EFFECT OF LEPTIN ON THE GALLBLADDER IN PATIENTS WITH METABOLIC SYNDROME.

The study involved 58 patients with chronic noncalculous cholecystitis (CNC) divided into two groups. Group I included 30 CNC patients with metabolic syndrome (MS), group II 28 CNC patients without MS. The control group consisted of 2O healthy people. MS was diagnosed according to Internationial Diabetes Federation guidelines (2005). The following anthroponetric parameters were determined: body mass index (BMI), waist to hip ratio, blood lipid profile (total cholesterol, triglycerides, high density lipoproteins (HDL), and low density lipoproteins (LDL)). Leptin and insulin levels were measured using com- mercial ELISA kits <> and <> (DRG International, Inc., USA) respectively Insulin resistance in- dex HOMA -JR (Homeostasis Model Assessment of Insulin Resistance) was calculated. It was shown that leptin level in CNC patients with MS was 2.61 times that in healthy subjects (p <0.001) and 2.47 times higher than in CNC patients without MS (p <0.001). Signficant direct correlations between leptin blood levels and BMI, HOMA-IR index, triglycerides, and cholesterol were documented The relationships between blood levels of leptin and the thickness of the gallbladder (GB) wall, the amount of cholesterol crystals in bile, and decreased bile release rate from GB which suggests effect of leptin on the structural and finctional changes in GB.

[Gastroesophageal reflux disease associated with duodenogastroesophageal reflux in patients with biliary pathology: the specific features of the course and esophagogastroduodenal microbial biocenosis].

AIM: To study the specific features of the clinical course of gastroesophageal reflux disease (GERD) associated with duodenogastroesophageal reflux (DGER) in patients with chronic acalculous cholecystitis (CAC) and cholelithiasis (CL), as well as qualitative and quantitative characteristics. SUBJECTS AND METHODS: The clinical, morphological, motor tonic characteristics of the esophagogastroduodenal area, mucosal microbial biocenosis in the esophagus, stomach, and duodenum were studied in detail in 83 patients with GERD that was associated with DGER and ran concurrently with CAC or CL. RESULTS: Impaired duodenal propulsive activity as a concomitance of the signs of gastrostasis and duodenal dyskinesia with dyscoordination of both anthroduodenal and duodenojejunal propulsion and with the development of duodenogastric reflux and DGER, which in turn determine esophageal and gastric pH values is shown to be of importance in CAC and CL, which match GERD. Abnormal microbiocenosis in the upper digestive tract is characterized by the higher quantitative and qualitative content of the mucous microflora. Opportunistic microorganisms exhibit cytotoxic, hemolytic, lecithinase, caseinolytic, urease, and RNAase activities. CONCLUSION: The found specific features of the course of GERD associated with DGER in patients with biliary tract abnormalities lead us to search for novel therapeutic approaches based on the correction of digestive motor tonic disorders and abnormal microbiocenoses of the mucous flora in the esophagus, stomach, and duodenum.

[The chronobiological peculiarities of the hepatobiliary system function in chronic cholecystitis with dysfunction of the gallbladder].

Study of biological cycles in chronic cholecystitis with dysfunction of gallbladder has a great practical importance. The results of chronoanalysis testify a dominance of 24-hours cycle in structure of cycles of functional activity of organs of hepatobiliary system. The comparative analysis of trust intervals reveals the intensification of internal connections, expressed intensification of synchronization of cycles of functional activity of system and a breach of synchronism of central regulation and self-regulation, testifying overstrain of proper adaptive possibilities and unconcordance in system of regulation. This manifestations of desynchronization provokes development and progress of dysfunction of gallbladder and dysbalance of vegetative nervous system, that make worse the present disturbances.

[Assessment of the effectiveness of laser reflexotherapy in combined treatment of patients with chronic acalculous cholecystitis].

AIM: To study effects of laserpuncture in combined treatment of chronic non-calculous cholecystitis on motor function gallbladder, clinical symptoms. MATERIALS AND METHODS: 73 patients of chronic non-calculous cholecystitis were divided in to groups: 35 patients were received treated only by the means of standard therapy (the control group), 38 patients were received a course laserpuncture as part of complex treatment (the study group). RESULTS: Influence laser radiation on acupuncture points was found to induce positive therapeutic effect, such as: decrease the durations of clinical symptoms, correction of motor function gallbladder. CONCLUSION: Laserpuncture is an effective method of non-calculous cholecystitis treatment and can be included in relevant combined schemes.

[The effectiveness of sulfate magnesium-calcium mineral water for the treatment of the patients presenting with chronic acalculous cholecystitis].

This paper was designed to report the results of investigations into the therapeutic effectiveness of "Kluchi" sulfate magnesiumcalcium mineral water used to treat 194 patients presenting with chronic acalculous cholecystitis and different types of biliary tract dysfunction. The control group was comprised of 92 patients who took a diet. It was shown, that mineral water "Kluchi" exerted well apparent beneficial action on the motor function of the gallbladder and the sphincter apparatus. Moreover, drinking the mineral water improved colloidal stability of bile. It is concluded that the therapeutic application of "Kluchi" sulfate magnesium-calcium mineral water results in the reduction of bile lihogenicity, produces anti-inflammatory and choleretic effects, and promotes normalization of the motor and tonic condition of the biliary tract.

Gallbladder motility disorders estimated by non-invasive methods.

BACKGROUND/AIMS: The aim is to compare the radionuclide (DC) and ultrasonographic (US) method in the assessment of gallbladder (GB) motility. METHODOLOGY: The study was performed in 15 controls (C), 10 patients with acute cholecystitis (AC), 20 patients with chronic acalculous cholecystitis (CAC), 26 patients with chronic cholecystitis with calculosis (CCC) as well as in 15 patients with GB dyskinesia (D). GB emptying period (EP), ejection fraction (EF) and ejection rate (ER) were estimated with dynamic cholescintigraphy (DC) and US. RESULTS: The DC and US finding in the patients with AC was typical in all the patients, i.e. GB was not visualized at all on DC, while on US, stone was visible in the cystic duct. There were significant differences (p<0.05) between the EF and ER values obtained between C and the three groups of patients CAC, CCC and D, using both methods. However, there were no significant differences in EF, EP and ER values among CAC, CCC and D (p>0.05). There was also high correlation between the results obtained with both methods in all the groups of patients studied. CONCLUSIONS: The results obtained by both methods are valuable for the assessment of GB motility. Although there are no significant differences and there is a high correlation between the values, radionuclide method is more precise, because it can register motility continuously.

[Effects of laser reflex therapy on a motor function of the gall bladder and physical properties of bile in patients with chronic acalculous cholecystitis].

AIM: To study effects of laser puncture in combined treatment of chronic non-calculous cholecystitis on motor function of the gallbladder, bile physical characteristics and clinical symptoms. MATERIAL AND METHODS: 73 patients with chronic non-calculous cholecystitis were divided into two groups: 35 patients received standard therapy alone (control group) and 38 patients were exposed to laser puncture as a component of combined treatment. RESULTS: Laser radiation on acupuncture points has a positive therapeutic result, i.e. shorter clinical symptoms, correction of motor function of the gallbladder and bile physical characteristics. CONCLUSION: Laser puncture is an effective method of acalculous cholecystitis treatment and can be included in relevant combined schemes.

Protective effect of melatonin on Ca2+ homeostasis and contractility in acute cholecystitis.

Impaired Ca2+ homeostasis and smooth muscle contractility co-exist in acute cholecystitis (AC) leading to gallbladder dysfunction. There is no pharmacological treatment for this pathological condition. Our aim was to evaluate the effects of melatonin treatment on Ca2+ signaling pathways and contractility altered by cholecystitis. [Ca2+]i was determined by epifluorescence microscopy in fura-2 loaded isolated gallbladder smooth muscle cells, and isometric tension was recorded from gallbladder muscle strips. Malondialdehyde (MDA) and reduced glutathione (GSH) contents were determined by spectrophotometry and cycloxygenase-2 (COX-2) expression was quantified by western blot. Melatonin was tested in two experimental groups, one of which underwent common bile duct ligation for 2 days and another that was later de-ligated for 2 days. Inflammation-induced impairment of Ca2+ responses to cholecystokinin and caffeine were recovered by melatonin treatment (30 mg/kg). This treatment also ameliorated the detrimental effects of AC on Ca2+ influx through both L-type and capacitative Ca2+ channels, and it was effective in preserving the pharmacological phenotype of these channels. Despite its effects on Ca2+ homeostasis, melatonin did not improve contractility. After de-ligation, Ca2+ influx and contractility were still impaired, but both were recovered by melatonin. These effects of melatonin were associated to a reduction of MDA levels, an increase in GSH content and a decrease in COX-2 expression. These findings indicate that melatonin restores Ca2+ homeostasis during AC and resolves inflammation. In addition, this indoleamine helps in the subsequent recovery of functionality.

Delayed necrotizing acalculous cholecystitis after multiple trauma.

This is a case report of a necrotizing acalculous cholecystitis 7 weeks after multiple orthopedic trauma successfully treated by operative intervention.

Acute acalculous cholecystitis complicating major trauma: a report of five cases.

The purpose of this study was to identify the clinical characteristics of the patients in our institution who developed acute acalculous cholecystitis (AAC) after major trauma. Data of all trauma patients who developed AAC from January 2001 through June 2006 were analyzed. Five out of 1386 (0.3%) major trauma patients were diagnosed with AAC. One out of five patients had hypotension and shock and received vasopressor treatment. Prior to the diagnosis of AAC, all patients received ventilatory support, intravenous opioid analgesia, had pneumonia, and experienced tachycardia. No specific clinical characteristic was identified in patients with AAC; however, prolonged ventilatory support, pneumonia, use of opioids, and new onset arrhythmias were seen in the majority of patients.

Gallbladder ascariasis in Kosovo - focus on ultrasound and conservative therapy: a case series.

BACKGROUND: Ascaris lumbricoides is one of the most common intestinal infections in developing countries, including Kosovo. In contrast to migration to the bile duct, migration of the worm to the gallbladder, due to the narrow and tortuous nature of the cystic duct, is rare. When it does occur, it incites acalculous cholecystitis. CASE PRESENTATIONS: This case series describes a 16-month-old Albanian girl, a 22-month-old Albanian girl, a 4-year-old Albanian girl, and a 10-year-old Albanian boy. Here we report our experience with gallbladder ascariasis including clinical manifestations, diagnostic procedures, and treatment. Fever, diarrhea and vomiting, dehydration, pale appearance, and weakness were the manifestations of the primary disease. In all patients, a physical examination revealed reduced turgor and elasticity of the skin. Abdomen was at the level of the chest, soft, with minimal palpatory pain. The liver and spleen were not palpable. A laboratory examination was not specific except for eosinophilia. There were no pathogenic bacteria in coproculture but Ascaris was found in all patients. At an ultrasound examination in all cases we found single, long, linear echogenic structure without acoustic shadowing containing a central, longitudinal anechoic tube with characteristic movement within the gallbladder. Edema of the gallbladder wall was suggestive of associated inflammation. There were no other findings on adjacent structures and organs. All patients received mebendazole 100 mg twice a day for 3 days. They also received symptomatic therapy for gastroenteritis. Because of elevated markers of inflammation all patients were treated with antibiotics, assuming acute cholecystitis, although ultrasound was able to confirm cholecystitis in only two of our four patients. Since the length of stay was dependent on the primary pathology it was 7 to 10 days. At control ultrasounds on 14th day, third and sixth month, all patients were free of ascariasis. CONCLUSIONS: Gallbladder ascariasis should be considered in all patients presenting with abdominal pain, distension, colic, nausea, anorexia, and intermittent diarrhea associated with jaundice, nausea, vomiting, fever, and severe radiating pain. Eosinophilia, ova, and parasites on stool examination as well as an anechogenic tube with characteristic movement within the bile duct found on abdominal ultrasound are conclusive for diagnosis. Mebendazole is an effective drug for the treatment. Surgical treatment is rarely needed.

HIDA scan ejection fraction does not predict sphincter of Oddi hypertension or clinical outcome in patients with suspected chronic acalculous cholecystitis.

BACKGROUND: Hepatobiliary iminodiacetic scan with ejection fraction (HIDA EF) is used to evaluate chronic acalculous cholecystitis (CAC). A presumed etiology of CAC is sphincter of Oddi hypertension (SOH). In this study, we evaluated the value of HIDA EF to predict patient response to laparoscopic cholecystectomy and to identify SOH. METHODS: A prospective study of 93 patients with biliary pain but without gallstones (CAC) who underwent preoperative HIDA EF was conducted. At laparoscopic cholecystectomy, transcystic antegrade biliary manometry was performed to determine the SO pressure. Patients were evaluated postoperatively for response to cholecystectomy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The outcomes were compared with the clinical impression. RESULTS: Of the 93 patients with both HIDA EF and SOP measurements, 50 had abnormal EF (< 35%); of these, 29 had SOH (SO pressure > or = 40 mmHg). Of the 43 patients with normal HIDA EF, 30 had SOH. The sensitivity was 49%, specificity 38%, PPV 58%, and NPV 30%. Eighty-six of the 93 patients returned for follow-up evaluation. Follow-up ranged from 0 to 99 months, with a mean of 26.4 months. Overall, 73 patients (85%) improved. Of the 46 with abnormal HIDA EF, 42 (91%) improved. Of the 40 patients with normal HIDA EF, 31 (77.5%) improved. The sensitivity was 57.7%, specificity 69.2%, PPV 91.3%, and NPV 22.5%. CONCLUSION: Although the PPV of abnormal HIDA EF is high, it is not much better than the clinical impression. The sensitivity and specificity are marginal. The NPV is poor. Based on the review of these 93 patients, HIDA EF is not reliable for identifying CAC. We recommend that patients with normal HIDA EF have additional testing or consultation before ruling out CAC. HIDA EF does not predict SOH.

Gallbladder motility and functional gastrointestinal disorders.

Functional gastrointestinal disorders can be defined as 'a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities'. Motor disorders are considered to be one of the pathogenetic mechanisms of these symptoms; in fact, it has been hypothesized that the smooth muscle of the whole gastrointestinal tract could be involved. Gallbladder motility has been evaluated in patients with dysmotility-like dyspepsia, irritable bowel syndrome and biliary disorders without gallstones; results of these observations are often inconclusive, conflicting and not always useful from a clinical point of view. The aim of this review is to explore the relationship between gallbladder motility and functional gastrointestinal disorders from pathogenetic and physiopathological points of view, and also to define the possible impact of these observations on clinical practice.

Acalculous biliary pain: new concepts for an old entity.

Biliary pain is commonly reported in household surveys with the presumed cause being gallstones. When gallstones are absent or other abnormalities as a potential cause of similar pain do not exist, a different approach is necessary. Although trans-abdominal ultrasound can detect stones down to 3-5 mm, the advent of endoscopic ultrasound provides an even better definition for microlithiasis of < 3 mm. Duodenal aspiration of bile can further detect cholesterol microlithiasis or bilirubin granules, another potential source of biliary-type pain and perhaps even pancreatitis. Only in this way can acalculous gallbladder disease be clearly defined. The percentage of cholecystokinin-stimulated gallbladder emptying has been reputed to be the most sensitive diagnostic test for 'biliary dyskinesia', but abnormality of gallbladder emptying can be due to a smooth muscle defect of the gallbladder itself or heightened tone in the sphincter of Oddi. The value of surgical intervention has not been clearly established. The advent of laparoscopic cholecystectomy, however, has increased the number of patients with acalculous biliary disease who undergo surgery. Surgery is best done using impaired gallbladder emptying as the criterion for operation with improved outcome. Often, following cholecystectomy, biliary pain does not resolve the so-called 'post cholecystectomy syndrome'. Absence of the gallbladder as a pressure reservoir leaves the sphincter of Oddi as the prime determinant of bile duct pressure. Sphincter of Oddi dysfunction also exists in patients with an intact biliary tract and may become evident following cholecystectomy. Biliary manometry has clarified who might benefit from sphincterotomy. Choledochoscintigraphy is a non-invasive preliminary test. Advent of visceral hypersensitivity and better definition of this entity has shown, that in some of these patients with type III sphincter of Oddi, dysfunction appears to reside in duodenal hyperalgesia. It is clear that improved criteria are required to perform gallbladder emptying and better techniques to detect visceral hypersensitivity. Nonetheless, functional biliary pain in the absence of gallstone disease is a definite entity and a challenge for clinicians.

Value of measuring gallbladder motility in clinical practice.

Measurement of gallbladder motility is a powerful research tool, but its value in clinical practice is uncertain. Three main conditions have been investigated for potential clinical application of this measurement. The first potential application is for identification of patients at risk of recurrence following gallstone dissolution with medical therapy. Results in this clinical setting are disappointing due to the low positive predictive value for gallstone recurrence in sluggish gallbladder emptying. The second potential application is for identification of obese patients at risk of gallstone formation during rapid weight loss. In this condition, a high negative predictive value has been reported for a normal gallbladder emptying pattern. The third potential application is for patients with recurrent biliary colic and acalcolous gallbladder disease. The diagnostic value of a provocative test involving intravenous cholecystokinin injection as a method of identifying patients likely to benefit from cholecystectomy is uncertain, partly as a consequence of non-standardized methodology. The balance of evidence reported in this review suggests a low inherent value of measurement of gallbladder motility in clinical practice. Acalcolous gallbladder disease is the clinical setting deserving further investigation on the value of the cholecystokinin provocative test, but this test needs to be standardized.

Efficacy of laparoscopic cholecystectomy in acalculous gallbladder disease: long-term follow-up.

OBJECTIVE: Our aim was to determine the efficacy of laparoscopic cholecystectomy in symptomatic patients with ultrasound negative and abnormal gallbladder ejection fractions; Patients with gallbladder ejection fractions less than 35% on hepatobiliary scan were offered laparoscopic cholecystectomy. METHODS: Between January 1995 and January 2001, 1564 patients underwent laparoscopic cholecystectomy at our institution: 256 were confirmed to have acalculous gallbladder disease by pathology report and reconfirmation of abnormal hepatobiliary scan data. A 30-day postoperative follow-up was obtained by retrospective medical record review. For this study, we contacted all 256 patients by mail questionnaire and followed up on nonresponders with telephone interviews; we also reviewed hospital records to verify preoperative symptom patterns. The survey was completed by 154 patients (60%): 48 (31%) by mail and 106 (69%) by telephone interviews. The study included 115 (75%) female and 39 (25%) male patients, and the average age was 42 years (range, 13 to 95). All hepatobiliary laboratory parameters were normal pre- and postoperatively. The survey was completed in December 2001, 1 to 5 years postoperatively (mean 3 years). RESULTS: Preoperatively, 142 patients (92%) had right upper quadrant pain, 114 (74%) had nausea, 88 (57%) had vomiting, 120 (73%) had heartburn, and 118 (77%) had food intolerance. In a 30-day postoperative period, these numbers had reduced to 48 (37%), 14 (90%), 8 (5%), 22 (14%), and 34 (22%), respectively. had laparoscopic cholecystectomy, and 95% stated that they would recommend laparoscopic cholecystectomy to other patients. CONCLUSION: This study shows that patients with acalculous gallbladder disease benefit from laparoscopic cholecystectomy.

[Use of tykveol in the treatment of impaired biliary tract function in patients with chronic non-calculous cholecystitis]. / Primenenie tykveola v lechenii narushenii funktsional'nogo sostoianiia zhelchevyvodiashchikh putei u bol'nykh khronicheskim nekal'kuleznym kholetsistitom.

The therapeutic efficacy of tykveol was evaluated in 22 patients with chronic non-calculous cholecystitis and/or dyskinesia of the biliary tract (BT) concurrent with gallbladder deformity (GD). Supplementation of tykveol to the combined therapy in the patients with chronic non-calculous cholecystitis concurrent with GD was shown to exert a pronounced therapeutic effect. This caused positive changes in clinical symptoms and BT function, diminished the lithogenic propertes of bile. With the use of tykveol, recovery of neurohumoral regulation is an important factor that improves biliary tract function, as evidenced by decreased gastrin secretion.