Cholelithiasis and Cholecystitis: DISCUSSION

Cholelithiasis and Cholecystitis DISCUSSION

More than 95% of biliary tract diseases are attributable to cholelithiasis. Gallstones afflict 10-20% of the adult population in developed countries, including the United States. Experts estimate that 16-22 million people in the United States have gallstones—as many as one in every 12 Americans. Most people with gallstones do not know that they have them and experience no symptoms. About 1 million new patients annually are found to have gallstones, of which approximately 600,000 undergo cholecystectomy.

The current mean prevalence in Europe obtained from autopsy studies is 18.5%, with the lowest prevalence being reported from Ireland (5%) and the highest from Sweden (38%).

In the United Kingdom, gallstones are found in approximately 10% of women in their 40s, increasing to 30% after the age of 60 years.
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Cholelithiasis and cholecystitis are not as common in Africa as in Europe and North America. However, with the changing lifestyle and dietary habits, especially increased intake of fat and refined sugar, there will continue to be an increase in the incidence of cholelithiasis and cholecystitis in Africans.

In a personal communication between Burkitt and Parnis in 1963, it was reported that only one case of gallbladder disease was operated upon in an African patient in Uganda over a period of 17 years. In a five-year review from Ibadan in 1964, 35 patients—an average of seven per year—were operated upon for inflammatory disease of the gallbladder. At the University College Hospital, in a three-year period from June 1974 to May 1977, 19 cases of inflammatory disease of the gallbladder were operated upon. In this study, there was an average of nine per year.

Bremner analyzed admission to a hospital serving an exclusively black population and found a sixfold increase in the hospital prevalence of cholecystectomy from 1-2/100,000 in 1956 to 12/100,000 in 1969. These changes were attributed to a rapidly urbanizing population and the associated changing diet, especially increased consumption of fat.
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Despite the gradual increase in incidence, it is still uncommon compared to Europe and North America. The only recent exceptional report from the African continent is from Ethiopia. In this (llorin) study, 46 patients had cholecystectomy for cholelithiasis and cholecystitis in five years. This gives an average of nine per year. In the first three years in llorin, 18 (39.1%) cases were seen, but in the next two years 28 (60.9%) patients had cholecys­ tectomy for inflammatory gallbladder disease.

The aphorism that gallstones occur in fair, fat, fertile females of 40 is only an approximation to the truth; people of either sex, any age, color, shape or fecundity may have gallstones. In this study, though 52.2% of the patients were between the ages of 40 and 59 years, 39.1% of the patients were <40 years of age. As in most previous studies, there is a female preponderance—male:female was 1 to 4.8. It is, however, noteworthy that in patients <30 years of age, the male:female was 3:2, but for patients age >40 years the maleifemale ratio was 1:13. This finding is different from that in developed countries where, with advancing age, the incidence in males equaled that of females. It is difficult to explain this observation. It may be that the fat intake is higher with advancing age in this population. Further study will be required to confirm this.
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Obesity and parity status are usually identified as predisposing factors. BMI, also known as the Quetelet index, is far more commonly used to define obesity and has been found to closely correlate with the degree of body fat in most settings. While several acceptable classifications and definitions exist for degree of obesity, the most widely accepted is the World Health Organization (WHO) criteria based on BMI. Under this convention for adults, grade-1 overweight (commonly called overweight) is a BMI of 25-29.9 kg/m2. Grade-2 overweight (commonly called obesity) is a BMI of 30-39.9 kg/m2. Grade-3 overweight (commonly called severe or morbid obesity) is a BMI of >40. Studies have shown that risk may triple in women who have a BMI of >32 compared to those with a BMI of 24-25. Risk may increase seven-fold in women with a BMI of >45 compared to those with a BMI of <24. In this study, only four (8.7%) of our patients had BMI of >30. All the remaining patients had BMI of 20-24.9. Obesity may not be a predisposing factor to gallstone formation in these patients.

In obese people, cholesterol secretion by the liver is augmented, and this leads to further super saturation of the bile with cholesterol.

Thirty-two (84.2%) of the female patients have had >2 children as at the time of presentation. This further confirms that multiparity may play an important role. This may be as a result of estrogenic influences, which increases the expression of hepatic lipoprotein receptors and stimulates hepatic hydrox-ymethylglutaryl coenzyme A (HMG CoA) reductase activity. Thus, both cholesterol uptake and biosynthesis are increased.
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There is a need for increased awareness on the part of healthcare providers to minimize delay in diagnosis, especially with many patients in this series being treated for peptic ulcer disease for a fairly long time. With the availability of noninvasive, inexpensive and simple diagnostic tools, such as ultrasound, the advantage should be readily utilized. The sensitivity and specificity of ultrasound in the diagnosis of gallstone and cholecystitis has been put at 98%. Ultrasound is not only the most sensitive and specific test for the detection of gallstones, but it also provides information about the size of the bile ducts as well as the status of the liver parenchyma and the pancreas.

Even though gallstones date back to antiquity and were observed in the mummified corpses of the Egyptian dynasty, it was only in 1882 that Carl Langenbuch performed the first open cholecystectomy in Berlin. He did more than remove the first gallbladder—he enunciated a principle that: “the gallbladder needs to be removed not because it contains stones but because it forms them.”

All patients in this series had open cholecystectomy. At the time of this study, facilities for laparoscopic cholecystectomy were not available in the study center. Laparoscopic cholecystectomy has been found useful in an African population, though there was a high conversion rate from laparoscopic cholecystectomy to open cholecystectomy attested to the severity and chronicity of disease, which made dissection of Calot’s triangle problematic. MyCanadian Order net

Most of the patients [43 (93.5%)] had multiple stones with the highest having 250 stones. Only three (6.5%) patients had a solitary stone. This is in agreement with the findings of other Nigerian workers, and it also confirms that the majority of Nigerians with gallstones are not suitable for nonsurgical treatment. The highest number of stones in a single gallbladder in a Nigerian to date is recorded by Ojukwu and Agu. The patient had 403 stones in her gallbladder.

Only four (10.9%) of stones in this series were pigmented compared to the findings of Ajao in Ibadan in the late 70s, where six out of 19 patients (31.6) were found to have pigmented stones.

All the patients did well after open cholecystectomy. There was no mortality and no significant postoperative morbidity.
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While the incidence of cholecystitis and cholelithiasis is still low in this environment as compared to Europe and North America, we are beginning to have an increase probably as a result of the changing dietary habit (increased caloric intake, high cholesterol/fat) of the population. There is a need to further investigate the changing dietary habit of Nigerians, especially those in urban areas, as compared to those in rural areas and relate this to increased incidence of gallstones. A high index of suspicion and careful clinical judgement coupled with the use of simple ancillary investigation, such as ultrasound, will make early diagnosis and treatment feasible.


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