Gall bladder volume and contractility in type 2 diabetes mellitus

Ugbaja CA, Ayoola OO, and Idowu BM, Departments of Radiology; Ikem R T, Internal Medicine (Endocrinology Unit), Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. Correspondence to: Michael Idowu. Email: ibmcontacts@gmail.com. Telephone: +2348032164229. Introduction Diabetes mellitus is a syndrome of chronic hyperglycaemia due to relative insulin deficiency, resistance or both.1 At least 220 million people worldwide are affected by this disease, with a projected rise to 440 million by the year 2030.1 The chronic hyperglycaemia causes longterm damage to various body organs including the eyes, kidneys, nerves, heart, and blood vessels.2,3 The gall bladder is one of the organs that may be affected by autonomic neuropathy because vagal parasympathetic fibres maintain its tone and influence its emptying.4–6 An increased incidence of cholesterol gallstones, inadequate emptying, and increased volume have been reported as gall bladder changes associated with type 2 diabetes.6,7 The purpose of this study was to establish sonographic abnormalities in the gall bladder of type 2 diabetes patients in Nigeria, and to determine any correlation between these changes and duration of disease. Patients and methods This prospective, non-randomised, case-control study was carried out in the Radiology Department of a tropical university teaching hospital from March 2010 to January 2011. Informed consent was obtained from all the participants. The study group comprised 100 type 2 diabetic patients with and without clinical evidence of neuropathy (50 of each), as well as 50 healthy, ageand sex-matched, non-diabetic controls asymptomatic of gall bladder disease or other systemic illness that may affect the gall bladder. The subjects were recruited consecutively from the Endocrinology Clinic and ward of the hospital. Patients with type 1 diabetes, liver disease, or biliary disease were excluded. Diabetes was diagnosed according to American Diabetic Association criteria.8 The age, sex, and duration of diabetes of each subject were documented. The presence of neuropathy was ascertained on physical examination by an endocrinologist. Autonomic neuropathy was tested for by taking the pulse rate at rest and repeating it while the patient performed a Vasalva manoeuvre. The subjects were then required to breathe normally and after a period of 5–10 minutes the pulse rate was taken again. The pulse rate is expected to normalise after this period to its resting state. Autonomic neuropathy was considered present when a subject had at least two abnormal cardiovascular reflexes, i.e. impaired heart rate response to Vasalva manoeuvre, standing, or deep inspiration. A postural fall in the systolic blood pressure of ≥30 mmHg when the patient changed from supine to an upright position also indicated autonomic neuropathy.9 Peripheral neuropathy was considered present when there was impairment of fine touch, pinprick sensation, vibration and position sense; or deep tendon reflexes. Based on these, the study subjects were divided into two groups: those without evidence of neuropathy and those with evidence of neuropathy. Fifty study subjects, consecutively recruited, were selected for these groups. Abdominal ultrasonography was performed with a Mindray® DC-6 ultrasound machine (Shenzhen Mindray Bio-medical Electronics, Nanshan, Shenzhen, China) with a 3.5–5.0 MHz curvilinear transducer. Sonographic examination was performed after an overnight fast and repeated 45 minutes after ingestion of a fatty meal (bread and butter of about 40–50 g). Each subject was scanned in the supine position. The transducer was placed longitudinally and beveled cephalad in the right hypochondrion to obtain the maximal Abstract The aim of this study was to sonographically evaluate gall bladder changes in type 2 diabetes. One hundred type 2 diabetic subjects (50 with neuropathy and 50 without neuropathy) and 50 healthy controls underwent sonographic evaluation of the gall bladder. Fasting and postprandial gall bladder volumes (FGBV and PPGBV) were measured, and the gall bladder contractility index (GBCI) calculated. The presence of gallstones was also noted. It was found that patients with diabetic neuropathy had a significantly higher FGBV and PPGBV, and lower GBCI, compared with diabetic patients without neuropathy; PPGBV and GBCI also differed significantly from non-diabetic controls. Gallstones were present in 22% of diabetic patients with neuropathy, in 10% of those without neuropathy, and in 8% of controls. We conclude that diabetic patients with neuropathy have significant abnormalities of gall bladder function, presumably due to autonomic nerve dysfunction. These patients also have a higher prevalence of gallstones, suggesting that ultrasound screening may be worthwhile.