Surgical practice in symptomatic and asymptomatic gallstone disease.

AIMS: To determine the surgical practice in individuals with symptomatic and asymptomatic gallstone disease using a questionnaire survey. METHODS: A questionnaire was sent to 724 patients with gallstone disease. Details of symptoms, duration of illness, nature of treatment including surgery, color of gallstones retrieved and postoperative follow-up particulars were obtained. RESULTS: The study group included 225 (54%) men; there was a rising trend of prevalence of gallstones in men with increasing age (p<0.05). A third of the patients (142 [34%]) were symptomatic. The mean duration of symptoms was 12.1 months. One hundred and ninety seven patients (48%), including 90 asymptomatic ones, underwent cholecystectomy. Most patients (92.5% of those symptomatic and 76.6% of those asymptomatic) underwent cholecystectomy within one year of diagnosis. Eight asymptomatic patients underwent surgery 3 years or more after diagnosis. The predominant color of stones retrieved was black or brown (57%) or mixed (39%). CONCLUSIONS: A majority of patients with gallstone disease had cholecystectomy within one year of diagnosis. Black or brown pigment stones were the dominant types of gallstones.     

Characteristics of silent and symptomatic myocardial ischemia during daily activities

In 191 patients with proven coronary artery disease, 24-hour Holter monitoring detected 587 transient episodes of ST depression during daily activities. Of that total, 424 episodes were silent (72.3%) and 163 were symptomatic (27.7%). There were no statistically significant differences between silent and symptomatic episodes as to their mean duration (15.1 vs 14.3 minutes, respectively), heart rate at onset of ST depression (93 vs 96 beats/min, respectively), heart rate at the time of maximal ST depression (114 beats/min, both) and mean maximal ST depression (1.9 vs 2.0 mm, respectively). Of the 191 patients, 104 (55%) had only silent episodes, 33 (17%) only symptomatic episodes and 54 (28%) had both types ("mixed"). All patients, regardless of episode type, were of similar age, received comparable medical therapy, had a similar extent of angiographically documented coronary artery disease and similar episode characteristics. However, mixed-episode patients had significantly more ischemic episodes per day (4.8) than silent-episode (2.6) and symptomatic-episode (1.9) patients (p less than 0.001 for both) and a longer total period of daily ischemia (60 minutes), than the other 2 groups (36 and 28 minutes, respectively, p less than 0.001 for both). Of the 191 patients, 97 (51%) had had a previous myocardial infarction. The characteristics of their silent and symptomatic episodes were similar to the 94 (49%) patients without infarction, except for a longer duration of the silent episodes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Body mass index, alcohol, tobacco and symptomatic gallstone disease: a Swedish twin study

BACKGROUND/AIMS: Both genetic and environmental factors are involved in the pathogenesis of gallstone disease (GD). We aimed to examine the association between symptomatic GD and overweight (body mass index, BMI, 25-30 kg m(-2)), obesity (BMI > 30 kg m(-2)), alcohol, smoking and smoke-free tobacco by analysing a large twin population. METHODS: The Swedish Twin Registry (STR) was linked to the Swedish Hospital Discharge and Causes of Death Registries for GD and GD-surgery related diagnoses. Weight, height, use of alcohol, smoking and smoke-free tobacco were provided by STR and analysed for possible associations by conditional logistic regression. RESULTS: Overweight and obesity were associated with a significantly higher risk for symptomatic GD in the whole study population (OR 1.86 and OR 3.38; CI: 1.52-2.28 and 2.28-5.02 respectively). High alcohol consumption was associated with a lower risk for GD in the whole population (OR 0.62; CI: 0.51-0.74) with no difference between discordant monozygotic and dizygotic twins (OR 1.08 and OR 0.96; CI: 0.82-1.42 and 0.79-1.16). Smoking or smoke-free tobacco was not correlated with GD. CONCLUSION: Consistent with epidemiological studies, we found positive associations between BMI and the development of symptomatic GD. High alcohol consumption was associated with a decreased risk against GD. Tobacco use has no impact on GD.     

Piezoelectric lithotripsy in the treatment of symptomatic gallstone patients. A 12-month follow-up

Between January and May 1989, 65 patients with symptomatic gallbladder stones were treated with extracorporeal piezoelectric lithotripsy (EPL) and supplementary dissolution therapy with oral bile acids. In 98% of the patients, fragmentation of stones was achieved. On average, each patient received 3.18 treatments. In addition to attacks of colic and asymptomatic changes in laboratory parameters, one hematoma of the gallbladder and one of the liver were observed, together with pancreatitis and cholecystitis in two patients each. During the follow-up period, three patients developed symptomatic bile duct stones. An endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy was performed on four occasions, while one female patient had to undergo urgent cholecystectomy for inflammation of the gallbladder and empyema. Six months after the initial treatment, 36 (55%) patients were free of stones, while the stone-free rate after 12 months was 64.5% (41 of 65). Ninety percent of the patients with a solitary stone less than or equal to 2 cm in diameter became stonefree within a year. Extracorporeal piezoelectric lithotripsy is clearly a feasible procedure for the treatment of certain gallstone patients.     

胆囊癌与胆囊结石关系的临床探讨

目的探讨胆囊结石与胆囊癌变的关系．方法１９７８年～１９９３年共收治原发性胆囊癌２２７例，男６０例，女１６７例，年龄３５岁～８３岁，平均５８１岁．进行了组织病理学及临床资料回顾分析．结果胆囊癌合并胆囊结石８３例，占３６６％，其中男性３３３％（２０／６０），女性３７７％（６３／１６７）均明显高于胆结石自然发病率，并随年龄增长而有增高趋势，５０岁以上者６５例（７８３％），各年龄组间有显著差异，病理学结果显示，胆结石所致的粘膜异型增生可癌变；本组腺癌最多，共６３例（８８７％）．结论胆囊结石可诱发癌变，应施行选择性预防胆囊切除术．     

Hemodynamic and electrocardiographic correlates of symptomatic and silent myocardial ischemia: pathophysiologic and therapeutic implications

Numerous hemodynamic, electrocardiographic, metabolic and radionuclide measurements in various subsets of patients with coronary artery disease (CAD) reveal that ischemia does not always occur on the basis of increases in myocardial oxygen consumption. Continuous hemodynamic monitoring indicates that most episodes of myocardial ischemia are not preceded by increases in such major determinants of oxygen consumption as heart rate or blood pressure, but that these usually increase in response to the development of ischemia. The development of pain during ischemia is a late feature and most episodes are silent. There are no significant differences in the hemodynamic characteristics of symptomatic versus asymptomatic episodes of myocardial ischemia in patients with angina at rest or between those associated with ST-segment depression and those with ST-segment elevation. Continuous Holter recordings analyzed by compact analog technique in hospitalized and ambulatory patients with ischemic heart disease indicate that in both unstable and chronic stable angina, over two-thirds of myocardial ischemic episodes are clinically silent. Symptomatic and silent episodes do not differ significantly with respect to duration. Most symptomatic and asymptomatic episodes are not triggered by increases in the determinants of oxygen demand. Such episodes may arise on the basis of a critical reduction in the lumen of the diseased coronary artery leading to a primary reduction in blood flow. Intermittent obstruction due to changes in coronary vasomobility or possibly formation of thrombi may be a common mechanism for the pathogenesis of myocardial ischemia in patients with a varying spectrum of coronary artery lesions. At present, the precise clinical and prognostic significance of silent ischemia in CAD is not completely defined.(ABSTRACT TRUNCATED AT 250 WORDS)     

Characteristics of transient ischaemic episodes in patients with silent and symptomatic exercise-induced myocardial ischaemia

To evaluate transient ischaemic episodes during daily life inpatients with coronary artery disease and exercise-induced myocardialischaemia, 38 patients underwent ambulatory ST-segment monitoringover 48 h. Sixteen patients had painless ischaemia during exerciseand occasional angina, and 12 patients had symptomatic ischaemiaand frequent angina during daily life. Ten patients with provencoronary artery disease but normal exercise electrocardiogramsserved as controls. The extent of coronary artery lesions andthe prevalence of myocardial infarction were similar in allgroups. ST-segment monitoring revealed 817 min and 98 episodesof ST depression in 13/16 patients of the asymptomatic groupand 111 min and 21 episodes in 5/12 patients of the symptomaticgroup (P<0.03). Subjective scores for physical activity duringHolter monitoring were significantly higher in the first groupthan in the second. The majority of ischaemic episodes in bothgroups was asymptomatic. No ischaemic ST changes occurred incontrol patients. Results indicate a higher frequency of transientischaemic episodes related to a higher level of physical activityin patients with silent ischaemia than in patients with symptomaticexercise-induced ischaemia.     

Association of bowel movement frequency and use of laxatives with the occurrence of symptomatic gallstone disease in a prospective study of women

OBJECTIVES: The authors prospectively examined the association between bowel movement frequency (used as a proxy for intestinal transit), laxative use, and the risk of symptomatic gallstone disease. METHODS: A total of 79,829 women, aged 36-61 yr, without a history of symptomatic gallstone disease and free of cancer, responded to a mailed questionnaire in 1982 that assessed bowel movement frequency and use of laxatives. Between 1984 and 1996, 4,443 incident cases of symptomatic gallstone disease were documented. Relative risks (RRs) of symptomatic gallstone disease and 95% confidence intervals (CIs) were calculated using logistic regression. RESULTS: After controlling for age and established risk factors, the multivariate RRs were, compared to women with daily bowel movements, 0.97 (95% CI 0.86-1.08) for women with bowel movements every third day or less, and 1.00 (95% CI 0.91-11.1) for women with bowel movement more than once daily. No trend was evident. As compared to women who never used laxatives in 1982, a significant modest inverse association was seen for monthly laxative use, with a multivariate RR of 0.84 (95% CI 0.72-0.98), and weekly to daily laxative use was associated with a RR of 0.88 (95% CI 0.78-1.02). CONCLUSIONS: These findings do not support an association between infrequent bowel movements and risk of symptomatic gallstone disease in women, and indicate that simple questions directed at bowel movement frequency are unlikely to enhance our ability to predict risk of symptomatic gallstone disease. The slightly inverse association between use of laxatives and risk of symptomatic gallstone disease may be due to a mechanism that is not related to bowel movement frequency.     

Long-term effect of magnesium consumption on the risk of symptomatic gallstone disease among men

BACKGROUND: Magnesium deficiency can cause dyslipidemia and insulin hypersecretion, which may facilitate gallstone formation. However, the effect of long-term consumption of magnesium on the risk of gallstone disease is unknown. METHODS: We prospectively studied magnesium consumption and risk of gallstone disease in a cohort of 42,705 U.S. men from 1986 to 2002. Magnesium consumption was assessed using a validated semiquantitative food frequency questionnaire. Newly diagnosed gallstone disease was ascertained biennially. RESULTS: We documented 2,195 incident cases of symptomatic gallstones during 560,810 person-years of follow-up. The age-adjusted relative risks (RRs) for men with total magnesium intake and dietary magnesium, when the highest and lowest quintiles were compared, were 0.67 (95% confidence interval [CI] 0.59-0.77, P for trend <0.0001) and 0.67 (CI 0.59-0.76, P for trend <0.0001), respectively. After adjusting for multiple potential confounding variables, when extreme quintiles were compared, the multivariate RR of total magnesium intake (RR 0.72, CI 0.61-0.86, P for trend = 0.006) and dietary magnesium (RR 0.68, CI 0.57-0.82, P for trend = 0.0006) remained significant with a dose-response relationship. CONCLUSIONS: Our findings suggest a protective role of magnesium consumption in the prevention of symptomatic gallstone disease among men.     

Evaluation of left ventricular contractility indexes for the detection of symptomatic and silent myocardial ischemia

This study evaluated the role of left ventricular (LV) ejection fraction and systolic blood pressure (BP) to end-systolic volume ratio to detect symptomatic and silent myocardial ischemia. The sensitivity and diagnostic accuracy of these contractility indexes were compared with angina and ST depression during exercise. Thirty consecutive patients referred for chest pain performed symptom-limited bicycle exercise and had coronary angiography within 3 months. Twenty-two had angiographically significant coronary artery disease and 8 had normal coronary anatomy. Systolic BP was measured by sphygmomanometry; LV ejection fraction and end-systolic volume were obtained by nuclear ventriculography. Normal values for contractility indexes were defined as LV ejection fraction greater than 52% at rest and increment of greater than or equal to 5% during exercise, and systolic BP to end-systolic volume ratio greater than 2.2 mm Hg/ml at rest and greater than 3.0 mm Hg/ml during exercise. The sensitivity of systolic BP to end-systolic volume ratio to identify patients with coronary artery disease at rest was 71 vs 33% for LV ejection fraction. During exercise, each contractility index had a sensitivity of 95% and there was a combined sensitivity of 100%. This compares with 71% for ST depression and 48% for exercise-induced angina. Thus, 52% had no angina and 36% of them were also silent by electrocardiography. Among the patients with symptomatic ischemia, 20% had no ST-segment depression. Measurement of contractility indexes enhanced the detection of silent myocardial ischemia and provided information on LV function vital to prognosis and management of patients with coronary artery disease.     

Intravenous diltiazem versus nitroglycerin for silent and symptomatic myocardial ischemia in unstable angina pectoris

For 18 patients consecutively admitted to the coronary care unit for unstable angina, 48-hour electrocardiographic Holter monitoring was performed after they were randomly assigned in a single-blind fashion to 1 of 2 treatment groups. The first group was treated with acetylsalicylic acid (ASA) and intravenous nitroglycerin, the second with ASA and intravenous diltiazem. All of the patients treated with nitroglycerin still had ischemic episodes after 48 hours (33% were symptomatic), in contrast with 11% of the diltiazem group (11% asymptomatic). Maximal ST-segment depressions of symptomatic and asymptomatic episodes were significantly different; and no significant increases in heart rate were observed either during the 15 seconds before ischemia began or during the ischemic episode. During the 48 hours, the diltiazem group had significantly fewer ischemic episodes (17) than did the nitroglycerin group (145). We concluded that "on-line" ST-segment observation is of prime importance for monitoring unstable angina; that the majority of the ischemic episodes associated with unstable angina are silent; and that intravenous diltiazem could be an effective pretreatment for patients who must undergo mechanical or surgical therapy.     

Differences in autonomic nerve function in patients with silent and symptomatic myocardial ischaemia.

BACKGROUND--Autonomic neuropathy provides a mechanism for the absence of symptoms in silent myocardial ischaemia, but characterisation of the type of neuropathy is lacking. AIM--To characterise and compare autonomic nerve function in patients with silent and symptomatic myocardial ischaemia. METHODS AND RESULTS--The Valsalva manoeuvre, heart rate variation (HRV) in response to deep breathing and standing, lower body negative pressure, isometric handgrip, and the cold pressor test were performed by patients with silent (n = 25) and symptomatic (n = 25) ambulatory ischaemia and by controls (n = 21). No difference in parasympathetic efferent function between patients with silent and symptomatic ischaemia was recorded, but both had significantly less HRV in response to standing than the controls (p < 0.005 for silent and p < 0.01 for symptomatic). Patients with silent ischaemia showed an increased propensity for peripheral vasodilatation compared with symptomatic patients (p < 0.02) and controls (p < 0.04). Impaired sympathetic function was found in patients with pure silent ischaemia (n = 4) compared with the remaining patients with silent ischaemia whose pain pathways were presumed to be intact. CONCLUSIONS--Patients with silent ischaemia and pain pathways presumed to be intact have an enhanced peripheral vasodilator response, and if this applied to the coronary vasculature it could provide a mechanism for limiting ischaemia to below the pain threshold. Patients with pure silent ischaemia have evidence of sympathetic autonomic dysfunction.     

Assessment of silent and symptomatic ischemia in daily activity by an ambulatory ventricular function monitor

We have assessed the sequential changes in left ventricular function and ECG in 39 patients with coronary artery disease (CAD) using an ambulatory ventricular function monitor. Following radionuclide ventriculography, the instrument detectors were placed over the region of the left ventricle and lung, and beat-to-beat left ventricular time activity curve and modified V5 ECG data were continuously monitored for up to 6 hours (mean 2.5 hours), while the patient performed various daily activities. Thirty-six episodes of transient ejection fraction (EF) decrease (6-18%) were recorded in 16 patients, 12 were symptomatic and 24 asymptomatic. ST segment changes were recorded in 6 of the 12 symptomatic and 5 of the 24 asymptomatic episodes. In 10 of the 12 symptomatic episodes, EF began to drop 30 to 90 seconds before the onset of the symptoms. Of 14 episodes of significant ST segment depression in five patients, 11 were associated with a significant EF decrease. We conclude that the combination of left ventricular function and ECG monitoring is a promising means for determining incidence of silent and symptomatic ischemia and for severity of ischemia in patients with CAD.     

Severe "silent" mitral regurgitation. A potentially reversible cause of refractory heart failure

Hemodynamically critical ("severe") mitral regurgitation is usually associated with an audible (if not loud) systolic murmur and signs of left ventricular volume overload. However, "silent" severe mitral regurgitation is being increasingly recognized. We review the case histories of nine patients with silent hemodynamically important mitral regurgitation (associated with acute myocardial infarction and chronic valvular, hypertrophic, and ischemic heart disease), six of whom survived mitral valve replacement, of whom five are alive and functioning well more than three years postoperatively. Performance of left ventriculography early in the hospital course of patients with severe unexplained congestive heart failure (with normal or near-normal left ventricular systolic function assessed noninvasively) identifies patients with severe silent mitral regurgitation who may have long-term benefit from mechanical therapy.