colic following Ceftriaxon therapy for purulent meningitis. Ultrasound made it possible to demonstrate sludge-balls, floating in the gallbladder, a follow up examination was normal. Moreover the features of gallbladder precipitations following Ceftriaxon therapy will be described, and the clinical consequences will be discussed.

Subacute toxicity of paraquat in beagle dogs: clinicopathology and pathologic examinations

Beagle dogs were allocated to 4 groups, each consisting of 3 males and 3 females, which received 0.055, 0.165 or 0.495 mg paraquat (PQ)/kg/day sc for 4 w to investigate subacute toxicity. Recovery 4 and 8 w postadministration was studied. In the early stage there was vomiting, decreased activity and undernourishment. Induration and ulcers at the injection sites were seen. The group receiving 0.495 mg PQ/kg had reduced food ingestion and occasional decreases in water consumption until the end of the 4-w injection period. Three animals in the 0.495 mg PQ/kg group were sacrificed in the moribund stage with marked decreases in body weight. Ophthalmologic examination at 4 w of recovery detected hemorrhage around the nasalis vein of the left fundus in 1 animal that received 0.495 mg PQ/kg. No abnormal changes in electrocardiography (ECG) were noted throughout the experimental period. Slightly increased urinary protein, reticulocyte counts, and fibrinogen were observed in a few animals in each group. A few animals that received 0.165 or 0.495 mg PQ/kg had increased phospholipid, blood urea nitrogen, and creatine phosphokinase. The lungs of the moribundly sacrificed animals had moderate atelectasis, localized atelectasis, moderate thickening of alveolar wall and pleura, proliferation of fibroblast-like cells, and abundant fibers in interstitium and alveoli. In the liver there was slight hemorrhage along the gallbladder. On electron microscopy of the lung, proliferation of fibroblasts, myofibroblasts and type II alveolar cells, and some mast cells were observed in thickened alveolar walls. Abundant collagen fibers, destroyed cell debris and mitotic figures of spindle-shaped fibroblasts were also observed in the dilated interstitium.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug-induced gallbladder disease. Incidence, aetiology and management

A great variety of drugs is reported to induce gallbladder disease by various pathogenetic mechanisms. Early epidemiological studies indicated a doubled risk of gallbladder disease in women taking oral contraceptives. More recent studies, however, have failed to confirm those findings; these conflicting results might be explained by the different methods used to define gallbladder disease. It was shown that the lithogenic index of the bile is increased during intake of oral contraceptives. Estrogens cause hypersecretion of cholesterol in bile, due to increase in lipoprotein uptake by the hepatocyte. Progesterone inhibits acyl coenzyme A-cholesterol acyl transferase (ACAT) activity, causing delayed conversion of cholesterol to cholesterol esters. Of the lipid lowering drugs, only clofibrate has been shown to increase the risk for gallstone formation. The other fibric acid derivatives have similar properties, but clinical experience is not as extensive. They seem to be inhibitors of the ACAT enzyme system, thereby rendering bile more lithogenic. Conflicting epidemiological data exist regarding the induction of acute cholecystitis by thiazide diuretics. Ceftriaxone, a third-generation cephalosporin, is reported to induce biliary sludge in 25 to 45% of patients, an effect which is reversible after discontinuing the drug. The sludge is occasionally a clinical problem. It was clearly demonstrated that this sludge is caused by precipitation of the calcium salt of ceftriaxone excreted in the bile. Long term use of octreotide is complicated by gallstone formation in approximately 50% of patients after 1 year of therapy, due to gallbladder stasis. Hepatic artery infusion chemotherapy by implanted pump is shown to be associated with a very high risk of chemically induced cholecystitis. Prophylactic cholecystectomy at the time of pump implantation is therefore advocated. Some drugs, such as erythromcyin or ampicillin, are reported to cause hypersensitivity-induced cholecystitis. Furthermore, there are reports on the influence of cyclosporin, dapsone, anticoagulant treatment, and narcotic and anticholinergic medication in causing gallbladder disease.

Spontaneous rupture of the gallbladder and haemoperitoneum in a patient with cardiac valve prostheses

A case is reported of isolated spontaneous rupture of the gallbladder with obstructed cystic duct and a stone in the cystic cavity, in a patient on anticoagulant treatment after cardiac valve replacement. The mechanism of the onset, the diagnosis and the treatment of the lesion are discussed together with a review of the literature.

Effects of steroidal contraceptives on gallbladder: a review

In regard to gallbladder disease and oral contraceptive use, more than ten controlled epidemiologic studies have been reported and reviewed in this paper. The findings presented concerning the association of oral contraceptive use with the development of a gallbladder disease are contradictory. Oral contraceptive use and use of estrogens in postmenopausal women have been reported to be associated with increased attack-rates of a gallbladder disease, but the increased risk is found higher in those using estrogens than progestin based oral contraceptives. Other studies, however, have reported little overall effect of oral contraceptive use on the risk of the gallbladder disease. Where increased risk has been documented, this has been more related to duration than overall. The increased risk of oral contraceptive use to gallbladder disease has been observed higher in the 6-12 months of usage. Only one study has reported increased risk of gallbladder disease in long-term users. The increased gallbladder disease in oral contraceptive users may be greater in multiparae than in nulliparae; pregnancy and obesity may also pose an increased risk to the disease in oral contraceptive users. However, these findings are not widely accepted.

Risks and benefits of long-term treatment with estrogens

The goal of contemporary hormone replacement is to minimize net predictable lifetime risk; success therefore depends upon quantitative assessments of the net quality of life, of net morbidity and of net mortality. Estrogens ameliorate menopausal symptoms, maintain bone integrity, and produce endometrial cancer; these facts and their quantitative aspects can be stimulated. Other links are gradually becoming clear: estrogens increase biliary disease, but prevent heart disease, and, it now seems, stroke. Conventional wisdom to the contrary notwithstanding, a critical review suggests that breast cancer is probably increased in frequency by long-term estrogen use; the increase is modest as a risk factor but because breast cancer is a common disease, it is substantial in absolute terms. The addition of progestin seems attractive as a method of opposing undesirable estrogenic effects on the endometrium. In fact, there is reason for concern about the effect of an added progestin upon the risks from breast cancer, heart disease, and stroke; even the magnitude of the expected reduction in endometrial cancer may not be great when the hormone is administered sequentially. Using a simple deterministic model of post-menopausal life with hormone replacement, we have inserted available estimates of the regimen-specific relative risk for each outcome, and translated each net impact into common denominators of morbidity and mortality. While estrogens probably increase net morbidity, as measured by either the number of hospitalizations to be anticipated or by the more arbitrary measure of expected days of disability, these negative changes are mostly due to gallbladder disease and endometrial cancer, both largely treatable conditions. Largely because of protection against heart disease, estrogen replacement in modest dose is likely to reduce substantially the number of deaths to be expected in women treated through age 75 and even into more advanced age. Hormone replacement which includes systemic progestin supplementation has not been empirically tested; it may be beneficial, but it is at least as likely to be harmful. Either a modest increment in the number of additional breast cancers produced by estrogens, a modest reduction in the number of cardiac events prevented by estrogens, or a simultaneous minor shift in the same direction for each condition, would have the effect of shifting the net reduction in cumulative deaths into an increase in the number of deaths as a result of treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

[Massive hemoperitoneum caused by spontaneous rupture of the gallbladder during anticoagulant treatment]

The Authors report main complications of anticoagulant treatment. Particularly, they describe a rare case of hemoperitoneum by spontaneous rupture of the gallbladder. They discuss etiopathogenesis and consequent clinico-therapeutic implications.

Increased risk of cholecystectomy in users of supplemental estrogen

We report the results of an analysis of information from a prospective cohort study of women examining the association between cholecystectomy and use of supplemental estrogens (never, current, and past use). There were 55 cases of cholecystectomy in those who had never used estrogen and 105 cases in those who had ever used estrogen. After adjustment for age, the relative risk of cholecystectomy in those who had ever used estrogen was 2.1 (95% confidence interval, 1.5-3.0). In women classified as current users based on information available in 1977, the relative risk of gallbladder disease was 2.7 (95% confidence interval, 1.8-4.0) and in past users as of this date, it was 1.6 (95% confidence interval, 1.1-2.5). When cases known to have reinitiated estrogen use after 1977 are removed from the numerator for past users and added to the numerator for current users, the relative estimate for past use decreased to 1.1 (95% confidence interval, 0.7-1.8), and the risk estimate for current use increased to 3.9 (95% confidence interval, 2.6-5.9). Although an increase in the risk of gallbladder disease in women using supplemental estrogens has been consistently observed in previous studies, the risk after cessation of use has received little attention but could be important. Our data suggest the possibility that the risk of gallbladder disease in estrogen users persists after use of the drug ceases. An increase in the risk of cholecystectomy in estrogen users that persists after drug use ends is plausible if estrogen-induced increases in the lithogenicity of bile cause gallstones to form during drug use and if these gallstones fail to dissolve even after bile lithogenicity returns to normal upon cessation of use. The effect of estrogen use on the gallbladder should be considered in weighing the net risk-benefit ratio of these drugs.

Intestinal metaplasia and altered enzyme expression in propylnitrosamine-induced Syrian hamster cholangiocellular and gallbladder lesions

Intrahepatic bile duct and gallbladder preneoplastic and neoplastic lesions induced in Syrian golden hamsters by propylnitrosamine treatment were investigated for the presence of polysaccharides and assayed immunohistochemically for expression of the enzymes glucose-6-phosphate dehydrogenase (G6PD) and glutathione-S-transferase (GST) molecular forms. On the basis of an increase in G6PD and the GST-placental form, a sequence of altered cell populations ranging from simple ductular proliferation through dysplasia and cholangiofibroma to cholangiocellular carcinoma could be established, the latter three lesions being characterized by marked increase in polysaccharide production. While similar goblet cell (intestinal) metaplasia and increased polysaccharide storage were also evident in carcinogen-induced gallbladder lesions G6PD and GST-P expression was decreased when compared with control epithelium.

Thiazide use and the risk of cholecystectomy in women

As part of a case-control study of gallstone disease conducted among the female members of Group Health Cooperative of Puget Sound, the authors investigated the possible etiologic role of prior use of thiazide diuretics. One hundred fifty-three women who underwent gallstone surgery between January 1979 and September 1980, and 156 controls selected from membership files, were interviewed about their past use of certain medications, their reproductive history, and physical and demographic characteristics. The risk of gallstone disease which required surgery among women who had used thiazides relative to those who had not used this drug, after controlling for age, race, pregnancy, and body mass index, was 1.9 (95% confidence interval (CI) = 1.0-3.7). However, this association was present only among women who were not overweight, i.e., those with body mass index less than or equal to 36, for whom the relative risk was 5.0 (95% CI = 1.8-13.5). Among overweight women, the relative risk was 1.0 (95% CI = 0.5-2.2). Among women who were not overweight, there was no further increase in risk with increasing duration or recency of thiazide use. These data fail to agree with data from earlier studies which show a possible thiazide-gallstone disease association. The results of the present study suggest that if thiazide use has any influence on the occurrence of gallstone disease in women, that influence exists primarily in those who are not overweight.

The menopause

Symptoms due to estrogen deficiency begin in the perimenopausal years and progress as serum levels of this hormone decrease Vasomotor instability, manifested by hot flushes or night sweats, may persist for several months to a few years. Psychologic symptoms include anxiety, tension, depression, insomnia, palpitations, and headaches. Atrophy of the genital epithelium may result in senile vaginitis with symptoms of irritation, burning, pruritus, dyspareunia, and even vaginal bleeding. Even the lower urinary tract mucosa is dependent upon estrogen. Postmenopausal osteoporosis affects 25 to 50% of older women and increases the risk for vertebral, hip, and other fractures. Estrogen therapy for menopausal complaints has received adverse publicity because several reports have indicated that unopposed estrogens increase the risk of endometrial cancer. Added progestogen not only negates this risk but reduces the incidence of endometrial adenocarcinoma in estrogen-progestogen users to less than that observed in untreated women. Estrogen replacement therapy does not increase the risk of breast cancer; the incidence of this malignancy, however, was also less in the estrogen-progestogen users when compared with either the untreated women or from that expected from the national cancer surveys. In evaluating postmenopausal women for hormone replacement, the benefits of estrogen-progestogen therapy must be weighed against possible risks.