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PubMed2007

Asymptomatic cholelithiasis in children with sickle cell disease: early or delayed cholecystectomy?

SUMMARY BACKGROUND DATA: Our study aimed to evaluate the role of elective laparoscopic cholecystectomy (LC) in children with sickle cell disease (SCD) and asymptomatic cholelithiasis and, furthermore, to determine whether the outcome is related to the operation timing. METHODS: The records of 30 children with SCD diagnosed with cholelithiasis from June 1995 to September 2005 were retraspectively reviewed. All 30 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them. The operation was accepted in the period of study by 16 children and refused by 14. During medical observation, 10 of the 14 children who refused surgery were admitted for severe biliary colics. Acute cholecystitis was diagnosed by abdominal ultrasound in 3 cases and in 1 case choledocholithiasis, ultrasonographically suspected, was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treated during endoscopic retrograde cholangiopancreatography (ERCP). All children, emergency admitted, underwent LC after the onset of symptoms. The patients were divided up into 2 groups (A: asymptomatic; B: symptomatic) depending on clinical presentation and operation timing and the respective outcomes were compared. RESULTS: Elective LC in asymptomatic children (group A) is safe with no major complications reported. During medical observation in children who refused elective surgery (group B), 6 biliary colics, 3 acute cholecystitis, and 1 choledocholithiasis were observed. Three sickle cell crises occurred in symptomatic children during biliary colics. The correlation between cholecystectomy performed in asymptomatic children (group A) and cholecystectomy performed in symptomatic children (group B) showed significant differences in the outcome. Morbidity rate and postoperative stay increased when children with SCD underwent emergency LC. CONCLUSIONS: Elective LC should be the gold standard in children with SCD and asymptomatic cholelithiasis to prevent the potential complications of biliary colics, acute cholecystitis, and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

Adolescent↗
PubMed2006

Decreased hepatic expression of PPAR-gamma coactivator-1 in cholesterol cholelithiasis.

BACKGROUND: Cholesterol cholelithiasis (gallstone disease) is a common disease in the Western world. The aim of the present study was to analyze the hepatic expression of a number of nuclear receptors involved in bile acid metabolism in human cholesterol gallstone disease. MATERIALS AND METHODS: Surgical liver biopsies were obtained from 11 patients with untreated cholesterol cholelithiasis and nine gallstone-free subjects; mRNA levels of cholesterol 7alpha-hydroxylase (CYP7A1) and related nuclear receptors and coactivators were assayed by quantitative real-time RT-PCR. RESULTS: No differences between the two groups were detected in mRNA levels of CYP7A1 and related nuclear receptors, with the exception of peroxysome proliferator-activated receptor-gamma coactivator 1 (PGC-1), which was significantly (P < 0.01) less expressed in gallstone subjects. Expression of PGC-1 was linearly correlated with farnesoid X receptor (FXR) in gallstone patients (r = 0.87 on a log scale, P < 0.01), but not in control subjects; in gallstone patients PGC-1 expression was also correlated with hepatocyte nuclear factor 4 (HNF-4) (r = 0.78, P < 0.01). CONCLUSION: These findings suggest that PGC-1 can play a role in the prevention of cholesterol gallstone disease in humans; this might take place via interaction with the bile acid receptor FXR, whose protective role in cholelithiasis has been suggested by recent evidence in animal models and other coactivators. The present data might help to understand the pathophysiology and possibly focus on new therapeutical targets in cholesterol gallstone disease.

Bile Acids and Salts↗
PubMed1987

Cholelithiasis: evaluation with CT.

Computed tomography (CT) is often the first imaging modality used in the diagnosis of patients with suspected abdominal disease. While it is known that early generation CT scanners often detect gallstones, the detection rate of newer equipment is not widely known. Abdominal CT scans of 226 patients who had undergone ultrasonographic (US) studies of the gallbladder were reviewed in a blinded study to determine the accuracy of state-of-the-art CT scanning equipment in the detection of cholelithiasis. Of 110 patients with US or surgical evidence of cholelithiasis, gallstones were demonstrated on CT images of 87 (79.1% sensitivity). Overall accuracy was 89.8%, while specificity was 100%. On CT images stones could appear densely (48.3%) or slightly (11.5%) calcified, as an area with a rim of increased density (21.8%), as an area of soft-tissue density (14.9%), or as an area of low density (3.4%). Stone size, stone density, section incrementation, and the pericholecystic anatomy affected the detection rate. Understanding the spectrum of findings and the other factors involved can optimize success of diagnosis of cholelithiasis on the basis of CT examinations.

Cholecystography↗
PubMed1999

Laparoscopic cholecystectomy in two patients with symptomatic cholelithiasis and situs inversus totalis.

BACKGROUND: Situs inversus viscerum is a rare condition with a genetic predisposition. We report 2 patients with situs inversus totalis and symptomatic cholelithiasis successfully treated via laparoscopic cholecystectomy. PATIENTS AND METHODS: The first patient was a 61-year-old female presenting with pain in the left upper quadrant associated with fever, chills, nausea and vomiting. The abdomen was tender with guarding and rebounding pain in the same region. Abdominal ultrasound and CT scan confirmed the diagnosis of gallstones as well as situs inversus with the liver and gallbladder on the left side and the spleen on the right. The second patient was a 37-year-old male with known situs inversus who presented with biliary colic due to cholelithiasis. In both patients cholecystectomy was performed laparoscopically in a reverse fashion. RESULTS: Laparoscopic cholecystectomy was carried out successfully despite the reversed anatomic relationships and both patients made a smooth recovery. CONCLUSION: Cholelithiasis occurring with situs inversus totalis is rare and may present a diagnostic problem. Laparoscopic cholecystectomy can be safely and effectively applied in the setting of situs inversus, although attention must be paid to the details of left-right reversal.

Adult↗
PubMed1998

Prevalence of cholelithiasis in non-diabetic haemodialysis and continuous ambulatory peritoneal dialysis patients.

Haemodialyzed (HD) patients have been found to have an increased bile cholesterol level and an increased saturation index in bile. These changes were markedly enhanced in the presence of a low-protein diet. To evaluate whether such changes influence the prevalence of cholelithiasis in patients with end-stage renal failure, real-time sonography was performed to detect the presence of gallstones (GS) in 54 HD (28 males, 26 females, mean age 52.4 +/- 15.4 years) and 39 continuous ambulatory peritoneal dialysis (CAPD; 22 males, 17 females, mean age 59.1 +/- 14.9 years) patients. No patient had diabetes. The patients' charts were reviewed for the following data: age, sex, primary renal disease, obesity (20% above ideal weight), history suggestive of gallbladder disease or previous cholecystectomy, duration of dialysis, and serum cholesterol levels. Overall, cholelithiasis was documented in 12 of 93 (12.9%) patients, 7 HD and 5 CAPD. When comparing the factors outlined above, no significant difference was found between HD and CAPD patient groups, either with or without cholelithiasis. Gallbladder disease was asymptomatic in all except 1 patient who required cholecystectomy. Using a healthy control group consisting of local age- and sex-matched inhabitants, GS were found in 8 of 134 (6%) of them (p > 0.05). We conclude that the prevalence rate of GS in our dialysis population (HD and CAPD) is similar to that of a local general population following a western-style diet, irrespective of dialysis mode.

Aged↗
PubMed2003

Impact of rapid weight reduction on risk of cholelithiasis after bariatric surgery.

BACKGROUND: Obesity alone and rapid weight loss induced by bariatric surgery are recognized risk factors for the development of cholelithiasis. The decision to perform prophylactic cholecystectomy at the time of bariatric operations remains controversial and at the surgeon's discretion. METHODS: From June 1998 to April 2001, 103 patients underwent Roux-en-Y gastric bypass (RYGBP) in Hospital das Clinicas/Unicamp (SP). 88 of these 103 patients had their preoperative ultrasonography of gallbladder recovered. 19 of these 88 patients showed gallstones before RYGBP, and the remaining 69 did not have ultrasonographic evidence of cholelithiasis. 36 of these 69 patients were followed with ultrasonography during the 12 postoperative months. They were divided into 2 groups: those who formed gallstones (n=19) and those who did not (n=17), to evaluate the importance of sex, age, preoperative BMI, preoperative excess weight and postoperative percent excess weight loss as risk factors in the gallstone formation. RESULTS: Preoperative incidence of cholelithiasis in the 88 operated patients was 21.6% and postoperative incidence in the 36 patients followed by ultrasonograph was 52.8%. There was no statistical evidence that postoperative gallstone formation is associated significantly with the variables studied. CONCLUSION: This study confirms the high correlation between morbid obesity, rapid weight loss and gallbladder disease. Predictive risk factors for gallstone formation were not found.

Adult↗
PubMed2006

Cholelithiasis and thrombosis of the central retinal vein in a renal transplant recipient treated with cyclosporin.

The use of cyclosporin has been associated with the development of cholelithiasis in transplant recipients. Cholelithiasis in turn enhances the effects of cyclosporin on increased platelet aggregation. In this report, a patient who had undergone a renal transplantation as a result of malignant hypertension, and who was on immunosuppressive therapy consisting of cyclosporin, prednisone and azathioprine, developed thrombosis of the central retinal vein 5 years following the transplantation. Seven years after the transplantation, cholelithiasis, cholecystitis, cholangitis and subsequently secondary chronic biliary sclerosis were detected. Latero-lateral anastomosis between the common bile duct and duodenum was performed during explorative laparotomy and ursodeoxycholic acid treatment was introduced. The possible inter-relationship of the cholestatis, central retinal vein thrombosis and immunosuppression are discussed.

Adult↗
PubMed1983

Cholelithiasis in children: recent observations.

All patients at Children's Hospital Medical Center who had ultrasonic evidence of cholelithiasis during the period from June 1979 to June 1982 were identified. Their charts and radiographs were reviewed, as were the surgical and pathologic reports of those who had cholecystectomy. Cholelithiasis was found to be less rare than expected. Sixty-five patients were identified during the three-year period. Exclusion of 13 patients more than 21 years old left 52 patients, 29 of whom were female and 23 male, ranging in age from 3 months to 21 years. Predisposing diseases or circumstances were present in 83 per cent of the cases. These included hemolytic anemia (15), cystic fibrosis (4), metabolic disease (3), liver disease (4), postpartum state (4), prior bowel resection or malabsorption (4), cardiac disease (4), prior orthopedic surgery (2), other (3). There were only nine cases in which no identifiable predisposition to cholelithiasis could be found. Although the gallstones were not subjected to chemical analysis, at least 53 per cent of them were visible on the 34 available abdominal radiographs, indicating the presence of calcium and thus stones of a mixed type.

Adolescent↗
PubMed1999

Predictive factors for cholelithiasis complications.

BACKGROUND: Cholelithiasis is a benign disease that is very frequently encountered throughout the world. Its surgical mortality is usually minimal (0.1%), but the risk is considerably greater (2-10%) in patients developing complications particularly if they are elderly. The identification of possible predictive signs of complications is therefore crucial for the indication of preventive surgery. METHODS: The present study retrospectively examined 490 patients admitted to hospital because of complicated and uncomplicated cholelithiasis in order to establish the existence of previous (clinical or instrumental) symptoms that may be predictive of the course of the disease. The analysis of some variables (age, sex, pregnancy, diet, ethanol consumption, smoking, previous/concomitant diseases, and blood chemistry and instrumental test results) and the specific symptoms of cholelithiasis made it possible to identify two potential risk factors: an age of more than 60 years and the onset of biliary colic. RESULTS: The risk of developing complications is 3.2 times greater in patients aged more than 60 years than in those who are younger, and 3.3 times greater in symptomatic than in asymptomatic patients. Statistical analysis also revealed that the risk of complications is about ten times greater in patients with both risk factors than in those with neither. CONCLUSIONS: In conclusion, the indication for surgery must be considered absolute in symptomatic patients aged more than 60 years and relative to younger symptomatic patients.

Adolescent↗
PubMed1975

Pathogenesis of human cholesterol cholelithiasis.

The pathogenesis of cholesterol cholelithiasis in humans has been studied by means of three techniques. The cholesterol-solubilizing capacity of bile may be determined by estimation of the relative composition of the three major lipid constituents of bile. Consistent reduction in the cholesterol-carrying capacity of gallbladder bile of persons with gallstones when compared with normal subjects has not been shown. Normal subjects frequently have supersaturated bile. Secretion rates of biliary lipids have been estimated by two methods; with the method that appears to be more physiologic no change in lipid secretion rates was found in gallstone patients. Bile acid pool size has been measured by isotope dilution techniques; it is reduced in patients with gallstones. It is not clear whether this reduction is important in the pathogenesis of cholesterol cholelithiasis, for the bile acid secretion rate is normal because of an increased rate of cycling of the pool through the enterohepatic circulation. The role of the gallbladder in the genesis of cholesterol cholelithiasis may be more important than has been realized.

Bile↗
PubMed2001

[Childhood cholelithiasis. Analysis of 24 patients diagnosed in our department and review of 123 cases published in Spain].

INTRODUCTION: Childhood cholelithiasis is being increasingly diagnosed worldwide, particularly in Spain. We retrospectively analyzed several epidemiological, clinical, diagnostic, etiologic and therapeutic aspects of this disease in 123 pediatric cases reported in Spain since 1971. PATIENTS AND METHODS: Twenty four patients with cholelithiasis were diagnosed in our department between 1981 and 1999. Data on sex, age at diagnosis, form of clinical presentation, imaging studies used in diagnosis, etiology and underlying associated diseases, complications and treatment were retrospectively analyzed. The data obtained on the patients in our study were compared with and added to those of a further 99 pediatric cases published in Spanish medical journals since 1971. Cases diagnosed during the neonatal period were not included. RESULTS AND CONCLUSIONS: The main findings were the following. The mean age at diagnosis was 7.8 years. The percentage of males was 51% and that of females was 49%. A total of 33.3% of the patients were asymptomatic and 66.6% were symptomatic. The most frequent symptoms were abdominal pain with or without vomiting (94%), jaundice (13.4%) and fever (9.7%). Etiology was idiopathic in 60.2% of patients and secondary in 39.8%. In the latter group the main causes of cholelithiasis were hemolytic anemia in 19 patients, obesity in 12, biliary tract malformations, hypercholesterolemia and liver disease in 4, and cystic fibrosis in 3. Diagnosis was based on abdominal ultrasonography in 89.4% of the patients and on Xray in 60.1%. Complications found were cholecystitis in five patients and pancreatitis in seven. One child with pancreatitis died from acute respiratory distress syndrome. Surgical treatment was given to 55.3% of the patients while 43.9% were treated conservatively. In one child cholelithotripsy was used.

Adolescent↗
PubMed1975

Kinetics of cholesterol and bile acids in patients with cholesterol cholelithiasis.

The kinetics of cholesterol and bile acid was determined from a 10-week analysis of the biliary lipids after a single injection of labeled cholesterol in parallel with a conventional 1-week study of primary bile acid kinetics. Six healthy controls and 6 patients with cholesterol cholelithiasis were studied. Two of the 6 cholesterol cholelithiasis subjects had kinetic values that were very similar to the controls and the other 4 were significantly different. These 4 patients had significantly smaller primary bile acid pools and significantly lower fractional conversions of cholesterol to both primary bile acids, with concomitantly lower bile acid flux. No significant differences were obtained for the size of the rapidly miscible cholesterol pool, the fractional rate of loss and flux of biliary neutral sterol, and the fractional turnover of the primary bile acid pools. These kinetic data support the hypothesis that in some patients with cholesterol cholelithiasis there is defective conversion of cholesterol to bile acids.

Adult↗
PubMedDate not supplied

[Cholesterol and its lipoprotein fraction in serum and bile of patients with cholelithiasis].

Total cholesterol, HDL, LDL and triglycerides were assayed in the blood serum and bile from the liver and gallbladder of both normal individuals and patients with cholelithiasis. It was found that all assayed parameters are significantly higher in patients with cholelithiasis. An increase in total cholesterol and HDL was seen in the bile from the liver whereas an increase in the level of unstable LDL by about four fold with simultaneous decrease in HDL level were found in the bile from the gallbladder. These differences in lipoprotein fractions level in patients with cholelithiasis indicate systemic disorders in cholesterol metabolism.

Adult↗
PubMedDate not supplied

The effects of cholelithiasis and cholecystectomy on gastric emptying.

In this clinical study, four groups, each consisting of 12 patients are established to determine how gastric emptying is influenced in cholelithiasis with accompanied flatulent dyspepsia and the relationship of symptoms and gastric emptying after cholecystectomy. 1. group: healthy people, 2. group: patients with dyspeptic cholelithiasis, 3. group: patients who have no dyspepsia after cholecystectomy, 4. group: patients whose dyspepsia is continued after cholecystectomy. Groups are compared according to solid phase gastric emptying scintigraphies performed with Tc 99m sulfur colloid bound with scrambled eggs. Gastric emptying delayed in second (p < 0.001) and fourth (p < 0.005) groups postprandially and not differed in the third group (p > 0.005). These results demonstrate that dyspepsia, in cholelithiasis and persisting after cholecystectomy have a close relation with delay in gastric emptying.

Cholecystectomy↗
PubMed1992

Cholecystitis and cholelithiasis in children.

Cholecystitis and cholelithiasis are being recognized with increasing frequency in infancy and childhood. Hematologic disorders continue to account for a large proportion of cases; however, many children are noted with cholelithiasis in association with total parenteral nutrition, ileal disorders, and prolonged fasting. Spontaneous stone resolution has been noted in many cases in infancy and a period of observation is indicated in the absence of obstructive symptoms. Cholecystectomy remains the procedure of choice for symptomatic cholelithiasis and cholecystitis and a laparoscopic procedure is possible in most cases after infancy.

Adolescent↗
PubMed1992

[The estrogen-androgen profile is unchanged in men with cholelithiasis].

It is well established that cholelithiasis is more frequent in women than in men. This difference is usually explained by the effects of estrogens and progesterone on the metabolism of bile acids, biliary cholesterol secretion and saturation, and gallbladder motility. Another explanation could be a protective effect of androgens against cholelithiasis in men. To test this hypothesis, we determined the hormonal, androgenic and estrogenic, status of 15 male patients with asymptomatic gallstone disease and in 15 control patients with normal gallbladder matched for age and body weight. No significant difference in the plasma concentrations and the urinary excretion rate of sex hormones (testosterone, dihydrotestosterone, androstenedione, testosterone and androstanediol glucuronides, estradiol, estrone, total estrogens), as well as in the plasma sex hormone binding globulin, was found between the 2 groups of patients. The development of cholelithiasis in men, therefore, does not appear to be related to modification of sex steroids.

Adult↗
PubMedDate not supplied

[Male gender-- difficulty factor in cholecystectomies for cholelithiasis].

Male gender has been recognized as a risk factor for an increased conversion rate of laparoscopic cholecystectomy and more severe disease in those with symptomatic cholelithiasis. The aim of this study was to determine the effect of male gender on the clinical presentation of symptomatic cholelithiasis, relation between male gender and acute cholecystectes, the operating time, the frequency of conversion and postoperative morbidity. The medical records of all patients with symptomatic cholelithiasis from 31 mars 1993 to 31 mars 2001 (4145 patients) were evaluated. These cases were divided into four groups: A--elective laparoscopic cholecystectomy group--patients with cholecystectes with elective laparoscopic cholecystectomy (3995 cases); B--patients with acute cholecystectes whose laparoscopic cholecystectomy was performed successfully (660 cases); C--acute conversion group converted to open surgery (240 cases); D--acute open group with elective open cholecystectomy. The study reveals that males suffer from a severe form of cholecystectes that raise difficulties when laparoscopic cholecystectomy is performed.

Adolescent↗
PubMed2005

Reappraisal of the management of cholelithiasis in diabetics.

Recently, dramatic advances in research have elucidated the prognosis of gallstone disease and have permitted a more selective choice of persons for treatment based on symptom status and projected prognosis. Ultrasound- detected-incidental gallstones are infrequently clinically significant, but this finding has prompted the surgeons to have a liberal attitude towards the operative indications for cholelithiasis particularly after the advent of laparoscopy. At the same time, the management of gallstones in the diabetics still remains controversial. Early retrospective studies reported an alarmingly high incidence of gallstones in diabetics as compared with the general population and in view of profound morbidity and mortality rates observed in the diabetics, prophylactic cholecystectomy was generally recommended. However, recent evidence-based studies challenged this approach and concluded that prophylactic cholecystectomy is not justified in diabetic patients with asymptomatic gallstones. It is inferred that, as in the general population, asymptomatic cholelithiasis in diabetics should be managed expectantly and preemptive surgery should not be routinely performed. However, early laparoscopic cholecystectomy is preferred in cases of symptomatic cholelithiasis.

Cholecystectomy↗