Asymptomatic Gallstone Disease Research Articles

Жовчнокам'яна хвороба в дітей

The prevalence of gallstone disease among children is 0.13-1.9%. Cholelithiasis in children is a multifactorial disorder. Scientific data analysis indicates a diversity of pathogenetic mechanism of gallstone formation. The purpose of the review is to summarize the scientific data about risk factors, clinical features, diagnosis and treatment of gallstone disease in children. Based on the literature data, the main factors for the disease are genetic, metabolic, low-calorie diet, nutritional disorders, liver and small intestine diseases. The main pathogenetic mechanisms of gallstone formation are liver dyscholia, disorders of enterohepatic circulation of bile acids, increased erythrocyte hemolysis and erythrocyte enzyme system insufficiency, a decrease in hepatic enzyme activity, impairment of gallbladder motility due to decreased sensitivity to cholecystokinin. Most children undergo asymptomatic gallstone disease: clinical features are absent, concrements in the gallbladder or bile ducts appear as accidental findings during ultrasound examination. The first stage of diagnosing cholelithiasis is an abdominal ultrasound examination. In case of absence of concrements during ultrasound examination and presence of typical clinical picture of cholelithiasis, endoscopic ultrasound and magnetic resonance cholangiopancreatography are prescribed. To reduce biliary pain, non-steroidal anti-inflammatory drugs and analgesics are required. The only way to treat symptomatic form of gallstone disease is cholecystectomy. The asymptomatic form is subject to observation without treatment. For the treatment and prevention of cholelithiasis, it is not recommended to take bile acid preparations due to the low effectiveness and frequency of relapses in the formation of stones after their complete dissolution. Conclusions. The incidence of gallstone disease among children and adolescents increases and more than half of patients has asymptomatic form. During the treatment of patients with cholelithiasis, cholecystectomy or observation tactics are used, depending on the clinical form of the disease. Prevention of gallstone disease relies on healthy lifestyle, weight loss for the obese children, physical activity, diet high in fiber and calcium. The authors declare that they have no conflicts of interest.

Incidence of Asymptomatic Gallstones in Obese Patients Who Underwent Bariatric Surgery in Qassim Region at King Fahad Specialist Hospital.

Gallstone is a significant health issue in the KSA and other developing countries. Multiple important risk factors have been identified as being associated with gallstones. Obesity is one of the risk factors for gallstone formation. Therefore, this study intends to determine the incidence of asymptomatic gallstone disease among the obese population in the Qassim region. The purpose of this study is to determine the incidence of asymptomatic gallstone in obese patients and the risk factors that contribute to its development in the Qassim region. As well as to compare the prevalence of gallstone disease between age groups and genders. A retrospective study of all patients who underwent bariatric surgery and had gallstones between January 2018 and January 2022 at King Fahad Specialist Hospital in Qassim Region, Saudi Arabia. The data, including age, gender, body mass index (BMI), and co-morbidities, will be collected from their charts. Results: The current study included 295 patients with a mean age of 34.83 years (SD = 11.7) and 126 (42.7%) male participants. The most common comorbidity was diabetes mellitus, which was present in 54 (18.4%) participants, followed by hypertension in 42 (14.3%) participants. Of the 295 participants, 232 (78.6%) had asymptomatic gallstones, while 63 (14.3%) patients were symptomatic. The results showed that younger people (16-25 years) had the highest odds ratio of having asymptomatic gallstones compared to the reference group (>55 years). Gender was also significantly associated with asymptomatic gallstones, with males having higher odds of having asymptomatic gallstones than females. Participants with comorbidities other than diabetes mellitus had lower odds of having asymptomatic gallstones. The present study's main finding is that obese patients receiving bariatric surgery had a significant prevalence of comorbidities and asymptomatic gallstones. According to the results, diabetes mellitus, male gender, and younger age may all be risk factors for the occurrence of asymptomatic gallstones in this population.

Updates and advances in the concept of gallbladder cancer treatment

The gallbladder is the most common site of tumor occurrence among biliary tract cancer. Gallbladder cancer accounts for approximately 0.6% of new cancers and 0.9% of cancer-related deaths. The risk factors identified for the development of gallbladder cancer include being female,>65 years of age, asymptomatic gallstone disease,and obesity. Surgical resection is the only curative treatment for early-stage gallbladder cancer, and some intermediate or advanced gallbladder cancers can be radically cured by extended resection. However, the extent of liver resection or lymph node dissection and whether to combine it with bile duct removal, revascularisation,and multiple organ resection remain somewhat controversial. After neoadjuvant treatment, up to a third of patients with locally advanced gallbladder cancer benefit from secondary surgical treatment. Only a small proportion of patients with gallbladder cancer at high risk for recurrence will benefit from postoperative adjuvant therapy. With the advent of different target-targeted drugs and the use of genetic tests in biliary tract cancer, targeted therapy and PD-1/PD-L1 inhibitors may become the new standard of care for gallbladder cancer and need to be further explored.

Association of Non-alcoholic Fatty Liver Disease with Symptomatic and Asymptomatic Cholelithiasis: Cohort from Southeast Asian Patients

Introduction: With increasing prevalence of metabolic syndrome, sedentary lifestyle, and diabetes mellitus the burden of non-alcoholic fatty liver disease (NAFLD) is also increasing along with its complications including gallstone disease. That is why, this study aims to determine the association between non-alcoholic fatty liver disease with the prevalence of gallstone disease and also, risk factors associated with symptomatic and asymptomatic cholelithiasis.
 Methods: A prospective study design was performed and during the data collection phase we have enrolled a total of 218 patients who were diagnosed as a case of NAFLD from Asian Institute of Medical Sciences, Hyderabad between the periods of 19 months from March 2019 to October 2020. Diagnosis of NAFLD was made using liver biopsy and cholelithiasis with ultrasound abdomen. Both males and females with a primary diagnosis of NAFLD were included in this study. Patients were divided into symptomatic and asymptomatic gallstone disease and were further assessed for underlying risk factor associated with symptomatic and asymptomatic gallstone disease. Statistical package for the social sciences version 21 (SPSS) used for the entry of data and final analysis and a p value of <0.05 were considered as statistically significant.
 Results: The overall prevalence of gallstone disease in patients with NAFLD was 12.84% (n = 28) among them 19 (67.85%) patients were having symptomatic gallstone disease while 9 patients had asymptomatic gallstones disease (32.14%). Patients having mean age 49.01 years, uncontrolled blood sugar level (209.24 mg/dl), mean alkaline phosphatase 106.22 IU/L, female gender, and having diabetes mellitus were significantly associated with symptomatic gallstones disease (p value <0.05).
 Conclusion: In our study, the cohorts have shown bidirectional association between gallstone disease and NAFLD. Also prevalence of symptomatic gallstone disease is quite high and it was strongly associated with increasing age, female gender, raised blood glucose levels, and diabetes mellitus.

Quality of life in patients after laparoscopic cholecystectomy due to gallstone disease - evaluation of long-term postoperative results.

<b>Introduction:</b> Currently, the standard treatment of gallstone disease is laparoscopic cholecystectomy. Considering its availability, reduction of postoperative pain and shortened stay in the hospital, a constant upward trend in the number of such procedures is observed. However, about one third of patients undergoing such treatment report pain and dyspeptic disorders following the surgery. The assessment of the quality of life of patients undergoing laparoscopic cholecystectomy, based on standardized questionnaires, should be one of the elements allowing for the assessment of the impact of the applied treatment on patients' lives. </br></br> <b>Aim:</b> The aim of this retrospective study is to evaluate the impact of laparoscopic cholecystectomy on the quality of life of patients operated in one center. </br></br> <b>Materials and methods:</b> The study has been carried out retrospectively with the use of a GIQLI questionnaire completed online by the patients 6 months after undergoing laparoscopic cholecystectomy. The study included patients over 18 years of age who have not experienced any complications within the perioperative period and did not require open surgery. The study group has been divided into two subgroups depending on the presence of symptoms of acute gallstone disease in the pre-operative period. </br></br> <b>Results: </b>The study group consisted of 205 patients (53 men, 152 women, aged 19 to 87, with an average of 54.3). The subgroup with an asymptomatic gallstone disease (dyspeptic disorders, without biliary colic) consisted of 47 patients (18 men, 29 women, aged 19-87). Symptomatic gallstone disease occurred in 158 people (35 men, 123 women aged 22 to 81). There have been certain statistically significant differences in the post-operative health condition between the group of patients with symptoms of gallstone disease and the asymptomatic patients. 94.3% of symptomatic patients concluded that their condition has improved and 5.7% that it remained unchanged. Among asymptomatic patients, only 53.2% of patients stated that they felt better post-surgery, 44.7% reported no changes (p < 0.001). There have been no significant differences in the overall QIQLI scores between these subgroups, although symptomatic patients assessed their social functioning better (8.9 ±1.5 vs 8.11 ±2.08, p = 0.004). There have been certain differences between men and women in the assessment of the quality of life in the context of the presence of key symptoms (M: 28.87 ±4.23, F: 26.77 ±5.0, p = 0.007). </br></br> <b> Conclusion:</b> The patients with a symptomatic gallstone disease report they feel better after laparoscopic cholecystectomy as compared to the group of asymptomatic patients. The overall QOL score measured by the GIQLI form does not depend on the presence of symptoms in the preoperative period. Men benefited more from surgery as regards key symptoms.

An inverse association of weight and the occurrence of asymptomatic gallbladder stone disease in hypercholesterolemia patients: a case-control study

BackgroundDespite the fact that the majority of gallstones formed in the gallbladder are mainly composed of cholesterol, as they are formed from cholesterol-supersaturated bile, and hypercholesterolemia is a common metabolic disorder, which is closely related to cardiac, hepatic, renal and other oxidative damage inflammation and necrosis, there is still no consensus regarding the contribution of blood serum lipids in the pathogenesis of gallbladder stone disease (GSD). This study aimed to investigate the relationship between hypercholesterolemia and the risk of new-onset asymptomatic GSD, and to determine the prevalence of factors associated with new-onset asymptomatic GSD in patients with hypercholesterolemia.MethodsIn this study, 927 Chinese patients with new-onset asymptomatic gallstone disease and 845 healthy controls were enrolled starting from August 2012. Patients were matched for age, gender, race, occupation, systolic blood pressure, diastolic blood pressure, and fasting blood glucose levels (FBG). Body mass index (BMI), nonalcoholic fatty liver disease (NAFLD) and serum lipids indexes were compared and the relationships between BMI, blood lipid and gallbladder stone hazards were examined by logistic multivariate regression models.ResultsThe result showed a significantly higher morbidity with GSD in hypercholesterolemia than non-hypercholesterolemia patients (Χ2 = 17.211, P < 0.001). Of hypercholesterolemia patients, low density lipoprotein (OR = 1.493, P = 0.029) and NAFLD (OR = 2.723, P = 0.022) were significant risk factors for GSD, while being male (OR = 0.244, P = 0.033), weight (OR = 0.961, P = 0.022), high density lipoprotein (OR = 0.305, P < 0.001), and FBG (OR = 0.687, P = 0.034) were significantly negatively correlated with GSD in univariate analysis. Multivariate logistic regression indicated weakly positive correlations with NAFLD (OR = 3.284, P = 0.054), and significant negative correlations with weight (OR = 0.930, P = 0.018), HDL-c (OR = 0.144, P < 0.001), and GSD.ConclusionHypercholesterolemia acts as an independent risk factor for new-onset asymptomatic GSD, while obesity and NAFLD are synergistic factors. Interestingly, it is first reported that elevated weight was inversely associated with GSD in patients with hypercholesterolemia. The results of this study suggest that effective control of hyperlipidemia is of greater significance than weight loss, which might make the situation worse, in the prevention of GSD in obese patients with hyperlipidemia.

Complications of Laparoscopic Cholecystectomy

Background: laparoscopic cholecystectomy is now regarded as the "Gold Standard" treatment option for benign gallbladder disease. But it is not free of procedure related complications. Objective: To review the complications of laparoscopic cholecystectomy for gall stone disease.&#x0D; Materials &amp; Method: A prospective observational study was carried out over a period of 9 years beginning from 1st of July 2003 till 30th of June 2012 in Comilla Medical College Hospital and several private hospitals of Comilla. A total of 946 patients who underwent laparoscopic cholecystectomy for symptomatic and asymptomatic gallstone disease as confirmed by ultrasound scan were included. Patient having cirrhosis of liver, ischaemic heart disease, suspected carcinoma of gall bladder were excluded from the study. The outcome including the complications was analyzed.&#x0D; Result: Out of 946 patients 632 (66.80%) were females and 314 (33.19%) were males. Most (92.3%) of them were between 21-50 years of age. The commonest immediate complication was bleeding from liver bed (9.40%), from vascular injury in Callot's triangle (5.17%) and from the trocar site (4%). There was spillage of gallstones in 104(10.99%) cases. Bowel injury was seen in only one (0.10%) case. Bile leakage was observed in 4(.42%) cases that also include CBD injury .in 3 cases. The procedure was converted to open surgery in 11(1.17%) cases. Port site infection was seen in 43 (4.54%) cases. Late complications include port site hernia in 6 (0.63%) cases, port site keloid in 1 (.1%) case and CBD stricture in 5 (0.54%) cases. Mortality was unavoidable in in 2(0.21%) cases.&#x0D; Conclusion: With increasing experience laparoscopic cholecystectomy can be a safe and effective procedure for most patients with cholelithiasis. Proper training and sound knowledge of possible complications can yield favorable results and lesser complications.&#x0D; Journal of Surgical Sciences (2013) Vol. 17 (2) :73-79

Is concomitant cholecystectomy with laparoscopic sleeve gastrectomy mandatory

Background Currently, laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric surgeries. Concomitant cholecystectomy is routinely performed for symptomatic patients. However, the management of patients with asymptomatic gallstones is still controversial. Again, the incidence, the prospective presentation of postoperative cholelithiasis in patients without previous gallstones disease is also deficient and unpredictable. Patients and methods This prospective study included 95 patients with asymptomatic gallstone disease (group A) and 755 patients without gallstone disease (group B) who underwent LSG. The endpoint was the development of symptomatic gallstones requiring surgical intervention. Types of presentation, relevant preoperative workup, and operative and postoperative findings were reported. Results In groups A and B, the mean age was 35.6±7.6 and 35.34±7.7 years; the preoperative BMI was 39.4±1.02 and 40.3±0.76 kg/m2; the percentage of excess weight loss was 50±2.54% and 67±2.8% at the time of presentation, and 67.4 and 71.3% patients were women, respectively. Symptomatic gallstones were found in 17 (18%) patients in group A, two of whom had acute presentation. Two hundred and eighteen (29%) patients in group B had newly developed symptomatic gallstones, 35 (16%) of whom had acute presentation; two of them showed obstructive biliary symptoms. The time of presentation was significantly different between the two groups (group A: 10.5±1.7 months; group B: 21±6.6 months; P=0.0001). The mean follow-up periods were 26±9 and 28±12 months in groups A and B, respectively. Our results showed a high incidence of symptomatic gallstone after LSG. Family history and percentage of excess weight loss were also significantly correlated with symptom development. No operative difficulties were encountered in any patients, and no conversion occurred in our study. Conclusion Symptomatic cholelithiasis can present soon after sleeve gastrectomy and may warrant surgical intervention. A significant number of preoperatively healthy patients develop gallstones, with acute presentation in some cases. Although no consensus on concomitant cholecystectomy for treating asymptomatic patients has been reached, we found this procedure mandatory for high-risk patients.

Statins Reduce the Development of Complications in Patients With Asymptomatic Gallstone Disease: A Propensity Matched Analysis

Introduction: In a time to event analysis, we previously demonstrated an association between statin use and a decreased frequency of gallstone-related complications in patients with asymptomatic gallstone disease. The aim of this study is to use propensity matching, a more robust form of analysis, to evaluate the efficacy of statins in reducing specific gallstone associated complications. Methods: Patients with asymptomatic gallstones diagnosed on CT or ultrasound reports between 1996 - 2016 were identified using a validated natural language algorithm. Patients with at least one completed prescription for statin were propensity matched (one-to-one with non-replacement) to patients not on statins based on 30 variables: demographic information, comorbidities, features of gallstones at the time of initial imaging, other medication use, and years to event or last follow up. Quality of propensity matching was assessed using t-test. Occurrence of gallstone complications of chronic cholecystitis (includes right upper quadrant pain), acute cholecystitis, gallstone pancreatitis, choledocholithiasis or cholangitis, gallbladder cancer or cholangiocarcinoma, and procedural interventions for these complications were compared in patients with and without statin use. Results: N=22,800 patients were propensity matched to 7,493 patients each in the statin and non-statin groups (Figure 1). T-test analysis yielded no significant differences between the groups based on any matched variables. As noted on Table 1, patients on statins had significantly reduced rates of any complication (No statins, 16.1% versus statin, 11.3%; P= versus 6.1%; P versus 2.5%; P=0.003), and gallstone pancreatitis (2.6% versus 1.8%; P=0.001). No significant differences were noted based on statin use for choledocholithiasis or cholangitis (2.5% versus 2.3%; P=0.368), gallbladder cancer or cholangiocarcinoma (0.5% versus 0.4%; P=0.377), surgery or percutaneous drainage for above indications (3.6% versus 3.1%; P=0.069).86_A Figure 1. One-to-one propensity matching was performed to match patients using statins to patients without statin use based on 30 variables. This figure shows propensity scores of the two matched groups along those excluded from the analysis.Conclusion: In this well-matched propensity analysis of a large cohort, statin use was associated with a 30% reduced incidence of subsequent cholecystitis (acute or chronic) and gallstone pancreatitis in patients diagnosed with asymptomatic cholelithiasis. Given the relative safety of statin medications, use of these medications may be considered in patients with asymptomatic gallstone disease at high risk for the development of symptomatic gallstone disease. A randomized control trial is needed to confirm these findings.86_B Figure 2. Differences in occurrence of gallstone complications in patients with and without statins.

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Asymptomatic gall stone disease: A clinicopathological correlation

Asymptomatic gall stone disease: A clinicopathological correlation

The Effect of Gallstone Presentation on Treatment Outcome in Symptomatic Cholelithiasis

Introduction: Gall stone disease (GSD) is a common surgical problem. Surgical treatment of asymptomatic GSD is still controversial. Complicated GSD has varied presentation and contributes substantially to healthcare costs and may be life threatening. The present study is aimed to know the effect of gall stone presentation on treatment outcome. Methodology: This is a retrospective study conducted in a tertiary health care centre. All patients who underwent cholecystectomy (open or laparoscopic) were included in the study and were grouped in uncomplicated (Group A) and complicated group (Group B), depending upon their presentation. Treatment outcome was analysed for various measures i.e. type of admission (emergency or elective), length of hospital stay, postoperative complications, type of surgery and mortality. Observations: Out of the 202 patients, 109 (53.9%) were in group A and 93 (46.1%) were in group B. Acute cholecystitis comprised 30.1% of complicated GSD, whereas gall stone pancreatitis, choledocholithiasis, mucocele, empyema gall bladder, perforation and gall stone ileus comprised 6.9%, 2.9%, 3.9%, 0.9%, 0.4% and 0.4% respectively. Comparatively, patients with uncomplicated GSD were admitted electively, were mostly managed laparoscopically and had lower incidence of post-operative complications and hence shorter length of hospital stay and lower treatment cost. Conclusion: Most of the patients who present early in course of GSD have better treatment outcome. We recommend early elective laparoscopic surgery for all patients who present with initial symptoms of GSD.

Impact of diabetes mellitus on cholecystectomy rate: A population-based follow-up study

Summary Background/Introduction Some reports suggest early cholecystectomy for diabetic patients with asymptomatic gallstone disease (GSD) to prevent subsequent serious infection. However, only a few studies have examined the incidence of cholecystectomy in response to GSD in diabetic patients. Our study attempts to elucidate the relationship between GSD and diabetes using the high coverage rate health insurance system of Taiwan and thus evaluate the validity of early cholecystectomy in diabetic patients. Purpose(s)/Aim(s) To investigate the rate of cholecystectomy in diabetic patients with GSD. Methods Diabetic patients without prior treatment for GSD on hospitalization or ambulatory visits were identified and compared with age- and sex-matched controls and were followed up for 8 years. Cholecystectomy incidence density rates were estimated according to the patients' diabetic status. Cox proportional hazards regression models were used to analyze the age- and sex-specific effects of diabetes on the risk of surgery for GSD. Results The incidence rates of patients who developed GSD and underwent cholecystectomy were 18.65% and 17.15% in the diabetic and control groups, respectively; thus, the rate of cholecystectomy was higher in the diabetic group than in the control group. Male sex and old age were associated with a high rate of cholecystectomy, irrespective of the diabetic status. Hypertension, cholangitis, and Caroli disease were associated with an increased risk of cholecystectomy in patients with GSD. Overall, diabetic patients exhibited a higher incidence of cholecystectomy than nondiabetic patients did over an 8-year follow-up period. Conclusion Men with GSD are more likely to undergo cholecystectomy than women, irrespective of the diabetic status; therefore, an aggressive GSD management approach for men must be considered for early identification of these patients before the need for emergency surgery.

Gallstone Disease

Gallstone disease (cholelithiasis), very common in the United States, afflicts around 15% of the adult population and accounts for approximately 1.8 million ambulatory visits per year. Elective laparoscopic cholecystectomy for the removal of gallstones is currently the most commonly performed abdominal operation in the United States, with around 750,000 operations per year. Although the majority of patients with asymptomatic gallstones will never develop symptoms, approximately 25% of these initially asymptomatic patients will develop biliary pain and 3% will develop complications over a 10-year follow-up period. This review discusses the pertinent pathophysiology and treatment of gallstones and their complications. It is imperative for the primary care physician, gastroenterologist, and surgeon to rapidly identify those patients at risk for complications of gallstone disease and offer the best evidence-based therapies available. It is also important for the physician to understand when and if to offer treatment for those patients with asymptomatic gallstone disease. Figures show the mixed micelle, the anatomy of gallstones, radial endoscopic sonogram of a gallstone in common bile duct (CBD), an algorithm depicting the risk of CBD stone in patients with known cholelithiasis, and endoscopic retrograde cholangiography images of a large gallstone within CBD and stone fragments in duodenum following lithotripsy and extraction. Tables list risk factors for gallstone formation, common medications associated with gallstone formation, and uncommon complications of gallstone disease. This review contains 5 highly rendered figures, 3 tables, and 53 references.

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

BackgroundThe study was designed to assess the prevalence of asymptomatic gallstone disease in North-East part of Bangladesh.Materials and methodsRandomly 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.ResultsTotal 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).ConclusionPrevalence 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 articleSaha 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.

Outcomes of Cholecystectomy in US Heart Transplant Recipients

The aim of this study was to evaluate outcomes and predictors of in-hospital mortality after cholecystectomy in heart transplant (HTx) recipients. There is a paucity of data on outcomes after cholecystectomy in HTx recipients. The Nationwide Inpatient Sample (NIS) database was used to identify HTx recipients who underwent cholecystectomy between 1998 and 2008. Multivariate logistic regression analysis was constructed using clinically relevant covariates (age, gender, Charlson comorbidity index, race, admission acuity, complicated gallstone disease, hospital teaching status, and open versus laparoscopic approach) to identify predictors of in-hospital mortality. A total of 1687 HTx recipients underwent cholecystectomy (open n = 420; laparoscopic n = 1267) during the study period. Mean age was 57.1 ± 12.5 years, and there were 1230 (72.9%) males. The majority of patients had acute cholecystitis (n = 1218; 72.2%) and were admitted urgently/emergently (n = 1028; 60.9%). Overall inpatient mortality occurred in 37 (2.2%) patients, with a higher mortality rate in open cholecystectomy compared with laparoscopic (6.2% vs. 0.9%; P = 0.009), and in urgent/emergent versus elective cases (3.6% vs. 0%; P = 0.04). Open or urgent/emergent cholecystectomies also had higher overall complication and respiratory failure rates as compared with laparoscopic or elective cases. Predictors of inpatient mortality in multivariable analysis included urgent/emergent admission, open cholecystectomy, and complicated gallstone disease (each P < 0.05). This is the largest reported study to date of cholecystectomy in HTx recipients. HTx patients appear to be at increased risk of inpatient mortality and morbidity after cholecystectomy as compared with the general population, and this rate is particularly high in those with a nonelective admission who undergo open cholecystectomy for complicated gallstone disease. Therefore, strong consideration should be given to prophylactic cholecystectomy in HTx recipients with asymptomatic and uncomplicated gallstone disease.

Asymptomatic Type I Mirizziʼs Syndrome Secondary to Busulfan Therapy

Purpose: Background: Complications from asymptomatic gallstone disease are rare. In 1948, Mirizzi described a syndrome of hepatic duct obstruction in the setting of cholelithiasis and cholecystitis, presenting with jaundice, abdominal pain, and recurrent cholangitis. Risk factors for this condition, however, have not been well-elucidated. We describe the first-reported case of possible busulfan-induced Mirizzi syndrome in an asymptomatic patient. Case Report: A 63 year old female with a history of transfusion-dependent myelodysplastic syndrome and acute myelogic leukemia presented to her hematologist's office for a routine visit where she was noted to be icteric. The patient had received one dose of busulfan at 100 mg/m2 for consolidation therapy 7 weeks prior to admission following induction with Ara-C, idarubicin, and etoposide. She did not receive cyclophosphamide. She denied any abdominal pain or fever, however she had developed light-colored stools and dark urine for the past 4 days. Physical exam was notable for hepatomegaly and scleral icterus. Laboratories revealed a total bilirubin of 3.7, direct bilirubin 3.7, alkaline phosphatase 487, AST 234, ALT 430, and a white count of 3.5. An abdominal ultrasound and CT scan showed multiple gallstones, a thickened gallbladder wall, and biliary ductal dilation. Endoscopic retrograde cholangiography was performed which demonstrated a smooth 1.8 cm long stricture in the proximal CHD with upstream dilation of the right, left, and intrahepatic ducts. The cystic duct was not opacified. A plastic biliary stent was inserted, with good drainage achieved. She subsequently underwent open cholecystectomy where a markedly enlarged gallbladder was found, packed with multiple pigmented stones of nearly identical shape and size with the exception of a 2 cm stone obstructing the gallbladder neck and cystic duct. Histopathology revealed an acutely and chronically inflamed gallbladder with fibrous tissue. Conclusion: Busulfan may be a rare cause of acute cholecystitis during induction chemotherapy. In one case series, 5 out of 35 patients had acute cholecystitis within 18 days of treatment after receiving cyclophosphamide and busulfan, and all presented with abdominal pain and fever. Our patient was unique given the absence of symptoms, and the concomitant presentation of Mirrizi syndrome. It is unclear if the stones are due to crystallized drug or due to recurrent hemolysis. Acute cholecystitis and its complications should be considered in patients undergoing induction chemotherapy with busulfan.

Gallbladder function and dynamics of bile flow in asymptomatic gallstone disease

To investigate the effects of gallbladder stones on motor functions of the gallbladder and the dynamics of bile flow in asymptomatic gallstone disease. Quantitative hepatobiliary scintigraphy was performed to detect the parameters of gallbladder motor function [gallbladder ejection fraction (GBEF), gallbladder visualization time (GBVT), gallbladder time to peak activity (GBT(max)), gallbladder half emptying time (GBT(1/2)), and transit time of bile to duodenum (TTBD)] in 24 patients with asymptomatic cholelithiasis who were diagnosed incidentally during routine abdominal ultrasonographic examination and 20 healthy subjects with normal gallbladder. Even though there was no significant difference in the clinical and laboratory parameters between the patient and control groups, all parameters of gallbladder function except TTBD were found to differ significantly between the two groups. GBEF in the patient group was decreased (P = 0.000) and GBVT, GBT(max), GBT(1/2) in the patient group were longer (P = 0.000, P = 0.015, P = 0.001, respectively). Our results showed that even if there were not any clinical and laboratory findings, gallbladder filling and emptying could be impaired in patients with gallstone disease.

Asymptomatic Cholelithiasis: Is Cholecystectomy Really Needed? A Critical Reappraisal 15 Years After the Introduction of Laparoscopic Cholecystectomy

Asymptomatic cholelithiasis is increasingly diagnosed today, mainly as a result of the widespread use of abdominal ultrasonography for the evaluation of patients for unrelated or vague abdominal complaints. About 10-20% of people in most western countries have gallstones, and among them 50-70% are asymptomatic at the time of diagnosis. Asymptomatic gallstone disease has a benign natural course; the progression of asymptomatic to symptomatic disease is relatively low, ranging from 10-25%. The majority of patients rarely develop gallstone-related complications without first having at least one episode of biliary pain ("colic"). In the prelaparoscopy era, (open) cholecystectomy was generally performed for symptomatic disease. The minimally invasive laparoscopic cholecystectomy refueled the discussion about the optimal management of asymptomatic cholelithiasis. Despite some controversy, most authors agree that the vast majority of subjects should be managed by observation alone (expectant management). Selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications. Concomitant cholecystectomy is a reasonable option for good-risk patients with asymptomatic cholelithiasis undergoing abdominal surgery for unrelated conditions. Routine cholecystectomy for all subjects with silent gallstones is a too aggressive management option, not indicated for most subjects with asymptomatic cholelithiasis. An in-depth knowledge of the natural history of gallstone disease is required to select the optimal management option for the individual subject with silent gallstones. Management options should be extensively discussed with the patient; he or she should be actively involved in the process of therapeutic decision making.

Apical sodium bile acid transporter and ileal lipid binding protein in gallstone carriers

Although a cholesterol supersaturation of gallbladder bile has been identified as the underlying pathophysiologic defect, the molecular pathomechanism of gallstone formation in humans remains poorly understood. A deficiency of the apical sodium bile acid transporter (ASBT) and ileal lipid binding protein (ILBP) in the small intestine may result in bile acid loss into the colon and might promote gallstone formation by reducing the bile acid pool and increasing the amount of hydrophobic bile salts. To test this hypothesis, protein levels and mRNA expression of ASBT and ILBP were assessed in ileal mucosa biopsies of female gallstone carriers and controls. Neither ASBT nor ILBP levels differed significantly between gallstone carriers and controls. However, when study participants were subgrouped by body weight, ASBT and ILBP protein were 48% and 67% lower in normal weight gallstone carriers than in controls (P < 0.05); similar differences were found for mRNA expression levels. The loss of bile transporters in female normal weight gallstone carriers was coupled with a reduction of protein levels of hepatic nuclear factor 1alpha and farnesoid X receptor. In conclusion, in normal weight female gallstone carriers, the decreased expression of ileal bile acid transporters may form a molecular basis for gallstone formation.