Small gallstones, preserved gallbladder motility, and fast crystallization are associated with pancreatitis

✍ Scribed by Niels G. Venneman; Willem Renooij; Jens F. Rehfeld; Gerard P. vanBerge-Henegouwen; Peter M. N. Y. H. Go; Ivo A. M. J. Broeders; Karel J. van Erpecum

• Publisher: John Wiley and Sons
• Year: 2005
• Tongue: English
• Weight: 208 KB
• Volume: 41
• Category: Article
• ISSN: 0270-9139
• DOI: 10.1002/hep.20616

✦ Synopsis

Acute pancreatitis is a severe complication of gallstones with considerable mortality. We sought to explore the potential risk factors for biliary pancreatitis. We compared postprandial gallbladder motility (via ultrasonography) and, after subsequent cholecystectomy, numbers, sizes, and types of gallstones; gallbladder bile composition; and cholesterol crystallization in 21 gallstone patients with previous pancreatitis and 30 patients with uncomplicated symptomatic gallstones. Gallbladder motility was stronger in pancreatitis patients than in patients with uncomplicated symptomatic gallstones (minimum postprandial gallbladder volumes: 5.8 ؎ 1.0 vs. 8.1 ؎ 0.7 mL; P ‫؍‬ .005). Pancreatitis patients had more often sludge (41% vs. 13%; P ‫؍‬ .03) and smaller and more gallstones than patients with symptomatic gallstones (smallest stone diameters: 2 ؎ 1 vs. 8 ؎ 2 mm; P ‫؍‬ .001). Also, crystallization occurred much faster in the bile of pancreatitis patients (1.0 ؎ 0.0 vs. 2.5 ؎ 0.4 days; P < .001), possibly because of higher mucin concentrations (3.3 ؎ 1.9 vs. 0.8 ؎ 0.2 mg/mL; P ‫؍‬ .04). No significant differences were found in types of gallstones, relative biliary lipid contents, cholesterol saturation indexes, bile salt species composition, phospholipid classes, total protein or immunoglobulin (G, M, and A), haptoglobin, and ␣-1 acid glycoprotein concentrations. In conclusion, patients with small gallbladder stones and/or preserved gallbladder motility are at increased risk of pancreatitis. The potential benefit of prophylactic cholecystectomy in this patient category has yet to be explored. (HEPATOLOGY 2005;41:738-746.) A cute pancreatitis is a severe complication of gallstone disease, with considerable mortality (5%-10%). 1 The annual incidence of acute pancreatitis in gallstone patients falls between 0.05% and 1%. 2,3 According to data from the National Information System on Hospital Care, the incidence of acute pancreatitis in The Netherlands increased by 30% in the period 1985-1995 4 and further increased by 35% in the period 1997-2002 (W. Hoogen Stoevenbelt, personal communication, 2004). Underlying causes could be increased gallstone prevalence, possibly related to increased prevalence of overweight and/or a higher proportion of elderly subjects in the population.

Limited data are available on the risk factors for pancreatitis in gallstone patients. Patients with small gallbladder stones might be at increased risk for pancreatitis. 5,6 In up to 70% of patients with acute "idiopathic" pancreatitis, cholesterol crystals have been found via polarizing light microscopy of bile obtained during endoscopic retrograde cholangiopancreatography or aspirated bile. 7,8 Cholesterol crystals might cause a functional obstruction at the sphincter of Oddi by inducing papillitis, spasm, or stenosis. 9 Potential factors promoting cholesterol crystallization in the aqueous phase include high cholesterol saturation index, hydrophobic bile salts, and pronucleating biliary proteins. Also, patients with low amounts of biliary phospholipids exhibit fast crystallization due to deficient ca-Abbreviation: CCK, cholecystokinin.