Serum insulin, insulin resistance, β-cell dysfunction, and gallstone disease among type 2 diabetics in Chinese population: A community-based study in Kinmen, Taiwan

AIM: To explore the association of serum insulin, insulin resistance, and β-cell dysfunction with gallstone disease (GSD) in type 2 diabetics.METHODS: We used a community-based study conducted between 1991 and 1993 in Kinmen, Taiwan to identify type 2 diabetics. A screening program for GSD was performed in 2001 by a panel of specialists who employed real-time ultrasound sonography to examine the abdominal region after the patient had fasted for at least 8 h. Screening was conducted in 2001 on 848patients diagnosed with type 2 diabetes. The HOMA method was used to compare the profile differences for insulin resistance (HOMA IR) and β-cell dysfunction (HOMA β-cell).RESULTS: We studied 440 type 2 diabetics who attended sonography check-ups. After excluding eight insulin-treated diabetics, the prevalence of GSD among the remaining 432 was 13.9% (26/187) among males and 14.7% (36/245) among females. After adjustment for other GSD-associated risk factors in addition to age and obesity, GSD risk increased among females with levels of serum insulin [4th vs 1st quartile odds ratios (OR)= 4.46 (95%CI: 1.71-11.66)] and HOMA IR [4th vs 1st quartile OR = 4.46 (95% CI: 1.71-11.66)]. Better HOMA β-cell function was significantly related to decreased risk of GSD [4th vs 1st quartile OR = 0.16 (95% CI: 0.03-1.70)].Among males, age and central obesity were the most significant risk factors for GSD. No association of GSD with serum insulin, HOMA IR, and HOMA β-cell was observed among males.CONCLUSION: Serum insulin, insulin resistance, and β-cell dysfunction are risk factors for GSD in females, but not males with type 2 diabetes.     

胆石性肠梗阻2例分析

胆石性肠梗阻在我国较少见，多见于老年女性患者。临床表现为单纯性肠梗阻，一般需手术治疗。如果有肠管坏死必要时行肠管部分切除术。手术前误诊率高。详细的病史、仔细的临床观察和客观有效的辅助检查，可以提高手术前诊断率。     

Prevalence of cholelithiasis in patients with chronic inflammatory bowel disease

AIM: To investigate the effect of chronic inflammatory bowel disease (CIBD) specific risk factors for cholecystolithiasis, as duration and involvement pattern of the disease and prior surgery in patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS: A total of 222 patients with CD (135 females, 87 mates; average age, 35.8±11.8 years; range 17-81 years) and 88 patients with UC (39 females, 49 males; average age, 37.2±13.6 years; range 16-81 years) underwent clinical and ultrasound examinations. Besides age, sex and degree of obesity, patients' CIBD specific parameters, including duration and extent of disease and prior operations were documented and evaluated statistically using logistic regression. RESULTS: The overall prevalence of gallbladder stone disease in patients with CD was 13% (n = 30). Only age could be shown to be an independent risk factor (P = 0.014). Compared to a collective representative for the general population in the same geographic region, the prevalence of cholecystolithiasis was higher in all corresponding age groups. Patients with UC showed an overall prevalence of gallbladder stone disease of only 4.6%. CONCLUSION:Only age but not disease-specific factors such as duration and extent of disease, and prior surgery are independent risk factors for the development of cholecystolithiasis in patients with CIBD.     

中西医结合防治胃切除术后胆石症的实验研究

目的:探讨中西医结合防治胃切除术后胆石症的可行性.方法:将杂种雄犬随机分为:对照组(行剖腹探查术)、手术组(行胃大部切除加Billroth-Ⅱ式胃肠重建术)、实验组(行胃大部切除术加Billroth-Ⅱ式胃肠重建加中西医结合药物治疗).应用美国BIO-RAD公司生产高效液相色谱分析仪,检测并观察3组动物胆汁成分的变化,并用ABR-ID-22及ABR-ID-10系统进行胆汁的需氧菌及厌氧菌鉴定.结果:手术组有需氧菌及厌氧菌的混合感染,并可见胆色素类结石形成.实验组较手术组总胆汁酸显著增加(P＜0.01)、初级胆汁酸及次级胆汁酸显著增高(P＜0.01),未形成结石.结论:中西医结合用药可抑制胃切除术后胆石的形成.     

Value of CT in the diagnosis and management of gallstone ileus

AIM: To retrospectively establish the diagnostic criteria of gallstone ileus on CT, and to prospectively apply these criteria to determine the diagnostic accuracy of CT to confirm or exclude gallstone ileus in patients who presented with acute small bowel obstruction (SBO). Another purpose was to ascertain whether the size of ectopic gallstones would affect treatment strategy. METHODS: Fourteen CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria. These criteria were applied in a prospective contrast enhanced CT study of 165 patients with acute SBO, which included those 14 cases of gallstone ileus. The hard copy images of 165 CT studies were reviewed by a different group of two radiologists but without previous knowledge of the patient's final diagnosis. All CT data were further analyzed to determine the diagnostic accuracy of gallstone ileus when using CT in prospective evaluation of acute SBO. The size of ectopic gallstone on CT was correlated with the clinical course. RESULTS: The diagnostic criteria of gallstone ileus on CT were established retrospectively, which included: (1) SBO; (2) ectopic gallstone; either rim-calcified or total-calcified; (3) abnormal gall bladder with complete air collection, presence of air-fluid level, or fluid accumulation with irregular wall. Prospectively, CT confirmed the diagnosis in 13 cases of gallstone ileus with these three criteria. Only one false negative case could be identified. The remaining 151 patients are true negative cases and no false positive case could be disclosed. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93%, 100%; and 99%, respectively. Surgical exploration was performed in 13 patients of gallstone ileus with ectopic stones sized larger than 3 cm. One patient recovered uneventfully following conservative treatment with an ectopic stone sized 2 cm in the long axis. CONCLUSION: Contrast enhanced CT imaging offered crucial evidence not only for the diagnosis of gallstone ileus but also for decision making in management strategy.     

Gallstone abscess as a result of dropped gallstones during laparoscopic cholecystectomy

INTRODUCTIONWith the advent of laparoscopic cholecystectomy we have seen a “disease of medical progress” (DOMP). Herein we report a complication that developed 7 years after laparoscopic cholecystectomy.PRESENTATION OF CASEA 42 year old woman presented with worsening right-sided pain and tenderness. Seven years prior she underwent a laparoscopic cholecystectomy. Computed tomography demonstrated a subhepatic retroperitoneal inflammatory mass. On open exploration a 4 cm × 6 cm retroperitoneal mass was excised. The mass contained purulent material and gallstones.DISCUSSIONLaparoscopic cholecystectomy has become the “gold standard” for the treatment of symptomatic gallstones. Prior to laparoscopic cholecystectomy there was no body of literature about lost gallstones thus making this a DOMP. In contrast, it is reported that as many as 5.4–19% of laparoscopic cholecystectomies have stones spilled with variable rates of retrieval. Our case demonstrates an extreme example of a complication resulting seven years after a laparoscopic cholecystectomy with gallstones left behind.CONCLUSIONRecognizing that gallstones will be lost during some cases of laparoscopic cholecystectomy, we must remain vigilant and make a full attempt to retrieve all stones to prevent such rare but not insignificant potential complications.     

新疆克拉玛依地区抽样人群中胆囊结石危险因素流行病学研究

目的了解新疆克拉玛依地区胆囊结石流行病学的特点。方法依据该地区人口学资料，计划调查8257人，按规模大小成比例概率抽样（PPS）的方法随机抽样以确定抽样人群。对象均接受人户问卷调查及物理查体，同时预约行胆囊B超和空腹血糖血脂检查。SPSS11．0软件进行统计学处理，Logistic回归分析得出危险因素。结果调查的应答率为92．4％。胆石症患病率为l5．45％。在众多危险因素中，贡献最大的依次为性别、胆总管内径和民族（OR值分别为1．92，1．83，1．4）。结论胆结石的形成是多因素作用的结果，其中性别、民族差异和胆总管内径对胆结石形成有一定的影响。     

胆囊结石患者临床症状与胰功能的关系探讨

对１００例胆囊结石患者行血糖、胰岛素、胰功肽和氨基酸消耗试验等检测。结果：７１例有消化道症状，１２例检出高血糖，其中６例有慢性肝病，１４例胰外分泌功能下降，２６例有胰头变硬。作者认为胆囊结石患者出现高血糖与并存慢性肝病有关，反复排石致胰形态、功能异常是胆石患者常见消化道症状的原因之一。     

Endoscopic sphincterotomy permits interval laparoscopic cholecystectomy in patients with moderately severe gallstone pancreatitis

Patients with moderately severe gallstone pancreatitis with substantial pancreatic and peripancreatic inflammation, but without organ failure, frequently have an open cholecystectomy to prevent recurrent pancreatitis. In these patients, prophylactic endoscopic retrograde cholangiography (ERC) with endoscopic sphincterotomy (ES) may prevent recurrent pancreatitis, permit laparoscopic cholecystectomy, and decrease risks. The medical records of all patients with pancreatitis undergoing cholecystectomy from 1999–2004 at the University of North Carolina Memorial Hospital were reviewed. Data regarding demographics, clinical course, etiology of pancreatitis, operative and endoscopic interventions, and outcome were extracted. Moderately severe gallstone-induced pancreatitis was defined as pancreatitis without organ failure but with extensive local inflammation. Thirty patients with moderately severe gallstone pancreatitis underwent ERC and ES and were discharged before cholecystectomy. Mean interval between ES and cholecystectomy was 102 ± 17 days. Cholecystectomy was performed laparoscopically in 27 (90%) patients, open in three (10%) patients, and converted to open in two (7%) patients, with a morbidity rate of 7% (two patients). No patient required drainage of a pseudocyst or developed recurrent pancreatitis. Interval complications resulted in hospital readmission in seven (23%) patients. In conclusion, recurrent biliary pancreatitis in patients with moderately severe gallstone pancreatitis is nil after ERC and ES. Hospital discharge of these patients permits interval laparoscopic cholecystectomy, but close follow-up is necessary in these potentially ill patients. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

体外胆石的CT分类和化学成分关系的研究

目的：探讨体外胆石的ＣＴ分类和化学成分的关系。材料和方法：６０例胆石标本进行体外ＣＴ扫描，以红外光谱仪定量分析所有结石的四种主要化学成分。结果：胆石分成５类；胆石的ＣＴ类型与其化学成分及形态特点密切相关；胆石的ＣＴ值与其胆固醇含量成显著负相关（ｒ＝－０．６３），而与碳酸钙的含量成显著正相关（ｒ＝０．６５）；胆固醇和非胆固醇性结石的ＣＴ值有显著差异，以ＣＴ值－５０Ｈｕ为两者的判断界值，其敏感性和特异性分别为９０％及９７．５％。结论：ＣＴ能准确预测胆石的化学性质和形态特点。