10 g of fat per day may keep gallstones away

1880

SELECTED

blood

volume

GASTROENTEROLOGY

in the heart

cavities,

of blood

contained

i.e., the volume points

SUMMARIES

that are temporally The aortic

in cirrhotics

as well as in controls.

1990;99:766-779) patients tricle

bifurcation

1988;95:1658-1663)

have reported

diameter.

tained chambers

However,

is only

from

the heart

Rector

and Hossak

et al. (Gastroenterology

increased a close

look

with

Moreover,

detection

ascites

changes

ment

by

correct

the configuration

standard

referred

Sweeting

provide

plasma

clearance

concentrations

(Life Sci 1990;47:

clearance

by the

liver

1992;16:790-793)

are the result 1173-l

and

180). Thus,

splanchnic

may counteract

rhosis,

resulting

more,

the missing

relation

plasma

to ANF

not

be

the findings

convincing

points

to influence

are

in cir-

Further-

diuretics,

which

Moreover,

are the

394) men-

1992;I 6: 1389-l

of a marked

under-

cirrhosis. vascular

increased

1984;1:1480-1483;

of ANF

release

levels of ANF.

et al. (Hepatology

We agree that there is no good present vasodilators

and

(Hepatology

concentrations.

tioned by Dr. Sweeting support our contention

in systematic

release

alterations

of ANF

received

the circulating

in decompensated

of both

in our study may in part be due

58% of the patients

ANF data by Angeli

crease

of

measure-

may

circulation

changes

in unchanged

to the fact that

filling

low accu-

volume

Altogether,

do not

that

our data.

ANF

likely

be recalled

procedures

199O;I 1:662-667).

to by Dr.

with our

if the presence

of the heart,

echocardiographic

(Hepatology

against

Thus,

ob-

(Hepatology

has a relatively

1983;52:1249-1257).

ven-

values

compared

it should

by echocardiography

racy (Am J Cardiol

in

in the cardiac

controls

decrease volume

at their

increase

a low difference

(300 mL).

in right

Gut

resistance, in

patients

explanation

for the de-

but a number

of potent

with

1988;29:1167-1172;

cirrhosis

(Lancet

J Hepatol

1991;12:

I 18-l 23). Finally, likely,

Several

the

enhanced

sympathetic

of central

nervous

and arterial

activity underfilling,

is, most not an

factor.

DR. DR. DR.

FLEMMING

BENDTSEN

ALEXANDER

NIELS JUEI. DR.

HELMER

DR. THORKILD

gallbladder

motility,

well as decreased normal

L. GERBES CHRISTENSEN

10 g OF FAT PER DAY GALLSTONES AWAY

MAY

other

7 with

weight

such

in response

14 healthy

a high

(percent

100.9 kg (146%), respectively. enrollment.

None

other

been

night

volume

The initial

Subjects consumed

subject

lated by dividing

the minimal

which

varied

of l-6

weeks.

consumption

Serial

intervals

of the liquid

of emptying reached

calculations

with

content.

was calcuby the initial

included

the rate

and the time to reach half the maximal

(t%).

The response

of the obese and normal-weight

in the dietary

showing

fat content

70%80%

mal stimulation

with

responded

restored

gallbladder

did not differ fat stimuli

emptying

after maxi20 g fat,

poor gallbladder

A test meal containing

emptying

to a maximal

con10 g fat

level. Consis-

the two body mass groups

significantly

in their

as far as rate constant

to

identical.

meal containing

with similarly

to a low fat stimulus.

subjects

was virtually

gallbladder

the liquid

traction

response

also

to the various

of emptying

and emptying

tM were concerned.

RING-LARSEN I. A. SDRENSEN

Comment.

Alteration

KEEP

of Medicine and Radiology, VA Medical Center and University of Minnesota, Minneapolis, Minnesota; and Sandoz Nu-

impaired

Minnesota).

Gallbladder subjects.

Hep-

with

an increased

emptying,

relationship

(Dig Dis Sci 1988;33:4-9; Intern

Med 1992;231:

impairment the result Animal gallbladder

studies

area

emptying

release

response

Marzio

to any volume

1779-l

et al. postulated

785; J

that this

in obese individuals

of cholecystokinin a more

stasis and CCK stimulation.

high cholesterol

as well as

gallbladder 1990;99:

and

is asso-

(CCK)

may be or dimin-

to CCK (Dig Dis Sci 1989;33:4-9).

have shown diet develop

et al. (Gastroenterology

obese

volume

in

et al.

be attributed

and

Gastroenterology

123-127).

Stone

that obesity

could

to

factor

between

gallbladder

surface

in postprandial of defective

differences

of which

body

Although

have observed

baseline

neither

between

ished gallbladder

It is commonly accepted that cholesterol cholelithiasis is increased as much as three- to fourfold in obese individuals. Moreover, there is evidence that persons undergoing rapid weight loss are also at increased risk for formation of gall-

others

in response

is a recognized

gallstones.

significant

subjects,

contractility

understood,

of cholesterol

no statistically

normal-weight ciated

in gallbladder

incompletely

the pathogenesis found

emptying stimuli in obese and normal-weight atology 1992;15:795-758.

after over-

at 20 minute

volume

Other

each subject

made

phenylalanine

at intervals

following

volume.

variations While

or

by real-time

from

meals,

The percentage

of emptying

emptying

before

sludge,

mL liquid meal over 5 min-

were measured

stimulus.

gallbladder

biliary ultra-

subjects

occasions.

fat, and

was tested

for a total of 2 hours

constant

all

obtained

a 210-300

volumes

emptying

body

using the sum-of-cylinders

were six such liquid

to carbohydrate,

Each

and the

mean

screening in

of measurements

on four separate

gallbladder

kg/m2)

Their

was measured

volume

an average

utes. There

as

stimuli.

7 of them with a

of gallstones,

and calculated

fasting

respect

Initial

evidence

gallbladder

represented

stasis,

conditions.

ultrasonography technique.

of

was 68.6 kg (95%) and

performed

had

pathological

Baseline

kg/m*).

ideal body weight)

had

in bile lith-

to feeding

subjects,

BMI (>33

No. 6

abnormalities

as starvation-induced

contractility

sonography

Stone BG, Amel H], Peterson FJ, and Gebhard RL (Departments

Minneapolis,

to increases

These include

body mass index (BMI) (BMI, <25.5

diet, although

Corporation,

contributing

tent with these observations, DR. JENS H. HENRIKSEN

trition

factors

have been studied.

both groups

a consequence

etiological

stones. ogenicity

Stone et al. recruited

diameters

increase

the average compared

(Gastroenter-

left atrial

I99 1;13: 1261). This is indeed in ECBV

to the aortic

Rector

taking

16 mL

tree,

tree up to

but this was applied

and a nonsignificant

by echocardiography

arterial

the arterial

is arbitrary,

and

with cirrhosis

and central

within

equidistant

bifurcation. ology

lungs,

Vol. 104,

gallstones

1983;85:

168-I

direct

relationship

Prairie

between

dogs that are fed a

at predictable 74) studied

rates.

prairie

Doty

dogs fed

June 1993

either

SELECTED SUMMARIES

a control

(low cholesterol)

der contraction analyzed

in response

to the following

in relation

cholesterol stones;

crystals difference

cholesterol

factors:

of crystals

with

in gallbladder

and control-fed

tals were present

(53% and 54% contraction, emptying

mals with

cholesterol

virtually

the same

stones

increased

showing

increased

pressure

Other

1982;82:

of gallstones

that

ministration

1308-l developed

one of eight

gallstones

emptying.

10 weeks

cholesterol

gallstones

operated

animals.

The authors

incidence

of gallstones

cause cholesterol to he high

sludge

weeks

of TPN.

These studies reduced

calorie

and high cholesterol

contractility

oxycholic

acid

found

patients

and reduced

and after

(Gastroenterology with

percent

abnormalities

before

of emptying

of the gallbladder

hyper-

Obesity

affects

15%20%

in dieting.

and those undergoing der disease. uals weight

than

The saturation in sex-

and

with

1779-l

6

of

ursode-

785).

fasting

They volume

The motility

unchanged

after dissolu-

rapid weight

with

loss carries

et al., who

a 25% incidence

weeks

(Arch

Intern

controls.

stabilization

a decrease

51 subjects of de novo

at a stable

thank

Drs.

Levenson

hut wish to make several on gallbladder 1988;95:

showing

gallbladder

decreased

emptying

study

did not find a significant

obese

versus

1992;231:

nonobese

123-l

are quoted

in emptying

or nondiabetics

Although

gallstone

Med 1989;140:1750-1753).

formation

one

fraction

(J Intern

in Med

(Gastroen-

The other

indicate

gallbladder

that

stimulus.

formation

bile. diets, 8

greater emptying

we tested than

We interpret

from

1990;98:

very large fasting

is not a substantial

as has Marzio

This

did not differ

gallhlad-

our data to risk factor

for

per se.

and virtually

et al. (Dig Dis Sci 1988;33:4-9), fat-free

meal was similar during

stasis may he one lithogenic Because

reported

stasis

in obesity,

of this question

(Gastroenterology

(Dig Dis Sci 1988;33:4-9).

formation

study

studies

emptying

subjects

1000-1007).

gallstone

saturation,

over

and their

der volumes

tying

gradual

of lithogenic

on weight-reduction

47 kg/ma, but nonobese

large

We did observe,

body weight

cholesterol

BMI averaging similarly

that a low protein

in obese individ-

‘I wo other

as

However,

27) and one paper did not study obesity

1990;99:1779-1785).

pre-

and nondiabetics

papers

in obesity.

difference

diabetics

no

confirming

diabetics

76). Three

for their

We observed

fraction,

weight

170-t

and Fromm

clarifications.

emptying

in obese and normal

(Gastroenterology

stone

weight

risk for gallhlad-

at a reduced

in hiliary

the risk of development

studied

found

Many of these individ(obese

loss) are at increased

age-matched

M.D.

have observed decreased gallbladder emptying fraction in obese individuals. One study involved massively obese individuals with

index of bile is greater

loss and a prolonged

can be associated Liddle

weight

are

treatment

of the gallbladder.

populations

that

terology

of Americans.

Both

The authors

vious work

as a neces-

in the setting

Reply.

effect of obesity

tion of the gallstones. uals engage

programs

of the gallbladder. I>. E. LEVENSON,

comments

developed

to 100% after

had a greater

remained

of the

to prevent

diets. Festi et al. studied

1990;99:

gallstones

adjustments

in weight-loss

are

formation

he sufficient

understimulation

gall-

that

in the

in all groups.

stasis develops

guidelines

simple

of fat per day may possibly of gallstones

underline

in impaired

H. FROMM, M.D.

of TPN (Gastroenter-

cholelithiasis

by relatively

loss is the

of gallstones

de-

parenteral

increased

that gallbladder

for cholesterol

gallbladder that

figure

specific

rel-

meal produces

(1) further plays

of conditions

by dietary

of weight

data

in the prevention

accompanied

has been found

total

These

important

the development

bile stasis, he-

50% of these patients

in a number

clinical

as well as for

to a liquid

understimulation

the

the dietary

Of particular

in sham-

that this difference by gallbladder

long-term

This

indicate

sary precondition

to those

likely to prove

that an

In addition,

hyperalimentation

(2) provide

signifi-

et al. indicates

fast for the purpose

and

received

in the pa-

regarding

contraction.

emptying.

emptying,

who

statistically

in obesity.

of 10 g fat added

role dietary

diet. Ten grams

animals

administration

equal

4-6 weeks after initiation

1983;84:1012-1019).

the

impairment

of eight

and cholecystitis

In one study,

ology

abolished

of bile was similar

receiving

(TPN).

gallbladder

contend

of cholelithiasis

diet. Ad-

1982;82:1308-1313).

by atropine

was mediated

in patients

alimentation

a lithogenic

(atropine)

in numbers

supersaturation

The incidence

bladder

diet, eight

followed

veloped

gallbladder

animals

that underwent

liquid

that a minimum

in the

is not a likely cause for

information

on parenteral

on modified

the critical

(Gastroenterology

that had sphincterotomy

those finding

maximal

Gastroen-

with a consequent

on a high-cholesterol

in

and gall-

new

for gallbladder

for patients

by Stone

contractility

ur-

J Med No gall-

decreased

was not

of gallstones

important

requirements evance

of Oddi

volume

incidence

provides

in the subjects

this

study

in gallbladder

2 months.

incidence

However,

the present

defect

the increased study

led to

aspirin.

stone

Engl

of the subjects

within

formed

The

weight-

placebo,

(New

percent

gallstones

crystals

in a rapid

receiving

respectively

Twenty-six

acid.

In summary,

into groups

aspirin,

developed

taking

intrinsic

cystic

in turn

and

or cholesterol

with this, the incidence

despite agent

was gall-

of, the gallbladder.

1981;81:663-667;

effect of sphincterotomy

of gallbladder

cant.

(10% and

of the sphincter

3 13). Associated Only

which

in gallbladder

of an anticholinergic

protective

both

to CCK,

ablation

tients

crystals,

group

stones

In condefect

acid,

ursodeoxycholic

crys-

without

with

placebo

et al., obese subjects

were randomized

sodeoxycholic

in the ani-

and gallstones

emptying

in a decrease

decreased.

sphincterotomy

After

crystals

bile stasis (Gastroenterology

terology

had crystals

loss program

1988;319:1567-1572).

gall-

the high

impaired

In the animals

in response

found

dogs resulted

bladder

both

between

the emptying

that

of

was no

respectively).

However,

in, but decreased

authors

prairie

crystals.

respectively).

duct resistance

without There

was significantly

in the animals

as in those

9% contraction,

of crystals gallstones.

as long as no cholesterol

trast,

gallbladder

of CCK was

(1) diet; (2) absence

contraction

animals

In a study by Broomfield

diet. Gallblad-

infusion

in bile; (3) presence

and (4) presence

significant

or cholesterol-rich

to a 30.minute

1881

liquid

1 g fat rapid factor

meal is a poor emp-

to meals

used in reports

weight-loss

diet.

of

Thus,

for the very low fat diet studied.

0, 4, 10, and 20 g of fat, we can only say that

4 g, hut no more

than

10 g, of fat was able to restore

to maximal. ROGER

I,. GERHARD,

b1.D.