RNA Sequencing Analysis of Gene Expression by Electroacupuncture in Guinea Pig Gallstone Models

Background. Clinical studies have shown that electroacupuncture (EA) promotes gallbladder motility and alleviates gallstone. However, the mechanism underlying the effects of EA on gallstone is poorly understood. In this study, the mRNA transcriptome analysis was used to study the possible therapeutic targets of EA. Methods. Hartley SPF guinea pigs were employed for the gallstone models. Illumina NovaSeq 6000 platform was used for the RNA sequencing of guinea pig gallbladders in the normal group (Normal), gallstone model group (Model), and EA-treated group (EA). Differently expressed genes (DEGs) were examined separately in Model vs. Normal and EA vs. Model. DEGs reversed by EA were selected by comparing the DEGs of Model vs. Normal and EA vs. Model. Biological functions were enriched by gene ontology (GO) analysis. The protein-protein interaction (PPI) network was analyzed. Results. After 2 weeks of EA, 257 DEGs in Model vs. Normal and 1704 DEGs in EA vs. Model were identified. 94 DEGs reversed by EA were identified among these DEGs, including 28 reversed upregulated DEGs and 66 reversed downregulated DEGs. By PPI network analysis, 10 hub genes were found by Cytohubba plugin of Cytoscape. Quantitative real-time PCR (qRT-PCR) verified the changes. Conclusion. We identified a few GOs and genes that might play key roles in the treatment of gallstone. This study may help understand the therapeutic mechanism of EA for gallstone.

1163 Genome-wide Association Study Reveals 55 Loci Associated with Gallstone Disease

Aim Gallstones have a prevalence of 20-40% in European populations and cause significant morbidity. Gallstones form from cholesterol and calcium bilirubinate and knowledge of genetic determinants remains incomplete. A genome-wide association study (GWAS) was performed to identify determinants of gallstones. Method A GWAS of 16,356,211 single nucleotide polymorphisms (SNPs) for 28,627 cases and 348,373 controls of European ancestry in the UK Biobank was undertaken. A logistic regression with additive allelic dosage was performed (significance: P < 5*10-8). Functional annotation and linkage disequilibrium clumping were performed to reveal distinct loci. Lead SNPs were investigated by linear regression for association with plasma lipids, liver enzymes and blood count markers. Results 55 lithogenic loci were identified of which 27 are novel. Functional annotation revealed genes involved in metabolism of cholesterol, glucose, bile acids and bilirubin with corresponding changes in serum biomarkers caused by those lithogenic alleles. Several novel variants did not alter cholesterol or other biomarkers. Lithogenic variants within genes controlling intra- and paracellular transport may govern biliary composition (PCDHB4, NUP153, CLDN7) and promote lithogenic bile. Variants within genes which may influence gallbladder motility (ANO1, TMEM147) and cholangiocyte ciliogenesis (TBC1D32, ADAMTS20, DYNC2LI1, HNF1B) may promote gallstone formation through reduced biliary flow. Conclusions We identified 27 novel associations with gallstones. Impact of lithogenic alleles on serum biomarkers was highly variable demonstrating that gallstone formation is partially driven by pathways which do not influence cholesterol, glucose or bilirubin metabolism. Variants within genes that may influence biliary composition, bile flow and gallbladder motility represent new targets for research into gallstones.

An Update on the Lithogenic Mechanisms of Cholecystokinin a Receptor (CCKAR), an Important Gallstone Gene for Lith13

The cholecystokinin A receptor (CCKAR) is expressed predominantly in the gallbladder and small intestine in the digestive system, where it is responsible for CCK’s regulation of gallbladder and small intestinal motility. The effect of CCKAR on small intestinal transit is a physiological response for regulating intestinal cholesterol absorption. The CCKAR gene has been identified to be an important gallstone gene, Lith13, in inbred mice by a powerful quantitative trait locus analysis. Knockout of the CCKAR gene in mice enhances cholesterol cholelithogenesis by impairing gallbladder contraction and emptying, promoting cholesterol crystallization and crystal growth, and increasing intestinal cholesterol absorption. Clinical and epidemiological studies have demonstrated that several variants in the CCKAR gene are associated with increased prevalence of cholesterol cholelithiasis in humans. Dysfunctional gallbladder emptying in response to exogenously administered CCK-8 is often found in patients with cholesterol gallstones, and patients with pigment gallstones display an intermediate degree of gallbladder motility defect. Gallbladder hypomotility is also revealed in some subjects without gallstones under several conditions: pregnancy, total parenteral nutrition, celiac disease, oral contraceptives and conjugated estrogens, obesity, diabetes, the metabolic syndrome, and administration of CCKAR antagonists. The physical–chemical, genetic, and molecular studies of Lith13 show that dysfunctional CCKAR enhances susceptibility to cholesterol gallstones through two primary mechanisms: impaired gallbladder emptying is a key risk factor for the development of gallbladder hypomotility, biliary sludge (the precursor of gallstones), and microlithiasis, as well as delayed small intestinal transit augments cholesterol absorption as a major source for the hepatic hypersecretion of biliary cholesterol and for the accumulation of excess cholesterol in the gallbladder wall that further worsens impaired gallbladder motor function. If these two defects in the gallbladder and small intestine could be prevented by the potent CCKAR agonists, the risk of developing cholesterol gallstones could be dramatically reduced.

Comparative Study Gallbladder Contractility Index Using Ultrasound in Patients with and without Liver Cirrhosis

Liver cirrhosis leads to impairment of gallbladder contractility resulting in bile stasis and facilitate the development of gallstones that will aggravate the clinical symptoms of the patients. The gallbladder contractility index is an indicator of gallbladder motility measured using ultrasound as the radiological choice of modality. This study aims to determine differences in the gallbladder contractility index using ultrasound in patients with and without liver cirrhosis. This study was an observational study of comparative analytic with cross-sectional design with sampling conducted by consecutive admissions sampling at Dr. Hasan Sadikin General Hospital Bandung from December 2017 to February 2018. Statistical analysis than performed by using an independent t test to find out the difference of gallbladder contractility index in patients with and without liver cirrhosis. A total of 22 subjects, 12 men, 10 women, with the youngest 37 years old and the oldest 70 years old. The result of the study was obtained mean fasting gallbladder volume (35.56±22.16 mL) and postprandial (21.25±16.08 mL) in patients with liver cirrhosis higher than without liver cirrhosis with mean fasting gallbladder volume (16.50±4.14 mL) and postprandial (5.44±2.10 mL). The average gallbladder contractility index on patients with liver cirrhosis (41.64±24.52%) smaller than without liver cirrhosis (66.73±9.19%). The result of the statistical test showed that there was a significant difference in the gallbladder contractility index on patients with liver cirrhosis than without liver cirrhosis (p=0.007, p≤0.05). In conclusion, there was a significant difference in the gallbladder contractility index that measured by using ultrasound between the patients with and without liver cirrhosis. PERBEDAAN INDEKS KONTRAKTILITAS KANDUNG EMPEDU MENGGUNAKAN ULTRASONOGRAFI PADA PENDERITA SIROSIS HATI DAN TANPA SIROSIS HATISirosis hati menyebabkan gangguan indeks kontraktilitas kandung empedu yang mengakibatkan stasis cairan empedu dan memudahkan kejadian batu empedu yang akan memperberat gejala klinis pasien. Indeks kontraktilitas kandung empedu merupakan indikator motilitas kandung empedu yang diukur menggunakan ultrasonografi (USG) sebagai modalitas pilihan radiologi. Penelitian ini bertujuan mengetahui perbedaan indeks kontraktilitas kandung empedu menggunakan ultrasonografi pada pasien sirosis hati dan tanpa sirosis. Penelitian ini menggunakan studi observasional analitik komparatif dengan rancangan cross-sectional dan pengambilan sampel dilakukan secara consecutive admissions sampling di RSUP Dr. Hasan Sadikin Bandung dari bulan Desember 2017 hingga Februari 2018. Uji statistik menggunakan independent t test. Subjek penelitian berjumlah 22, laki-laki 12 dan perempuan 10, serta usia termuda 37 tahun dan tertua 70 tahun. Hasil penelitian didapatkan volume rerata kandung empedu puasa (35,56±22,16 mL) dan pascaprandial (21,25±16,08 mL) pada pasien sirosis hati lebih besar daripada tanpa sirosis hati dengan volume rerata kandung empedu puasa (16,50±4,14 mL) dan pascaprandial (5,44±2,10 mL). Indeks kontraktilitas rerata kandung empedu penderita sirosis hati (41,64±24,52%) lebih rendah dibanding dengan tanpa sirosis hati (66,73±9,19%). Hasil uji statistik menunjukkan terdapat perbedaan bermakna antara indeks kontraktilitas kandung empedu penderita sirosis hati dan tanpa sirosis hati (p=0,007; p≤0,05). Simpulan, terdapat perbedaan bermakna antara indeks kontraktilitas kandung empedu menggunakan USG pada penderita sirosis hati dan tanpa sirosis hati.

GIP and GLP-1 Receptor Antagonism During a Meal in Healthy Individuals

Context The actions of both endogenous incretin hormones during a meal have not previously been characterized. Objective Using specific receptor antagonists, we investigated the individual and combined contributions of endogenous glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP-1) to postprandial glucose metabolism, energy expenditure, and gallbladder motility. Design Randomized, double-blinded, placebo-controlled, crossover design. Setting On four separate days, four liquid mixed meal tests (1894 kJ) over 270 minutes (min). Patients or Other Participants Twelve healthy male volunteers. Interventions Infusions of the GIP receptor antagonist GIP(3–30)NH2 (800 pmol/kg/min), the GLP-1 receptor antagonist exendin(9–39)NH2 (0–20 min: 1000 pmol/kg/min; 20–270 min: 450 pmol/kg/min), GIP(3–30)NH2+exendin(9–39)NH2, or placebo/saline. Main Outcome Measure Baseline-subtracted area under the curve (bsAUC) of C-peptide. Results Infusion of GIP(3–30)NH2+exendin(9–39)NH2 significantly increased plasma glucose excursions (bsAUC: 261 ± 142 mmol/L × min) during the liquid mixed meals compared with GIP(3–30)NH2 (180 ± 141 mmol/L × min; P = 0.048), exendin(9–39)NH2 (171 ± 114 mmol/L × min; P = 0.046), and placebo (116 ± 154 mmol/L × min; P = 0.015). Correspondingly, C-peptide:glucose ratios during GIP(3–30)NH2+exendin(9–39)NH2 infusion were significantly lower than during GIP(3–30)NH2 (P = 0.0057), exendin(9–39)NH2 (P = 0.0038), and placebo infusion (P = 0.014). GIP(3–30)NH2 resulted in significantly lower AUCs for glucagon than exendin(9–39)NH2 (P = 0.0417). Gallbladder ejection fraction was higher during GIP(3–30)NH2 compared with placebo (P = 0.004). For all interventions, energy expenditure and respiratory quotient were similar. Conclusions Endogenous GIP and GLP-1 lower postprandial plasma glucose excursions and stimulate insulin secretion but only endogenous GIP affects gallbladder motility. The two incretin hormones potentiate each other’s effects in the control of postprandial glycemia in healthy men.

Retroperitoneal perforation of a duodenal diverticulum containing a large enterolith after Roux-en-Y bypass and cholecystectomy

Roux-en-Y gastric bypass (RYGB) is one of the most frequently performed bariatric procedures worldwide. The postoperative incidence of cholelithiasis after RYGB is higher than in the general population (30% vs. 2–5%), because the altered anatomy may lead to impaired gallbladder motility and biliary stasis. We report the case of a 47-year-old female who presented 9 years after RYGB and cholecystectomy with acute pain in the upper abdomen because of a retroperitoneal perforation of a duodenal diverticulum. Intraoperatively, a huge enterolith was found in the diverticulum and removed via duodenotomy. We claim that the stone grew during the sober states as the bile accumulated locally, because the gall bladder has already been removed and no duodenal food passage remained. This acute and life-threatening situation was successfully managed by operation. Consequently, a duodenal diverticulum has to be considered as a possible but very rare complication after RYGB and cholecystectomy.

Hymecromone in the treatment of biliary diseases: options and prospects

Pharmacological treatment of biliary dyskinesia is to a great extend aimed at reducing smooth muscle spasms and recovering gallbladder motility. Prolonged courses of myotropic antispasmodics are used as the basic therapy. Hymecromone is notable to its predominantly spasmolytic action on the bile ducts and the sphincter of Oddi without any significant effect on the gallbladder contractility, and therefore it is safe in patients with cholecystolythiasis. Hymecromone decreases the severity of cholestasis, prevents the formation of cholesterol crystals and therefore, the development of cholelithiasis. It is effective both as a monotherapy and in combination with ursodeoxycholic acid for treatment of biliary sludge and prevention of the progression of gallstone disease. Its local action on the biliary tract and low systemic bioavailability after oral intake increases the treatment safety. Experimental studies demonstrated the antifibrotic and antihyperglycaemic effect of the drug. Key words: biliary dysfunction, cholelithiasis, sphincter of Oddi dysfunction, biliary sludge, hymecromone, ursodeoxycholic acid