Gallstone Formation Research Articles

Predictive factors of biliary complications after laparoscopic sleeve gastrectomies and laparoscopic Roux-en-Y gastric bypass surgeries

BackgroundPrevious studies have confirmed the association between biliary disease and bariatric operations. Biliary complications may include cholecystitis, biliary pancreatitis, cholangitis, biliary polyps, biliary sludge and gallstones. It is believed that cholelithiasis is the result of increased biliary stasis due to alterations in the enterohepatic circulation and hormonal changes associated with weight loss. However, research regarding predictive factors other than the percentage of excess weight loss (EWL) is limited. In addition, preventive measures of gallstone formation and potential related complications are still debated. AimThe goal of this article is to assess the predictive factors of biliary complications after laparoscopic sleeve gastrectomies (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in order to review the possible need for future surveillance via radiological studies. Methodology: A retrospective review of 118 patients who underwent LSG and LRYGB between 2015 and 2016 in Jordan University Hospital (single centre) was performed in order to complete this cohort study. Patients with previous cholecystectomies or biliary disease prior to bariatric operations were excluded from the study. Utilizing the hospital's electronic records system, patients were contacted by telephone and were asked a series of questions listed in a custom-made questionnaire. ResultsMean age ± SD was 34.9 ± 12.0 years old (68.64% Females). Eleven patients (9.32%) underwent LRYGB, 100 patients underwent LSG and seven patients underwent both, with a preoperative mean body mass index (BMI) ± SD of 45.2 ± 6.3. 29 patients (24.58%) developed postoperative biliary complications. The main biliary complications were as follows: biliary pancreatitis (0.85%), biliary polyps (0.85%), biliary sludge (0.85%), cholecystitis/gallstones (22.03%). ConclusionIn conclusion, it was found that approximately 24.58% of patients have post-operative late biliary complications. Of these patients, predictive factors other than EWL were not significant enough to recommend prophylactic screening via radiological studies.

Cholesterol crystals activate NLRP3 inflammasomes and promote gallstone formation by increasing mucin secretion

ABSTRACT Cholesterol crystals participate in cholesterol nucleation; however, the role of cholesterol crystals in gallstone development is unknown. Mucin secretion contributes to increased size of gallstones. Cholesterol crystals activate inflammasomes and participate in many sterile inflammation related human diseases. We investigated the role of cholesterol crystals and mucins in sterile inflammation and gallstone enlargement. We found that expression of mucin 5AC (MUC5AC), NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) and interleukin-1b (IL-1b) was increased significantly in tissues adjacent to gallstones. Experiments in vitro showed that cholesterol crystals promote MUC5AC secretion; they also increase expression of NLRP3, NLR family CARD domain-containing 4 (NLRC4), apoptosis-associated speck-like protein containing caspase recruitment domain (ASC), and cleaved caspase-1 in biliary epithelial cells. Inhibition of Inflammasomes by NLRP3, ASC or caspase-1 small interfering RNAs reduced MUC5AC secretion. Also, the IL-1 receptor antagonist, IL1RA, and caspase-1 inhibitor, Ac-YVAD, both inhibited MUC5AC secretion induced by cholesterol crystals. We found that inflammasome activation participates in cholesterol crystal induced mucin secretion and gallstone development.

Correlation between Gallstones and Hypothyroidism: Our Experiance

Background: Among biliary pathology, Gallbladder Stones are the most common. There are well established risk factors associated with formation of Gallstone. Since Biliary motility is affected by thyroid hormone, Patients with hypothyroidism will have Gallbladder Hypokinesia and deranged lipid metabolism leading to formation of Gallstones. Aims & Objectives: The aim of this study is to find out the hypothyroidism is a risk factor in formation of specific type of Gall stone. Methods: A total of 50 patients with gallstone disease were included in the study. Thyroid function tests were performed in all of them. And divided in to two group, Group-A 25 Euthyroid patients and Group-B 25 Hypothyroid patients and morphological type of gallstones assessed post operatively (Pigment or Cholesterol stones). Results: Of the 50 patients included in the study, Group A patient had 18 Pigment stones and 7 Cholesterol stones in Gallbladder and Group B patient had 15 Pigment stones and 10 Cholesterol stones in Gallbladder. On Statistical analysis, the p-value is 22067. The result is not significant at p<.05. Conclusion: Gallstones are more common in patient with hypothyroidism compared to general population but hypothyroidism does not promote any specific type of stone formation. Which suggest that Hypothyroidism is not the individual risk factor for gallstone formation.

Association Study of SLCO1B3 and ABCC3 Genetic Variants in Gallstone Disease.

There is growing evidence that gallstone formation may be genetically determined. Recent studies have shown that polymorphism of genes encoding proteins involved in bile acid transport may be associated with the risk of gallstone disease. The aim of this study was to investigate the association between SLCO1B3 (rs4149117:G>T, rs7311358:A>G) and ABCC3 (rs4793665:T>C, rs11568591:G>A) genetic variants and susceptibility to cholesterol gallstone disease, as well as gallstone composition. The study included 317 patients suffering from cholelithiasis who underwent cholecystostomy and 249 controls with no evidence of stones, confirmed by ultrasound examination. There were no statistically significant differences in the distribution of studied gene polymorphisms between patients with gallstone disease and healthy controls. No significant associations were observed between studied genotypes and the content of analyzed gallstone components: total cholesterol, bilirubin, CaCO3, nor the total bile acids. There was also no association between bile acid content in gallstones and the polymorphisms studied. The results of this study suggest that polymorphisms of SLCO1B3 and ABCC3 genes are not a valuable marker of gallstone disease susceptibility and do not influence gallstone composition.

Dealkenylation of neoandrographolide, a phytochemical from Andrographis paniculata stimulates FXR (Farnesoid X Receptor) and enhances gallstone dissolution

FXR (Farnesoid X Receptor) is one of the nuclear receptors expressed in the liver performing a significant role in the maintenance of bile acid concentration. An imbalance of cholesterol and bile acid ratio due to any undefined reason could cause gallstone formation. Hence, this paper aims to screen phytochemicals that could maintain a requisite balance of cholesterol and bile acid by targeting FXR and thereby contributing to the dissolution of gallstone. Nineteen phytochemicals were selected and queried for Pa and Pi in the way2drug online server for hepatoprotective property, cholesterol synthesis and absorption inhibition property, and β-glucuronidase inhibiting activity. Cianidanol, neoandrographolide, cynarine, saponins, and tanins with satisfying stated properties were docked with the screened FXR (PDB ID- 1OSH) using HADDOCK server, followed by pharmacokinetics study utilizing SwissADME tool. Neoandrographolide fits best among the other selected literature-based phytochemicals with minor violation of ‘Brenk’s rule’. The violation was corrected with the removal of an alkene group in the provided ChemDraw space of SwissADME. This Dealkenylated compound was further docked with FXR. The promising response under the static condition of the Dealkenylated compound was analyzed for molecular dynamic simulation at physiological conditions for 100 ns. Dealkenylated Neoandrographolide (DN) exhibited hepatoprotective, cholesterol synthesis and absorption inhibition property, and β-glucuronidase inhibition activity with a superior binding score of −42.6+/-1.5 with FXR. The interaction of the FXR receptor and the DN showed exceptional stability at physiological conditions during MD simulation and fit for the ADME properties, therefore it could be a potent candidate to dissolve gallstones. Communicated by Ramaswamy H. Sarma.

Probiotics for gallstone prevention in patients with bariatric surgery: A prospective randomized trial

Gall stone disease was known to increase after bariatric surgery. Ursodeoxycholic acid (UDCA) might reduce the gallstone formation rate after bariatric surgery. However, other option for gallstone prevention was unclear. We reported the result of a randomized trial comparing the gallstone prevention efficacy of probiotics and digestive enzyme versus UDCA. This prospective, randomized trial was held in an institute of Taiwan. Patients were eligible for inclusion if their body-mass index (BMI) was 32.5kg/m2 or higher with the presence of comorbidity, or 27.5kg/mw or higher with not-well controlled type 2 diabetes, and were aged 18-65 years. Participant were randomized assigned (1:1:1) to probiotic, digestive enzyme or UDCA. The primary endpoint was assessed in the incidence of gallstone disease at 6 months after surgery. This study is registered with ClinicalTrials.gov. number NCT03247101, and is now completed. From January 2016 to December 2018, of 186 patients screened for eligibility, 152 were randomly assigned to probiotic (52) or digestive enzyme (52) or UDCA (52). In the per-protocol population, mean age was 35.9 years (SD 10.6), mean BMI was 40.3kg/m2 (SD 6.9), 57(58.2%) were female. After 6 months, the incidence of gall bladder diseased was 15.2%, in the probiotics group, 17.6% in UDCA group and 29.1% in digestive enzyme groups, confirming non-inferiority of probiotic (p=0.38). Female gender was identified as a risk factor for gall bladder disease after bariatric surgery (odds ratio=4.61, 95% confidence interval=1.05, 20.3, p=0.04). The poor drug compliance rate was 19.5%, 22.7% and 26.2% in probiotics, UDCA and digestive enzyme group respectively. UDCA group had a higher drug adverse effect than probiotic group (15.9% vs. 2.4%, p=0.03). Probiotic is not inferior to UDCA regarding gall bladder disease prevention after bariatric surgery at 6 months.

Common variant p.D19H of the hepatobiliary sterol transporter ABCG8 increases the risk of gallstones in children

Gallstones are increasingly common in children. Genetic analyses of adult cohorts demonstrated that the sterol transporter ABCG8 p.D19H and Gilbert UGT1A1*28 variants enhance the odds of developing gallstones. The genetic background of common lithiasis in children remains unknown. Overall, 214 children with gallstone disease (1month-17years, 107 boys) were inclueded. The control cohorts comprised 214 children (age 6-17years, 115 boys) and 172 adults (age 40-92years, 70 men) without gallstones. The ABCG8 p.D19H and UGT1A1*28 polymorphisms as well as ABCB4 (c.504C>T rs1202283, c.711A>T rs2109505) and NPC1L1 variants (p.V1296V rs217434, c.-18C>A rs41279633) were genotyped using TaqMan assays. Serum concentrations of plant sterols and cholesterol precursors were measured by gas chromatography/mass spectrometry. The ABCG8 risk allele was associated with an increased risk of stones (OR=1.82, p=.03). Children carrying the p.19H allele presented with lower serum concentrations of surrogate markers of intestinal cholesterol absorption and decreased ratios of phytosterols to the cholesterol precursor desmosterol. Carriers of the common NPC1L1 rs217434 allele had an increased gallstone risk compared with stone-free adults (OR 1.90, p<.01). This variant also affected the ratio of phytosterols to cholesterol precursors (p=.03). Other tested variants were not associated with gallstone risk. The p.D19H ABCG8 and, to a lesser extent, NPC1L1 rs217434 variants increase the risk of early-onset gallstone formation. These results point to the presence of a common lithogenic pathway in children and adults.

Risk Factors for Symptomatic Gallstone Disease and Gallstone Formation After Bariatric Surgery

PurposePatients who undergo bariatric surgery are at risk for developing cholesterol gallstones. We aimed to identify risk factors that are associated with symptomatic gallstone disease and gallstone formation after bariatric surgery.Materials and MethodsWe included participants of the UPGRADE trial, a multicenter randomized placebo-controlled trial on the prevention of symptomatic gallstone disease with ursodeoxycholic acid (UDCA) after bariatric surgery. The association between patient characteristics and symptomatic gallstone disease, and gallstone formation was evaluated using logistic regression analysis.ResultsOf 959 patients, 78 (8%) developed symptomatic gallstone disease within 24 months. Risk factors were the presence of a pain syndrome (OR 2.07; 95% CI 1.03 to 4.17) and asymptomatic gallstones before surgery (OR 3.15; 95% CI 1.87 to 5.33). Advanced age (OR 0.95; 95% CI 0.93 to 0.97) was protective, and UDCA prophylaxis did not reach statistical significance (OR 0.64; 95% CI 0.39 to 1.03). No risk factors were identified for gallstone formation, whereas advanced age (OR 0.98; 95% CI 0.96 to 1.00), statin use (OR 0.42; 95% CI 0.20 to 0.90), and UDCA prophylaxis (OR 0.47; 95% CI 0.30 to 0.73) all reduced the risk.ConclusionYoung patients with a preoperative pain syndrome and/or asymptomatic gallstones before bariatric surgery are at increased risk for symptomatic gallstone disease after surgery. Whether statins, either alone or in combination with UDCA prophylaxis, can further reduce the burden of gallstones after bariatric surgery should be investigated prospectively.Graphical abstract

Transintestinal cholesterol excretion in health and disease

The transintestinal cholesterol efflux (TICE) pathway is the second described route for plasma cholesterol fecal elimination. This article summarizes recent TICE research progresses, involving TICE inducers, molecular determinants of this pathway, and its role in lipoprotein metabolism. TICE is an active pathway in mice, rats, and humans. Kinetic measurements showed that under basal conditions, the relative contribution of TICE in fecal elimination of plasma cholesterol is quantitatively less important than the hepatobiliary pathway. However, the amplitude of TICE can be induced by numerous nutritional factors and pharmacological drugs. More importantly, by contrast with the stimulation of biliary cholesterol excretion that is associated with an increased risk of gallstone formation, TICE appears as a safer therapeutical target. Finally, several independent studies have demonstrated that TICE is actively contributing to the anti-atherogenic reverse cholesterol pathway reinforcing the interest to better understand its mode of action. The discovery of TICE and the understanding of its mode of action open new therapeutical perspectives for patients at high risk of cardiovascular diseases.

Management of gallstone disease prior to and after metabolic surgery: a single-center observational study.

Rapid weight loss after bariatric surgery is a risk factor for gallstone formation. There are different strategies regarding its management in bariatric patients, including prophylactic cholecystectomy (CCE) in all patients, concomitant CCE only in symptomatic patients, or concomitant CCE in all patients with known gallstones. We present the safety and long-term results of the last concept. Retrospective single-center analysis of a prospective database on perioperative and long-term results of patients with laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) over a 15-year period. The minimal follow-up was 24 months. Concomitant CCE was intended for all patients with gallstones detected by preoperative sonography. Academic teaching hospital in Switzerland. After exclusion of patients with a history of CCE (11.5%), a total of 1174 patients (69.6% LRYGB, 30.4% LSG) were included in the final analysis. Preoperative gallbladder pathology was detected in 21.2% of patients, of whom 98.4%, or 20.9% of the total patients, received a concomitant CCE. The additional procedure prolonged the average operation time by 38 minutes (not significant) and did not increase the complication rate compared with bariatric procedure without CCE (3.7% versus 5.7%, P = .26). No complication was directly linked to the CCE. Postoperative symptomatic gallbladder disease was observed in 9.3% of patients (LRYGB 7.0% versus LSG 2.3%, P = .15), with 19.8% of those patients initially presenting with a complication. The concept of concomitant CCE in primary bariatric patients with gallstones was feasible and safe. Nevertheless, 9.3% of primary gallstone-free patients developed postoperative symptomatic gallbladder disease and required subsequent CCE despite routine ursodeoxycholic acid prophylaxis.

Microstructural and Geochemical Characterization of Gallstones: Implication for Biomineralization.

Stone formation in the gallbladder is one of the growing health issues reported throughout the world. However, studies on the characteristics of gallstone in the Sri Lankan community are very limited. Detail investigation of gallstone is important for identifying the causative factors and understanding the formation process. The present study aimed to investigate the compositional and microstructural characteristics of gallstone in Sri Lankan patients. Twenty-three patients who were admitted for cholecystectomies were selected for the study. The socio-demographic information was collected from patients using a structured questionnaire. Stones that were removed from surgeries were analyzed by their microstructural and compositional features using Fourier Transformed Infra-Red Spectrometer (FT-IR) and Inductively Coupled Plasma Mass spectroscopy (ICP-MS), Scanning Electron Microscope (SEM), and polarizing microscope. 44% of stones were the mixed type that comprised mainly cholesterol and bilirubinate and followed by pigment type (30%) that mainly contained bilirubinate. The pure cholesterol stones which comprise only cholesterol are the least abundant type of stones. Calcium is the major element found in stones followed by Cu, Mn, Fe, Mg, Zn, and Ni. Higher content of these elements was found in pigment stones compared to the other types. The core and crust regions of stones were enriched with Ca compared to the middle part. Concentric layers that comprise alternating dark and light color bands were observed in the crust, reflecting the compositional variation in bile during the formation of gallstones. The electron microscope images confirmed lightly stacked cholesterol with plate- and needle-like crystals and irregularly arranged clumps of bilirubinate. The Ca-rich core of gallstone confirmed that the Ca-salt precipitation possibly provided a nucleus for the stone formation.

THE EFFECT OF USE OF DIFFERENT DOSES OF URSODEOXYCOLIC ACID ON GALLSTONE FORMATION AFTER SLEEVE GASTRECTOMY

Objective: To evaluate the effects of using different doses of ursodeoxycholic acid (UDCA) for six months in prevention of gallstones after Laparoscopic Sleeve Gastrectomy (LSG) on the formation of gallstones in the 6th and 12th months. Materials and Methods: The data of patients who underwent LSG for morbid obesity were analyzed. Three groups of 20 people were formed. These were the control group, Group I who were treated with UCDA 500 mg/day for six months after LSG, and Group II who were treated with UCDA 1000 mg/day for 6 months after LSG. Demographic characteristics, co-morbid diseases, cholesterol and triglyceride differences before and after surgery, excess weight loss (EWL%), total weight loss (TWL%), body mass index (BMI), and abdominal ultrasound (US) data for the occurrence of cholelithiasis (CL) preoperatively and at six and 12 months after surgery were collected. Results: The results of tests taken on these patients in the sixth month revealed that the stone detection rate in the US results of the control group was significantly higher than that in Group II (p=0.001; p&lt;0.01). There was no statistically significant difference between the control group and Group I (p=0.149), and between Group I and Group II (p=0.066). The results of tests taken in the 12th month showed that the stone detection rate in the US results of the control group was significantly higher than Group I and Group II (p=0.010; p&lt;0.05). There was no statistically significant difference between Group I and Group II. Conclusion: As a result of this study, we recommend that patients be given 1000 mg/day UDCA after LSG.

Ursodeoxycholic acid for the prevention of gall stones after laparoscopic sleeve gastrectomy: a prospective controlled study.

Obesity is a risk factor for cholelithiasis. Besides, rapid weight loss after bariatric surgery upsurges the rate of cholelithiasis and acute cholecystitis. This study aimed to compare gallstone development frequency after LSG under ursodeoxycholic acid (UDCA) prophylaxis. This prospective controlled study included 332 patients scheduled for LSG randomized to receive 500mg UDCA daily for 12months (UDCA Group) or no treatment (Control Group). Ultrasonography was done 6 and 12months after surgery to detect gallstones. Cholecystectomy was done for complicated cases of cholelithiasis. Seventy-one patients were lost to follow-up, and 3 developed severe adverse effects of UDCA and excluded. Data are presented for 130 patients in the UDCA group and 128 in the Control group. Collectively, 11 patients (8.5%) of the UDCA group and 41 (32.0%) of the Control group developed gall stones during the first postoperative year (p < 0.001). Cholecystectomy was indicated in 3 patients (2.3%) of the UDCA group and 9 (7.0%) of the Control group (p = 0.072). On multivariate analysis, higher BMI, dyslipidemia, and lacking UDCA prophylaxis were the independent factors significantly associated with stone development. Also, stone development was associated with higher weight loss after 6 and 12months. UDCA 500mg once daily for 12months after LSG is effective in reducing gallstone formation at 1 year. UDCA administration reduced the frequency of cholecystectomies from 7 to 2.3%. High BMI and dyslipidemia are the independent preoperative factors significantly associated with stone development.

Gut microbiota promotes cholesterol gallstone formation by modulating bile acid composition and biliary cholesterol secretion

Cholesterol gallstone disease is a worldwide common disease. Cholesterol supersaturation in gallbladder bile is the prerequisite for its pathogenesis, while the mechanism is not completely understood. In this study, we find enrichment of gut microbiota (especially Desulfovibrionales) in patients with gallstone disease. Fecal transplantation of gut microbiota from gallstone patients to gallstone-resistant strain of mice can induce gallstone formation. Carrying Desulfovibrionales is associated with enhanced cecal secondary bile acids production and increase of bile acid hydrophobicity facilitating intestinal cholesterol absorption. Meanwhile, the metabolic product of Desulfovibrionales, H2S increase and is shown to induce hepatic FXR and inhibit CYP7A1 expression. Mice carrying Desulfovibrionales present induction of hepatic expression of cholesterol transporters Abcg5/g8 to promote biliary secretion of cholesterol as well. Our study demonstrates the role of gut microbiota, Desulfovibrionales, as an environmental regulator contributing to gallstone formation through its influence on bile acid and cholesterol metabolism.

Important risk factors for gallstones after laparoscopic gastrectomy: a retrospective study

BackgroundThe frequency of gallstones is higher in patients who have undergone gastrectomy than in the general population. While there have been some studies of gallstone formation after open gastrectomy, there are few reports of gallstones after laparoscopic gastrectomy (LG). Therefore, this study aimed to evaluate the incidence of gallstones after LG.MethodsWe retrospectively reviewed the records of 184 patients who underwent LG between January 2011 and May 2016 at Saiseikai Utsunomiya Hospital. After gastrectomy, abdominal ultrasonography was generally performed every 6 months for 5 years. Patients who underwent cholecystectomy before LG, underwent simultaneous cholecystectomy, and did not undergo abdominal ultrasonography, with an observation period of < 24 months, were excluded from the study. Finally, 90 patients were analyzed. Laparoscopic cholecystectomy was performed whenever biliary complications occurred. Patient characteristics were compared using the two-tailed Fisher’s exact test or Chi-square test. In addition, the risk factors for postoperative gallstones were analyzed using logistic regression analysis.ResultsAmong the 90 patients included in this study, 60 were men (78%), and the mean age was 65.5 years. Laparoscopic total gastrectomy was performed for 15 patients and laparoscopic distal gastrectomy for 75 patients. D2 lymph node dissection was performed for 8 patients (9%), whereas 68 patients underwent LG with Roux-en-Y reconstruction (76%). Gallstones were detected after LG in 27 of the 90 (30%) patients. Multivariate analysis identified Roux-en-Y reconstruction and male sex as significant risk factors of gallstones after gastrectomy. The incidence of gallstones was significantly higher (53%) in male patients who underwent Roux-en-Y reconstruction. Symptomatic gallstones after laparoscopic cholecystectomy were found in 6 cases (6/27, 22%), and all patients underwent laparoscopic cholecystectomy.ConclusionRoux-en-Y reconstruction and male sex were identified as significant risk factors for gallstones after LG.

Intraoperative Findings of Elective Laparoscopic Cholecystectomy in Diabetics Versus Nondiabetics: A Comparative Study.

ObjectivesDiabetes mellitus predisposes to the formation of gallstones. Surgery for gallstone disease (GSD) in diabetic patients also carries more risk compared with nondiabetic patients. The objective of the present study was to evaluate the intraoperative findings of elective laparoscopic cholecystectomy in diabetics and nondiabetics.MethodsThis study was carried out for two years in the department of general surgery as a prospective observational study. Two groups of patients with uncomplicated gallstone disease were recruited: one group included 75 diabetics and the other one included 75 nondiabetics. The two study groups were matched by age and gender. Detailed history and intraoperative findings and their outcomes were recorded. Patients with emergencylaparoscopiccholecystectomy for acute cholecystitis and its complications and cholecystectomy associated with common bile duct (CBD) stones were excluded from the study.ResultsThe results of elective laparoscopic cholecystectomy in the groups were compared. No demographic differences were found between the groups. Adverse intraoperative findings such as thick-walled gallbladder (GB), pericholecystic collections, and adhesions to the surrounding structures, surgical difficulties, modification to subtotal cholecystectomy, and open conversion were more frequent in diabetic patients than in nondiabetic patients.ConclusionLaparoscopic cholecystectomy in diabetic patients had more adverse intraoperative findings in comparison to nondiabetic patients. However, in elective laparoscopic cholecystectomy, good preoperative preparation and meticulous surgical technique are mandatory to achieve similar outcomes between the groups.

The impact of ursodeoxycholic acid on gallstone disease after bariatric surgery: a meta-analysis of randomized control trials.

Ursodeoxycholic acid (UDCA) is a bile acid that has been shown to reduce the formation of gallstones after significant weight loss. This study aimed to evaluate the impact of UDCA on the incidence of gallstones after bariatric surgery. An electronic search of PubMed (Medline), Cochrane Central Register of Controlled Studies (CENTRAL), Scopus (Elsevier) databases, EMBASE, CINAHL, Clinicaltrials.gov, and Web of Science. A meta-analysis of randomized control trials was performed. The primary outcome was the incidence of gallstones after bariatric surgery. Secondary outcomes included type of operation and time interval to and characteristics associated with gallstone formation. Ten randomized control trials including 2583 patients were included, 1772 patients (68.6%) receiving UDCA and 811 (31.4%) receiving placebo. There was a significant reduction in gallstone formation in patients who received UDCA postoperatively (risk ratio [RR] .36, 95% confidence interval [CI] .22-.41, P < .00001). The overall prevalence of gallstone formation was 24.7% in the control group compared to 7.3% in the UDCA group. A dose of ≤600 mg/day had a significantly reduced risk of gallstone formation compared to the placebo group (risk ratio .35; 95% CI .24-.53; P < .001). The risk reduction was not significant for the higher dose (>600 mg/day) group (risk ratio .30; 95% CI, .09-1.01, P = .05). UDCA significantly reduces the risk of both asymptomatic and symptomatic gallstones after bariatric surgery. A dose of 600 mg/day is associated with improved compliance and better outcomes regardless of type of surgery. UDCA should be considered part of a standard postoperative care bundle after bariatric surgery.

Prevention of Gallstones After Bariatric Surgery using Ursodeoxycholic Acid: A Narrative Review of Literatures.

Obesity by itself is a factor in the development of gallstone disease, and periods of weight loss after bariatric surgery further increase the risk of gallstone formation. In patients with obesity, hypersecretion of cholesterol may increase the risk of gallstone formation, which is approximately five-fold higher than that in the general population. The incidence of gallstone formation after bariatric surgery is 10-38% and often associated with a proportional increase in the risk of developing biliary complications. Routine postoperative administration of ursodeoxycholic acid (UDCA) is recommended to prevent gallstone formation. Several randomized trials have indicated that UDCA can effectively prevent gallstones and reduce the risk of cholecystectomy after bariatric procedures. The effective daily dose of UDCA in each study ranged from 500 to 1,200 mg, and it may be considered at least during the period of rapid weight loss (first 3-6 months postoperatively) to decrease the incidence of symptomatic gallstones.

Clinical Presentation and Management of Cholelithiasis: A Hospital based study.

Introduction: In the recent years, cholelithiasis has become one of the major cause of increased abdominal morbidity and mortality through the world. The impaired metabolism of cholesterol, bilirubin and bile acids, leads to formation of gallstones in the hepatic bile duct, common bile duct, or gallbladder. Objectives: The study was conducted to analyze the clinical presentation, incidence and variations of presentation among the various age/sex groups and the various mode of management of Cholelithiasis. Results: The present study Included 65 patients with cholelithiasis, out of which 41 were females and 24 were males. The mean age group of patients was 45years and incidence rate was more common in female patients with mean age of 45.3years. It is also observed that mixed stones 36 (55%) were commonly seen compared to pigment stones 21(32%) and cholesterol stones08(12%). Significant association was seen with patients who are on mixed diet(N=39). Upper abdominal pain was the primary presentation seen in all patients, associated with dyspepsia, nausea, vomiting and fever in few patients. As laparoscopic cholecystectomy is considered as gold standard technique, 83% of patients underwent same surgery with minimal postoperative complications compared to open cholecystectomy. Conclusion: Laparoscopic cholecystectomy reduces the number of hospital days and was associated with lesser postoperative morbidity. Further studies are required in larger population to find out the prevalence rate as well as mode of management in patients with cholelithiasis. Key Words: Cholelithiasis, Laparoscopic Cholecystectomy, Mixed Stones

Study of association of H. pylori infection of the gall bladder and calculous cholecystitis

Background: Helicobacter pylori infection of the gallbladder has been shown to increase the precipitation of cholesterol to form stones. Also it has been shown that urease induced calcium precipitation by Helicobacter species may initiate gallstone formation. This has raised a question about the possible role of Helicobacter species in the aetiology of gallbladder diseases especially cholelithiasis. Owing to conflicting results on the topic in the studies presently available and more so, only a few studies being reported in Northern India regarding this aspect and additionally having discordant findings. Our study was conceptualized in the Southern India scenario. Methods: During 18 months study period those diagnosed with calculous cholecystitis with USG, patients underwent Laparoscopic Cholecystectomy, the gall bladder specimen sent for histopathological examination for the presence of H. pylori and the mucosal changes associated with infection of the gallbladder with Helicobacter pylori. Results: No statistical significance was seen between H. pylori and gender. Among those having H. pylori majority were females. (p=0.23). No statistical significance was seen between H. pylori and type of stone. Among those having H. pylori majority were pigmented type. (p=0.67) High statistical significance was seen between H. pylori and Inflammatory mononuclear infiltrate. P